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Romanian Reports in Physics, Vol. 66, No. 1, P. 175–181, 2014
THE RESULTS OF COMBINATION OF IFOSFAMID AND
LOCOREGIONAL HYPERTHERMIA (EHY 2000) IN PATIENTS
WITH ADVANCED ABDOMINAL SOFT-TISSUE SARCOMA
AFTER RELAPSE OF FIRST LINE CHEMOTHERAPY*
SIMONA RUXANDRA VOLOVAT1, CONSTANTIN VOLOVAT2, VIOREL SCRIPCARIU1 ,
CRISTIAN LUPASCU3, LUCIAN MIRON1
1 Regional Institute of Oncology, Iasi, Gral Henry Mathias Berthlot Str. no. 2-4, Iasi, Romania
E-mail: simona_v2002@yahoo.com
2 Euroclinic Oncology Center, Iasi, Vasile Conta str., no. 2, Iasi, Romania
E-mail: constantin.volovat@victoria-hospital.ro
3 Emergency County Hospital Sf. Spiridon, Iasi, Vasile Conta str., no. 2, Iasi, Romania
Received April 23, 2013
Abstract. From 2003 to 2011, 24 patients with advanced soft-tissue sarcoma with high-
risk pretreated using first line chemotherapy with doxorubicin and recurrence disease
were treated with chemotherapy (ifosfamide 3000mg/sqm, day 1–3) and locoregional
hyperthermia (1 hour application with temperature between 41.5°C and 42°C,
3 days/week). The purpose was to evaluate the efficacy and safety of chemotherapy
combined with locoregional non-invasive hyperthermia for local tumor control in
patients with retroperitoneal or visceral advanced soft tissue sarcomas. From 24
patients, 18 patients have had an evaluable response on CT scan using RECIST 1.0
(stable disease 8 patients for 4 months and 1 patients for 1 month, partial response
8 patients for 4 months, progression disease for 1 patient). The response was mainly on
local tumor site. The side effects were correlated only with chemotherapy (neutropenia
grade III 40%, grade 4 20%, trombocytopenia 2%, anemia grade III 10%, neurologic
toxicity 9%). No toxicity was correlated with hyperthermia treatment.
Key words: soft-tissue sarcoma, chemotherapy, locoregional hyperthermia.
1. INTRODUCTION
Soft tissue sarcoma prognosis factors are high grade histology results, large
tumor size (>5cm) and deep localization [1]. If median overall survival for the
* Paper presented at the 1
st Annual Conference of the Romanian Society of Hadrontherapy
(ICRSH 2013), February 21–24, 2013, Predeal, Romania.
Simona Ruxandra Volovat et al. 2
176
patients with extremity STS is 33 months, the patients with retroperitoneal STS
have reported an overall survival between 9 and 20 months [2, 3]. It was proven
that retroperitoneal or visceral sites are an additional poor prognostic factor,
independent of other factors like grade, tumor size and recurrence [4].
After radical excision, five-year survival rates of undifferentiated retroperi-
toneal and visceral STS were reported to be as low as 16% [5]. In a strategy to
improve local tumor control, a multimodal treatment including regional
hyperthermia (RHT) seemes attractive to be explored in this high-risk patient
population.
The rationale for the combination of cytotoxic drugs with hyperthermia in the
treatment of high-risk STS (HR-STS) is based on experimental evidence that heat
exposure increases tumor cells death rate by direct thermal cytotoxicity and is able
to sensitize perfused tumor tissue towards chemotherapy in a synergistic manner
[6].
The primary endpoint of this trial was represented by the response rate of
combined chemotherapy (ifosfamide) with loco-regional hyperthermia for patients
with metastatic soft tissue sarcoma with progression after first line chemotherapy
with doxorubicin. The response rate can be an indicator for efficacy of treatment if
in a small group of patients, there is a response rate greater than 40% at 3 months
for the second line treatment [7, 8].
