GIAMMARIA FIORENTINI, DIPARTIMENTO ONCOLOGICO OSPEDALE S.GIUSEPPE – ANTICA SEDE EMPOLI (ITALY)...
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GIAMMARIA FIORENTINI,
DIPARTIMENTO ONCOLOGICO
OSPEDALE S.GIUSEPPE – ANTICA SEDE
EMPOLI (ITALY)
CAGLIARI – 23/24 giugno 2005CAGLIARI – 23/24 giugno 2005
CHEMIO-IPERTERMIA: CHEMIO-IPERTERMIA: primi risultati clinici su primi risultati clinici su
100 casi con lesioni 100 casi con lesioni epatiche avanzateepatiche avanzate
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Direct heat-necrosis (relatively high temperatures)
ATP decrease in cells, energy deprivation
Lactic acid forming, acidosis
Blood-perfusion decrease in tumors, hypoxia
Radio- and chemo-sensitizing, synergy
Suppressing the adoption mechanisms
Blood-perfusion increase in healthy tissue
Hyperthermia effects summaryHyperthermia effects summary
Micro-embolization, angiogenetic block
HSP membrane expression, gain of the apoptotic signal
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pHR
EL
AT
IVE
SU
RV
IVA
L
Developing lactic acid (acidosis) Developing lactic acid (acidosis)
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ATP/CELL (M)S
UR
VIV
ING
FR
AC
TIO
N
Decreasing ATPDecreasing ATP
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Temperature (°C)
Rel
ativ
e ch
ange
in b
lood
flo
w
Tem
p. C
hang
e (°
C)
Decreasing blood perfusionDecreasing blood perfusion
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University Witter-Herdecker, Dr. Sahimbas
May 22, 2000 May 24, 2000 May 25, 2000
Angio-block by electro Angio-block by electro hyperthermiahyperthermia
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E
+
[ 500 V/m = 5 V/cm 5 mV/cell ]
cell (2- 10 m)
4-5 nm, 50-90 mV [ 1*107 - 9*107 V/m ]
+
Cell-membrane
Cell-membrane
Cell membrane “encapsulation”
Membrane shielding Membrane shielding for electric fieldfor electric field
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Extra-cellularliquid
(conducts current)Intra-cellular
liquid(“encapsulated”
electrolyte)
Characteristically 2-8 m
current current
Extracellular heating
Tumor heating
Healthy tissue
Tumor tissue
Current lines
Conductivity of tumor-tissue is considerable higher
Selective conduction Selective conduction behaviorbehavior
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Polarizing energy absorption
disordered ordered
Good absorption No absorption
External field
tt
Condenser arrangement
Patient-like dielectricsTumor-like
dielectrics
Active electrode Passive
electrode
Healthy tissue
Tumor tissue
Current lines
Conductivity of tumor-tissue is considerable higher
Complex impedance
selects
Self-focusingSelf-focusing
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0.00
20.00
40.00
60.00
80.00
100.00
120.00
0.00 2.00 4.00 6.00 8.00 10.00 12.00 14.00 16.00 18.00time [h]
no electrohyperthermia no chemo
CDDP alone
electrohyperthemia alone no chemo
CDDP with electrohyperthermia
Tu
mor
-cel
l act
ivit
y [%
]
Electro-hyperthermia effectsElectro-hyperthermia effects
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1.0
10-1
10-2
10-3
10-40 4 8 12
radiation only
Rad.+ heat
Heat + rad.
Sur
viva
l
Dose (Gy)
EHY action EHY action Increasing radio-sensitivity Increasing radio-sensitivity
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Indice Terapeutico dei tumoriIndice Terapeutico dei tumori
CHEMIO CHEMIO RADIORADIO HTHT
Cell. ossigenate +++ +++ +
Cell. ipossiche + - +++
Endotelio vasi + ++ ++
Stroma + + +
Microcircolo - + ++
SCORE 6+ 7+ 9+
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Un generatore di radiofrequenze a 13.56 Mhz produce ipertermia selettiva dei
tumori profondi fra i 46 e i 50°C mentre la T° dei tessuti sani rimane 40°C. le
frequenze vengono inviate all’organismo mediante applicatori e piastre parallele applicate sulla cute.
