Table of Contents
Conference Papers in Medicine
Volume 2013 (2013), Article ID 192435, 4 pages
http://dx.doi.org/10.1155/2013/192435
Conference Paper

Treatment of Advanced Cervical Cancer with Complex Chemoradio-Hyperthermia

Department of Oncoradiology, Non-Profit Trust, Markusovszky Hospital, Vas County, Szombathely, Hungary

Received 21 January 2013; Accepted 18 April 2013

Academic Editors: G. F. Baronzio, M. Jackson, and A. Szasz

This Conference Paper is based on a presentation given by L. Pesti at “Conference of the International Clinical Hyperthermia Society 2012” held from 12 October 2012 to 14 October 2012 in Budapest, Hungary.

Copyright © 2013 L. Pesti et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

This single arm, retrospective, single institution study investigated intention to treat patients ( ) with advanced cancer of cervix of uterus. The study was performed in 2001–2010, providing 331 sessions. All patients had radiotherapies as fractional radiotherapy and intracavital brachytherapy. Some patients ( ) received chemotherapy (Cisplatin 40 mg/m2/week; concomitantly with tele-radiotherapy) as well. Complementary to the teleradiotherapy, oncothermia was used two times a week, targeting the pelvis. Applied energy dose was 45 W, 60 min. Oncothermia was applied immediately after the infusion, when chemotherapy was also administered. Complete and partial remission were achieved in trimodal therapies for 73.5% of the patients, while we could stabilize the disease for 14.7% of the patients.

1. Introduction

Carcinoma of the cervix of uterus is the second deadly female malignancy after mammary carcinomas. Cervical cancer incident in Hungary: 21 incidences per 100,000 females (higher than the rate in Eastern Europe) and the mortality rate is 9.6/100,000 women/year, which means the deaths of 500 women a year, [1].

Hyperthermia treatments are popular for gynecological applications [2, 3]. These focus on radiotherapy combinations [4], showing highly significant benefit of hyperthermia in overall survival, disease-free survival, and local-relapse-free survival made by randomized trial [4]. A large randomized controlled clinical trial of the radiohyperthermia is published in the Lancet [5], with great success. The results were very promising [5], but the control study [6] was disappointing. The explanation may be simple; a reference point was missing [7]. The chemotherapy combination (Cisplatin + hyperthermia for previously radiated cases) also shows feasibility [8] as well as the trimodal applications for cervix [911]. There are large debates in the topic [12], with counterpoints [13] and contras [14]. Our objective is to treat advanced cervical tumors with a new kind of hyperthermia (oncothermia) and add new results for the professional discussions.

Our department accepts patients from the three neighboring counties (Veszprém, Zala, and Vas) for preoperative, postoperative, definitive, and palliative treatments. In addition to the applied standard professional protocols since 2001 we have the possibility to apply complementary oncothermia treatments.

2. Method

A single arm, retrospective, single institution study investigated intention to treat patients ( ) with advanced cancer of cervix of uterus for intention to treat (ITT) population. The study was performed from 2001 till 2010, involving 331 oncothermia treatment sessions.

After a complete medical check-up upon the decision of the conference of professionals (OncoTeam), the treatment protocol was prescribed and the patients were hospitalized. Patients with solid diagnostic proofs of advanced cervix carcinoma were involved in the study. The chemoradio-therapy was administered according to the standard protocol, and in the appropriate indications complementary oncothermia was used. All patients had radiotherapy. The CT based radiation with 3D conformity, targeting the pelvic regional lymphnodes up to 30 Gy, was followed by field-concentration in 1-2 steps until 50 Gy, in fractional solution by 2 Gy doses. Intracavital brachytherapy was applied complementary to teletherapy. After-loading technique was used once a week and three times altogether, providing 6-7 Gy/treatment. Additional chemotherapy was applied for patients, (Cisplatin 40 mg/m2/week; concomitantly with teleradiotherapy). Complementary to the tele-radiotherapy, oncothermia was used two times a week, targeting the pelvis. Two types of treatment devices were in use—“EHY 2000” and “EHY 3000” (Oncotherm GmbH, Germany). Applied energy dose was 45 W, for 60 min. (In days of chemotherapy it was applied just after the infusion.) (The electrode positioning is shown in Figure 1.) The applied forwarded energy density on the skin was 0.45 W/cm2.

fig1
Figure 1: Arrangement of the treatment electrodes of oncothermia EHY2000 (a) and EHY3000 (b) type devices.

