A self-assembling nanoparticle for paclitaxel delivery in ovarian cancer

Paclitaxel (PTX) is one of the most effective chemotherapeutic drugs for the treatment of a variety of cancers. However, it is associated with serious side effects caused by PTX itself and the Cremophor EL emulsifier. In the present study, we report the development of a well-defined amphiphilic linear-dendritic copolymer (named as telodendrimer) composed of polyethylene glycol (PEG), cholic acid (CA, a facial amphiphilic molecule) and lysine, which can form drug-loaded core/shell micelles when mixed with hydrophobic drug, such as PTX, under aqueous condition. We have used PEG(5k)-CA(8), a representive telodendrimer, to prepare paclitaxel-loaded nanoparticles (PTX-PEG(5k)-CA(8) NPs) with high loading capacity (7.3 mg PTX/mL) and a size of 20-60 nm. This novel nanoformulation of PTX was found to exhibit similar in vitro cytotoxic activity against ovarian cancer cells as the free drug (Taxol) or paclitaxel/human serum albumin nanoaggregate (Abraxane). The maximum tolerated doses (MTDs) of PTX-PEG(5k)-CA(8) NPs after single dose and five consecutive daily doses in mice were approximately 75 and 45 mg PTX/kg, respectively, which were 2.5-fold higher than those of Taxol. In both subcutaneous and orthotopic intraperitoneal murine models of ovarian cancer, PTX-PEG(5k)-CA(8) NPs achieved superior toxicity profiles and anti-tumor effects compared to Taxol and Abraxane at equivalent PTX doses, which were attributed to their preferential tumor accumulation, and deep penetration into tumor tissue, as confirmed by near infrared fluorescence (NIRF) imaging.

Intraperitoneal administration of paclitaxel solubilized with poly(2-methacryloxyethyl phosphorylcholine-co n-butyl methacrylate) for peritoneal dissemination of gastric cancer

Intraperitoneal (i.p.) administration of paclitaxel (PTX) is a hopeful therapeutic strategy for peritoneal malignancy. Intravenously (i.v.) injected nanoparticle anticancer drugs are known to be retained in the blood stream for a long time and favorably extravasated from vessels into the interstitium of tumor tissue. In this study, we evaluated the effect of i.p. injection of PTX (PTX-30W), which was prepared by solubulization with water-soluble amphiphilic polymer composed of PMB-30W, a co-polymer of 2-methacryloxyethyl phosphorylcholine and n-butyl methacrylate, for peritoneal dissemination of gastric cancer. In a peritoneal metastasis model with transfer of MKN45P in nude mice, the effect of i.p. administration of PTX-30W was compared with conventional PTX dissolved in Cremophor EL (PTX-Cre). The drug accumulation in peritoneal nodules was evaluated with intratumor PTX concentration and fluorescence microscopic observation. PTX-30W reduced the number of metastatic nodules and tumor volume significantly more than did conventional PTX dissolved in Cremophor EL (PTX-Cre), and prolonged the survival time (P < 0.05). PTX concentration in disseminated tumors measured by HPLC was higher in the PTX-30W than in the PTX-Cre group up to 24 h after i.p. injection. Oregon green-conjugated PTX-30W, i.p. administered, preferentially accumulated in relatively hypovascular areas in the peripheral part of disseminated nodules, which was significantly greater than the accumulation of PTX-Cre. I.p. administration of PTX-30W may be a promising strategy for peritoneal dissemination, due to its superior characteristics to accumulate in peritoneal lesions.

Surgical management of malignant bowel obstruction: strategies toward palliation of patients with advanced cancer

The management of malignant bowel obstruction is a challenging problem because of the poor definition of malignant bowel obstruction compounded by its myriad clinical presentations. Surgeons are called upon to perform invasive procedures designed to alleviate symptoms or correct the underlying obstruction. Unfortunately, interventions may carry a high rate of morbidity and mortality. Balancing these risks and potential benefits is complicated, and there is a paucity of data to help guide these difficult decisions. The surgeon is further handicapped when he or she is not understanding of the patient's disease status, prognosis, or long-term goals. Diligent discussion with the primary team and frank discussions with the patient and his or her family are essential to formulate an appropriate plan. It is also essential that the surgeon have a thorough understanding of the surgical options to relieve or palliate malignant bowel obstruction as well as effective nonsurgical interventions. The best approach may be appropriate surgical intervention coupled with aggressive medical management.

Evidence-based medicine in the treatment of peritoneal carcinomatosis: Past, present, and future

The current treatment of peritoneal surface malignancies (PSMs) is moving from a nihilistic approach, into a combined modality approach offering selected patients long-term survival. As primary PSM are rare, extrapolation of data from clinical trials of related disease is necessary to develop treatment guidelines. Secondary PSM are more common, and therefore, treatment guidelines should be developed based on prospective clinical trials. We reviewed the published and ongoing clinical trials studying the treatment of PSM.

