Bakacs et al. a minimum RT dose of 30 Gy and at least four mEHT treatments for reporting toxicities, which was the primary aim of the larger study. Results: Thirty-three patients treated with RT and mEHT, both applied to the same lesion, were included. The median RT dose was 45.5 Gy in 20 fractions (fxs) and the median number of mEHT treatments was 12 (range, 4C20). Most patients had subsequent systemic therapy after one course of RT and mEHT. Three patients (9.1%) developed autoimmune toxicities. Case number 1 1 received RT and mEHT only; case number 2 2 had two cycles of concurrent low dose chemotherapy during RT; and case number 3 3 received concurrent immune checkpoint inhibitors. None of the three patients received any further systemic treatment due to obvious treatment-related autoimmune reactions which occurred rapidly after RT; one had autoimmune hepatitis, one had dermatitis herpetiformis and the third developed severe myasthenia gravis. Interestingly, what we surmise to be long-lasting abscopal responses outside the irradiated area, were noted in all three patients. Conclusion: RT combined with mEHT could putatively result in enhancing immune responsiveness. These preliminary observational findings lead to the generation of a hypothesis that this combination induces both an vaccination events. Thymus-derived regulatory T (Treg) cells played a critical role in the control of immune tolerance to self-antigens, however, they also resulted in reduced anti-tumor immunity (24). There were very few literature reports on how therapy related autoimmunity-mediated antitumor activity (25, 26). We speculated that the incidence of the abscopal effect may be higher in patients who develop autoimmunity. Bakacs et al. reported that immune related adverse events (irAEs) induced by ipilimumab are very similar to the chronic graft vs. host disease that ensues allogenic bone marrow transplantation (27). Autoreactive T cells may bypass the negative selection pressure in the microenvironment of the tumor and differentiate to memory T cells that recognize both self and tumor. We report, we believe for first time, that patients treated with RT and mEHT may have a long treatment-free period once they unleash an autoimmune reaction, and further, that in such patients, successful salvaging through low-dose ICP inhibitors may be possible at tumor recurrence. Materials and Methods We performed a single institution, observational case-cohort study for patients with metastatic cancers of various origins, treated with a combination of RT and mEHT, with a minimum RT dose of 30 Gy and at least four mEHT treatments, to report unexpected adverse events. This retrospective analysis was conducted as part of a post-marketing safety surveillance program after the approval of the mEHT device in L-Lactic acid the class L-Lactic acid III medical category in Taiwan. The study was approved by the Institutional Review Board and was conducted according to the guidelines of Good Clinical Practice. Patient Selection Enrolled patients were 20 years of age or older, presented with inoperable, recurrent, or metastatic diseases, requiring palliation with RT. In our study, all patients underwent concurrent RT and mEHT with or without systemic therapies, based on the underlying clinical condition. All institution-specific consent requirements were adhered to; written informed consent was obtained from the participants for the publication of the case series. Radiotherapy RT was performed using conventional fractionation (and not hypofractionated) schedules, with a dose of 2 to 3 3.5 Gy per fraction (fx), five times L-Lactic acid per week to at least 30 Gy, as clinically appropriate and necessary. The L-Lactic acid clinical target volume (CTV) was defined as the gross tumor volume (GTV) plus a margin of 3C5 mm, based on the specific tumor type being addressed. Patients were treated with Elekta Synergy? (Elekta, Stockholm, Sweden) or TomoTherapy? (Accuray, Sunnyvale, CA, USA) with standard immobilization devices, using image-guided, modulated arc therapy with 6-MV photons for most of the patients. For patients who had received RT prior to the study, the original treatment plans were retrieved in every case of suspected overlap with the prior RT fields, and appropriate organ-at-risk constraints were adhered to. Hyperthermia (mEHT) The mEHT treatment was applied using an EHY 2000+ hyperthermia device (OncoTherm GmbH, Germany). Treatment lasted for 60 min and was administered once weekly. A 30 cm in diameter circular electrode was placed at the irradiated tumor site, approximating placement at the radiation field isocenter. A 13.56 MHz radiofrequency (RF) was used with a real-time, automatic tuning device resulting in energy-transfer matching and L-Lactic acid ensuring a standard wave ratio of ~1 (the most ideal value). The power was initially set to Mouse monoclonal to KRT13 80 Watts (W) and a step-up protocol was applied.
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- Bakacs et al
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