[Regional chemotherapy of liver metastases of colorectal carcinoma using implanted gas pressure pumps. Results of a prospective phase II study]

22 patients with liver metastases of colorectal carcinomas were given floxuridine infusions into the hepatic artery using a totally implantable pump system (Infusaid, model 400). The course of the disease was compared to that of 22 untreated controls matched for age, sex, extent of metastatic disease and performance status. No therapy-related mortality was observed in the treatment group, morbidity was 37%. Response rate was 77% based on CEA decrease by more than 33% after 6 months, and 64% related to a more than 50% reduction in metastasis size. Median survival time was 10 months in the control group as compared to 26 months in the therapy group; the one-year survival rate was 37.5% and 88%, respectively.

Fibrosis of extrahepatic biliary system after continuous hepatic artery infusion of floxuridine through an implantable pump (Infusaid pump)

A case of severe fibrosis of the extrahepatic biliary system after hepatic artery infusion of floxuridine is described. The clinical and pathologic features are presented, and its pathogenesis discussed. The authors suggest investigation of an alternate drug schedule and/or dosage of floxuridine to eliminate or minimize this serious complication.

Cholecystitis secondary to infusion chemotherapy

This report centers on a patient with metastatic colorectal cancer who developed acute and chronic cholecystitis secondary to the infusion of FUDR (fluoro-deoxyuridine) into the hepatic artery. This was documented by sonography, cholescintigraphy, and, ultimately, pathologically on the surgically removed specimen. Undoubtedly, with increasing cumulative treatment days made possible through technological advances in delivery systems, this complication will be seen more frequently. Prophylactic removal of the gallbladder, at the time of pump placement, which does not significantly prolong the operative time nor increase the operative mortality, should be performed to prevent this complication from occurring.

Toxicities and complications of implanted pump hepatic arterial and intravenous floxuridine infusion

Toxicities and complications were prospectively analyzed in patients with liver metastases receiving hepatic intra-arterial (IA) and systemic intravenous (IV) floxuridine (FUDR) with the Infusaid (Intermedics-Infusaid Corp., Norwood, MA) implantable pump. Among 55 patients treated with IA FUDR (0.3-0.1 mg/kg/day X 14, every 28 days), elevations in liver enzyme values, not attributable to disease progression, developed in 96% of patients. Serious biliary toxicity occurred in 31 patients (56%). In 16, biliary sclerosis was documented radiographically and was diagnosed clinically in 15 additional patients. Ten patients were hospitalized for biliary toxicity, including five who required cholecystectomy for acalculous cholecystitis. Because of the high reported incidence of serious gastroduodenal toxicity after IA FUDR infusion, our procedure for hepatic arterial cannulation was designed to eliminate misperfusion of the stomach and duodenum with drug; none of our patients experienced FUDR-associated gastroduodenal ulceration or bleeding. Cyclic IV FUDR (0.05-0.15 mg/kg/day X 14, every 28 days) was administered to 31 participants of the Northern California Oncology Group trial (3L-82-1) of IV versus IA FUDR. Dose-limiting toxicity was diarrhea. Serious toxicities were: protracted diarrhea (three), dermatitis (two), tear duct stenosis (two), and stomatitis (two). Three patients were hospitalized for toxicity. No hematologic or biliary toxicity occurred. The optimal route for treatment of hepatic metastases with continuous FUDR infusion has not yet been established. Systemic IV infusion has low morbidity, but preliminary response data need to be substantiated in controlled clinical trials before there can be widespread clinical application. High response rates for IA infusion have been previously documented. Morbidity due to acalculous cholecystitis and gastroduodenal ulceration can now be avoided. Despite significant progress in characterization of hepatobiliary toxicity, it remains dose-limiting. Continuous IA FUDR infusion should remain under the aegis of dedicated treatment centers until standardized protocols with diminished toxicity are established.