Secondary objectives were: safety evaluation of the combined chemotherapy-
hyperthermia treatment and evaluation of progression free survival.
Patients and methods. Between 2003 and 2011, a total of 24 patients
diagnosed with metastatic soft tissue sarcoma and progressive disease after
doxorubicin treatment were enrolled in the trial. STS was localized in abdominal
and retroperitoneal regions, with positive histopathology and no cKIT mutations.
Relapsed disease after treatment was confirmed by CT scan evaluation with
RECIST 1.0 and after signing the informed consent. The treatment from this
protocol with ifosfamide and locoregional hyperthermia was approved by the local
ethics committee of the Euroclinic Center of Oncology.
Patients' characteristics. The criteria for inclusion in this study were the
following: a minimum of 2 points at ECOG performance status evaluation, no
major cardiac disease, adequate bone marrow, good hepatic and renal functions
(bilirubin less than 2 x ULN), retroperitoneal or abdominal soft-tissue sarcoma
with positive histopathology and no c-KIT mutations. Every patient have received
minimum 2 cycles of doxorubicin before progression of the disease. The main
characteristics of the patients are presented in Table 1.
3 Chemotherapy and hyperthermia for abdominal soft-tissue sarcoma
177
Table 1
Characteristic Nr. of patients
Performance status
ECOG 2 4
ECOG 3 14
Site of metastasis
Lung 8
Liver 11
Bone 7
Hystopathologic Type
Fibrosarcoma 5
Mixofibrosarcoma 2
Synovial sarcoma 3
Leiomyosarcoma 3
Epithelioid Sarcoma 2
Angiosarcoma 3
Chemotherapy regimen. The chemotherapy protocol comprised of
ifosfamide given 3 consecutive days (ifosfamide 3000 mg/sqm, day 1–3) and
uroprotection (Mesnum), repeated at 21 days (Fig.10). As premedication, the
following were administered: Ondansetron 8 mg po/IV q 8 h × 3 doses (first dose
pre-chemotherapy), dexamethasone 8 mg po/IV pre-chemotherapy, then 4 mg
po/IV q 12 h × 10 doses, Lorazepam 1 mg SL q 4–6 h prn nausea, sleep or
restlessness, Prochlorperazine 10 mg po/IV q 4–6 h prn nausea and vomiting.
IFOSFAMID 3000 mg/msqP IV
Day 1,2,3
+ MESNUM 1800 mg/msq PIV
D.1 D.3 D.5 D.7 D.9 D.11 D.13 D15 D.17 D19 D.21 (D.1)
HT-
60min
HT-
60min
HT-
60min
HT-
60min
1 cycle = 21 days
CT evaluation after 2 cycles
IFOSFAMID 3000 mg/msqPI V
Day 1,2,3
+ MESNUM 1800 mg/msq PIV
Fig. 1 – The schedule of treatment (chemotherapy + hyperthermia).
Simona Ruxandra Volovat et al. 4
178
Locoregional non-invasive hyperthermia. The treatment with locoregional
hyperthermia was performed 3 days/week with 1 hour applications between 41.5°C
and 42°C, repeated at 21 days, until progression.
Toxicity evaluation. Adverse events were collected after every cycle and
were reported after CTC-AE system.
Treatment Evaluation. The response of the treatment (chemotherapy with
hyperthermia) was evaluated with CT evaluation (after every 2 cycles of the
treatment) using RECIST system.
2. RESULTS
Treatment delivery and toxicities. A total of 76 chemotherapy cycles were
administered to 18 patients. Locoregional hyperthermia was administered
concomitently with chemotherapy. Chemotherapy was interrupted when disease
progression was demonstrated (after CT evaluation - RECIST system) or when the
performance status of the patient was higher than ECOG 3 (clinical progression of
the disease). Four patients had their treatment stopped due to low performance
status.
