Intratumoral pO2-measurements as predictive assay in the treatment of carcinoma of the uterine cervix

Knocke, Tomas-Hendrik; Weitmann, Hajo-Dirk; Feldmann, H.J.; Selzer, Edgar; Pötter, Richard

doi:10.1016/s0167-8140(99)00139-5

Cited by 203 publications

(101 citation statements)

References 29 publications

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“…We utilized the Eppendorf Histograph to measure oxygen concentrations because it is currently the only clinically applicable technique whose strong predictive value in terms of radioresistance, tumour progression and metastasis has been extensively documented in patients (Gatenby et al, 1988;Höckel et al, 1993;Brizel et al, 1996;Höckel et al, 1996;Nordsmark et al, 1996;Brizel et al, 1997;Fyles et al, 1998;Sundfør et al, 1998, Knocke et al, 1999.…”

Section: Discussionmentioning

confidence: 99%

“…Presently, the determination of oxygen concentration with polarographic electrodes is the only method of measuring hypoxia that has been extensively studied in patients. Decreased tumour oxygenation, as measured with polarographic electrodes, has been reported to be a predictor of poor local response following radiotherapy in cervix cancer (Höckel et al, 1993;Fyles et al, 1998;Sundfør et al, 1998;Knocke et al, 1999;Lyng et al, 2000) head and neck cancer (Gatenby et al, 1988;Nordsmark et al, 1996;Brizel et al, 1997) and soft tissue sarcoma (Brizel et al, 1996). Recently, clinical data have emerged suggesting that hypoxia adversely affects locoregional control of cervical cancer, irrespective whether the initial treatment modality is radiotherapy or surgery (Höckel et al, 1996).…”

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confidence: 99%

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Relationship of hypoxia to metastatic ability in rodent tumours

2001

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SummaryThe relationship between tumour oxygenation in vivo and metastatic potential was investigated in 2 rodent tumour models, KHT-C fibrosarcoma and SCC-VII squamous cell carcinoma. The oxygen status in these rodent tumours transplanted intramuscularly in syngeneic mice was measured using the Eppendorf pO 2 Histograph. The results indicate a considerable heterogeneity in oxygenation between individual tumours within each tumour cell line. At different tumour sizes, animals were killed and lung lobes were examined for macroscopic and microscopic lung metastases. In the KHT-C tumours, a significant increase in early pulmonary metastasis formation was observed in mice with hypoxic primary tumours. Hypoxic SCC-VII tumours did not give rise to enhanced lung metastasis formation despite oxygenation in a range similar to the KHT-C tumours. However, the overall metastasis incidence in the SCC-VII model was very low. The results obtained in the KHT-C model, which show that hypoxic tumours are more likely to metastasize, are in agreement with recent clinical data suggesting that a hypoxic environment might be implicated in metastatic ability of human tumours.

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Section: Discussionmentioning

confidence: 99%

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confidence: 99%

Relationship of hypoxia to metastatic ability in rodent tumours

2001

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“…The higher (albeit low in absolute terms) recurrence rate seen in the ELIOT trial might therefore be because of the lower oxygen saturation of the tissues being irradiated as it is well known that tissue ischaemia reduces the effectiveness of radiation. [134][135][136][137][138][139][140][141] In addition, theoretically, some at-risk tissue such as the retracted skin and subcutaneous breast tissue and the prepectoral tissue behind the shield would not receive any radiation while exposing more raw surface to tumour seeding.…”

Section: Other Trialsmentioning

confidence: 99%

An international randomised controlled trial to compare TARGeted Intraoperative radioTherapy (TARGIT) with conventional postoperative radiotherapy after breast-conserving surgery for women with early-stage breast cancer (the TARGIT-A trial)