Toxicities and complications of implanted pump hepatic arterial and intravenous floxuridine infusion

Toxicities and complications were prospectively analyzed in patients with liver metastases receiving hepatic intra-arterial (IA) and systemic intravenous (IV) floxuridine (FUDR) with the Infusaid (Intermedics-Infusaid Corp., Norwood, MA) implantable pump. Among 55 patients treated with IA FUDR (0.3-0.1 mg/kg/day X 14, every 28 days), elevations in liver enzyme values, not attributable to disease progression, developed in 96% of patients. Serious biliary toxicity occurred in 31 patients (56%). In 16, biliary sclerosis was documented radiographically and was diagnosed clinically in 15 additional patients. Ten patients were hospitalized for biliary toxicity, including five who required cholecystectomy for acalculous cholecystitis. Because of the high reported incidence of serious gastroduodenal toxicity after IA FUDR infusion, our procedure for hepatic arterial cannulation was designed to eliminate misperfusion of the stomach and duodenum with drug; none of our patients experienced FUDR-associated gastroduodenal ulceration or bleeding. Cyclic IV FUDR (0.05-0.15 mg/kg/day X 14, every 28 days) was administered to 31 participants of the Northern California Oncology Group trial (3L-82-1) of IV versus IA FUDR. Dose-limiting toxicity was diarrhea. Serious toxicities were: protracted diarrhea (three), dermatitis (two), tear duct stenosis (two), and stomatitis (two). Three patients were hospitalized for toxicity. No hematologic or biliary toxicity occurred. The optimal route for treatment of hepatic metastases with continuous FUDR infusion has not yet been established. Systemic IV infusion has low morbidity, but preliminary response data need to be substantiated in controlled clinical trials before there can be widespread clinical application. High response rates for IA infusion have been previously documented. Morbidity due to acalculous cholecystitis and gastroduodenal ulceration can now be avoided. Despite significant progress in characterization of hepatobiliary toxicity, it remains dose-limiting. Continuous IA FUDR infusion should remain under the aegis of dedicated treatment centers until standardized protocols with diminished toxicity are established.

The implantable "Infusaid" infusion pump. The Sydney experience using 5-fluorouracil

The experience is reported of the use of the totally implantable "Infusaid" infusion pump in the treatment of 14 patients in our combined clinics for metastatic carcinoma in the liver by means of the antimetabolite 5-FU. At the time of this study the more active antimetabolite 5-FUDR was not available. A comparison is made of overseas reports of the use of 5-FUDR in the Infusaid infusion pump with the experience, in our clinic, of the use of 5-FU.

[Comparison of the performance of a totally implantable pump and conventional access systems in regional arterial chemotherapy of liver tumors]

Forty-nine patients with liver tumors have been submitted to regional arterial chemotherapy by means of either totally implantable Infusaid 400 pumps (29 casse) or implantable ports (20 cases). The latter were subsequently perfused with external pumps. There was one single major operative complication and no operative deaths. Most patients underwent continuous FUDR infusion. Access related complications in the Pump and Port groups respectively included 1 and 0 malfunctions, 7 and 2 seromas, 2 and 0 pocket necroses, 8 and 10 thromboses, 2 and 4 catheter dislocations, 0 and 2 portal breakages. Treatment was stopped for access related complications in 5 and 5 patients respectively. In most of those cases, however, more than 6 cycles of chemotherapy have been performed. The Infusaid 400 pumps showed a 12-month duration of 58.4% with a 13 month median versus 17% and 9 month median of the Ports. The difference was not significant. The new implantable systems give better results in comparison with traditional regional methods; the performance of the Port systems appear very similar to the totally implantable pumps, with an obvious advantage, however, for the pumps as far as quality of life is concerned.

Flow-directed catheter for superselective arterial catheterization: an experimental evaluation

A coaxial infusion catheter of 3 Fr Teflon and Gore-Tex was developed to facilitate superselective catheterization of cerebral arteries for the delivery of therapeutic agents. The catheter, technique for use, and preliminary results are described.

Totally implantable catheters for cancer chemotherapy: French experience on 325 cases

325 implantable catheters (PAC) were successfully used for treatment of 310 patients with neoplastic diseases in 21 French medical centers. 263 were placed in central venous sites; 43 in the hepatic artery and 11 in intra-portal sites. There was no failure at insertion time nor was there any death attributable to the method. While average duration of catheterization was 182 days, 72 catheters remain patent after one year of use or longer. Occlusion risk was found to be 3.6%: 1.5% for IV sites and 13.9% for intra-arterial sites (due to smaller inner diameter). 2.4% of the implantations showed cutaneous necrosis and in 2.7% sepsis occurred. Sepsis was much more likely to occur after percutaneous insertions. These results support the use of this device for long term chemotherapy.

