Regional chemotherapy for inoperable pancreatic carcinoma

Intra-Arterial Infusion Chemotherapy in Advanced Pancreatic Cancer: A Comprehensive Review

Simple Summary

Pancreatic cancer has a very poor prognosis. The few available therapeutic options are characterized by low efficacy and high toxicity due to the intrinsic chemoresistance of this tumor type. To improve clinical results, some clinical trials have evaluated regional chemotherapy as a treatment option for PC. The pancreatic arterial infusion of chemotherapeutics has the aim of obtaining higher local concentrations of drugs and, at the same time, of limiting systemic toxicity. This therapeutic approach has already been successfully evaluated for the treatment of several types of tumors. Regarding advanced pancreatic cancers, only a few clinical studies have investigated the safety and efficacy of this treatment, with very promising results. Therefore, in this review, we summarize literature data on the clinical approaches to pancreatic arterial drug administration for the treatment of advanced PC to deepen knowledge on this topic.

Abstract

Advanced pancreatic cancer (PC) has a very poor prognosis due to its chemoresistant nature. Nowadays, only a few therapeutic options are available for PC, and the most effective ones are characterized by low response rates (RRs), short progression-free survival and overall survival, and severe toxicity. To improve clinical results, small series studies have evaluated loco-regional chemotherapy as a treatment option for PC, demonstrating its dose-dependent sensitivity towards the tumor. In fact, pancreatic arterial infusion (PAI) chemotherapy allows higher local concentrations of chemotherapeutic agents, sparing healthy tissues with a lower rate of adverse events compared to systemic chemotherapy. This therapeutic approach has already been evaluated in different types of tumors, especially in primary and metastatic liver cancers, with favourable results. With regard to advanced PC, a few clinical studies have investigated the safety and efficacy of PAI with promising results, especially in terms of RRs compared to systemic chemotherapy. However, clear evidence about its efficacy has not been established yet nor have the underlying mechanisms leading to its success. In this review, we aim to summarize the literature data on the clinical approaches to pancreatic arterial drug administration in terms of techniques, drug pharmacokinetics, and clinical outcomes for advanced PC.

A Study Comparing the Effects of Targeted Intra-Arterial and Systemic Chemotherapy in an Orthotopic Mouse Model of Pancreatic Cancer

Systemic chemotherapy is the first line treatment for patients with unresectable pancreatic cancer, however, insufficient drug delivery to the pancreas is a major problem resulting in poor outcomes. We evaluated the therapeutic effects of targeted intra-arterial (IA) delivery of gemcitabine directly into the pancreas in an orthotopic mouse model of pancreatic cancer. Nude mice with orthotopic pancreatic tumors were randomly assigned into 3 groups receiving gemcitabine: systemic intravenous (IV) injection (low: 0.3 mg/kg and high: 100 mg/kg) and direct IA injection (0.3 mg/kg). Treatments were administered weekly for 2 weeks. IA treatment resulted in a significantly greater reduction in tumor growth compared to low IV treatment. To achieve a comparable reduction in tumor growth as seen with IA treatment, gemcitabine had to be given IV at over 300x the dose (high IV treatment) which was associated with some toxicity. After 2 weeks, tumor samples from animals treated with IA gemcitabine had significantly lower residual cancer cells, higher cellular necrosis and evidence of increased apoptosis when compared to animals treated with low IV gemcitabine. Our study shows targeted IA injection of gemcitabine directly into the pancreas, via its arterial blood supply, has a superior therapeutic effect in reducing tumor growth compared to the same concentration administered by conventional systemic injection.

Pancreatic cancer cell and microparticle procoagulant surface characterization: involvement of membrane-expressed tissue factor, phosphatidylserine and phosphatidylethanolamine

