Intraarterial infusion of 5-fluoro-2-deoxyuridine-C8 dissolved in a lymphographic agent in malignant liver tumors. A preliminary report

Prognostic Factors in Liver Metastases after Transcatheter Arterial Embolization or Arterial Infusion

From January 1986 to December 1988, 85 patients (55 men and 30 women, mean age 59 years) with metastatic liver tumors were treated with hepatic artery embolization (TAE) or infusion (HAI). Sixty-eight patients with successful catheterization were treated with TAE using iodized oil (Lipiodol) mixed with anticancer agent (ACA). In 12 of 68 patients with hypervascular tumors gelatin sponge was added. Patients with unsuccessful catheterization were treated with hepatic artery infusion of ACA. Forty-three patients received oral chemotherapy following TAE or HAI. Overall, the 6-month, and 1- and 2-year survival rates were 69.5, 31.8 and 4.1 per cent, respectively (mean 233 days). A univariate analysis of prognostic factors showed that number of metastases, stage, treatment times and oral chemotherapy were all significant factors (p<0.05). Ascites, jaundice, percentage of hepatic replacement and treatment protocol also had some influence (p<0.1). Sex, age, primary site, elevation of tumor markers, other metastatic lesions, portal vein involvement and difference in anticancer agent had no prognostic significance. A multivariate analysis using Cox's proportional hazard model revealed that the number of treatments had the most important prognostic significance, followed by oral chemotherapy, stage and percentage of hepatic replacement.

The state of regional therapy in the management of metastatic colorectal cancer to the liver

Colorectal cancer (CRC) is one of the leading causes of cancer-related mortality in the United States. Most colorectal cancer patients die from advanced disease, and two-thirds of CRC deaths are due to liver metastases. Liver resection provides the best curative option for patients with colorectal liver metastases (CRLM), yet only 20% of those patients are eligible for liver metastases resection for curative intent. Loco-regional treatment of CRLM may provide additional benefits in terms of down-staging for resection and prolonged hepatic disease control. This review focusses on hepatic arterial infusion, radioembolization and chemoembolization.

From Physical Pharmacy to Clinical Pharmacology

Research works on molecular interactions in solutions were carried out at School of Pharmacy, the University of Wisconsin under the direction of Prof. T. Higuchi and at Faculty of Pharmaceutical Sciences, Kyoto University under the direction of Prof. H. Sezaki. Studies on permeation of drugs through polymer membranes were carried out at Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Canada and at Pharmaceutical Chemistry Research Laboratories at Food and Drug Directorate, Department of Health and Welfare, Canada. Studies on modification of delivery patterns by means of pharmaceutical approaches were carried out at Faculty of Pharmaceutical Sciences, Hokkaido University. Topics related to modification of drug delivery patterns include employment of amorphous forms such as ground mixture with micro-crystalline cellulose and coprecipitate with polyvinylpyrrolidone, use of biodegradable polymers such as polylactic acid and polycarbonates, gel-forming materials such as konjac, agar and hydroxypropylcellulose, and physicochemical systems such as complexation. Works related to drug delivery and disposition of drugs in humans were carried out at Department of Pharmacy, Kumamoto University Hospital. Topics related to drug delivery in humans include injections containing anticancer drugs for intra-arterial administration, lidocaine gels for dermal anesthesia, glucagon solution for nasal administration. Topics related to disposition of drugs in humans include clinical pharmacokinetic studies in infants and elderly and medical uses of adsorbents.