Hepatic abscess following hepatic arterial infusion chemotherapy with an implantable pump

A patient with an intrahepatic abscess associated with an implantable pump for hepatic arterial infusion for metastatic colonic tumor is described. In view of the increased use of this device, clinicians should be aware of this complication.

Acute cholecystitis associated with hepatic arterial infusion of floxuridine

In a 1 year period, 13 patients underwent pump implantation for liver metastasis from a primary colorectal tumor. The gallbladders were not removed at the time of pump implantation in the initial six patients. In these patients, chemotherapy consisted of floxuridine given every 2 weeks followed by a 2 week rest period and cisplatin over 1 hour by way of the side portal on day 8 of the cycle. The treatment was repeated every 28 days. All patients whose gallbladders were not removed at the time of pump implantation required reoperation for acute or chronic acalculous cholecystitis from 1 to 9 months (mean 5.4 months) after pump implantation. At operation, all patients were found to have various degrees of inflammation and fibrosis. In one patient, significant sclerosing cholangitis was documented that involved the entire intrahepatic ductal system and hepatic duct bifurcation. Cholecystectomy and operative cholangiography are recommended in all patients who undergo pump implantation for metastatic disease to the liver.

A reversible enteropathy complicating continuous hepatic artery infusion chemotherapy with 5-fluoro-2-deoxyuridine

This article describes two patients with hepatic metastases from colorectal cancer in whom a reversible enteropathy developed during the administration of hepatic artery infusion chemotherapy with 5-fluoro-2-deoxyuridine (5-FUdR) via an Infusaid Series 400 pump (Infusaid Corp., Sharon, MA). Both patients had severe diarrhea and signs that suggested small bowel obstruction. Barium studies revealed a distinctive radiologic appearance of severe narrowing of the ileum associated with complete loss of normal mucosal patterns. Results of an extensive evaluation for an infectious or toxin-related enterocolitis were negative. Perfusion studies confirmed the appropriate position of the catheters and revealed no extrahepatic perfusion. Systemic shunting of the 5-FUdR through the liver or tumor bed is postulated as the primary event, with the small bowel manifesting the major toxicity.

Complications of implantable chemotherapy pump. A case of pump inversion

Regional chemotherapy with the use of implantable pumps is becoming more frequent. The authors report here a case of the pump inverting in the subcutaneous pocket. Speculation on diagnosis, correction, and prevention are discussed.

Chemical cholecystitis associated with hepatic arterial chemotherapy delivered by a permanently implanted pump

The introduction of chemotherapeutic agents directly into the proper hepatic artery via an indwelling catheter results in perfusion of the gallbladder, because the cystic artery is usually a branch of the right hepatic artery. Five gallbladders, removed two to 16 months after insertion of permanently implanted Infusaid model 400 pumps, were examined. All of the gallbladders had significant arteritis, with narrowing or occlusion of lumina or necrosis of vessel walls. Fibrosis of the gallbladder wall was also a constant finding. Nuclear atypia of mucosal epithelium and connective tissue was common. Varying degrees of acute and chronic inflammation were present. These abnormalities may have a radiomimetic and direct irritant pathogenesis.

[Intra-arterial infusion chemotherapy of hepatic carcinoma using a totally-implantable Infusaid pump]