Pharmacokinetics and pharmacodynamics of perioperative cancer chemotherapy in peritoneal surface malignancy

The peritoneal surface remains an important failure site for patients with gastrointestinal and gynecologic malignancies. During the last 2 decades, novel therapeutic approaches, combining cytoreductive surgery with intraoperative intracavitary and intravenous chemotherapy, have emerged for peritoneal carcinomatosis patients. This has resulted in remarkable clinical successes in contrast with prior failures. Although further clinical data from phase II and III trials supporting this combined treatment protocols are necessary, an optimalization of the wide variety of different perioperative cancer chemotherapy protocols used in these treatment regimens is equally important. To this date, a clear understanding of the pharmacology of perioperative chemotherapy is still lacking. The efficacy of intraperitoneal cancer chemotherapy protocols is governed as much by nonpharmacokinetic variables (tumor nodule size, density, vascularity, interstitial fluid pressure, and binding) as by the pharmacokinetic variables (dose, volume, duration, pressure, and carrier solution). Our recent data support the importance of the tumor nodule as the most meaningful pharmacologic end point. Timing of perioperative intravenous chemotherapy may substantially influence the pharmacokinetics. This review aims to clarify the pharmacokinetic and pharmacodynamic data currently available regarding the intraperitoneal delivery of cancer chemotherapy agents in patients with peritoneal carcinomatosis.

The role of hyperthermic intraperitoneal chemotherapy (HIPEC) in ovarian cancer

Overall outcomes for women with epithelial ovarian cancer (EOC) remain relatively poor, and superior methods of treatment are needed. EOC is a peritoneal surface malignancy that is relatively sensitive to chemotherapy agents, making it a good target for i.p. chemotherapy. Because there is strong laboratory data demonstrating the ability of hyperthermia to increase the efficacy of chemotherapeutic agents, the addition of hyperthermia to i.p. chemotherapy, hyperthermic intraperitoneal chemotherapy (HIPEC), makes theoretical sense. This article reviews the current literature and discusses the possible role for HIPEC in EOC at significant natural history time points: front line, at the time of interval debulking, in consolidation, and for recurrent disease. The conclusion is that much further research is needed but that HIPEC could sensibly be researched at all the natural history time points in EOC.

Secondary tumors and tumorlike lesions of the peritoneal cavity: imaging features with pathologic correlation

Tumors and tumorlike lesions that secondarily involve the mesothelial or submesothelial layers of the peritoneum are a diverse group of disorders that range in biologic behavior from benign to highly malignant. The anatomy of peritoneal ligaments and mesenteries and the normal circulation of peritoneal fluid dictate location and distribution of these diseases within the peritoneal cavity. Peritoneal carcinomatosis is the most common secondary tumor to affect the peritoneal cavity. When it arises from carcinomas of the gastrointestinal tract or ovary, the prognosis is grave. However, when low-grade mucinous adenocarcinoma of the appendix spreads to the peritoneal cavity, the consequence is typically pseudomyxoma peritonei, which is a clinical syndrome, characterized by recurrent and recalcitrant voluminous mucinous ascites due to surface growth on the peritoneum without significant invasion of underlying tissues. Carcinomas from elsewhere in the body, as well as lymphomas and sarcomas, may also produce diffuse peritoneal metastasis. Granulomatous peritonitis is the consequence of disseminated infection such as tuberculosis or histoplasmosis, foreign materials, or rupture of a tumor or hollow viscus. Finally, a group of benign miscellaneous conditions that range from common disorders such as endometriosis and splenosis to very rare conditions such as gliomatosis peritonei and melanosis may also affect the peritoneum diffusely. Secondary tumors and tumorlike lesions of the peritoneum have overlapping imaging features when compared with each other and primary peritoneal tumors. Knowledge of peritoneal anatomy, normal fluid circulation within the peritoneal cavity, and clinical and pathologic features of secondary peritoneal lesions is essential for identification of these lesions.

Multi-detector CT in peritoneal carcinomatosis: diagnostic role of thin slices and multiplanar reconstructions

BACKGROUND

In order to investigate whether 1-mm thin slices and multiplanar reconstructions (MPRs) of multi-detector computed tomography (CT) datasets interpreted in addition to isotropic 5-mm thick slices in one session improve the detection of peritoneal carcinomatosis.

METHODS

The abdominal CT datasets of 44 patients with histologically proven tumors of the abdomen or pelvis were retrospectively evaluated for peritoneal carcinomatosis by four radiologists with variable experience (radiologist 1: >or=10 years, radiologists 2 and 3: 1.5 years, radiologist 4: 0.5 years). In three successive steps, the radiologists evaluated first the axial 5-mm slices, second the 1-mm slices, and third the MPRs and rated their diagnostic confidence.

RESULTS

Specificity was nearly unchanged for all the four radiologists. Sensitivity improved for the most experienced and the least experienced radiologists and was unchanged for the two readers with intermediate skills. Except for the third step of radiologist 4, no statistically significant differences in diagnostic performance were detected. The diagnostic confidence of all the four readers benefited to variable degrees from interpretation of the 1-mm slices and MPRs.

