[Constant intra-aortic infusion chemotherapy for advanced abdominal cancer--a technic and the effect in patients with peritoneal metastases]

Constant intra-aortic infusion chemotherapy using an artificial graft was performed in 39 patients with advanced abdominal cancer. This method was easy for insertion and re-insertion of the catheter; thus it is suitable for long-term and repeated constant infusion therapy. Complications encountered with the catheter were obstruction (8 cases); cracking (4 cases); cracking of the connector (4 cases); infection of the graft (2 cases), and arterial thrombosis (1 case). Minor complications encountered upon using the catheter were solved by our method, however, infection represents a serious problem. In cases with peritoneal metastases, the response rate was excellent (43% by Karnofsky's criterion and 67% as determined by the ascitic effect) and this therapy was effective for symptoms resulting from peritoneal metastases. In conclusion, ours seems to be useful therapeutic method for advanced abdominal cancer with peritoneal metastases.

Hepatic arterial chemotherapy for colorectal cancer metastatic to the liver

Hepatic metastases of colorectal origin are resistant to radiation and immunotherapy. Traditional intravenous chemotherapy produces responses in 10% to 30% of patients, and surgical resection is feasible in approximately 20% of patients who have a solitary or unilobar lesion. Infusion of cytotoxic agents into the hepatic artery, introduced 2 decades ago, is the most promising form of therapy for unresectable hepatic metastases. Fluorouracil, floxuridine, and mitomycin have been most commonly administered by hepatic arterial infusion. The recent development of a totally implantable pump has allowed prolonged ambulatory infusion of chemotherapeutic agents into the hepatic artery. We review the recent data on the pharmacology, therapeutic outcome, administration techniques, and complications of hepatic arterial chemotherapy. Future trials in this area should use uniform stratification variables and standardized criteria for evaluating response, time to progression, and survival.

Regional chemotherapy of colorectal cancer metastatic to the liver

Ninety-three patients with biopsy-proven colorectal cancer metastatic to the liver were treated with hepatic arterial infusion of 5-fluorodeoxyuridine (FUDR). There were 52 men and 41 women (median age, 60 years). Forty-two patients (45%) had failed prior systemic chemotherapy. Catheters were operatively placed and multiple catheters were used if dictated by hepatic arterial anatomy in order to obtain perfusion of the entire liver. The drug was delivered by a totally implanted INFUSAID model 400 pump and patients received cyclic therapy consisting of 2 weeks of 0.3 mg/kg/d FUDR alternating with 2 weeks of saline. Patients with extrahepatic tumor or patients whose hepatic tumor failed to respond to FUDR were given a 30 minute intraarterial infusion of mitomycin C, 15 mg/m2, every 6 to 8 weeks in addition to FUDR. Fifty of the 93 evaluable patients presented with metastatic tumor confined to the liver. Of these 50 patients, 83% demonstrated a significant reduction in tumor size with a median duration of response of 13 months and a median survival of 25 months from diagnosis of liver metastases. Twenty-four of these 50 patients remain alive. Forty-three patients presented with extrahepatic metastases in addition to their liver tumor, and 74% had a response with a median duration of 6 months and a median survival of 14 months. Only six patients of those presenting with extrahepatic tumor remain alive. None of the 93 patients died solely of uncontrolled liver tumor, and only 9 died as a result of uncontrolled liver metastases and disseminated extrahepatic tumor. The duration of survival for both groups was determined by the uncontrolled progression of extrahepatic tumor. In patients with metastatic colorectal cancer involving only the liver, hepatic arterial FUDR alone and with the addition of mitomycin C provided excellent control of hepatic tumor. Survival appeared to be prolonged in this uncontrolled study.

An improved technique for regional perfusion chemotherapy in the presence of a replaced right hepatic artery using a single implantable pump

A new technique is described for regional perfusion chemotherapy in the presence of a replaced right hepatic artery. By anastomosis of the replaced right hepatic artery end-to-side to the left hepatic artery, a single implantable pump can be used to perfuse both lobes of the liver. This technique has the advantage of facilitating postoperative follow-up and substantially reducing the cost of the procedure.

Intraarterial chemotherapy for head and neck cancer, Part 2: Clinical experience

Despite almost 3 decades of experience, the use of intraarterial (IA) chemotherapy for the treatment of head and neck cancer is not universally accepted. The overall reported response rates are not substantially different from the therapeutic results obtained with systemic therapy. The additional complications associated with establishing and maintaining arterial access have further dampened enthusiasm for this approach. It is clear that considerable improvement in the techniques and efficacy of IA chemotherapy is necessary. This second and last part of this article considers the past and present clinical experience with IA therapy in the treatment of head and neck cancer and explores future developments.