In vitro antitumor activity, intracellular accumulation, and DNA adduct formation of cis-[((1R,2R)-1,2-cyclohexanediamine-N,N')bis(myristato)] platinum (II) suspended in lipiodol

SM-11355, cis-[((1R,2R)-1,2-cyclohexanediamine-N,N')bis(myristato)] platinum (II), is a lipophilic platinum complex under clinical development that targets primary hepatocellular carcinoma using Lipiodol as a carrier. SM-11355 was compared with cisplatin (CDDP) using an in vitro evaluation system capable of examining the release characteristics and the cytotoxicity of drugs suspended in Lipiodol. SM-11355 suspended in Lipiodol (SM-11355/Lipiodol) and CDDP suspended in Lipiodol (CDDP/Lipiodol) showed cytotoxic activity against rat ascites hepatoma AH-109A cells in a dose-dependent manner. Their IC50 values following 7-day exposure were 22.3 and 0.40 microg/ml, respectively. Following the subsequent 7-day exposure, from day 7 to day 14 after preparation of the suspension, SM-11355/Lipiodol showed an almost equivalent activity, but CDDP/Lipiodol did not show any activity at all. SM-11355/Lipiodol showed a sustained release into the culture medium over the course of a 14-day exposure. Following the exposure to CDDP/Lipiodol, the platinum concentration in the medium was at its maximum on the first day and remained constant thereafter. Intracellular platinum uptake and formation of platinum-DNA adducts were dependent on the release characteristics of each drug suspension. For SM-11355/Lipiodol, the drug release, intracellular drug uptake, and formation of platinum-DNA adducts over the course of the subsequent 7-day exposure were similar to those observed during the first 7 days. DPC, one of the compounds released from SM-11355/Lipiodol, was taken up by cells and showed formation of platinum-DNA adducts. Thus, this study suggests that SM-11355/Lipiodol may release active platinum compound(s) that bind to nuclear DNA and mediate the cytotoxic activity of SM-11355/Lipiodol.

A phase I study of chemoembolization with cisplatin, thiotepa, and lipiodol for primary and metastatic liver cancer

Thirty patients with primary hepatocellular carcinoma or liver metastases were entered into a program of chemoembolization with cisplatin, lipiodol, and escalating doses of thiotepa. Doses of cisplatin were 100/m2, and thiotepa doses ranged from 9 mg/m2 to 24 mg/m2. Two of three patients with ocular melanoma had partial responses in the liver metastases for 3+ and 16 months. In patients with either hepatocellular carcinoma (15 patients) or primary cholangiocarcinoma of the liver (three patients), there were two partial responses, for 22 and 33 months. Five patients had minor responses: four with a 40% reduction in tumor and one with a mixed response. There were four early deaths, which involved sepsis in two patients, respiratory failure in one, and acute myocardial infarction in one. Otherwise, toxicity was tolerable and reversible and included abdominal pain and transient elevation of serum creatinine, bilirubin, and transaminases. Less common toxicities included ototoxicity and peripheral neuropathy. Chemoembolization of the liver with cisplatin, thiotepa, and lipiodol can produce responses, but toxicity can be significant. The recommended starting phase II dose for future studies is thiotepa 24 mg/m2 and cisplatin 100 mg/m2.

Retinoic acid-induced apoptosis is prevented by serum albumin and enhanced by Lipiodol in human hepatoma Hep3B cells

The effects of retinoic acid (RA) on the cell growth and viability of human hepatoma Hep3B cells were examined. We showed that removal of serum in the presence of RA results in cell death in a dose-dependent manner in human hepatoma Hep3B cells. Time-course cell death analysis showed that RA at a dose of 10 microM induces a rapid (48-72 h) fall in cell viability (>95%). The drug-induced cell death was RA-specific, since three RA analogs (retinol, retinal and retinol acetate) did not show any cytocidal activity at an equimolar dose. Fluorescence microscopy and DNA fragmentation analysis showed that Hep3B cells treated with RA underwent a death process highly reminiscent of apoptosis, with chromatin condensation, nuclear fragmentation and the presence of a 180-200 bp DNA fragment ladder. Additionally, we found that RA-induced apoptosis was reduced by 70-80% when the medium was supplemented with serum albumin (human and bovine) at a concentration of 0.05%. However, a variety of known growth factors were ineffective in preventing RA-induced apoptosis. Preincubating serum and serum albumin with Lipiodol restored the apoptotic effects of RA demonstrated in serum-free systems. These data suggest that the binding of RA by serum albumin may have reduced the bioavailability of RA, restricting its apoptotic effects on Hep3B cells. Blocking RA-albumin interactions with a lipid lymphographic contrast medium (Lipiodol) may improve the bioavailability of RA and significantly enhance its apoptotic effect on human hepatoma Hep3B cells.