CONCLUSIONS

While 5-mm slices are sufficient for the detection of peritoneal carcinomatosis, 1-mm slices and MPRs can improve sensitivity and diagnostic confidence.

Multicellular spheroids in ovarian cancer metastases: Biology and pathology

Epithelial ovarian cancer (EOC) has a relatively high mortality rate ( approximately 55%). One of the presiding causes is that the current chemotherapeutic regimes are unable to achieve sustained remission, despite frequently producing a positive response at first treatment. One of the reasons that EOC is difficult to treat is that the mechanism of dissemination is unusual. EOC dissemination characteristically involves local invasion of pelvic and abdominal organs. Unlike many epithelial cancers, initial dissemination rarely requires the vasculature, although the vasculature is often implicated in the advanced stages of disease. Recently, it has become apparent that aggregates of malignant cells (spheroids) contained within malignant ascites represent a significant impediment to efficacious treatment of late stage EOC. In vivo, spheroids are present in the malignant ascites of EOC patients, while in vitro cultured spheroids are capable of tumorgenesis in vivo and display a reduced response to chemotherapeutic drugs when compared to monolayers. A major problem associated with the current generation of chemotherapy agents is that they do not address the anchorage- and vascular-independent growth conditions associated with a 3-dimensional structure that has formed and/or grown in suspension. Thus, spheroid formation may represent a key component of platinum/taxane-sensitive recurrence. If this is correct, a better understanding of spheroid biology may contribute to the identification of new treatment opportunities for the sustained treatment of metastatic EOC. This review article outlines the key biological features of spheroids, specifically discussing their role in EOC dissemination and chemo-response as well as providing insights into spheroid functionality.

Current status and future directions: management of colon cancer with peritoneal dissemination

Colorectal cancer is one of the most common cancers worldwide, and although it carries a favorable prognosis when detected at early stages, it is associated with limited survival when metastatic disease is present. Modern systemic therapy has improved median survival in those patients with hematogenous dissemination, but the role of these newer combinations of cytotoxic chemotherapy and biological agents remains undefined in patients with peritoneal carcinomatosis. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy have resulted in long-term good outcomes for patients whose carcinomatosis can be completely removed, but offers no advantage over supportive care for those patients with incomplete tumor removal. At the present time, we lack proven therapeutic strategies on how to treat a patient newly diagnosed with peritoneal carcinomatosis of colorectal origin. A large Phase III multi-institutional trial is being developed to address these issues, and will need full collaboration between medical and surgical oncologists.

Evaluation of preoperative computed tomography in estimating peritoneal cancer index in colorectal peritoneal carcinomatosis

Peritoneal Cancer Index (PCI) has been recognized as an independent prognostic indicator for long-term outcomes. It also influences the likelihood of complete cytoreduction, another principal determinant of long-term survival. The objective of this study was to evaluate the utility of preoperative CT in estimating PCI during the patient selection process. The efficacy of CT in demonstrating peritoneal disease was evaluated by comparing the radiological and intraoperative lesion size and PCI scores using the Wilcoxon signed-rank test. Tumor distribution was assessed in each abdominopelvic region as tumor present versus absent. The sensitivity, specificity, positive predictive value, and negative predictive value were calculated in each abdominopelvic region. Overall, where CT identifies the presence of disease, it portrayed lesion size accurately in 60%, underestimated in 33%, and overestimated in 7% of cases. Analysis of individual abdominopelvic regions demonstrated a statistically significant difference between radiologically and intraoperatively visualized lesion sizes (P < 0.05) except in the epigastrium, left upper, and left flank regions. The sensitivity of CT in detecting peritoneal implants was influenced by lesion size. Small nodules (<0.5 cm) were visualized on CT with only a sensitivity of 11%, which is in contrast to 94% with nodules exceeding 5 cm. Radiological PCI scores significantly underestimated intraoperative PCI (P < 0.001). This study demonstrated that the sensitivity of CT in detecting peritoneal implants was influenced by lesion size and CT PCI significantly underestimated clinical PCI. The role of CT in refining patient selection and improving prognosis remains to be closely evaluated.

Regional chemotherapy: overview

Regional chemotherapy was developed in the 1950s and continues to play an integral part in the development of newer therapies for advanced solid malignancies. Regional therapies have evolved in complexity but are still based on the pharmacokinetics of drug delivery to solid malignancies. Newer techniques demonstrate that the combination of regional therapies, hyperthermia, and surgery is essential in promoting improved patient outcomes.

The eligibility for local-regional treatment of peritoneal surface malignancy

At the Fifth International Workshop on Peritoneal Surface Malignancy, held in Milan, the consensus on technical aspects of cytoreductive surgery (CRS) for peritoneal surface malignancy was obtained through the Delphi process. General conflicting points concerning the eligibility to the local-regional therapy were discussed and voted.