A prospective phase II clinical trial of continuous FUDR regional chemotherapy for colorectal metastases to the liver using a totally implantable drug infusion pump

A prospective phase II evaluation of regional FUDR chemotherapy using a totally implantable drug infusion pump was conducted in 81 patients with colorectal metastases to the liver. The survival results were compared to a historical control group of 129 patients with isolated liver metastases. The two groups were comparable with respect to their dominant prognostic factors. The pump patients received their continuous chemotherapy on an outpatient basis and had an 88% response rate, as evidenced by a fall in their serum CEA levels by one-third or greater after two cycles of chemotherapy. By four criteria, the regional chemotherapy patients had an improved survival rate compared to the control series. First, the 1 year survival and median survival was better for the entire group of pump patients vs. controls (82% vs. 36%, 26 months vs. 8 months, p less than 0.0001). The survival for the regional chemotherapy patients was not influenced by the extent of tumor involvement, whether previous systemic 5-FU was given, or whether the patient had symptomatic disease. Second, the entire group of regional chemotherapy patients (including nonresponders) had a greater 1 year survival compared to the most favorable subgroup of control patients with the following characteristics: normal liver function tests, no symptoms, and only one lobe involved (82% vs. 66%, p = 0.009). Third, a subgroup of 49 pump patients, whose initial treatment for metastatic disease was regional chemotherapy (within 3 months of diagnosis) had a better 1 year survival than an exactly matched group of 49 control patients (67% vs. 30%, p = 0.000003). Fourth, the actuarial survival for all 81 pump patients was significantly better than predicted by a mathematical model constructed to predict the patient's clinical course based upon the seven dominant prognostic variables identified in a multifactorial analysis (82% survival at 1 year vs. 33% predicted survival). While liver metastases could be controlled in most patients, the major cause of death was tumor progression in extrahepatic sites, particularly lung metastases and abdominal carcinomatosis. Although it appears that regional chemotherapy with an implantable pump appears to prolong life by 12 to 18 months more than matched historical controls, these results must be confirmed by a randomized (phase III) prospective clinical trial.

[Photodocumentation of intra-arterial infusions using fluorescein]

Intra-arterial chemotherapy was given to 12 patients with Head and Neck tumours with the aim of selective perfusion of the tumour area, usually located in the area of supply of the lingual and/or facial artery. A catheter was inserted retrograde into the external carotid artery. The skin or mucous membrane area thus selectively infused by the antineoplastic drug and fluorescein solution could be controlled and documented using an excitation- and barrier filter. Serial photographs were used to demonstrate the higher fluorescence in the perfused area during the intra-arterial infusion lasting 60 or 90 minutes. The use of a balloon catheter increased the selectivity of the fluorescent region. At the end of the infusion the fluorescence disappeared rapidly. From our findings we conclude that it is possible to produce a selective higher concentration of a substance in the tumour during the intra-arterial infusion.

[Placement of catheters for intra-arterial chemotherapy. A new technic using balloon microcatheters]

A system employing a micro-balloon catheter is proposed for the introduction of catheters for intra-arterial chemotherapy.

Augmentation of surviving flap area by intraarterial vasodilators administered through implantable pumps

Using the implantable Infusaid Model 300 pump, several vasodilators (prostaglandin E1, isoxsuprine, bradykinin, trimethaphan, and reserpine) were infused intraarterially into an abdominal island flap in the rabbit. All produced a large increase in flap surviving area over saline controls at forty-eight hours, measuring as high as a 2.8-fold increase in random portions of the flap with prostaglandin E1. The agents possessed differing modes of action but had the common property of vasodilatation. The results raise questions concerning the possible physiological role of endogenous prostaglandins in the surgical delay phenomenon. The Infusaid pump was a valuable tool in the study and was well tolerated by the animals.

[Completely implantable infusion pump. A new therapeutic possibility for selected patients with liver tumors]

The action of floxuridine depends greatly on its concentration for treatment of liver metastases of colorectal carcinomas and other tumors. In isolated liver metastases it is best infused regionally in order to achieve a high concentration and to reduce systemic toxicity, particularly as it is almost entirely extracted by the liver. A totally implantable infusion pump has established itself as an effective, safe and reliable device of regional chemotherapy with floxuridine for palliative treatment of selected patients with metastases of colorectal carcinomas and other tumors. Life expectancy of patients with metastases of colorectal carcinomas was prolonged by 12-18 months when compared to a precedent control group without regional chemotherapy. This results require confirmation in a randomised phase III study. Patients with hepatocellular carcinoma can be treated with intraarterial doxorubicine and floxuridine infusions. Preliminary results are encouraging. The implantable system represents a major advance in drug administration, not only for the treatment of malignant disease but also a large number of other diseases. Continuous infusion of drugs using an implantable pump system will probably achieve greater importance in the future in the treatment of cancer.