Vaidya

Wenz

Bulsara

et al. 2016

Health Technol Assess

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BackgroundBased on our laboratory work and clinical trials we hypothesised that radiotherapy after lumpectomy for breast cancer could be restricted to the tumour bed. In collaboration with the industry we developed a new radiotherapy device and a new surgical operation for delivering single-dose radiation to the tumour bed – the tissues at highest risk of local recurrence. We named it TARGeted Intraoperative radioTherapy (TARGIT). From 1998 we confirmed its feasibility and safety in pilot studies.ObjectiveTo compare TARGIT within a risk-adapted approach with whole-breast external beam radiotherapy (EBRT) over several weeks.DesignThe TARGeted Intraoperative radioTherapy Alone (TARGIT-A) trial was a pragmatic, prospective, international, multicentre, non-inferiority, non-blinded, randomised (1 : 1 ratio) clinical trial. Originally, randomisation occurredbeforeinitial lumpectomy (prepathology) and, if allocated TARGIT, the patient received it during the lumpectomy. Subsequently, the postpathology stratum was added in which randomisation occurredafterinitial lumpectomy, allowing potentially easier logistics and a more stringent case selection, but which needed a reoperation to reopen the wound to give TARGIT as a delayed procedure. The risk-adapted approach meant that, in the experimental arm, if pre-specified unsuspected adverse factors were found postoperatively after receiving TARGIT, EBRT was recommended. Pragmatically, this reflected how TARGIT would be practised in the real world.SettingThirty-three centres in 11 countries.ParticipantsWomen who were aged ≥ 45 years with unifocal invasive ductal carcinoma preferably ≤ 3.5 cm in size.InterventionsTARGIT within a risk-adapted approach and whole-breast EBRT.Main outcome measuresThe primary outcome measure was absolute difference in local recurrence, with a non-inferiority margin of 2.5%. Secondary outcome measures included toxicity and breast cancer-specific and non-breast-cancer mortality.ResultsIn total, 3451 patients were recruited between March 2000 and June 2012. The following values are 5-year Kaplan–Meier rates for TARGIT compared with EBRT. There was no statistically significant difference in local recurrence between TARGIT and EBRT. TARGIT was non-inferior to EBRT overall [TARGIT 3.3%, 95% confidence interval (CI) 2.1% to 5.1% vs. EBRT 1.3%, 95% CI 0.7% to 2.5%;p = 0.04; Pnon-inferiority = 0.00000012] and in the prepathology stratum (n = 2298) when TARGIT was given concurrently with lumpectomy (TARGIT 2.1%, 95% CI 1.1% to 4.2% vs. EBRT 1.1%, 95% CI 0.5% to 2.5%;p = 0.31; Pnon-inferiority = 0.0000000013). With delayed TARGIT postpathology (n = 1153), the between-group difference was larger than 2.5% and non-inferiority was not established for this stratum (TARGIT 5.4%, 95% CI 3.0% to 9.7% vs. EBRT 1.7%, 95% CI 0.6% to 4.9%;p = 0.069; Pnon-inferiority = 0.06640]. The local recurrence-free survival was 93.9% (95% CI 90.9% to 95.9%) when TARGIT was given with lumpectomy compared with 92.5% (95% CI 89.7% to 94.6%) for EBRT (p = 0.35). In a planned subgroup analysis, progesterone receptor (PgR) status was found to be the only predictor of outcome: hormone-responsive patients (PgR positive) had similar 5-year local recurrence with TARGIT during lumpectomy (1.4%, 95% CI 0.5% to 3.9%) as with EBRT (1.2%, 95% CI 0.5% to 2.9%;p = 0.77). Grade 3 or 4 radiotherapy toxicity was significantly reduced with TARGIT. Overall, breast cancer mortality was much the same between groups (TARGIT 2.6%, 95% CI 1.5% to 4.3% vs. EBRT 1.9%, 95% CI 1.1% to 3.2%;p = 0.56) but there were significantly fewer non-breast-cancer deaths with TARGIT (1.4%, 95% CI 0.8% to 2.5% vs. 3.5%, 95% CI 2.3% to 5.2%;p = 0.0086), attributable to fewer deaths from cardiovascular causes and other cancers, leading to a trend in reduced overall mortality in the TARGIT arm (3.9%, 95% CI 2.7% to 5.8% vs. 5.3%, 95% CI 3.9% to 7.3%;p = 0.099]. Health economic analyses suggest that TARGIT was statistically significantly less costly than EBRT, produced similar quality-adjusted life-years, had a positive incremental net monetary benefit that was borderline statistically significantly different from zero and had a probability of > 90% of being cost-effective. There appears to be little uncertainty in the point estimates, based on deterministic and probabilistic sensitivity analyses. If TARGIT were given instead of EBRT in suitable patients, it might potentially reduce costs to the health-care providers in the UK by £8–9.1 million each year. This does not include environmental, patient and societal costs.LimitationsThe number of local recurrences is small but the number of events for local recurrence-free survival is not as small (TARGIT 57 vs. EBRT 59); occurrence of so few events (< 3.5%) also implies that both treatments are effective and any difference is unlikely to be large. Not all 3451 patients were followed up for 5 years; however, more than the number of patients required to answer the main trial question (n = 585) were followed up for > 5 years.ConclusionsFor patients with breast cancer (women who are aged ≥ 45 years with hormone-sensitive invasive ductal carcinoma that is up to 3.5 cm in size), TARGIT concurrent with lumpectomy within a risk-adapted approach is as effective as, safer than and less expensive than postoperative EBRT.Future workThe analyses will be repeated with longer follow-up. Although this may not change the primary result, the larger number of events may confirm the effect on overall mortality and allow more detailed subgroup analyses. The TARGeted Intraoperative radioTherapy Boost (TARGIT-B) trial is testing whether or not a tumour bed boost given intraoperatively (TARGIT) boost is superior to a tumour bed boost given as part of postoperative EBRT.Trial registrationCurrent Controlled Trials ISRCTN34086741 and ClinicalTrials.gov NCT00983684.FundingUniversity College London Hospitals (UCLH)/University College London (UCL) Comprehensive Biomedical Research Centre, UCLH Charities, Ninewells Cancer Campaign, National Health and Medical Research Council and German Federal Ministry of Education and Research (BMBF). From September 2009 this project was funded by the NIHR Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 20, No. 73. See the NIHR Journals Library website for further project information.