Three patients with primary carcinoma of the liver and 11 patients with metastatic carcinoma of the liver were treated by hepatic arterial infusion of 5-FU and Mitomycin C (MMC), using a totally-implantable, percutaneously-refillable infusion pump: INFUSAID 210, 400. The infusion cannulae were placed into the hepatic arteries under direct vision on laparotomy, and the pumps were placed in subcutaneous pockets. The implanted pumps were well tolerated in these patients, who received chemotherapy as outpatients; the only adverse effects noted were related to 5-FU and MMC toxicity. The cumulative duration of successful infusion exceeded 104 months (for individual patients: range 2 to 20 months; average 7.4 months). Complications associated with conventional intraarterial chemotherapy (artery thrombosis, catheter sepsis and dislodgement, pump infusion variation and pump failure) were not seen with the INFUSAID delivery system. The pump is refilled every two weeks via percutaneous puncture. All therapy was given on an outpatient basis. Pump acceptance and tolerance was 100%. Our study using this infusion pump to deliver 5-FU and MMC has shown response rates of 66% (2/3) for primary carcinoma of the liver with cirrhosis and 82% (9/11) for metastatic carcinoma of the liver. The average survival for the primary and metastatic carcinomas of the liver were 6.0 months and 8.4 months respectively. Utilization of the totally-implantable INFUSAID pump provides a convenient, cost-effective, and safe administration technique for patients with primary and metastatic carcinomas of the liver.

[Surgical technics for implantation of hepatic intra-arterial catheters for local chemotherapy. Experience with 42 cases]

Based on the experience of 42 cases of surgical implantation of hepatic intra-arterial catheters (HIAC) for local chemotherapy, the techniques used are analyzed principally as a function of anatomical variations of the hepatic artery. A conventional procedure (HIAC implanted into gastroduodenal artery) was performed in 60% of cases, while in 26% of patients this was possible only after section of a right and/or left hepatic artery. Atypical implantation was necessary in 14% of cases to ensure complete perfusion of liver. The different methods employed and the reasons for their choice are discussed.

Sclerosing cholangitis after continuous hepatic artery infusion of FUDR

Eight of 46 (17.4%) patients treated in our trial of continuous hepatic artery infusion (CHAI) of fluorodeoxyuridine (FUDR) by Infusaid pump developed biliary strictures. The lesions were clinically, radiographically, and pathologically identical to the idiopathic sclerosing cholangitis frequently seen in association with inflammatory bowel disease. Treatment included immediate cessation of intraarterial FUDR, and surgical or percutaneous drainage of the biliary tree if it was dilated. Two of the eight patients died of the complication. Three patients stabilized after biliary system drainage, and two patients improved on observation only. The pathogenesis of this complication is not understood. This report details the clinical and pathological features of this entity.

Treatment of colorectal cancer hepatic metastases by hepatic artery chemotherapy

Our clinical experience with 69 patients with metastatic colorectal cancer to the liver treated with hepatic artery chemotherapy is reviewed. All patients have had a minimum of six months follow-up. The Infusaid implantable drug delivery system was used by direct laparotomy in one third, and via the transaxillary approach in the remaining two thirds. Two thirds of the patients had at least 25 percent of the liver replaced with tumor. Chemotherapeutic agents included FUdR, mitomycin C, and BCNU. The overall response rate was 51 percent and 69 percent for the three-drug combination. Efficacy was not different in patients who had received prior systemic fluorouracil. Median survival from start of hepatic artery chemotherapy was one year.

Supraclinoid intracarotid chemotherapy using a flow-directed soft-tipped catheter

In an attempt to avoid toxic reactions of the eye as a complication of internal carotid arterial infusion of cisplatin, carmustine, or a combination of both for the treatment of brain tumors, a new Gore-Tex/Teflon coaxial catheter system has been used for supraclinoid placement. Catheter placement was successful in 14 of 16 attempts in eight patients. Two patients experienced eye pain and conjunctivitis--a result of the chemotherapeutic agent leaking through the Gore-Tex portion of the catheter at the infusion rate of 170 ml/h. No complications were noted as long as the infusion rate was maintained at 125 ml/h or lower.