Treatment of hepatic metastases by transaxillary hepatic artery chemotherapy using an implanted drug pump

The objective of this study was to evaluate the feasibility of integrating an implantable, refillable drug infusion pump with transaxillary angiographic hepatic arterial catheterization. The implantation is performed under local anesthesia in the radiology suite. A 2-3 cm incision in the left upper arm is made through skin and subcutaneous tissue. Through an axillary artery puncture, a 5.3F polyethylene catheter is fluoroscopically placed into the hepatic artery. To minimize gastroduodenitis, the gastroduodenal artery is occluded with a Gianturco coil and Gelfoam. The Model 400 Infusaid pump is implanted in the upper chest and attached subcutaneously to the angiography catheter using a friction connector. Patients are discharged 2-3 days later. Over a two-year period, 20 such implants have been performed. Floxyuridine (FUdR) has been used by continuous infusion; mitomycin-C (MMC) and 1,3-bis-(2-chloroethyl)-1-nitrosourea (BCNU) by intermittent intra-arterial infusion. The pump/catheter system has been left in place for as long as 18 months. Partial responses in the colorectal cases are as follows: FUdR four of nine patients, MMC two of three, FUdR + MMC one of one, and FUdR + MMC + BCNU three of three. No arm vascular complications, hepatic arterial occlusions, peripheral emboli, pump malfunctions, or catheter occlusions took place over a total experience of 3210 patient days. Three catheter migrations occurred requiring repositioning in two patients, and three cracked catheters required replacement. This innovative approach offers a comfortable, convenient method for long-term ambulatory hepatic arterial chemotherapy obviating both laparotomy and extra-corporeal pumps.

Long-term hepatic arterial infusion of 5-fluorodeoxyuridine for liver metastases using an implantable infusion pump

Twenty-one patients with liver metastases of various histologies (predominantly colorectal carcinoma) underwent Infusaid pump implantation for long-term hepatic arterial 5-fluorodeoxyuridine (5-FUdR) infusion. Patients received 5-FUdR infusion on a 2-wk cycle alternating with a 2-wk saline--heparin infusion. A dosage of 0.2-0.3 mg/kg/day (average 0.23 mg/kg/day) was infused for a cumulative 5-FUdR administration of 1940 days. Six patients (29%) responded to therapy (five colorectal, one carcinoid); median response duration was 6 mo. Median survival for the treated group was 17 mo from diagnosis of liver metastases and 13 mo from pump implantation. Median survival among the six responding patients was 15 mo from diagnosis of liver metastases and 11 mo from pump implantation. Comparison of survival from the diagnosis of liver metastases of the treated group to ten patients found ineligible for the study by virtue of extrahepatic metastases revealed no significant difference in median (18 mo for ineligible group) or overall survival. However, median survival for the treated group after pump implantation (13 mo) was significantly better than the median survival of the ineligible group after evaluation for this study (4 mo). Toxicities of therapy included fatigue, anorexia, nausea, vomiting, toxic hepatitis, epigastric pain, and diarrhea. No patients died of toxicity, but six patients required hospitalization for management of pain or vomiting. No serious technical complications developed in any patient except separation of the infusion catheter at its junction with the pump in one patient, necessitating pump replacement for continuation of therapy. These survival data suggest identification of new anticancer agents for hepatic arterial infusion.

Supraophthalmic carotid infusion for brain-tumor chemotherapy. Technical note

The ocular complications of intracarotid infusion of drugs for brain-tumor chemotherapy may be eliminated by infusion of the chemotherapeutic agent into the carotid artery above the origin of the ophthalmic artery. The authors have developed a catheter that can negotiate the carotid siphon. This catheter is not balloon-tipped but incorporates a flexible tip with an expanded end to facilitate drag by flowing blood. The exit hole is placed to allow remote manipulation of the tip by hydraulic forces. Using this catheter, the authors have been consistently able to infuse the supraophthalmic carotid artery.

