Pharmacokinetics of mitomycin C in pelvic stopflow infusion and hypoxic pelvic perfusion with and without hemofiltration: a pilot study of patients with recurrent unresectable rectal cancer

Multidisciplinary palliation for unresectable recurrent rectal cancer: hypoxic pelvic perfusion with mitomycin C and oxaliplatin in patients progressing after systemic chemotherapy and radiotherapy, a retrospective cohort study

Background

Innovative systemic treatments and loco-regional chemotherapy by hypoxic pelvic perfusion (HPP) have been proposed for unresectable recurrent rectal cancer (URRC). Regorafenib and trifluridine-tipiracil reported significantly increased PFS 1.9-2.0 months, OS 6.4-7.1 months vs placebo, respectively. Present study evaluated safety and efficacy of mitomycin/oxaliplatin HPP associated to intravenous cetuximab, and of third line systemic therapy in clinical practice.

Methods

HPP consisted of: isolation, perfusion, chemofiltration. Patients received mitomycin 25 mg/m² and oxaliplatin 80 mg/m² during HPP; from days 21 to 28, cetuximab 250 mg/m²/week. In case of partial response or stable disease, HPPs were repeated every 8 weeks. In control group, systemic third and further lines of therapy were defined in clinical practice according to clinical (age, comorbidities, performance status), biological parameters (KRAS, NRAS, BRAF genotype).

Results

From 2005 to 2018, 49 URRC patients were enrolled; 33 in HPP/target-therapy, 16 in systemic therapy control group. No HPP related complications were reported. Most common adverse events were skin, bone marrow toxicities. In HPP/target-therapy group, ORR and DCR were 36.4 and 100%; in systemic therapy control group, 18.7 and 31.25%, respectively. In HPP/target-therapy compared with systemic therapy group, respectively, DCR seemed significantly favourable (P = 0.001), as PFS 8 vs 4 months (P = 0.018), and OS 15 vs 8 months (P = 0.044).

Conclusions

Present data showed that integration of HPP/target-therapy may be effective in local control, and efficacy as third line treatment of URCC patients. This therapeutic strategy deserves further prospective randomized trials to be compared to conventional systemic treatments.

Hypoxic pelvic perfusion with cisplatin and mitomycin C in multidisciplinary palliative treatment of patients with unresectable recurrent rectal cancer: a retrospective study

BACKGROUND

Patients with unresectable recurrent rectal cancer that progresses after systemic chemotherapy and radiotherapy may be candidates for palliation with hypoxic pelvic perfusion (HPP). The aim of this observational retrospective study was to evaluate if a multimodality treatment including HPP and targeted-therapy may be useful to prolong clinical responses and survival of these patients.

METHODS

Thirty-seven patients with unresectable recurrent rectal cancer in progression after standard treatments underwent repeated HPP with mitomycin C (25 mg/m2) and cisplatin (70 mg/m2). Twenty patients, exhibiting epidermal growth factor receptor (EGFR) overexpression, also received cetuximab targeted-therapy, following the ultimate HPP treatment.

RESULTS

Following initial HPP treatment, median progression-free survival was 7 months (range: 5-19 months), median time-to-death or termination of follow-up was 13 months (range: 9-18 months), one-year survival-rate was 59.45%, two-year survival rate was 10.81%, and three-year survival rate was 2.7%. Survival was significantly influenced by cetuximab targeted-therapy post-HPP and the presence of additional metastatic sites (P<0.03).

CONCLUSIONS

Repeated HPP treatments with mitomycin C plus cisplatin, followed by cetuximab targeted-therapy, may represent a safe and efficacious palliative therapy in patients with unresectable recurrent rectal cancer, in progression following standard systemic chemo- and radio-therapy, and thus warrants confirmation in a larger phase III study.