Advanced pancreatic cancer is associated with a high risk of patients developing venous thromboembolism. This increased risk is thought to be tumour-driven and associated with tissue factor (TF) and microparticles. The aim of this study was to investigate the role of TF and phospholipid expression in the procoagulant properties of pancreatic cell lines and microparticles. Pancreatic cancer cell lines (MIA-PaCa-2, ASPC-1 and CFPAC-1) were assessed for expression of TF and microparticle release. Procoagulant potential was determined by a prothrombin time assay. Cell surface expression of TF was highest in CFPAC-1, with low expression on ASPC-1 and little/no expression on MIA-PaCa-2. Clotting time (CT) was cell number and TF-dependent (P < 0.001). Blocking of TF resulted in slower CT for CFPAC-1 and ASPC1 and prevented clotting in MIA-PaCa-2. Microparticles were shown to be procoagulant and the majority of procoagulant potential could be removed by passing cell-free media through a 0.1 μm filter. A dose-dependent CT was observed in both ASPC-1 and CFPAC-1 cell-free media. Furthermore, addition of duramycin prevented microparticle-supported coagulation. The data presented suggest a key role for cell and microparticle surface-expressed TF and phospholipids in coagulation and highlight duramycin-mediated disruption of clotting.

Expanding surgical treatment of pancreatic cancer: the role of regional chemotherapy

OBJECTIVES

Pancreatic cancer is a lethal disease that offers little chance of long-term survival for patients with unresectable tumors. Surgery remains the most effective means of attaining prolonged survival, yet its role remains limited. Regional chemotherapy has been described for patients with pancreatic cancer, including reports of objective tumor regression allowing for tumor resection in previously unresectable cases. However, comprehensive data have not been reviewed to date.

METHODS

A review of the literature from 1995 to 2010 was performed to analyze the results of regional chemotherapy administered to patients with advanced pancreatic cancer. Reports of individual cases, postoperative regional therapy, and treatment of mixed tumor types were excluded.

RESULTS

Twenty-one reports of 895 total patients with pancreatic cancer were reviewed. Greater than 95% of the patients had stage III or IV adenocarcinoma. Objective response rates ranged from nil to 58%, with associated median survivals of 4 to 22 months. Low-grade gastrointestinal and hematologic toxicities were not uncommon.

CONCLUSIONS

Regional chemotherapy can be administered safely to patients with pancreatic cancer but with unclear benefit. Advanced pancreatic tumors converted to resectable status by the use of regional chemotherapy may improve patient survival.

Intra-arterial infusion chemotherapy with 5-fluorouracil and cisplatin in advanced pancreatic cancer: a feasibility study

OBJECTIVE

Our aim was to examine the efficacy and tolerability of intra-arterial infusion chemotherapy with 5-fluorouracil (5-FU) and cisplatin in advanced pancreatic cancer.

METHODS

Sixteen patients with unresectable locally advanced or metastatic pancreatic cancer (12 Stage IVa and 4 Stage IVb with liver metastasis) were enrolled. The catheter for intra-arterial infusion was placed at the position to distribute chemotherapeutic drugs to both the pancreatic tumor and the liver. Continuous infusion of 5-FU (250 mg/m(2) per day, 7 days) with intermittent bolus injection of cisplatin (5 mg/m(2) per day, 5 days) was repeated twice via the catheter, followed by intermittent injection of 5-FU (375 or 750 mg/m(2)) or cisplatin (7.5 mg/m(2)) once a week. The survival of these patients was compared with that of the matched historical control patients treated with other modalities.

RESULTS

In 12 Stage IVa locally advanced patients, the response rate was 58.3% (7 partial response). The median survival time was 22.0 months, and the 1-, 2-, and 3-year survival rates were 83.3%, 41.7%, and 16.7%, respectively. The locally advanced patients treated with intra-arterial infusion chemotherapy showed significantly better survival than the control patients. In contrast, Stage IVb patients with liver metastasis showed no response to the treatment (response rate, 0%). Treatment was discontinued in 2 patients until recovery from hematologic or hepatic toxicity, but fatal adverse events were not observed.

CONCLUSION

These results suggest that intra-arterial infusion chemotherapy with 5-FU and cisplatin is tolerable and feasible treatment to improve the prognosis in locally advanced pancreatic cancer patients without distant metastasis.

Comparison of intrahepatic and pancreatic perfusion on fusion images using a combined SPECT/CT system and assessment of efficacy of combined continuous arterial infusion and systemic chemotherapy in advanced pancreatic carcinoma

PURPOSE

The purpose of this study was to compare intrahepatic and pancreatic perfusion on fusion images using a combined single-photon emission computed tomography (SPECT)/CT system and to evaluate the efficacy of combined continuous transcatheter arterial infusion (CTAI) and systemic chemotherapy in the treatment of advanced pancreatic carcinoma.