3. TOXICITY ASSESSMENT
Chemotherapy toxicity. Chemotherapy related toxicity was assessed after
every cycle and was related to CTC-AE criteria. All toxicities were transitory and
were resolved without sequelae. There were 3 patients with dose reduction due to
grade IV neutropenia.
Toxicity [%] of patients
Hematologic
neutropenia grade III 40
neutropenia grade IV 20
anemia grade III 10
thrombopenia grade III 2
Non-hematologic
neurologic toxicity 9
5 Chemotherapy and hyperthermia for abdominal soft-tissue sarcoma
179
Hyperthermia associated toxicity. There were some adverse effects related
to hyperthermic treatment: discomfort related with bolus pressure in 4 patients
(grade II – CTC AE criteria) and pain related with position in 3 patients (grade II –
CTC AE criteria).
Combined treatment toxicity (chemo + locoregional hyperthermia) was
within normal values, mostly related to chemotherapy, demonstrating that
association between hyperthermia and chemotherapy is safe.
Response. The primary endpoint was represented by response rate of
chemotherapy (ifosfamide) combined with loco-regional hyperthermia. For this
purpose, the Simon two stage design was utilised. According to a Van Glabbekea
study [7], if soft tissue sarcomas treatment has a response rate greater than 40% at
3 months, it becomes a treatment efficacy indicator; less than 20% is an indicator
of non-efficacy. In this trial, out of 18 patients, 8 (44%) had stable disease
4 months, 1 patient (6%) had stable disease 1 months , 8 patients (44%) with partial
response 4 months and 1 patient (6%) with progression disease. In these conditions,
there is a rate of 44% for partial response and this indicates a necessity to continue
patient enrollment.
For the progression free survival period, this was calculated and the median was
4.7 months (Fig. 2).
PFS
123456
0
20
40
60
80
100
Time
Survival probability (%)
N
umber at risk
17 17 17 12 4 0
group
1
Fig. 2 – Progression free survival for 18 patients enrolled.
Simona Ruxandra Volovat et al. 6
180
Treatment safety was evaluated after every cycle and the conclusion was that
the treatment adverse events were only related with chemotherapy.
4. DISCUSSION
For phase II trials, the most popular statistical design is the two steps optimal
and minimax designs proposed by Simon [9]. Fleming [10] has also proposed a
single step design based on a similar hypothesis, but not relevant for this study. The
design proposed by Gehan [11] is sometimes used in early phase II trials, when a
decision rule is not crucial.
Results obtained in this study of 44% rate of response (partial response for 4
months) is relevant towards taking a decision about whether the study and
enrollment should continue or not. Van Glabbekea [7] considers that a response of
more than 40% in a treatment is relevant when assessing the efficacy of that
treatment.
Concomitantly, the progression free survival of 4.7 months for the group of
18 patients with metastatic soft tissue sarcoma treated in second line with
ifosfamide and hyperthermia is an encouraging result.
The efficacy of locoregional hyperthermia (electro-hyperthermia) induced by
the EHY-2000 device was demonstrated in preclinical studies where the main
effects of electro-hyperthermia were classified in thermal effects (changes on ion-
gradient and membrane potential, increase glicolitic activity, glucose and lactate,
decrease hypoxia in tumors, increase of oxygen-free radicals, induction of heat
shock proteins) and non-thermal effects (for electromagnetic fields 1–30MHz) –
direct electromagnetic coupling on cancer cells.
The combination of chemotherapy and hyperthermia was reported with a
pathological response rate of 42% in neoadjuvant chemo-hyperthermia treatment of
soft-tissue sarcoma [12] with a median OS of 31 months. Correlated with this trial,
where the response rate is 44%, this result suggests that the combination of
hyperthermia + chemotherapy with ifosfamid can be promising related with
progression free survival. Low rate of side-effects demonstrates that the
combination of hyperthermia and chemotherapy with ifosfamid is a safe treatment.
The extension of the group of patients with soft-tissue sarcoma is mandatory for
more concludent data.
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