IPERTERMIA DIELETTRICA IPERTERMIA DIELETTRICA SECONDO LE VEENSECONDO LE VEEN
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Il fascio di radiofrequenza è perpendicolare alla superficie dell’elettrodo/applicatore.
Il tessuto adiposo,muscolare, osseo e tumorale si riscaldano diversamente a seconda del contenuto in acqua, sali
minerali e intrinseche proprietà elettriche e vascolari del tessuto.
IPERTERMIA DIELETTRICA IPERTERMIA DIELETTRICA SECONDO LE VEEN 2SECONDO LE VEEN 2
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La penetrazione del fascio si correla alla superficie cutanea riscaldata:
Più questa è ampia più in profondità giunge il fascio.
Collegando il generatore ad un amplificatore della potenza di 1 Kilowatt si raggiunge
una profondità maggiore.
IPERTERMIA DIELETTRICA IPERTERMIA DIELETTRICA SECONDO LE VEEN 3SECONDO LE VEEN 3
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Gli elettrodi sono modificati mediante serpentina di rame o sacche di plastica raffreddate con circolazione ad
acqua.Questo accorgimento permette di elevare del 20-30%
l’emissione del generatore con innalzamento della T° nei tessuti sottostanti lo strato adiposo evitando ustioni.
L’energia necessaria alla distruzione cellulare per azione diretta del calore è di 120-145 Kcal/mole.
In associazione con farmaci e/o radioterapia questa energia si riduce a 20-40 kcal/mole (TER: Thermal
Enhancenment Ratio)
IPERTERMIA DIELETTRICA IPERTERMIA DIELETTRICA SECONDO LE VEEN 4SECONDO LE VEEN 4
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Jacoba van der Zee, Dionisio Gonzalez Gonzalez, Gerard C van Rhoon, Jan D P van Dijk, Wim L J van Putten, Augustinus A M Hart.
On behalf of the Dutch Deep Hyperthermia Group
THE LANCET •Vol 355 •April 1, 2000
COMPARISON OF RT ALONE WITH RT PLUS COMPARISON OF RT ALONE WITH RT PLUS HYPERTHERMIA IN PELVIC TUMORS: A HYPERTHERMIA IN PELVIC TUMORS: A
PROSPECTIVE, RANDOMIZED, PROSPECTIVE, RANDOMIZED, MULTICENTRE TRIALMULTICENTRE TRIAL
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METHODSMETHODS
358 pts included in a 358 pts included in a prospective randomized trial prospective randomized trial
from 1990 to 1996.from 1990 to 1996.Bladder ca. stages T2, T3 or T4 Bladder ca. stages T2, T3 or T4
N0 M0N0 M0Cervical ca. FIGO IIB, IIIB, IV Cervical ca. FIGO IIB, IIIB, IV
Rectal ca. stages M0 – 1Rectal ca. stages M0 – 1
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METHODS 2METHODS 2
Pts randomly assigned to RT Pts randomly assigned to RT alone (n=176) or RT plus alone (n=176) or RT plus Hyperthermia (n=182).Hyperthermia (n=182).
Primary endpoints: complete Primary endpoints: complete response and duration to local response and duration to local
control. control.
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FINDINGSFINDINGS
CR rates were 39% after RT CR rates were 39% after RT and 55% after RT plus and 55% after RT plus
Hyperthermia (pHyperthermia (p<0.001).<0.001).The duration of local control The duration of local control was longer with RT+HT than was longer with RT+HT than
with RT alone (p=0.04)with RT alone (p=0.04)
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FINDINGS 2FINDINGS 2
The addition of HT seemed to be The addition of HT seemed to be most important for cervical ca., for most important for cervical ca., for wich CR rate with RT+ HT was 83% wich CR rate with RT+ HT was 83% compared with 57% after RT alone compared with 57% after RT alone
(p=0.003).(p=0.003).3-year overall survival was 27% in 3-year overall survival was 27% in
RT group and 51% in RT+HT RT group and 51% in RT+HT group. group.
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INTERPRETATIONINTERPRETATION
HT in addition to RT may be useful in HT in addition to RT may be useful in advanced cervical tumors.advanced cervical tumors.