Preoperative investigations in the management of peritoneal surface malignancy with cytoreductive surgery and perioperative intraperitoneal chemotherapy: Expert consensus statement

At the Fifth International Workshop on Peritoneal Surface Malignancy, in Milan, the consensus on preoperative investigations for peritoneal surface malignancy was obtained through the Delphi process. The results showed that 100% of the voters considered that contrast-enhanced multi-sliced CT was the fundamental imaging modality, whereas MRI, PET, laparoscopy and serum tumor markers were regarded as useful, but not fundamental investigational modalities.

Choice of the optimal pancreaticojejunal anastomosis technique: how can we improve patient safety in pancreatic surgery?

BACKGROUND/PURPOSE

The cause of the morbidity and mortality following pancreaticoduodenectomy (PD) in the surgical treatment of benign and malignant diseases of the periampullary region is leakage from the pancreaticojejunal anastomosis. The size of the main pancreatic duct and the texture of the remnant pancreas are very important factors for a secure pancreaticojejunal anastomosis.

METHODS

A new technique was developed for patients having pancreatic ducts smaller than 3 mm and a hard remnant pancreas.

RESULTS

Pylorus-preserving PD was performed for 28 patients who underwent PD at our hospital between January 2004 and January 2007, without mortality. The new technique was used in the 8 patients who had pancreatic ducts smaller than 3 mm and a hard remnant pancreas. With our new technique, different from other previously described techniques, the anastomosis was performed with the sutures passing from the cut-surface of the parenchyma of the pancreas. All patients were operated on by the same surgeon and surgical team. None of the patients developed a fistula.

CONCLUSIONS

We believe that this anastomosis technique can be performed securely in patients having a hard remnant pancreas and a main pancreatic duct smaller than 3 mm.

Hyperthermia adds to chemotherapy

The hallmarks of hyperthermia and its pleotropic effects are in favour of its combined use with chemotherapy. Preclinical research reveals that for heat killing and synergistic effects the thermal dose is most critical. Thermal enhancement of drug cytotoxicity is accompanied by cellular death and necrosis without increasing its oncogenic potential. The induction of genetically defined stress responses can deliver danger signals to activate the host's immune system. The positive results of randomised trials have definitely established hyperthermia in combination with chemotherapy as a novel clinical modality for the treatment of cancer. Hyperthermia targets the action of chemotherapy within the heated tumour region without affecting systemic toxicity. In specific clinical settings regional hyperthermia (RHT) or hyperthermic perfusion has proved its value and deserve a greater focus and investigation in other malignancies. In Europe, more specialised centres should be created and maintained as network of excellence for hyperthermia in the field of oncology.

Different tissue distribution of paclitaxel with intravenous and intraperitoneal administration

PURPOSE

Paclitaxel is considered to be suitable for disseminated cancer in the peritoneal cavity because of its high molecular weight and lipophilic characteristics. However, the difference in pharmacokinetics of paclitaxel after intraperitoneal (i.p.) and intravenous (i.v.) administration is not fully defined. Here, we investigated the tissue concentration of paclitaxel in various organs at various time points after i.p. or i.v. administration.

METHODS

Paclitaxel (5 mg/kg) was administrated in an ear vein or in the abdominal cavity of rabbits. At 0.5, 6, 24, and 48 h after administration, the rabbits were sacrificed, and organs as well as peripheral blood were harvested. The serum and tissue concentrations of paclitaxel were measured by HPLC procedure.

RESULT

The concentration of paclitaxel was high in the i.v. group at 0.5 h, whereas it was significantly higher in the i.p. group at 6 and 24 h. The AUC (area under the curve) was markedly higher in the omentum, mesenteric lymph nodes as well as ovary and stomach in the i.p. group.

CONCLUSION

Compared with i.v. administration, paclitaxel concentration was maintained at a high level in the whole body by i.p. administration. Repeated i.p. paclitaxel can produce more marked clinical effects than i.v. administration for metastatic lymph nodes and primary lesions as well as peritoneal dissemination.

Preoperative imaging for metastasectomy

For most solid neoplasms, medical imaging is a vital component of tumor staging and surveillance. Imaging strategies vary according to the type and grade of primary neoplasm, tumor stage at diagnosis, tumor markers, previous therapies, and patient symptoms. In this article, we address imaging of individual organs (lung, liver, adrenals) and outline imaging strategies for specific types of neoplasms.

Ultrasound mediated delivery of drugs and genes to solid tumors

It has long been shown that therapeutic ultrasound can be used effectively to ablate solid tumors, and a variety of cancers are presently being treated in the clinic using these types of ultrasound exposures. There is, however, an ever-increasing body of preclinical literature that demonstrates how ultrasound energy can also be used non-destructively for increasing the efficacy of drugs and genes for improving cancer treatment. In this review, a summary of the most important ultrasound mechanisms will be given with a detailed description of how each one can be employed for a variety of applications. This includes the manner by which acoustic energy deposition can be used to create changes in tissue permeability for enhancing the delivery of conventional agents, as well as for deploying and activating drugs and genes via specially tailored vehicles and formulations.