Selected Hypoxic Stop-flow Perfusions: Indication and Limits

Aims and Background

The treatment of unresectable cancers is still one of the main medical challenges. Stop-flow perfusion has been used as locoregional chemotherapy based on blood supply blockage of the tumor-bearing area. The aim of the present paper is to report our personal experience in the clinical use of hypoxic stop-flow perfusion and discuss future prospects for research.

Methods and Study Design

Since December 1997 more than 500 stop-flow perfusions have been performed at the University of L'Aquila. Hypoxic perfusion was adopted for the following indications: recurrent rectal cancer, advanced pancreatic cancer, recurrent pelvic and limb melanoma, and recurrent limb melanoma.

Results

For recurrent rectal cancer median survival was 12.2 months, for advanced pancreatic cancer 9.6 months, for recurrent pelvic and limb melanoma 34.4 months, and for recurrent limb melanoma 23.8 months.

Conclusions

Based on these encouraging results, stop-flow perfusion should be considered an effective treatment. Future fields of research include tailored chemotherapy and hyperthermia.

Challenges in chemotherapy delivery: comparison of standard chemotherapy delivery to locoregional vascular mass fluid transfer

Standard intravenous chemotherapy delivery to neoplasms relies on simple diffusion gradients from the intravascular to the interstitial space. Systemic perfusion creates untoward effects on normal tissue limiting both concentration and exposure times. Regional intra-arterial therapy is limited by drug recirculation and vascular isolation repeatability and does not address the interstitial microenvironment. Barriers to delivery relate to chaotic vascular architecture, heterogeneous fluid flux, increased interstitial and variable solid tumor pressure and ischemia. To address these difficulties, a delivery system was developed allowing mass fluid transfer of chemotherapeutic agents into the interstitium. This implantable, reusable system is comprised of multiple independently steerable balloons and catheters capable of controlling the locoregional hydraulic and oncotic forces across the vascular endothelium.

Surgical versus percutaneous isolated pelvic perfusion (IPP) for advanced melanoma: comparison in terms of melphalan pharmacokinetic pelvic bio-availability

Background

Isolated pelvic perfusion (IPP) can be used to treat unresectable melanoma metastases of the pelvis. IPP can be performed either by surgical or percutaneous approaches, using different balloon catheters. The aim of this study was to examine whether the surgical and percutaneous approaches were comparable with respect to tumor drug exposure in the pelvis.

Methods

A pharmacokinetic study was performed in 5 melanoma patients treated with surgical IPP and five with percutaneous IPP. Both groups received melphalan at the dose of 30 mg/m². Melphalan pharmacokinetic analyses were performed and the main parameter used to evaluate pelvic tumor drug-exposure was the ratio of areas under the melphalan plasma concentration curves in the pelvis and the systemic compartment, during the perfusion time (AUC_{0 to 20}). Non-parametric Mann–Whitney tests were employed for statistical comparisons.

Results

The median and interquartile range (IQR) values of the ratios between melphalan AUC_{0 to 20} in pelvic and systemic compartments were 7.9 (IQR 7.2 to 9.9) and 5 (IQR 4 to 7.9) for surgical and percutaneous IPPs, respectively (p = 0.209).

Conclusions

Tumor exposure to drug using these two methods did not statistically differ and both methods, therefore, can be adopted interchangeably, utilizing a perfusion blood flow rate of approximately 120 ml/min. The small sample size is a limitation of this study but our preliminary results can be used to calculate the effect size of a larger trial.

Trial Registration Clinical Trials.gov Identifier NCT01920516; date of trial registration: August 6, 2013

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-017-2738-y) contains supplementary material, which is available to authorized users.

Isolated thoracic perfusion with chemofiltration for progressive malignant pleural mesothelioma

Introduction

Therapy of malignant pleural mesothelioma and especially the adequate role of surgery in this context remain the subject of controversial discussions. Radical surgery in particular, which is associated with substantial morbidity, failed to translate into a definite survival advantage. We report on interim results of an ongoing Phase II study of regional chemotherapy in terms of isolated thoracic perfusion with chemofiltration (ITP-F).