In our istitutions RT+HT is now the In our istitutions RT+HT is now the treatment of choice in cervical ca. FIGO treatment of choice in cervical ca. FIGO
stage IIB-IVA.stage IIB-IVA.For the other tumor sites, evidence is For the other tumor sites, evidence is required from trials with more patients required from trials with more patients
before practical recommendations can be before practical recommendations can be mademade
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EHY
NON-INVASIVE
Treating area: REGIONAL (Deep seated tumors)
Invasivity:
Electro-Hyperthermia Electro-Hyperthermia TherapyTherapy
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MATHERIALS AND MATHERIALS AND METHODSMETHODS
•Hyperthermia delivered by EHY 2000 machine
•Treating schedule: 60 – 80 minutes for 8 sessions for 2 times
•Energy delivered: 100-120 Watt corresponding to 22000-35000 KJ
every session•CDDP 20-30 mg total dose
administered before HTH on day 1-3-5-7-9 as bolus i.v.
•CT control every 60 days for 3 times
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PATIENTS SELECTIONPATIENTS SELECTION
112112 pts proposed with liver metastases from colo-rectal cancer
and hepatoca.
1212 excluded for:4 far advanced disease
4 body conformation and obesity3 cardiac pace makers
1 implanted electronic pump
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PATIENTS SELECTION PATIENTS SELECTION 22
78 78 pts with liver metastases from colo-rectal cancer: stage II/III (30/48) Pettavel
classification.
AllAll pts treated with at least 3 lines of chemo
6666 received also RFA
5252 underwent surgical excision
2222 pts with hepatoca: 2222 Child C., Okuda stage II/III (15/7)
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PATIENTS SELECTION PATIENTS SELECTION 33
22 pts with hepatoca: 22 Child C., Okuda stage II/III (15/7)
AllAll pts treated with different chemotherapy
18 received RFA 8 underwent surgical excision
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RESULTS AND TOXICITYRESULTS AND TOXICITY
Liver metastases from CRC:2 CR, 11 PR, 2 CR, 11 PR, 13 RR = 16.6%13 RR = 16.6%
20 SD = 25.6% 20 SD = 25.6%
TTP = 14 (5 – 22) wksTTP = 14 (5 – 22) wks
ST = 20 (16 – 33) wksST = 20 (16 – 33) wks 39 PD = 50%39 PD = 50%
ST = 12 (4 – 16) wksST = 12 (4 – 16) wks
Better QoL = 48 (61.5%)Better QoL = 48 (61.5%)
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RESULTS AND TOXICITY RESULTS AND TOXICITY 22
Hepato Cellular Carcinoma:2 CR, 6 PR, 2 CR, 6 PR, 8 RR = 36.4%8 RR = 36.4%
4 SD = 18.2% 4 SD = 18.2%
TTP = 18 (7 – 36) wksTTP = 18 (7 – 36) wks
ST = 27 (9 – 41) wks ST = 27 (9 – 41) wks
10 PD = 45.4%10 PD = 45.4%
ST = 16 (5 – 21) wksST = 16 (5 – 21) wks
Better QoL = 16 (68.2%)Better QoL = 16 (68.2%)
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RESULTS AND TOXICITY RESULTS AND TOXICITY 33
•SKIN BURNS: 2 CASESSKIN BURNS: 2 CASES•LOCAL PAIN/RUSH/OEDEMA: 4/3/1 LOCAL PAIN/RUSH/OEDEMA: 4/3/1
CASESCASES•NEUROPATHY G 2-3: 6 CASESNEUROPATHY G 2-3: 6 CASES
•MYELOSOPPRESSION G 2: 8 CASES MYELOSOPPRESSION G 2: 8 CASES •NEFROPATHY G 3: 2 CASESNEFROPATHY G 3: 2 CASES
•CHANGE OF BEHAVIOUR: 1 CASECHANGE OF BEHAVIOUR: 1 CASE•ALOPECIA: 1 CASEALOPECIA: 1 CASE
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CONCLUSIONSCONCLUSIONS
1.1. Evidence of responses in Evidence of responses in pretreated ptspretreated pts
2.2. Increase of QoL also in pts Increase of QoL also in pts without responsewithout response
3.3. Good compliance Good compliance
4.4. Feasibility on out patient clinic Feasibility on out patient clinic basisbasis
5.5. Low cost treatment Low cost treatment
6.6. Low toxicityLow toxicity
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No pain
Before treatment (%)
0
10
20