Phase II trial of chemoembolization for the treatment of metastatic colorectal carcinoma to the liver and review of the literature

BACKGROUND

Hepatic artery chemoembolization represents an alternative treatment for patients whose neoplastic lesions are not amenable or have become refractory to other treatment modalities. This project was designed to test the feasibility of regional chemoembolization for patients with colorectal carcinoma metastasis to the liver who had experienced failure with one or more systemic treatments.

METHODS

Thirty patients who met the study entry criteria underwent one to three hepatic artery chemoembolizations. The chemoembolization regimen consisted of an injection of a bovine collagen material with cisplatin (10 mg/mL), doxorubicin (3 mg/mL), and mitomycin C (3 mg/mL). Repeat treatments were performed at 6- to 8-week intervals.

RESULTS

Radiologic responses, as measured by a decrease in lesion density of at least 75% of the lesion or a 25% decrease in the size of the lesion, occurred in 63% of the cases. A decrease of at least 25% of the baseline carcinoembryonic antigen level occurred in 95% of the cases. All responses were transient. Median survival for all 30 patients was 8.6 months after the initiation of chemoembolization and 29 months after the initial diagnosis of metastasis to the liver. Common toxicities included a "postembolization syndrome," which consisted of fever > 101 degrees F (83%), pain in the right upper quadrant (100%), nausea, and vomiting. Lethargy was a common occurrence (in 60+% of cases) and lasted up to 6 weeks. Hematologic toxicities included leukocytosis, anemia, and thrombocytopenia.

CONCLUSIONS

Chemoembolization is a feasible treatment modality for patients with colorectal carcinoma metastasis to the liver who have experienced failure with other systemic treatments. It results in high response rates with transient mild-to-moderate toxicity. Responses are measured in months, however, and all patients have eventual progression of disease. Patients who are able to undergo three or more chemoembolization procedures may receive the most clinical benefit.

Transcatheter oily chemoembolization for hepatocellular carcinoma. A 4-year study of 127 French patients

BACKGROUND

In Western countries, only a small proportion of patients with hepatocellular carcinoma (HCC) can be treated with surgical resection. For other patients, locoregional management by transcatheter oily chemoembolization seems to be useful and warrants evaluation.

METHODS

One hundred and twenty-seven French patients with an inoperable HCC were treated by transcatheter oily chemoembolization. The efficiency of the treatment was assessed by a comparison of this group with a group of 127 untreated patients. Each patient of the treated group was matched closely with an untreated patient for all the main clinical, anatomic, and biologic features that characterize the spontaneous evolution of HCC.

RESULTS

The overall probabilities of survival in the treated group were 64%, 38%, 27%, and 27% at 1, 2, 3, and 4 years, respectively; those for the untreated group were 18%, 6%, and 5% at 1, 2 and 3 years, respectively (P < 0.0001). The survival was significantly increased in patients with Okuda Stage I and II disease (P < 0.0001), but not in those with Stage III. Karnofsky and Child-Pugh scores remained stable during the follow-up period and dropped only shortly before patients died.

CONCLUSION

Transcatheter oily chemoembolization is an efficient treatment for unresectable HCC for the palliation of symptoms as well as for the prolongation of survival with a good quality of life.

Treatment of hepatocellular carcinoma with transcatheter arterial embolization. Analysis of prognostic factors

BACKGROUND

Transcatheter arterial embolization (TAE) is a useful treatment modality for hepatocellular carcinoma (HCC). To study the prognostic factors, survival time of patients with HCC after TAE was analyzed retrospectively using clinical manifestations of coexisting liver cirrhosis and clinical features of HCC.