Male breast cancer: is the scenario changing

Background

The overall incidence of male breast cancer is around 1% of all breast cancers and is on the rise. In this review we aim to present various aspects of male breast cancer with particular emphasis on incidence, risk factors, patho-physiology, treatment, prognostic factors, and outcome.

Methods

Information on all aspects of male breast cancer was gathered from available relevant literature on male breast cancer from the MEDLINE database over the past 32 years from 1975 to 2007. Various reported studies were scrutinized for emerging evidence. Incidence data were also obtained from the IARC, Cancer Mondial database.

Conclusion

There is a scenario of rising incidence, particularly in urban US, Canada and UK. Even though more data on risk factors is emerging about this disease, more multi-institutional efforts to pool data with large randomized trials to show treatment and survival benefits are needed to support the existing vast emerging knowledge about the disease.

Preoperative staging of colorectal cancer: CT vs. integrated FDG PET/CT

Accurate preoperative staging is essential in determining the optimal therapeutic planning for individual patients. The computed tomography (CT) in the preoperative staging of colorectal cancer, even if controversial, may be useful for planning surgery and/or neoadjuvant therapy, particularly when local tumor extension into adjacent organs or distant metastases are detected. There have been significant changes in the CT technology with the advent of multi-detector row CT (MDCT) scanner. Advances in CT technology have raised interest in the potential role of CT for detection and staging of colorectal cancer. In recent studies, MDCT with MPR images has shown promising accuracy in the evaluation of local extent and nodal involvement of colorectal cancer. Combined PET/CT images have significant advantages over either alone because it provides both functional and anatomical data. Therefore, it is natural to expect that PET/CT would improve the accuracy of preoperative staging of colorectal cancer. The most significant additional information provided by PET/CT relates to the accurate detection of distant metastases. For the evaluation of patients with colorectal cancer, CT has relative advantages over PET/CT in regard to the depth of tumor invasion through the wall, extramural extension, and regional lymph node metastases. PET/CT should be performed on selected patients with suggestive but inconclusive metastatic lesions with CT. In addition, PET/CT with dedicated CT protocols, such as contrast-enhanced PET/CT and PET/CT colonography, may replace the diagnostic CT for the preoperative staging of colorectal cancer.

Results of systematic second-look surgery in patients at high risk of developing colorectal peritoneal carcinomatosis

OBJECTIVE

The aim of this prospective study was to analyze the impact of second-look surgery in an attempt to treat peritoneal carcinomatosis (PC) at an early stage in a series of patients at high risk of developing PC from colorectal cancer.

BACKGROUND

The prognosis of colorectal PC has recently been improved with hyperthermic intraperitoneal chemotherapy (HIPEC) after complete cytoreductive surgery (CCRS), and could be further improved if PC could be treated at an early stage. But, currently, the diagnosis of early PC is not accessible to imaging.

PATIENTS AND METHODS

From 1999 to 2006, 29 patients without any sign of recurrence on imaging studies underwent second-look surgery 13 months after resection of the primary tumor. Patients were selected according to primary tumor-associated criteria: resected minimal synchronous macroscopic PC (n = 16), synchronous ovarian metastases (n = 4), perforated primary tumor (n = 9).

RESULTS

PC was found and treated with CCRS plus HIPEC in 16 of 29 (55%) cases, corresponding to 10 of 16 patients with initial PC, 3 of 4 patients with synchronous ovarian metastases and 3 of 9 patients with a perforated primary tumor. There was no postoperative mortality, and morbidity (grade III/IV) occurred in 14% of cases. After a median follow-up of 27 months (range, 6-96), 8 of 16 patients treated with CCRS and HIPEC are free of disease, 4 relapsed in the peritoneum, and 4 developed isolated visceral metastases.

CONCLUSION

Performing second-look surgery at 1 year in selected patients at high risk of developing PC allowed the early detection and treatment of PC in 55% of cases. Our preliminary results have encouraged us to pursue this strategy and to evaluate it in a prospective multicenter trial.

Reducing peritoneal vascular endothelial growth factor concentration and inhibiting cancer scattering in a mouse model of laparoscopy

OBJECTIVE

The objective of the study was to investigate the efficacy of early intraperitoneal (i.p.) paclitaxel administration in reducing vascular endothelial growth factor (VEGF) concentration in peritoneal fluid and preventing intraoperative cancer scattering during laparoscopy.

STUDY DESIGN

Nude mice were given i.p. ovarian cancer SKOV-3 xenografts to simulate intraoperative cancer dissemination and were assigned into concurrent- (day 0) and salvage-giving (day 5) treatment groups and nontreatment and nonxenografted groups.

RESULTS

The xenografted nontreatment group showed markedly increased peritoneal VEGF concentrations, whereas the paclitaxel (no-tumor) control group showed significantly reduced concentrations. In mice with cancer xenografts, both concurrent- and salvage-giving treatment groups showed significantly decreased peritoneal VEGF concentrations (P < .05), and the concurrent-giving group had significantly fewer implanted cancer nodules (P < .05), whereas the salvage-giving group had decreased total tumor weights (P < .05) compared with nontreatment. Total tumor weights were found closely correlated to peritoneal VEGF concentrations in a positive exponential relationship (P = .003, R(2) = 0.581).