30
40
50
60
70
%
Moderate pain Severe pain
3 month after treatment (%)
Pain-reduction, higher life quality Pain-reduction, higher life quality
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HCC vg PR lasting 24 HCC vg PR lasting 24 weeksweeks
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Metastases from CRC: Metastases from CRC: CR lasting 20 weeksCR lasting 20 weeks
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Metastases from CRC: Metastases from CRC: CR lasting 24 weeksCR lasting 24 weeks
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DEEP ELECTRO-DEEP ELECTRO-HYPERTHERMIA WITH HYPERTHERMIA WITH RADIOFREQUENCIES RADIOFREQUENCIES
COMBINED WITH COMBINED WITH THERMO-ACTIVE DRUGS THERMO-ACTIVE DRUGS
IN PATIENTS WITH IN PATIENTS WITH LIVER METASTASES LIVER METASTASES
FROM COLORECTAL FROM COLORECTAL CANCER:CANCER:
VERY GOOD PRVERY GOOD PR
(lasted 11 months)(lasted 11 months)
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TREATMENT RESULTS OF THE FIRST 72 PATIENTS TREATED BY DR. J. BRENNER, Telhashomer Hosp. Israel, (1997-1999)
• COMPLETE RESPONSE: 4.2%COMPLETE RESPONSE: 4.2%
• PARTIAL RESPONSE: 11.1%PARTIAL RESPONSE: 11.1%
• MAJOR RESPONSE: 15.3% MAJOR RESPONSE: 15.3%
• MINOR RESPONSE:MINOR RESPONSE: 12.5% 12.5%
• STABLE DISEASE:STABLE DISEASE: 8.3% 8.3%
• OVERAL RESPONSE: 36.1%OVERAL RESPONSE: 36.1%
Only EHY for hopeless casesOnly EHY for hopeless cases
72 PATIENTS PROGRESSED AFTER CONVENTIONAL MEDICINE
NONE OF THE PATIENTS HAD OTHER THERAPIES AT THE SAME TIME WITH THE ELECTRO-HYPERTHERMIA
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Diagnosis: GlioblastomaMale, 64 years, unable to walk, aphasia
Treatment: Local hyperthermia + ACNU 3 x 50 mg every 5 weeks
before treatment
after 3 cycles of treatment patient walks again, speaks fluently
(gently from Dr.A.Herzog, Benediktusquelle)
after treatment
Glioblastoma
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ASTROCYTOMA relapsed(vg PR confirmed at 14 months)
JAN. ‘04 APR. ‘04
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JAN. ‘04 APR. ‘04
ASTROCYTOMA relapsed(vg PR confirmed at 14 months)
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Nodes relapsed from Nodes relapsed from sarcoma:sarcoma:
march 2004 sept. 2004march 2004 sept. 2004
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liver and nodes metastases liver and nodes metastases from paraganglioma: vgPR from paraganglioma: vgPR
lasting 28 wks lasting 28 wks
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Internal mammary relapse :Internal mammary relapse :before and after IPHT before and after IPHT ( march – august 2004)( march – august 2004)
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The electro-hyperthermia is a new treatment modality for primary and secondary liver tumors
The combination of electro-hypertermia and CDDP is feasible on out-patient basis
HPT permits new applications in palliative fields
The hyperthermia methods are cost-effective
Hyperthermia conclusions 1Hyperthermia conclusions 1
Pain reduction, improving life quality
Warrant further well planned studies.
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Hyperthermia conclusions 2Hyperthermia conclusions 2
ESHOESHOEuropean Society Hyperthermia Oncology
SITILOSITILOSocietà Italiana Terapie Integrate Locoregionali
in Oncologia
AIROAIROAssociazione Italiana Radioterapia Oncologica
ICHSICHSInternational Clinical Hyperthermia Society
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International Clinical International Clinical Hyperthermia SocietyHyperthermia Society
XXVII ICHSXXVII ICHSCONFERENCECONFERENCE
FLORENCE FLORENCE 27/28 Oct. 27/28 Oct.
20052005Mark on your
Mark on your
calendar!!!
calendar!!!