METHODS

Eighty-seven patients with HCC were treated with TAE between 1984 and 1991 and observed at Nagasaki University Hospital. All the patients also had liver cirrhosis.

RESULTS

The survival time of the 87 patients after TAE ranged from 2 months to 8.1 years (mean +/- standard deviation, 2.7 +/- 0.3 years). Survival curves after TAE did not differ between men and women (P > 0.5) or between hepatitis B and C viral infection (P > 0.8), but they depended on clinical stages of coexisting liver cirrhosis (P < 0.01). The cumulative survival after TAE was significantly longer in patients with uninodular tumors than in patients with multinodular tumors (P < 0.0001) (3-year survival, 53.3% vs. 13.3%; 5-year survival, 32.2% vs. 3.3%, respectively). In contrast, patients' survival time was not associated with the size of the tumor detected at the time of treatment with TAE (P > 0.1).

CONCLUSIONS

Treatment of HCC with TAE is well indicated regardless of tumor size for patients with nonadvanced liver cirrhosis and uninodular tumors. Alternatively, treatment of HCC with TAE alone is still insufficient in patients with multinodular tumors. Other treatment modalities in combination with TAE should be considered to achieve a more favorable prognosis of these patients.

In-vitro stability and cytostatic activity of liposomal formulations of 5-fluoro-2'-deoxyuridine and its diacylated derivatives

The water-soluble antineoplastic agent 5-fluoro-2'-deoxyuridine (FUdR) was encapsulated in the water phase of liposomes of different lipid compositions. The retention of this drug upon storage and during contact with plasma was assessed. It was found that, upon refrigeration, diffusion of FUdR across the liposome bilayer was considerably faster when the drug was encapsulated in fluid-type liposomes (egg PC/PS/CHOL) than in solid-type liposomes (DSPC/DPPG/CHOL). With either composition, leakage of the drug from the liposomes was accelerated upon contact with plasma. To achieve improved liposomal retention of the drug, FUdR was converted to a lipophilic prodrug by esterifying the free hydroxyl groups in the deoxyribose moiety with fatty acids of different chain lengths. Thus FUdR-dipalmitate (C-16) and FUdR-dioctanoate (C-8) were synthesized and incorporated in liposomes. The dipalmitoyl derivative could be incorporated upto 13 mol% in solid-type liposomes but to only 2 mol% in fluid-type liposomes. Freeze-fracture electron microscopy revealed no major differences between control liposomes and those containing the prodrug. FUdR-dipalmitate was found to be firmly associated with the liposomal bilayer in both liposome-types: no exchange of the pro-drug with blood constituents or hydrolysis by serum esterases could be registered when the liposomes were incubated with serum. On the other hand, liposome-incorporated FUdR-dioctanoate was found to be readily extracted from the liposomes by serum components (predominantly albumin) and was found to be degraded rapidly by serum esterase activity. The antitumor activity of FUdR-prodrugs was determined using C26 colon adenocarcinoma cells. This cell line was found to be highly sensitive to FUdR. Liposomal FUdR-dioctanoate inhibited cell growth in the same concentration range as unesterified FUdR. FUdR-dipalmitate, however, was more than two orders of magnitude less potent in inhibiting cell proliferation. Its antiproliferative activity was dependent on the liposome-type used: when incorporated in fluid-type liposomes, antiproliferative activity of FUdR-dipalmitate was several-fold higher than in solid-type liposomes. The difference in antitumor activity between FUdR-dipalmitate and FUdR-dioctanoate and between FUdR-dipalmitate in the fluid- and solid-type liposomes could be explained by differences in the rate of hydrolysis of the prodrugs to FUdR by esterase activity in the tumor cells or in the growth medium.