Hepatic artery infusion for metastatic neoplastic disease

Specific conclusions can be drawn concerning HAI in the treatment of neoplastic hepatic disease. Over-all, a rate of response of 50 per cent is noted, with the results of more recent studies showing improved response rates as measured by a CEA marker. There are extremely few, if any, complete responders. Nonresponders have one-half the survival time of responders. The median time of survival in patients who have received HAI is about one year. There have been series in which the mean survival rate is greater than that in historical control patients, but no one has demonstrated this fact with a matched group of patients in a prospective controlled trial; many such controlled trials are now underway. The duration of survival in patients receiving treatment is strongly influenced by the development and progression of extrahepatic lesions. Placing HAI catheters by laparotomy is more dangerous to life, but the morbidity is higher with percutaneous HAI. On the other hand, patients treated percutaneously have a much higher incidence of thrombosis of the hepatic artery and of other problems related to the catheter, including migration and dislodgment, so that treatment is compromised. The high numbers of patients treated by percutaneous therapy in the past who had an increased incidence of thrombosis of the hepatic artery perhaps have had some influence on the response rate. The technology of HAI has improved rapidly and markedly during the last several years with the development of such pumps with advanced design as the totally implantable, refillable and rechargeable infusion pump. What is needed now are studies designed to determine the best agent or combination of agents that can be administered through these advanced systems. Long term, controlled clinical trials of HAI in the ambulatory patient are underway, but the results are not yet available.

Assessment of treatment of intrahepatic malignancies using chemotherapy via an implantable pump

Thirty patients in whom an implantable pump was used for hepatic arterial perfusion of chemotherapeutic agents to treat hepatic malignancy were evaluated. Three patients with primary hepatocellular carcinoma demonstrated less than 50% reduction in tumor size. One patient with metastatic gastric carcinoma and one patient with metastatic islet cell carcinoma also showed a decrease of less than 50% in the size of the tumor mass. Among the 25 patients with metastatic carcinoma from the colon or rectum, 23 had elevated carcinoembryonic antigen (CEA) levels before surgery and 75% of these revealed a reduction of at least 50%. Only three of 20 patients followed with sequential imaging studies showed a 50% decrease in the size of the tumor mass. No increase in the duration of survival could be defined when the treated patients were compared with 13 patients who had not received chemotherapy. The pump functioned well in all patients, but 77% showed signs of toxicity. This experience, coupled with a review of the literature, suggests that the procedure should be regarded as experimental and should not be applied liberally until a definite benefit can be demonstrated.

Surgical aspects of intra-arterial chemotherapy of outpatients with head and neck cancer

We have evaluated the use of the completely implantable infusaid pump in 22 patients with advanced cancer confined to the head and neck. Unilateral head lesions are treated with a single-catheter pump infusing the external carotid artery. A dual-catheter pump is used for midline or bilateral head lesions (both external carotid arteries infused) or unilateral head and neck disease (the second catheter positioned in the thyrocervical trunk). The infused volume of each catheter is determined by nuclear tomography after slow intra-arterial injection of 99mTc-labeled macroaggregated albumin through the pump's auxiliary port. The injection port/infusion chamber configuration of the pump permits long-term, multiple-course, combination-drug intra-arterial therapy on an outpatient basis. To date, 15 patients have been treated longer than 6 months and five longer than 1 year with no bleeding or neurologic complications. Eight of 10 patients treated with cisplatin and fluorodeoxyuridine (FUdR) have responded. The Infusaid pump permits long-term, practical, cost-effective, intra-arterial therapy to the entire tumor volume of ambulatory head and neck cancer patients with a high rate of tumor response.

Experience with continuous regional chemotherapy and hepatic resection as treatment of hepatic metastases from colorectal primaries. A prospective randomized study

Sixty-five patients with hepatic metastases from colorectal primaries were studied in a prospective randomized fashion. The five patients with solitary metastases all had resection of metastases and 50% were randomized to pump therapy. Of the 16 patients with multiple resectable metastases, 7 had pump only and 9 had resection plus pump. Although the difference was not significant, there was a trend of improved survival for the patients with resection plus pump. For the patients with unresectable disease, those patients with positive portal nodes had poor survival matching those patients with extra hepatic metastases. Patients with unresectable disease treated with pump had a 73% therapeutic response rate and a median survival of 22 months. Significant complications included chemical hepatitis and biliary stenosis. The long-term efficacy of continuous hepatic artery infusion versus the hazards of treatment and the financial cost will need further investigation.

[Intermittent and ambulatory intra-arterial chemotherapy using a subcutaneous access chamber in the treatment of isolated hepatic metastases. Preliminary results]

Discontinuous daily ambulatory intra-arterial chemotherapy using a needle access chamber implanted subcutaneously was achieved for treatment of nonresectable isolated hepatic metastases. This original approach is a compromise between the uncomfortable exterior catheter and the exorbitant cost of a pump implant. Phase I study (6 cases) brought out the technical problems involved in this method. Phase II study (presently 11 cases) of only primary colonic or rectal tumor metastases treated with 5-fluorouracil and mitomycin C was undertaken. The preliminary results of this small series yields 64 percent objective improvement for which 55 percent are complete remissions.