Patients and methods

Twenty-eight patients (25 male, 3 female, mean age 63.4 years) with advanced pleural mesothelioma were included in this study. Isolation of the chest was achieved by insertion of a venous and arterial stop-flow balloon catheter via a femoral access. The aorta and inferior vena cava were blocked at the level of the diaphragm and the upper arms were blocked by pneumatic cuffs. Chemotherapy, consisting of 60 mg/m² cisplatin and 15 mg/m² mitoxantrone, was administered directly into the aorta. The isolated circuit was maintained for 15 minutes followed bŷ45 minutes of chemofiltration with a hemoprocessor until 5 L of filtrate were reached. The endpoints of the study were overall survival and quality of life (QoL).

Results

Out of 28 patients enrolled in the study, 5 had prior surgeries, 10 patients had systemic chemotherapy, and 5 patients additional irradiation. In all patients in restaging, clinical progress was noted. In all, 162 cycles were administered. Due to chemofiltration, toxicity was within tolerable limits, revealing World Health Organization grade I leucopenia and thrombocytopenia in 9 patients and mucositis grade I in 6 patients. The major surgical complication was inguinal lymphatic fistula in 40% of the cases. Gastrointestinal toxicity and/or neurotoxicity were never observed. One-year survival was 49%, 2-year and 3-year survival was 31%, and 5-year survival was 18%. Median overall survival was 12 months and progression-free survival 9 months.

Conclusion

ITP-F for patients with advanced pleural mesothelioma, progressive after standard therapies, is an effective and well-tolerated treatment modality, offering comparably long survival data at a good QoL.

Mitomycin C hypoxic pelvic perfusion for unresectable recurrent rectal cancer: pharmacokinetic comparison of surgical and percutaneous techniques

Abstract

Patients with unresectable recurrent rectal cancer that progresses after standard and multi-modular treatments are candidates for hypoxic pelvic perfusion. Hypoxic pelvic perfusion can be performed using a surgical or percutaneous approach. The aim of this study was to examine whether the surgical and percutaneous approaches are comparable with respect to tumor drug exposure in the pelvis. A pharmacokinetic study was performed in 18 patients. Both the surgical and percutaneous procedures were performed using mitomycin C (MMC) at a dose of 25 mg/m². The main parameter that was used to evaluate pelvic tumor drug exposure was the ratio of the areas under the MMC plasma concentration curves in the pelvis and the systemic compartment during the perfusion time (AUC_0–20). The mean values ± SD for the ratios between the MMC AUC_0–20 in the pelvic and systemic compartments were 14.38 ± 4.31 and 13.15 ± 4.26 for the surgical and percutaneous techniques, respectively (p = 0.53). This pharmacokinetic study demonstrated that the percutaneous approach for hypoxic pelvic perfusion did not statistically differ from the surgical approach. When perfusion must be repeated several times in the same patient, the percutaneous and surgical methods may be adopted interchangeably.

ClinicalTrials.gov Identifier

NCT01891552.

Negative-balance isolated pelvic perfusion in patients with incurable symptomatic rectal cancer: results and drug dose correlation to adverse events

BACKGROUND

Drug leakage and lack of a drug-removal system have prevented clinical application of isolated pelvic perfusion (IPP). These barriers were overcome with negative-balance IPP (NIPP) in experimental pig models. Here, a phase 1 clinical study of NIPP was performed in patients with incurable symptomatic rectal cancer.

PURPOSE

To establish a safe regimen of high-dose regional chemotherapy with NIPP using cisplatin in patients with incurable rectal cancer.

MATERIAL AND METHODS

Between June 2004 and January 2007, NIPP therapy was performed for 23 patients (11 women, 12 men; mean age, 58 years). NIPP was routinely performed twice over a 4-week interval. Dose-limiting toxicities (DLTs) were defined using a 5 + 3 design, and cisplatin doses were escalated from 170 mg/m(2), with a fixed 5-fluorouracil dose of 1000 mg/m(2). The grade of adverse events (AEs) at the first and second sessions of NIPP therapy, pharmacokinetics, and antitumor response were evaluated.