Non-surgical treatment of hepatocarcinoma

Hepatocellular carcinoma (HCC) is one of the most common tumors affecting man. It is the general feeling that only hepatectomy can give a chance for cure. However, less than 20% of patients can be resected, and other treatment modalities are required. Systemic (chemotherapy, hormonotherapy, immunotherapy) and loco-regional (intratumoral injection of alcohol, intra-arterial chemotherapy embolization, internal radiotherapy) approaches have been developed. In view of the small number of patients, tumor and patient heterogeneity, and difficulties in assessing tumor response, the real place of these treatments is difficult to evaluate. A review of the literature suggests that embolization with Gelfoam, even when given without chemotherapy, has an effect on response rate and on survival, and could be considered, at the present time, as the most attractive treatment in non-operable HCC. Chemotherapy seems effective only if combined with embolization. When administered alone by the systemic or the intra-arterial hepatic route, no clinically significant activity can be found. Unexpectedly, Lipiodol by itself seems inactive, and the co-administration of chemotherapy does not improve activity. Other approaches such as intratumoral injection of alcohol, immunotherapy, hormonotherapy, and radioimmunotherapy are still experimental, and well-designed studies are needed to identify their role.

In vivo distribution and antitumour activity of liposomal 3',5'-O-dipalmitoyl-5-fluoro-2'-deoxyuridine

3',5'-O-dipalmitoyl-5-fluoro-2'-deoxyuridine (FUdR-dipalmitate), a lipophilic prodrug of 5-fluoro-2'-deoxyuridine (FUdR), was incorporated in different types of liposomes. The in vivo distribution and intrahepatic deacylation of liposomal FUdR-dipalmitate was found to be strongly dependent on liposome composition and on drug to lipid ratio. The use of fluid-type liposomes (egg PC/PS/CHOL) rendered FUdR-dipalmitate more susceptible to enzymatic breakdown than solid-type liposomes (DSPC/DPPG/CHOL). A decrease of the retention of the drug in the body was also obtained when FUdR-dipalmitate was incorporated in solid-type liposomes with high drug to lipid ratio (1:10) than with low ratio (1:50). In spite of these substantial differences in the rates at which FUdR was liberated from liposomes with different fluidity, size, or drug to lipid ratio, only minor differences in therapeutic effect were observed in a number of murine tumour models (P388 leukaemia, Lewis Lung carcinoma, B16 melanoma and a C26 adenocarcinoma liver metastasis model). The lipophilic prodrug of FUdR exhibited antitumour activity at 100-600 times lower doses than the free drug. However, at these therapeutic doses FUdR-dipalmitate was also far more toxic. This prohibited the use of higher doses to increase antitumour activity.

Evaluation of oil-soluble FUdR ester for transcatheter arterial treatment of hepatomas

From January 1987 to December 1989, we performed a prospective study of transcatheter arterial chemoembolization therapy with iodized oil (Lipiodol) mixed with an anticancer agent. A new oil-soluble modification of FUdR, FUdR-C8 ester, was developed and dissolved in Lipiodol as an embolic material, which was administered to 36 patients with hepatomas. Water-soluble adriamycin emulsified in Lipiodol was used as control in 67 patients with hepatomas. Initial effects on tumors were observed as decrease of tumor size in 25.0% for the FUdR group and 17.9% for the control group. Alpha-fetoprotein decreased more than half in 41.9% of the FUdR group, and 16.1% of the ADM group. Six-month and one-year survivals were 74.2% and 46.8% for the FUdR group (median survival 317 days), whereas the control group yielded 61.0% and 28.3% survivals, respectively (median survival 191 days).

Prognostic factors in the treatment of hepatocellular carcinoma with transcatheter arterial embolization and arterial infusion