The most important aspect of the treatment was the time schedule. The precise timing between chemo-, radio-, and brachytherapy treatments was organized with high care. Oncothermia was applied immediately after chemo- or brachytherapy treatments (few minutes for fixing), and at max 20 min before EBRT. This timing is delivered during the whole course of the treatment schedule. The effectiveness was measured within confines of the oncological care. Imaging procedures as well as gynecological check-ups used to keep track of the development of the patients’ status.

Note, this complementary treatment is currently not financed by the social insurance; therefore, patients pay privately for the oncothermia treatments. Unfortunately, this problem may affect the therapeutic plan in numerous cases, when the patient is unable to finance their own complementary treatment modality, even when the treatment is justified by professional aspects. In case of private cofinancing, the treatment plan of the commentary application is carefully designed to achieve the best available results.

3. Results

First, we are showing the case report. The anamnesis of the 54-year-old female patient was G2,P2, with comorbidity hypertonia for 15 years. She had a stroke at the age of 54. She had vaginal bleeding symptom at first diagnosis: Neoplastic cervix uterus stage IIIB-IV, Figure 2. Histology: carcinoma planocellulare. She received the first external irradiation 2 Gy/day fractions, with 50 Gy complete dose. Additionally, after-loading brachytherapy was applied for three times: 8 Gy, 5 Gy, and 4.5 Gy, subsequently.

fig2
Figure 2: The diagnosis and the planning of the radiation and oncothermia complementary.

Chemotherapy Cisplatin 40 mg/m2/week complementary to external radiation was performed, and oncothermia was given to her in 10 sessions. The result was a complete remission. Permanent control followed the treatment and no evidence of the disease (NED) was found. The last control (four years after the finishing of the oncothermia) was NED again, Figure 3.

fig3
Figure 3: Control MRI of the patient: 1 months after oncothermia (a), one year after oncothermia, (b), four years after oncothermia (c).

Patients had various number of treatments, Figure 4; in average 4.7 sessions were applied.

192435.fig.004
Figure 4: Distribution of the number of treatments for the patients ( ).

The clinical response was measured in cases of trimodal applications (radiotherapy, chemotherapy, and oncothermia, ). Results are promising: 73.5% (25/34) complete and partial remissions, 14.7% (5/34) stable disease, and 11.8% (4/34) progressive disease, Figure 5.

192435.fig.005
Figure 5: Clinical response of the combined treatment. Progression was observed only in 12% of the patients.

Our experience has shown that the addition of oncothermia had increased the effectiveness of conventional modalities, measured in the quality of life and survival elongation.

4. Conclusions

With a therapeutic plan prepared with due care and implemented precisely—especially the time between treatments and appropriate setting of treatment parameters—oncothermia can effectively complement the conventional oncotherapies. We will present our results in a case study, in which a patient’s treatment was started only with palliative intent but at the end complete remission became available.