Improved quality of life with an implantable pump for liver perfusion

In spite of the current discussion on whether liver perfusion is effective (Grage et al. 1979; Ansfield et al. 1975), the implantable perfusion pump offers the possibility of combining the still questionable therapeutic success with a high quality of life during the time remaining to such patients.

Superselective injection of BCNU through a latex calibrated-leak balloon

Carmustine (BCNU) has been used extensively to treat glioblastomas by injection through a catheter placed in the cervical internal carotid artery. The technique causes severe pain to the eye and has resulted in ipsilateral blindness. The use of a latex calibrated-leak balloon positioned above the ophthalmic artery in the internal carotid artery or in one of its branches appears to circumvent the ocular complications mentioned. At an infusion rate at 125 ml/hr the balloon does not inflate and does not occlude the artery. This new technique has been used to treat 10 patients without complications.

Totally implanted venous and arterial access system to replace external catheters in cancer treatment

A totally implanted venous and arterial access system was tested in 30 cancer patients. The device, an injection port (Infuse-A-Port, Infusaid Corp., Sharon, Mass.), consisted of a 3.5 by 1.5 cm conical chamber with a self-sealing silicone rubber septum connected to a Silastic catheter. Ten patents had the injection port operatively placed for arterial access. A total of 39 bolus injections and 18 continuous infusions lasting an average 5.4 +/- 3.4 days were administered through the port. The total time of arterial access ranged from 70 to 370 days. No special program of heparinization was required to maintain patency. The injection port was used for central venous access in 20 patients. The first six patients had a small lumen catheter of 0.38 mm internal diameter, and five had occlusion between 142 and 447 days. Subsequently, 19 ports with a larger catheter lumen of 0.63 mm were used. These ports functioned for an average of 274 +/- 110 days (23 to 382 days). There were 380 single bolus injections and 64 continuous infusions. A variety of anticancer agents as well as whole blood, blood products, and antibiotics were administered with the device without difficulty. Patient acceptance was excellent.

Long-term intraarterial chemotherapy infusion of ambulatory head and neck cancer patients

The complications of percutaneous intraarterial infusion chemotherapy of the head-and-neck-cancer patient has dampened enthusiasm for this approach. A totally implantable infusion pump system circumvents many of these complications and will in the long term enhance the opportunity to expand upon the advantages of infusion chemotherapy for the benefit of all cancer patients.

[A method to retain subcutaneously the catheter end connected to a new silicone reservoir in intraarterial infusion chemotherapy]

A method to retain subcutaneously the catheter end connected to a new silicone reservoir was developed in intraarterial infusion chemotherapy and applied to 12 patients. Its advantages were discussed. The method can be performed with only minor invasion; in addition, the retained catheter and reservoir needs no aseptic care. Accordingly, it liberates patients from restrictions in the daily life thus far experienced in the conventional method. The intraarterial infusion therapy can be done more easily and without hospitalization by this method. Thus, the method is considered to be quite beneficial in taking care of advanced cancer patients.

Intra-arterial chemotherapy using an implantable infusion pump and liver irradiation for the treatment of hepatic metastases

Liver metastases are a common cause of death in colon carcinoma. The dual blood supply of the liver permits regional perfusion while hepatic catabolism fo 5-fluorouracil (FU), floxuridine (FUdR) permit higher drug exposures than systemic (IV) administration. We have studied the effect of continuous intra-arterial chemotherapy (FU: 5-10 mg/kg/day and FUdR: 0.2 mg/kg/day) and whole liver irradiation (1000 rad every 4 weeks, total dose of 3000 rad) for metastatic colon carcinoma to liver. Eighteen patients with metastases to liver only are reported using this combination therapy. Seven patients had percutaneous placement of a catheter via the brachial artery, two had operative placement of a catheter via the gastroduodenal artery, all of which were connected to the Cormed infusor system, nine had operative placement of the Infusaid implantable pump with catheter placement into the hepatic artery via the gastroduodenal artery. The median survival for the entire group was 241 days. In those patients whose liver function tests (bilirubin and alkaline phosphatase) were less than two times normal, the median survival was 770 days. The median survival of the patients with greater than two times normal LFT's was 178 days. Two patients died of complications of the treatment. One who developed irreversible radiation hepatitis but at autopsy had only two areas of microscopic tumor foci in the liver and another who had received only 15 days of infusion and 1000 rad to liver. This patient developed irreversible chemical enteritis secondary to chemotherapy infusion into the superior mesenteric artery. Three patients have undergone abdominal reexploration and one at autopsy, who were found to have no gross evidence of tumor in the liver despite previous pathologic confirmation. It appears that some patients with minimal tumor burdens can have sterilization of their tumors. There were three cases of reversible liver function abnormalities. Complications associated with conventional intra-arterial 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 2-3 weeks via percutaneous puncture. All therapy was given on an outpatient basis. Pump acceptance and tolerance was 100%. Intra-arterial chemotherapy can now be accomplished without the morbidity associated with it in the past. The combination of chemotherapy and liver irradiation may offer improved survival in selected patients.