From January 1986 to December 1988, a prospective trial of transcatheter arterial treatment was carried out for hepatocellular carcinoma (HCC). Two hundred seventy-five patients were included. Okuda's staging system was employed. Patients with Stage I and II HCC were treated by transcatheter arterial embolization (TAE) with a gelatin sponge containing an anti-cancer agent (protocol 1a); a gelatin sponge and iodized oil mixed with an anti-cancer agent (protocol 1b); or iodized oil mixed with an anti-cancer agent (protocol 2). Patients with Stage III HCC were treated with iodized oil with anti-cancer agent (protocol 2). As an exception, patients with an unsuccessful superselective catheterization into the proper hepatic artery by Seldinger technique or obstruction of the main trunk of the portal vein were treated with percutaneous transcatheter arterial infusion into the common hepatic artery regardless of stage (protocol 3). Tumor type and extension, area of tumor involvement, portal vein involvement, method of treatment, and presence of ascites and icterus were found to be the significant factors for an initial response to therapy. Treatment method was the most important factor. Respective survival rates at 1 and 2 years were 70.9% and 55.3% for protocol 1a; 62.3% and 43.8% for protocol 1b; 37.8% and 18.3% for protocol 2; and 16.5% and 0% for protocol 3. Many factors proved to significantly influenced prognosis; however, tumor type had the most important prognostic significance followed by AFP value, ascites, treatment protocol, and area of tumor involvement.

Hepatocellular carcinoma in the Amsterdam area. A retrospective analysis in 61 patients

In a retrospective study clinical features of hepatocellular carcinoma (HCC) in the Amsterdam area (1984-89) were assessed in 61 cases. The data obtained were used to discuss some of the current concepts on aetiology, diagnosis, and treatment of HCC. Presenting symptoms and findings usually reflected advanced (incurable) disease. Of the patients 25% had a normal alpha-1-foetoprotein (AFP), 55% had elevated levels, and in 20% data were absent. Platelet counts greater than 500 x 10(9)/l were found in 8% and hypercalcaemia in 10% of the patients. Treatment modalities were none (70%), surgery (16%), chemotherapy (8%), radiotherapy (3%), and endoprosthesis (2%). Sixty to 70% had died after 3 months and more than 90% after 1 year. Long survivors included 2 patients with the fibrolamellar type of HCC. The low incidence of HCC in The Netherlands probably precludes cost-effective screening programs to identify resectable small HCC. Unidentified masses are malignant until proven otherwise and should be resected if no firm diagnosis of benign disease can be made. Awareness of HCC and its risk factors may lead to earlier diagnosis and more selective use of diagnostic tests.

Biochemical pharmacology and analysis of fluoropyrimidines alone and in combination with modulators

After more than three decades since their introduction, fluoropyrimidines, especially FUra, are still a mainstay in the treatment of various solid malignancies. The antitumor effects of fluoropyrimidines are dependent upon metabolic activation. FdUMP, FUTP and FdUTP were identified as the key cytotoxic metabolites that interfere with the proper function of thymidylate synthase and nucleic acids. The relevance of these metabolites is cell-type specific. Recently, fluorouridine diphospho sugars have been detected, but the precise function of this class of metabolites is currently unknown. In mammalian systems fluoropyrimidines and their natural counterparts share the same metabolic pathways since the substrate properties in enzyme-catalyzed reactions are frequently comparable. Ongoing studies indicate that the metabolism and action of fluoropyrimidines exhibit circadian rhythms, which appear to be due to variations in the activity of metabolizing enzymes. Essential for the expanding knowledge of the pathways and effects of fluoropyrimidines has been the constant improvement of analytical methods. These include ligand binding techniques, numerous dedicated HPLC systems and 19F-NMR. Because the overall response rates achieved with fluoropyrimidines are modest, strategies based on biochemical modulation have been devised to enhance their therapeutic index. Biochemical modulators include a wide range of various compounds with different modes of action. In recently completed clinical trials, combinations of FUra with leucovorin, a precursor for 5,10-methylene tetrahydrofolate, or with levamisole, an anthelminthic with immunomodulatory activity, appeared to be superior to FUra alone. At the preclinical level combinations of fluoropyrimidines with, e.g. interferons or L-histidinol were demonstrated to be interesting candidates for further testing. The future therapeutic utility of fluoropyrimidines will depend on both the improvement of combination regimens currently used in the treatment of cancer patients and the judicious clinical implementation of promising experimental modulation strategies. Moreover, novel fluoropyrimidines with superior pharmacological properties may become important as part of or instead of modulation approaches.