References

  1. Human Papillomavirus and Related Cancers, “WHO Report, WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre),” Summary Report Update. September 15, 2010.; HUNGARY, Human Papillomavirus; and Related Cancers in Hungary. Summary Report, 2010, January 2013, http://www.who.int/hpvcentre/en/.
  2. F. A. Gibbs, “Thermoradiotherapy for genituorinary and gynecological tumors,” in Thermoradiotherapy and Thermochemotherapy, Vol 2. Clinical Applications, M. H. Seegenschmiedt, P. Fessenden, and C. C. Vernon, Eds., Springer, Telos, France, 1995. View at Google Scholar
  3. K. Sekiba, T. Hasegawa, and Y. Kobashi, “Hyperthermic treatment for gynaecological malignancies,” in Cancer Treatment by Hyperthermia, Radiation and Drugs, T. Matsuda, Ed., pp. 261–270, Taylor & Francis, 1993. View at Google Scholar
  4. Y. Harima, K. Nagata, K. Harima, V. V. Ostapenko, Y. Tanaka, and S. Sawada, “A randomized clinical trial of radiation therapy versus thermoradiotherapy in stage IIIB cervical carcinoma,” International Journal of Hyperthermia, vol. 17, no. 2, pp. 97–105, 2001. View at Publisher · View at Google Scholar · View at Scopus
  5. J. van der Zee, D. González González, G. C. van Rhoon, J. D. P. van Dijk, W. L. J. van Putten, and A. A. M. Hart, “Comparison of radiotherapy alone with radiotherapy plus hyperthermia in locally advanced pelvic tumours: a prospective, randomised, multicentre trial,” Lancet, vol. 355, no. 9210, pp. 1119–1125, 2000. View at Google Scholar · View at Scopus
  6. A. Vasanthan, M. Mitsumori, J. H. Park et al., “Regional hyperthermia combined with radiotherapy for uterine cervical cancers: a multi-institutional prospective randomized trial of the international atomic energy agency,” International Journal of Radiation Oncology Biology Physics, vol. 61, no. 1, pp. 145–153, 2005. View at Publisher · View at Google Scholar · View at Scopus
  7. D. Fatehi, J. Van der Zee, E. Van der Wal, W. N. Van Wieringen, and G. C. Van Rhoon, “Temperature data analysis for 22 patients with advanced cervical carcinoma treated in Rotterdam using radiotherapy, hyperthermia and chemotherapy: a reference point is needed,” International Journal of Hyperthermia, vol. 22, no. 4, pp. 353–363, 2006. View at Publisher · View at Google Scholar · View at Scopus
  8. R. C. Rietbroek, M. S. Schilthuis, P. J. M. Bakker et al., “Phase II trial of weekly locoregional hyperthermia and cisplatin in patients with a previously irradiated recurrent carcinoma of the uterine cervix,” Cancer, vol. 79, no. 5, pp. 935–943, 1997. View at Google Scholar
  9. E. L. Jones, T. V. Samulski, M. W. Dewhirst et al., “A Pilot Phase II trial of concurrent radiotherapy, chemotherapy, and hyperthermia for locally advanced cervical carcinoma,” Cancer, vol. 98, no. 2, pp. 277–282, 2003. View at Publisher · View at Google Scholar · View at Scopus
  10. H. Tsuda, M. Tanaka, T. Manabe et al., “Phase I study of combined radiation, hyperthermia and intra-arterial carboplatin for local recurrence of cervical cancer,” Annals of Oncology, vol. 14, no. 2, pp. 298–303, 2003. View at Publisher · View at Google Scholar · View at Scopus
  11. A. M. Westermann, E. L. Jones, B. Schem et al., “First results of triple-modality treatment combining radiotherapy, chemotherapy, and hyperthermia for the treatment of patients with stage IIB, III, and IVA cervical carcinoma,” Cancer, vol. 104, no. 4, pp. 763–770, 2005. View at Publisher · View at Google Scholar · View at Scopus
  12. J. van der Zee and D. González González, “The Dutch Deep Hyperthermia trial: results in cervical cancer,” International Journal of Hyperthermia, vol. 18, no. 1, pp. 1–12, 2002. View at Publisher · View at Google Scholar · View at Scopus
  13. L. Prosnitz and E. Jones, “Counterpoint: test the value of hyperthermia in patients with carcinoma of the cervix being treated with concurrent chemotherapy and radiation,” International Journal of Hyperthermia, vol. 18, no. 1, pp. 13–18, 2002. View at Publisher · View at Google Scholar · View at Scopus
  14. J. van der Zee, P. C. M. Koper, L. C. H. W. Lutgens, and C. W. Burger, “Point-counterpoint: what is the optimal trial design to test hyperthermia for carcinoma of the cervix? Point: addition of hyperthermia or cisplatin to radiotherapy for patients with cervical cancer; two promising combinations—no definite conclusions,” International Journal of Hyperthermia, vol. 18, no. 1, pp. 19–24, 2002. View at Publisher · View at Google Scholar · View at Scopus