RESULTS

No DLTs were observed during the first session of NIPP. However, at the second session, two patients experienced the DLT of neuropathy after administration of 200 mg/m(2) cisplatin. Therefore, 190 mg/m(2) cisplatin was indicated as the maximum tolerated dose (MTD). The plasma pelvic-to-systemic exposure ratio was 18.4 based on the maximum concentration and 19.0 based on the concentration-time curve. Solid tumor responses included complete response in two patients, partial response in five patients, stable disease in 15 patients, and progressive disease in one patient.

CONCLUSION

NIPP may offer the safe delivery of high-dose regional chemotherapy (MTD of 190 mg/m(2) cisplatin) with negligible AEs and effective control of tumor growth in patients with incurable rectal cancer.

Isolated pelvic perfusion in irradiated unresectable recurrence of pelvic tumor: preliminary outcome and ongoing study

The technique of isolated pelvic perfusion (IPP) using extracorporeal circulation is capable of delivering high dose chemotherapy in the pelvic cavity. This technique has improved over time, notably with the use of a G-suit placed and inflated above the iliac bifurcation to impede flow through percutaneous vascular routes. This approach is of potential value in patients with previously irradiated, locally advanced recurrences of cancer originating from the gynecological or gastrointestinal organs. Administration of tumor necrosis factor alpha (TNF-α) in combination with melphalan seems to provide response rates similar to those obtained in the technique of isolated extremity perfusion. A preliminary phase I study has shown promising results in terms of feasibility and response rates. A randomized study is currently underway to compare IPP to standard treatment in patients with unresectable recurrent pelvic tumors of gynecological or gastrointestinal origin.

Complications and toxicity after abdominal and pelvic hypoxic stop-flow perfusion chemotherapy: incidence and assessment of risk factors

BACKGROUND

Controversial results regarding the efficacy and toxicity of hypoxic abdominal and pelvic stop-flow perfusion chemotherapy (SFP) have been reported in relatively small series. Hence, because adequate assessment of its benefit in large homogenous cohorts is missing, acceptable morbidity should initially be assured in a series of adequate size. Additionally, risk factors should be assessed for eventual patient selection.

METHODS

The morbidity of abdominal and pelvic SFP performed on a miscellaneous group of patients in our institute was analyzed and potential risk factors for adverse events were evaluated.

RESULTS

Seventy abdominal (n = 42) and pelvic (n = 28) SFP were performed on 55 patients. In total, 28 adverse effects were observed after 30% of the procedures. Severe (grade 3) adverse events were recorded only after 4% of the procedures, while treatment-related life-threatening events and deaths were not present. Abdominal procedures when compared with pelvic ones were associated with increased systemic toxicity (36 vs. 7%, p = 0.005). Advanced age, gender, prior chemotherapy and/or radiotherapy, limited experience, repeated procedure, drug choice and omission of hemofiltration after SFP completion were not associated with statistically significant increase of procedures with overall or systemic adverse events.

CONCLUSIONS

In the present series, abdominal and pelvic SFP was associated with an acceptable morbidity, which was mostly mild or moderate. Abdominal procedures were associated with increased toxicity. This procedure seems to be repeatable and also well tolerated both by elderly patients and by patients who had undergone prior chemotherapy and/or radiotherapy, while hemofiltration does not appear to decrease the incidence of systemic toxicity.

A phase I pharmacokinetic study of hypoxic abdominal stop-flow perfusion with gemcitabine in patients with advanced pancreatic cancer and refractory malignant ascites

PURPOSE

As no curative treatment for advanced pancreatic and biliary cancer with malignant ascites exists, new modalities possibly improving the response to available chemotherapies must be explored. This phase I study assesses the feasibility, tolerability and pharmacokinetics of a regional treatment of gemcitabine administered in escalating doses by the stop-flow approach to patients with advanced abdominal malignancies (adenocarcinoma of the pancreas, n = 8, and cholangiocarcinoma of the liver, n = 1).