Therapy for metastatic colorectal cancer with hepatic artery infusion chemotherapy using a subcutaneous implanted pump

Sixty-two patients with metastatic colorectal carcinoma involving the liver were treated by hepatic intra-arterial chemotherapy using an implantable infusion pump. The 53 patients with metastases confined to the liver had a median survival (MS) of 17 months and an objective response rate of 32%. Four patients (8%) demonstrated a complete response (CR), with normal abdominal computed tomography (CT) scan results and plasma carcinoembryonic antigen (CEA) levels, and 13 patients (25%) demonstrated a partial response (PR), with at least a 50% decrease in the liver lesions by CT scan and at least a 50% decrease in CEA levels. Thirty patients (57%) had stable disease (S), and six patients (11%) had no response (NR). Nine patients with extrahepatic tumor plus hepatic metastases had an MS of only 4.9 months. None of these patients had an objective response, and only four patients had S. Quality of response was clearly associated with longevity. Forty patients treated with floxuridine (FUDR) and mitomycin (M) (F + M) showed a 20% objective response rate, while the 13 patients treated with FUDR and dichloromethotrexate (DCMTX) (F + D) attained a 69% objective response rate. Although F + D treatment appears to be superior, there may have been selection biases that make such an observation only preliminary. Twenty-six (49%) of the 53 patients developed hepatitis during infusion chemotherapy, which resolved after temporary cessation of the chemotherapy. Of the 17 patients with CR or PR, 12 patients (71%) had hepatitis, whereas only 14 (39%) of the 36 patients with S or NR had hepatitis. Eleven patients had evidence of peptic ulceration by endoscopic examination during the infusion chemotherapy. All the ulcers healed after chemotherapy was discontinued.

[Hepatic chemotherapy by hepatic arterial catheterization with an implantable system allowing permanent vascular access]

This technique of anti-cancer treatment of hepatic cancers has a twofold interest: it delivers local chemotherapy in direct contact with the tumours and it allows repeated access to the blood supply of the liver without the need for surgery. This second point is particularly emphasized in the form of a technical description of the method of approach to the hepatic arterial system, which is as non-aggressive as possible and which allows permanent vascular access. This study, which required close collaboration between the departments of Vascular Radiology, Radiotherapy and Surgery, was initially considered as a feasibility study of a technique enabling the simple use of implantable vascular access sites.

Modification of the catheterization procedure for the totally implantable infusion pump

The totally implantable infusion pump is a new and expensive device. Once this pump is unpacked and is in contact with a patient, it is impossible to have it resterilized. For this reason, we suggest the use of a separate catheter for catheterization. Once the catheter is successfully placed in the appropriate artery, then the pump can be unpacked and attached to this catheter. If catheterization proves impossible, the pump is still sterile and can be used for the next patient.

The totally implantable infusion pump in treatment of metastatic colorectal cancer

Final evaluation of the Infusaid Pump system (Infusaid Corporation, Sharon, MA) for administration of regional chemotherapy must await completion of trials prospectively comparing survival of matched patients treated in this manner and patients treated by traditional systemic chemotherapy. A review of the current medical literature confirms our personal experience that response rates within the liver are high. Survival reports appear encouraging but this may represent an artifact in patient selection. An algorithm is presented to offer surgeons a reasonable and conservative means for selection of those colorectal cancer patients with metastatic involvement of the liver who are most likely to benefit from this system of drug delivery.

The subcutaneous injection port: a new chest-wall artifact

A totally implanted central venous catheter with a subcutaneous injection port is now in use in patients in whom long term venous access is required. This injection port creates a new artifact that can mimic a pulmonary lesion on chest radiographs.