[X-ray-findings in intra-arterial chemotherapy of tumours of the head and neck (author's transl)]

On the basis of x-ray-findings in 70 patients with tumours of the head and neck, who had intraarterial chemotherapy the authors demonstrate the varying approaches to an indirect catheterisation of the external carotid artery. Paying due attention to possible complications arising from i.a. catheterisation, they stress the need for x-ray checks of the correct position of the catheter before commencement of intraarterial chemotherapy.

Penetrating duodenal ulcer associated with an operatively implanted arterial chemotherapy infusion catheter

A 65-yr-old man with hepatic metastases from adenocarcinoma of the colon treated with hepatic arterial infusion of 5-fluoro-2'-deoxyuridine and radiation therapy, presented with major gastrointestinal bleeding from an endoscopically documented giant duodenal ulcer with a portion of the hepatic arterial catheter visible in the ulcer crater. A penetrating giant duodenal ulcer was confirmed during an operative procedure. This patient with giant duodenal ulcer penetration associated with an operatively implanted arterial infusion catheter represents an unusual complication of this form of chemotherapy for hepatic tumors.

Portable infusion pumps in ambulatory cancer chemotherapy

Fifty-seven adult patients receiving chemotherapy were treated with a total of 133 infusions using portable user-worn infusion pumps, the Autosyringe AS*2F Cormed ML6-4, and two earlier versions of the latter, the Sigmamotor ML6-2 and ML6-3. Ninety-eight infusions were given on an ambulatory basis. Fourteen infusions were given through peripheral venous catheters, 115 through central venous catheters, and four intra-arterially. Of 127 evaluable infusions, 65 were completed within 5% and 87 within 10% of the planned rate; results are similar for both inpatient and outpatient infusions. The Cormed ML6-4 pump was equal to the Autosyringe AS*2F in reliability but superior to the latter in patient preference. There were no instances of dangerously rapid administration of the drug. The only serious catheter complications were a pneumothorax after insertion of a subclavian catheter in one patient and cellulitis in a leukopenic patient with a Broviac catheter. All but three patients preferred outpatient therapy to hospitalization. Outpatient therapy costs about $300 per day less than in-hospital treatment.

Intraarterial infusion chemotherapy for head and neck cancer using a totally implantable infusion pump

Intraarterial infusion chemotherapy has not been widely accepted for the treatment of head and neck cancer due to the high rate of complications it involves. To avoid these complications, a totally implantable infusion pump has been developed to achieve continuous low-level drug delivery for long periods of time. The pump is implanted in a subcutaneous pocket and connected to a permanent, indwelling, arterial catheter. It can be repeatedly refilled with chemotherapeutic agents by hypodermic needle injection through the skin and through a self-sealing septum located at the entry to the pump. Refilling the pump recharges an inexhaustible power source for the next delivery cycle. Preliminary results suggest that long term intraarterial infusion chemotherapy for the treatment of head and neck cancer is practical for outpatients.

[First experiences with a new method of intra-arterial chemotherapy in tumours of the head and neck (author's transl)]

The article reports on the use of a new catheter in intraarterial infusion therapy of head and neck tumours. A balloon catheter is inserted into the external carotid artery so that the catheter tip is positioned at the juncture of the artery which provides the blood supply in the tumourous area. Through temporary blockage of the balloon, selective perfusion of the tumour artery with cytostatic drugs is possible. In 10 patients with squamous cell carcinoma of the oral cavity this catheter was used, and the possibilities of this method of selective perfusion explored in contrast to the conventional procedure practised so far.

[A simple safe system for intra-arterial infusion by pressure-constant cuff compression of the infusion bag with the help of a reducing valve]

We describe a simple and cheap system of intraarterial infusion. It consists exclusively of single parts which are available on the market. A source of pressure is connected with a modified pressure-reduction valve which produces a constant pressure in an attached pressure cuff, respectively in an enclosed infusion-bag, so that a constant flow rate of the infusion is maintained. First clinical experiences with more than hundred angiological patients have shown that this new system has many advantages. In our routine work we had neither functional disturbances nor other complications.