Examining the Role of Transrectal High Intensity Focused Ultrasound (HIFU) in Rectal Pelvic Cancer

2014-08-27 03:14:51 | BioPortfolio


Objective: A single centre pilot Phase I/II trial to establish the feasibility of transrectal HIFU as an additional option treatment modality in patients with locally advanced pelvic rectal cancer that is either primary or recurrent and for whom all available current therapy is inappropriate and/or exhausted.

We shall make a preliminary assessment of safety & dosage for later evaluation in a randomised controlled trial. Whilst efficacy data are limited in a small feasibility study; radiological and biochemical analyses of the patient and histopathological analysis of patient specimens together with specific validated symptom and quality of life questionnaires (QoL), will be used to provide surrogate preliminary measures in this patient cohort.

Hypothesis: HIFU is safe and will improve patient symptoms and QoL where no alternative contemporary therapies are available.


Background information on the project:

Colorectal cancer is the third most common cause of cancer and cancer death (35000 and 16000 respectively in UK) in both men and women. There are about 1million cases and a 500 000 deaths annually world wide.

Primary treatment is usually surgical with, in appropriate cases, adjuvant or neo−adjuvant therapy including radiotherapy, cytotoxic chemotherapy or a combination. Unfortunately, the overall 5 year survival of locally advanced disease is at best 50%. Many patients who have residual, refractory or recurrent rectal cancer experience serious morbidity from local tumour invading and destroying adjacent tissues including bone, nerves (sacral), bladder and skin. This causes severe interference with normal activities of daily living especially with bowel function and causes great distress in terms of pain, tenesmus and rectal blood and mucous loss with many patients requiring permanent palliative colostomies.

High Intensity Focused Ultrasound (HIFU) is a method of accurately delivering ablative energy at high temperature non−invasively or endo−luminally focused to specific areas in the body using imaging (ultrasound or MR) guidance.

Intracavitary or endo−luminal (also called transrectal) HIFU has been appraised by NICE in the treatment of prostate cancer. It is currently used in the main for primary prostate cancer and there is early evidence that it may be effective in treating prostate cancer that has recurred after radiotherapy. Short and medium term data demonstrate that HIFU may be equivalent to some current prostate cancer therapies but with much reduced morbidity and length of stay. Also, as it becomes increasingly possible to accurately determine the focality and site(s) of primary prostate cancer, research into the use of HIFU to deliver hemiablation and/or focal ablation (thus preserving otherwise normal areas and decreasing morbidity even further) is underway. As the prostate and rectum are adjacent we now propose a natural evolution to translate the success in prostate to the adjacent rectum.

There is a large unmet clinical need for new treatments for patients with residual or progressing local pelvic cancer (such as rectal in origin but including other pelvic malignancies) in whom all current therapies are exhausted. Intracavitary (transrectal) HIFU offers such a therapy. There are 2 distributors of transrectal HIFU devices in the UK. Sonoblate (UKHIFU) have agreed to loan a device currently CE marked and approved for use in prostate cancer to be assessed in rectal cancer (current retail cost approx. £280K). They have agreed to charge only for associated costs e.g. transportation and disposables.

HIFU has the potential to offer a genuine non−invasive alternative to current therapies in a wide number of clinical conditions, especially cancers, saving substantial patient morbidity and healthcare costs. Assessing this potential is timely. We propose to test for 1. safety and 2. efficacy of an intracavitary HIFU device in patients with otherwise untreatable pelvic rectal cancer (which can subsequently be applied to other pelvic cancers as appropriate and as experience grows).

Ethical approval from the National Research Ethics Committee has been granted (details). For the initial study, up to 20 patients with rectal cancer will be offered intracavitary HIFU (at increasing energy doses) under general anaesthesia and monitored for toxicity and ablative efficacy using ultrasound & MRI scans pre and post-treatment. None of the intracavitary devices have been used for rectal tumours; therefore is important that the energy intensity and resultant rectal cancer tissue destruction from a range of different treatment energies, starting initially with 50% of that used for prostate cancer. In this manner, the first phase of this trial is equivalent to the 'dose escalation' phase of a drug trial.

Once the optimum energy levels, safety and treatment protocol are known, a further 30 patients will be treated. Patients will undergo MRI and ultrasound pre− and 4 weeks post−treatment to objectively assess tumour changes (ablation should result in a necrotic area). They will complete QoL questionnaires, pain scores and functional questionnaires. Survival data will be documented.

Design, hypothesis and measurable aims of project:

Hypothesis: HIFU is safe and will improve patient symptoms and QoL where no alternative contemporary therapies are available.

Design: In two stages:

Phase I (Up to 20 patients) will assess safety, feasibility and toxicity of HIFU.

Cohorts of 3 patients will be assessed at escalating energy levels starting at 50% of a standard prostate cancer protocol. If no grade 4 toxicity is observed within 3 weeks, and no more than one patient has a grade three toxicity, then the next dose escalation will occur to 75% and thereafter, subject to toxicity, in 25% increments until necrosis of the targeted cancer areas are achieved. If there is doubt or grade 3 toxicity occurs in more than 2 out of 3 patients, a further 3 patients will be treated at the same energy level. The optimum level is where the grade three toxicity is less than or equal to 33% of the expanded cohort, otherwise we would reduce down one level until this is achieved.

If safety is acceptable by an (already constituted) Data Monitoring Committee we will proceed to the efficacy part / phase II.

Phase II will extend the Phase I cohort to up to a total of 50 patients and assess efficacy, symptom and QOL outcomes.

Primary and secondary objectives will be measured using tumour size (RECIST) criteria as well as tumour marker changes (CEA and CA19.9), pain relief (visual analogue scales, analgesia consumption), symptom control, rectal function and quality of life scores (EORTC QLQ−C30 and EORTC QLQ−CR38). Post treatment imaging will involve pelvic MRI at 4 week post treatment. Patients in this rectal cancer category usually progress rapidly, so that survival end−points will be calculated at 30, 60 and 90 days post procedure.

Study Design

Endpoint Classification: Safety/Efficacy Study, Intervention Model: Single Group Assignment, Masking: Open Label, Primary Purpose: Supportive Care


Rectal Cancer


Sonablate 500 (High Intensity Focused Ultrasound (HIFU))


Imperial College Healthcare NHS Trust (Hammersmith Hospital)
United Kingdom
W12 0HS




Imperial College London

Results (where available)

View Results


Published on BioPortfolio: 2014-08-27T03:14:51-0400

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