The use of a volumetric infusion pump for the intra-arterial infusion of drugs

Volumetric infusion pumps are widely used for intravenous infusions. We have extended their use to the intra-arterial infusion of drugs. An in vitro evaluation of the performance of such devices, under experimental conditions comparable to an intra-arterial infusion, was carried out. The results obtained confirmed the accuracy of volumetric infusion pumps for intra-arterial infusions. The system was found to be safe, reliable and simple in clinical practice.

[A computer model for the simulation of intra-arterial tumor therapy in the area of the external carotid artery]

The complex theoretical background of intra-arterial (i.a.) tumour therapy induced the installation of a computer assisted model based on the use of 7 variables, the most important factors being the blood flow of the infused organ and the clearance of the drug, as well as the tissue binding of the drug. Various relevant conditions of i.a. infusion are represented by simple but typical diagrams allowing quick orientation on the principles governing i.a. infusion even for those who are not very familiar with the theoretical background of i.a. infusion. The model represents an improvement in the individual planning of effective i.a. chemotherapy.

Single-agent and combination-drug regional chemotherapy for head and neck cancer using an implantable infusion pump

Chemotherapy delivered through angiographically placed catheters requires patient hospitalization, and is usually limited to short-term infusions. Treatment given through surgically placed catheters with external portable infusion pumps permits greater patient freedom and longer infusion durations. However, some patient restrictions remain, and thrombotic or infectious complications are common with long-term therapy. A totally implantable pump has allowed long-term intraarterial therapy in an outpatient population. Patient activity was unrestricted, and the complication rate has been low. This system has been used to deliver single-agent therapy with FUdR, dichloromethotrexate or bleomycin, and combination-drug treatment with cisplatin + FUdR or bleomycin + mitomycin C + dichloromethotrexate. The majority of patients have responded to at least one drug program. Seven of 14 patients who had pumps implanted over 1 year ago have received therapy for at least 1 year, and four patients have had functioning system for over 2 years. Systemic toxicity (except for nausea and vomiting with cisplatin) has been uncommon. Further clinical experience with these programs will be necessary to fully establish the objective response rate. However, the Infusaid Pump has proven safe, reliable and has high patient acceptance.

Constant intrarenal infusion of PGE1 into a canine renal transplant using a totally implantable pump

A method was devised whereby PGE1 could be administered to a canine renal transplant recipient on a chronic basis. PGE1 was stored in the reservoir of an implantable pump and delivered continuously in high doses directly into the renal transplant artery. In the model studied a contralateral untreated transplant from the same donor served as a control. Sequential renal scans were used to study the effect of intraarterial PGE1 on the rejection process. Continuous delivery of PGE1 into the renal transplant artery did not prevent allograft failure under these conditions; blood flow diminished similarly in both PGE1-treated and untreated transplants. There were, however, striking differences in the histologic appearance of treated and untreated transplants. PGE1 perfusion resulted in the appearance of large numbers of polymorphonuclear leukocytes but few lymphocytes. In the untreated control allograft, however, the findings were typical of lymphocyte-mediated acute rejection. The distinctive differences noted histologically suggested that the local administration of PGE1 influenced the mechanism by which graft failure occurred. The ability to manipulate cell populations infiltrating an allograft represents a potentially important means for modifying the immune response.

Treatment with combined intra-arterial 5-FUdR infusion and whole-liver radiation for colon carcinoma metastatic to the liver. Preliminary results

Twenty-eight patients with colon carcinoma metastatic to the liver were treated with continuously infused intra-arterial 5-fluorouracil deoxyriboside (5-FUdR) and cyclical whole-liver radiation (2000-3000 rad). Survivorship ranged from 25 days to almost 4 years and was a clear function of the extent of liver dysfunction at the time of initiation of this treatment. Difficulties in establishing the objective complete response rates in patients with minor imaging abnormalities were frequently noted. Both extracorporeal and permanently implanted arterial infusion devices have been employed, the results favoring the internal infusion units. Under ideal circumstances (early treatment, disease limited to the liver, and a permanent indwelling pump), a median survivorship of approximately 2 years can be projected with a significant number of patients rendered free of progressive cancer in the liver for months to years. The dose-limiting feature of this approach is treatment-related to hepatitis, which proved lethal in one of 28 patients thus far treated. Preclinical studies on the original and reduction of drug- and x-ray-induced liver toxicity should have high research priority.