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“…A correlation between the presence of hypoxia and response to therapy has been shown in a range of human tumor sites. Studies performed in patients with soft tissue sarcomas (Brizel et al, 1996;Nordsmark et al, 2001a), carcinomas of the uterine cervix (Hockel et al, 1996;Fyles et al, 1998;Knocke et al, 1999;Fyles et al, 2002), and of the head and neck (Nordsmark et al, 1996;Brizel et al, 1997Brizel et al, , 1999Nordsmark and Overgaard, 2000) indicated that the presence of hypoxic regions adversely affects locoregional control and/or disease-free survival after primary radiotherapy. Radiation resistance induced by the oxygen effect is unlikely to be the only explanation, since tumor oxygen status has been observed to be the most important prognostic factor for treatment outcome and metastatic free survival in cervical carcinoma after radiotherapy as well as surgery (Hockel et al, 1996).…”

Section: Hypoxia and Response To Treatment Radioresistancementioning

confidence: 99%

How to overcome (and exploit) tumor hypoxia for targeted gene therapy

Greco

Marples

Joiner

et al. 2003

Journal Cellular Physiology

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Tumor hypoxia has long been recognized as a critical issue in oncology. Resistance of hypoxic areas has been shown to affect treatment outcome after radiation, chemotherapy, and surgery in a number of tumor sites. Two main strategies to overcome tumor hypoxia are to increase the delivery of oxygen (or oxygen-mimetic drugs), or to exploit this unique environmental condition of solid tumors for targeted therapy. The first strategy includes hyperbaric oxygen breathing, the administration of carbogen and nicotinamide, and the delivery of chemical radiosensitizers. In contrast, bioreductive drugs and hypoxia-targeted suicide gene therapy aim at activating cytotoxic agents at the tumor site, while sparing normal tissue from damage. The cellular machinery responds to hypoxia by activating the expression of genes involved in angiogenesis, anaerobic metabolism, vascular permeability, and inflammation. In most cases, transcription is initiated by the binding of the transcription factor hypoxia-inducible factor (HIF) to hypoxia responsive elements (HREs). Hypoxia-targeting for gene therapy has been achieved by utilizing promoters containing HREs, to induce selective and efficient transgene activation at the tumor site. Hypoxia-targeted delivery and prodrug activation may add additional levels of selectivity to the treatment. In this article, the latest developments of cancer gene therapy of the hypoxic environment are discussed, with particular attention to combined protocols with ionizing radiation. Ultimately, it is proposed that by adopting specific transgene activation and molecular amplification systems, resistant hypoxic tumor tissues may be effectively targeted with gene therapy.

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Intratumoral pO2-measurements as predictive assay in the treatment of carcinoma of the uterine cervix

Cited by 203 publications

References 29 publications

Relationship of hypoxia to metastatic ability in rodent tumours

Relationship of hypoxia to metastatic ability in rodent tumours

An international randomised controlled trial to compare TARGeted Intraoperative radioTherapy (TARGIT) with conventional postoperative radiotherapy after breast-conserving surgery for women with early-stage breast cancer (the TARGIT-A trial)

How to overcome (and exploit) tumor hypoxia for targeted gene therapy

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