CONCLUSION

Early treatment with IP paclitaxel significantly decreased the VEGF concentration in peritoneal fluid, which was associated with reduced implantation and growth of disseminated cancer cells after laparoscopy. These encouraging results suggest a useful strategy for future clinical applications.

Management of malignant bowel obstruction

Malignant bowel obstruction (MBO) is a common and distressing outcome particularly in patients with bowel or gynaecological cancer. Radiological imaging, particularly with CT, is critical in determining the cause of obstruction and possible therapeutic interventions. Although surgery should be the primary treatment for selected patients with MBO, it should not be undertaken routinely in patients known to have poor prognostic criteria for surgical intervention such as intra-abdominal carcinomatosis, poor performance status and massive ascites. A number of treatment options are now available for patients unfit for surgery. Nasogastric drainage should generally only be a temporary measure. Self-expanding metallic stents are an option in malignant obstruction of the gastric outlet, proximal small bowel and colon. Medical measures such as analgesics according to the W.H.O. guidelines provide adequate pain relief. Vomiting may be controlled using anti-secretory drugs or/and anti-emetics. Somatostatin analogues (e.g. octreotide) reduce gastrointestinal secretions very rapidly and have a particularly important role in patients with high obstruction if hyoscine butylbromide fails. A collaborative approach by surgeons and the oncologist and/or palliative care physician as well as an honest discourse between physicians and patients can offer an individualised and appropriate symptom management plan.

Novel sugar-cholestanols as anticancer agents against peritoneal dissemination of tumor cells

Chemically synthesized sugar-cholestanols with mono-, di-, and tri-saccharides attached to cholestanol showed strong inhibiting activity against the proliferation of colorectal and gastric cancer cells. In contrast, cholestanol without sugar moieties was totally ineffective. Furthermore, when cancer cells were exposed to GlcNAcRbetacholestanol (R=(-) or beta1-3Gal), the compound was rapidly taken up via the lipid rafts/microdomains on the cell surface. The uptake of sugar-cholestanol in mitochondria increased gradually and was followed by the release of cytochrome c from mitochondria and the activation of apoptotic signals through the mitochondrial pathway and the caspase cascade, leading to apoptotic cell death, characterized by DNA ladder formation and nuclear fragmentation. Additionally, the examination of GlcNAcRbetacholestanol in a mouse model of peritoneal dissemination showed a dramatic reduction of tumor growth (P < 0.003) and prolonged mouse survival time (P<0.0001). Based on these observations, we believe that the sugar-cholestanols described here have clinical potential as novel anticancer agents.

Cytoreductive surgery and intraoperative hyperthermic intraperitoneal chemotherapy with paclitaxel: a clinical and pharmacokinetic study

BACKGROUND

Intraperitoneal chemotherapy has been recommended as a treatment option for ovarian cancer with peritoneal dissemination. Although its treatment duration is significantly shorter, intraoperative hyperthermic intraperitoneal perfusion chemotherapy (HIPEC) has several advantages over simple intraperitoneal instillation chemotherapy. While platinum compounds have usually been used, only a few have administered paclitaxel during HIPEC. Its large molecular weight suggests a much more favorable pharmacokinetic profile than that of platinum compounds. The pharmacokinetics of paclitaxel during and after HIPEC have not been studied before.

METHODS

Thirteen women, mainly with ovarian cancer, underwent cytoreductive surgery and HIPEC with 175 mg/m(2) paclitaxel for 2 h. Morbidity was noted. Peritoneal fluid samples and blood samples were harvested during and until 5 days after HIPEC for pharmacokinetic study in ten patients.

RESULTS

No treatment-related mortality was noted. Overall morbidity was 38% (two wound infections, one deep venous thrombosis, two grade 1 thrombopenia, one grade 2 neutropenia, and one grade 3 pancytopenia). Mean maximal intraperitoneal paclitaxel concentration was 101 mg/L, which was an average of 1178 times higher than the peak plasma levels. The peritoneal fluid versus plasma AUC ratio was 1462 for the 2-h HIPEC duration and 366 for the total 5-day study period. Cytotoxic drug concentrations were detected in peritoneal fluid for a mean period of 2.7 days, despite drainage of the drug solution after 2 h of treatment.

CONCLUSIONS

HIPEC with paclitaxel following cytoreductive surgery is feasible, relatively safe, and associated with a highly favorable pharmacokinetic profile, despite its short treatment duration. Larger studies with a more homogenous patient cohort and adequate follow-up should be performed to demonstrate its efficacy.

Staging of peritoneal carcinomatosis: enhanced CT vs. PET/CT

PURPOSE

To assess and compare the performance of CT and 18F-FDG-PET/CT in the evaluation of peritoneal carcinomatosis (PC).