MATERIALS AND METHODS

CTAI was performed in 33 patients (22 men, 11 women; age range, 35-77 years; mean age, 60 years) with stage IV pancreatic cancer with liver metastasis. The reservoir was transcutaneously implanted with the help of angiography. The systemic administration of gemcitabine was combined with the infusion of 5-fluorouracil via the reservoir. In all patients we obtained fusion images using a combined SPECT/CT system. Pancreatic perfusion on fusion images was classified as perfusion presence or as perfusion absent in the pancreatic cancer. Using WHO criteria we recorded the tumor response after 3 months on multislice helical CT scans. Treatment effects were evaluated based on the pancreatic cancer, liver metastasis, and factors such as intrahepatic and pancreatic perfusion on fusion images. For statistical analysis we used the chi-square test; survival was evaluated by the Kaplan Meier method (log-rank test).

RESULTS

On fusion images, pancreatic and intrahepatic perfusion was recorded as hot spot and as homogeneous distribution, respectively, in 18 patients (55%) and as cold spot and heterogeneous distribution, respectively, in 15 (45%). Patients with hot spot in the pancreatic tumor and homogeneous distribution in the liver manifested better treatment results (p < 0.05 and p < 0.01, respectively). Patients with hot spot both in the pancreatic cancer and in the liver survived longer than those with cold spot in the pancreatic cancer and heterogeneous distribution in the liver (median +/- SD, 16.0 +/- 3.7 vs. 8.0 +/- 1.4 months; p < 0.05).

CONCLUSIONS

We conclude that in patients with advanced pancreatic cancer, CTAI with systemic chemotherapy appeared to be effective and may prolong their survival. The development of a reservoir port system allowing for the homogeneous distribution of anticancer drugs is necessary to improve the prognosis of patients with advanced pancreatic cancer.

Evaluation of the Efficacy of Combined Continuous Arterial Infusion and Systemic Chemotherapy for the Treatment of Advanced Pancreatic Carcinoma

PURPOSE

To evaluate the effects of combined continuous transcatheter arterial infusion (CTAI) and systemic chemotherapy in patients with advanced pancreatic carcinoma.

METHODS

CTAI was performed in 17 patients with stage IV pancreatic cancer with (n = 11) or without (n = 6) liver metastasis. The reservoir was transcutaneously implanted with the help of angiography. The inferior pancreatic artery (IPA) was embolized to achieve delivery of the pancreatic blood supply through only the celiac artery. The systemic administration of gemcitabine was combined with the infusion of 5-fluorouracil via the reservoir. Treatment effects were evaluated based on the primary tumor size, liver metastasis, and survival time and factors such as tumor size, tumor location, and stage of pancreatic carcinoma; the embolized arteries were analyzed with respect to treatment effects and prognosis.

RESULTS

A catheter was fixed in the gastroduodenal artery and splenic artery in 10 and 7 patients, respectively. Complete peripancreatic arterial occlusion was successful in 10 patients. CT showed a decrease in tumor size in 6 of 17 (35%) patients and a decrease in liver metastases in 6 of 11 (55%) patients. The survival time ranged from 4 to 18 months (mean +/- SD, 8.8 +/- 1.5 months). Complete embolization of arteries surrounding the pancreas was achieved in 10 patients; they manifested superior treatment effects and prognoses (p < 0.05).

CONCLUSION

In patients with advanced pancreatic cancer, long-term CTAI with systemic chemotherapy appeared to be effective not only against the primary tumor but also against liver metastases. Patients with successfully occluded peripancreatic arteries tended to survive longer.

Selective intraarterial contrast-enhanced CT of pancreaticoduodenal tumors: early clinical experience in evaluating blood supply and detectability

OBJECTIVE

The purpose of this study was to compare CT with selective intraarterial contrast enhancement with IV contrast-enhanced CT for diagnostic usefulness in the detection of tumors in the pancreaticoduodenal region.

SUBJECTS AND METHODS

intraarterial contrast enhanced CT was performed in 36 patients with tumors of the pancreaticoduodenal region. Feeding arteries of the tumors and distribution of hyperattenuating areas on intraarterial contrast-enhanced CT were analyzed with various routes of contrast material injections. The intraarterial contrast-enhanced CT scans were compared with the IV contrast-enhanced CT scans.

RESULTS

In all 29 patients with standard vascular anatomy, the right cephalic portion of the pancreatic head was enhanced on CT during common hepatic or gastroduodenal arteriography and the left caudal portion was enhanced on CT during superior mesenteric arteriography. The enhanced areas were complementary to each other in the whole pancreatic head, including the tumor. Tumor conspicuity from the surrounding pancreatic tissue on intraarterial contrast-enhanced CT was not superior to that on IV contrast-enhanced CT in all but four patients with cystic tumors. After intraarterial contrast-enhanced CT, three patients with tumors less invasive than pancreatic ductal carcinoma underwent local resection of their lesions.

CONCLUSION

Intraarterial contrast-enhanced CT for pancreaticoduodenal tumors has potential technical problems and is not valuable in improving the detectability of tumors other than cystic lesions because the enhancement of the wall and septa of the tumor is emphasized. However, the feeding artery of the tumor and its surrounding tissue were clearly depicted.

The dominant negative H-ras mutant, N116Y, suppresses growth of metastatic human pancreatic cancer cells in the liver of nude mice

In pancreatic cancer, the mutation of c-K-ras is a critical event of tumor growth and metastasis. We have previously demonstrated a dominant negative effect of N116Y on the growth of pancreatic cancer cells. To evaluate the potential of N116Y for suppressing the metastatic growth of pancreatic tumor cells, we made a replication-deficient recombinant N116Y adenovirus driven by the carcinoembryonic antigen (CEA) promoter (Ad CEA-N116Y). We demonstrated that the expression of N116Y, growth inhibition, and apoptotic death induction were all specific to pancreatic cancer cell lines (PCI-35 and PCI-43) that were promoter positive, whereas no growth retardation was observed in human embryonic pancreas-derived cell line 1C3D3 after Ad CEA-N116Y infection. We examined the effect of Ad CEA-N116Y on the metastatic growth of PCI-43 colonies in liver, which was generated by tumor injection into the spleen of nude mice. The results showed that Ad CEA-N116Y effectively reduced the number of metastatic colonies without any complication by injecting intrasplenically 5 days after tumor cell inoculation. Thus, N116Y can selectively suppress the metastatic growth of pancreatic tumor cell by using the CEA promoter-driven adenovirus vector indicating that N116Y gene therapy may be potentially useful for the treatment of pancreatic cancer patients with liver micrometastasis.

Celiac axis infusion chemotherapy in advanced nonresectable pancreatic cancer

CONCLUSION

Based on these data we suggest that regional intra-arterial chemotherapy for advanced pancreatic cancer seems not to be superior to common treatment modalities, such as combined radiochemotherapy.

BACKGROUND

The prognosis for advanced pancreatic cancer is very poor. No standard treatment is available. Recently, better survival and quality of life was reported from regional cancer treatment via celiac axis infusion. In an attempt to confirm these results we conducted a phase II study of intra-arterial chemotherapy for nonresectable pancreatic cancer.

METHODS

From May 1994 to February 1995, 12 consecutive patients with biopsy-proven advanced ductal carcinoma of the exocrine pancreas were given intra-arterial infusions consisting of Mitoxantrone, 5-FU + folinic acid, and Cisplatin via a transfemorally placed catheter in the celiac axis. Six patients were classified as UICC stage III and six as stage IV with the liver as the sole site of distant metastasis. Nine patients had primary and three had recurrent pancreatic carcinoma after a Whipple procedure. Nonresectability of primary tumors was assessed in all patients by laparotomy or laparoscopy.

RESULTS

A total of 31 cycles of chemotherapy (mean 2.6 cycles/patient) was administered. Catheter placement was technically feasible in all cycles. A groin hematoma was the only catheter complication. The follow-up by CT scans at 2-mo intervals revealed partial remission in 1 patient (8%), temporary stable disease in 4 patients (33%), and disease progression in 7 patients (58%). The same response was obtained after analyzing the CA 19-9 course. Median survival in stage III patients was 8.5 mo (3-12 mo) and in stage IV patients 5 mo (2-11 mo). Toxicity according to WHO criteria consisted of grade III (4 events), grade II (10 events), and grade I (17 events), mainly resulting from leucopenia and diarrhea/vomiting. Nine of 11 patients experienced temporary relief of pain immediately after regional treatment.