METHOD AND MATERIALS

Thirty consecutive patients with PC and scheduled for a surgery underwent a CT of the abdomen and pelvis and a whole-body 18F-FDG PET/CT. The extent of PC was assessed precisely using the peritoneal cancer index combining the distribution of tumor throughout 11 abdominopelvic regions with a lesion size score. CT and PET/CT imaging results were compared in all patients with intraoperative findings using an interclass correlation test.

RESULTS

The presence of PC was correctly determined on CT and PET/CT in 23/28 and 16/28 patients, respectively. The extent of PC was understaged with CT and PET/CT in 27 patients and overstaged with CT and PET/CT in 1 and 2 patients, respectively. The interclass correlation was 0.53 (moderate) between CT and surgery and 0.12 (low) between PET/CT and surgery. The interclass correlation was higher for mucinous tumor (0.63) than for non-mucinous (0.16) on CT imaging whereas no difference was found in PET/CT.

CONCLUSION

The intraperitoneal assessment of the extent of carcinomatosis, necessary to assess prognosis and treatment planning, is not accurate enough with CT and PET/CT imaging.

Targeting therapy with docetaxel thermosensitive nano-micelles of human gastric cancer xenografts in nude mice

AIM: To study the curative effects of docetaxel thermosensitive nano-micelles on human gastric cancer xenografts in nude mice.

METHODS: Human gastric cancer cell line BGC-823 was implanted into 48 nude mice. Different drugs were injected through the caudal vein in eight groups after establishment of the experimental model. Permanent temperature of the tumor was taken in the thermotherapy group. Tumor growth was monitored once every other day. Dynamic viewing and determining the rate of tumor regression in terms of tumor weight and volume were used to evaluate therapeutic efficacy. The side effect was evaluated through surveying all the condition and the relative variation in mouse body weight.

RESULTS: Tumor growth speed in the docetaxel thermosensitive nano-micelle thermotherapy group was significantly slower than that in the other groups. Tumor volume and weight regression in the docetaxel thermosensitive nano-micelle thermotherapy group were 81.5% and 85.4%, respectively, which were markedly higher than those of the docetaxel thermosensitive nano-micelle group (32.2% and 37.5%) and the docetaxel injection group (49.2% and 58.0%) (both P < 0.05). The drug side effects and toxicity of docetaxel thermosensitive nano-micelle thermotherapy were significantly less than those in the other groups.

CONCLUSION: Docetaxel thermosensitive nano-micelles show good inhibition of tumor growth, which indicates a favorable potential in clinical application.

What makes a man a man? The lived experience of male breast cancer

Male breast cancer is a rare condition with scant research into its psychosocial impact. This phenomenologic study sought to elicit its lived experience. Following analysis of interview data, 4 key themes emerged: Living with male breast cancer, concealment as a strategy for managing the diagnosis, a contested masculinity, interacting with health services. Male breast cancer constitutes a unique lived experience for men that is unparalleled in other disease profiles. The idea of living with a feminized illness was very distressing and stigmatizing for some men. Furthermore, treatment resulted in a profound change to the concept of their embodied selves and constituted a significant change to body image and sexuality. This was reinforced in participants who experienced erectile dysfunction related to tamoxifen therapy. Sadly, some health professionals were unable to offer specific psychosocial support, and participants felt marginalized from the potential benefits of the treatment environment. However, participants adapted to the illness by reasserting and renegotiating masculinity and finding ways to accommodate life with a stigmatizing condition and an altered body image.

Learning curve of combined modality treatment in peritoneal surface disease

BACKGROUND

Cytoreductive surgery with intraperitoneal chemotherapy has emerged as a new standard approach for peritoneal surface disease. This study investigated the learning curve of this combined modality treatment at a single institute.

METHODS

Variables analysed over three consecutive treatment periods (1996-1998, 1999-2002 and 2003-2006) included number of abdominal regions affected, Simplified Peritoneal Cancer Index (SPCI) score, result of cytoreduction, morbidity, duration of hospital stay and survival.

RESULTS

A total of 323 procedures were performed between January 1996 and June 2006, 184 for peritoneal carcinomatosis of colorectal cancer origin and 139 for pseudomyxoma peritonei (PMP), including second procedures in 11 patients with PMP. The mean SPCI score decreased significantly over the study period (P < 0.001), but the number of regions affected did not. The rate of complete cytoreductions increased from 35.6 to 65.1 per cent (P = 0.012). The postoperative morbidity rate decreased from 71.2 to 34.1 per cent (P < 0.001). The median duration of hospital stay decreased from 24 to 17 days. The peak of the learning curve, graded by the percentage of complete cytoreductions, was reached after approximately 130 procedures.

CONCLUSION

The learning curve of combined modality treatment for peritoneal surface disease is long, and reflects patient selection and treatment expertise.

Ototoxicity after intraperitoneal chemotherapy: a case report

Recently, the National Cancer Institute endorsed intraperitoneal (IP) therapy as the treatment of choice for optimally debulked epithelial ovarian cancer. However, there are no drug regimens that are clearly indicated, and the exact method of administration has not been established. Furthermore and most importantly, physicians are unaware of what toxicities should be expected with their use of IP therapy. We report a recent unanticipated toxicity from IP cisplatin therapy and review the literature. A 63-year-old female with optimally debulked stage IIIC papillary serous carcinoma of ovary was admitted on postoperative day 14 for her first cycle of IP cisplatin. She received a cisplatin infusion of 100 mg/m(2). Four days after the cycle, she suffered acute onset of bilateral tinnitus and hearing loss (ototoxicity grade 3). Thus, we conclude that high-frequency hearing loss remains a potentially serious and permanent adverse effect of cisplatin.

Effects of carrier on disposition and antitumor activity of intraperitoneal Paclitaxel

PURPOSE

The rationale for intraperitoneal (IP) chemotherapy is to expose peritoneal tumors to high drug concentrations. While multiple phase III trials have established the significant survival advantage by adding IP therapy to intravenous therapy in optimally debulked ovarian cancer patients, the use of IP chemotherapy is limited by the complications associated with indwelling catheters and by the local chemotherapy-related toxicity. The present study evaluated the effects of drug carrier on the disposition and efficacy of IP paclitaxel, for identifying strategies for further development of IP treatment.

MATERIALS AND METHODS

Three paclitaxel formulations, i.e., Cremophor micelles, Cremophor-free paclitaxel-loaded gelatin nanoparticles and polymeric microparticles, were evaluated for peritoneal targeting advantage and antitumor activity in mice after IP injection. Whole body autoradiography and scanning electron microscopy were used to visualize the spatial drug distribution in tissues. A kinetic model, depicting the multiple processes involved in the peritoneal-to-plasma transfer of paclitaxel and its carriers, was established to determine the mechanisms by which a drug carrier alters the peritoneal targeting advantage.

RESULTS

Autoradiographic results indicated that IP injection yielded much higher paclitaxel concentrations in intestinal tissues relative to intravenous injection. Compared to the Cremophor and nanoparticle formulations, the microparticles showed slower drug clearance from the peritoneal cavity, slower absorption into the systemic circulation, longer residence time, 10- to 45-times greater peritoneal targeting advantage and approximately 2-times longer increase in survival time (p < 0.01 for all parameters).

CONCLUSIONS

Our results indicate the important roles of drug carrier in determining the peritoneal targeting advantage and antitumor activity of IP treatment.

[Intraperitoneal chemotherapy in ovarian cancer]

Ovarian cancer represents 4500 new cases a year in France and the prognosis of such tumor is not yet clear, even for the early stages. This is notably owing to the amount and size of peritoneal tumor residual. Recently, five therapeutic trials were published concerning the intra-peritoneal chemotherapy of ovarian cancer stage III in patients to whom an optimal debulking surgery had been done. These studies were variable in there outcome showing on the one hand, either the absence of significant difference or a significant lengthening of both total life duration and life without recurrence during the period of treatment with intra-peritoneal chemotherapy. On the other hand, there was a significant increase in hematological toxicity and temporary impairment of the quality of life during intra-peritoneal treatments. There were also complications linked to the intra-peritoneal catheter, which led to the termination of the treatment protocol in some cases. However, results showed a mattering benefit of survival in spite of a notable rate of incomplete treatment protocols. These results have demonstrated the necessity to consider the intra-peritoneal adjuvant chemotherapy as a treatment option in patients with epithelial ovarian cancer stage III. Patients must be highly selected and well counseled, in order to go for this treatment option after receiving optimal debulking surgeries.

Hyaluronic acid-paclitaxel: antitumor efficacy against CD44(+) human ovarian carcinoma xenografts

Numerous human tumor types, including ovarian cancer, display a significant expression of the CD44 family of cell surface proteoglycans. To develop tumor-targeted drugs, we have initially evaluated whether the CD44 ligand hyaluronic acid (HA) could serve as a backbone for paclitaxel (TXL) prodrugs. HA-TXL was prepared by modification of previous techniques. The in vitro cytotoxicity of HA-TXL against the CD44(+) human ovarian carcinoma cell lines SKOV-3ip and NMP-1 could be significantly blocked by preincubation with a molar excess of free HA. Female nude mice bearing intraperitoneal implants of NMP-1 cells were treated intraperitoneally with a single sub-maximum tolerated dose dose of HA-TXL or with multiple-dose regimens of paclitaxel (Taxol; Mead Johnson, Princeton, NJ) to determine the effects of these regimens on host survival and intraperitoneal tumor burden, with the latter being assessed by magnetic resonance imaging. NMP-1 xenografts were highly resistant to Taxol regimens, as host survival was only nominally improved compared to controls (T//C approximately 120), whereas single-dose HA-TXL treatment significantly improved survival in this model (T//C approximately 140; P = .004). In both NMP-1 and SKOV-3ip models, MR images of abdomens of HA-TXL-treated mice obtained shortly before controls required humane sacrifice revealed markedly reduced tumor burdens compared to control mice. This study is among the first to demonstrate that HA-based prodrugs administered locoregionally have antitumor activity in vivo.