EXPERIMENTAL DESIGN

Gemcitabine at 500, 750 and 1,125 mg/m(2) was administered to three patients at each dose level by loco-regional chemotherapy, using hypoxic abdominal stop-flow perfusion. This was achieved by an aorto-caval occlusion by balloon catheters connected to an extracorporeal circuit. Gemcitabine and its main metabolite 2',2'-difluorodeoxyuridine (dFdU) concentrations were measured by high performance liquid chromatography with UV detection in the extracorporeal circuit during the 20 min of stop-flow perfusion, and in peripheral plasma for 420 min. Blood gases were monitored during the stop-flow perfusion and hypoxia was considered stringent if two of the following endpoints were met: pH </= 7.2, pO(2) nadir ratio </=0.70 or pCO(2) peak ratio >/=1.35. The tolerability of this procedure was also assessed.

RESULTS

Stringent hypoxia was achieved in four patients. Very high levels of gemcitabine were rapidly reached in the extracorporeal circuit during the 20 min of stop-flow perfusion, with C (max) levels in the abdominal circuit of 246 (+/-37%), 2,039 (+/-77%) and 4,780 (+/-7.3%) mug/ml for the three dose levels 500, 750 and 1,125 mg/m(2), respectively. These C (max) were between 13 (+/-51%) and 290 (+/-12%) times higher than those measured in the peripheral plasma. Similarly, the abdominal exposure to gemcitabine, calculated as AUC(t0-20), was between 5.5 (+/-43%) and 200 (+/-66%)-fold higher than the systemic exposure. Loco-regional exposure to gemcitabine was statistically higher in presence of stringent hypoxia (P < 0.01 for C (max) and AUC(t0-20), both normalised to the gemcitabine dose). Toxicities were acceptable considering the complexity of the procedure and were mostly hepatic; it was not possible to differentiate the respective contributions of systemic and regional exposures. A significant correlation (P < 0.05) was found between systemic C (max) of gemcitabine and the nadir of both leucocytes and neutrophils.

CONCLUSIONS

Regional exposure to gemcitabine-the current standard drug for advanced adenocarcinoma of the pancreas-can be markedly enhanced using an optimised hypoxic stop-flow perfusion technique, with acceptable toxicities up to a dose of 1,125 mg/m(2). However, the activity of gemcitabine under hypoxic conditions is not as firmly established as that of other drugs such as mitomycin C, melphalan or tirapazamine. Further studies of this investigational modality, but with bioreductive drugs, are therefore warranted first to evaluate the tolerance in a phase I study and later on to assess whether it does improve the response to chemotherapy.

Recovery profiles of general anesthesia and spinal anesthesia for chemotherapeutic perfusion with circulatory block (stop-flow perfusion)

BACKGROUND

Chemotherapeutic stop-flow perfusion is a new investigational treatment for locally advanced cancers that is usually performed under general anesthesia (GA), and, less frequently, under spinal anesthesia (SA). We designed this clinical trial to compare the clinical profiles of GA and SA for stop-flow perfusion.

METHODS

Anesthesia and recovery times, scores on visual analog scales for postoperative pain, and postoperative nausea and vomiting, and admission to the postanesthesia care unit were measured in 40 cancer patients who randomly received either GA with propofol, nitrous oxide/sevoflurane, and fentanyl, or SA with bupivacaine hydrochloride for lower limb or pelvic stop-flow perfusion.

RESULTS

GA and SA did not differ in times to achieve home readiness or patient satisfaction. Compared with GA, SA significantly (P < 0.05) reduced anesthesia times (34 vs 16 min), postoperative visual analog scale scores for pain (5 vs 0) and nausea (8 vs 2), and the number of admissions to the postanesthesia care unit (9 vs 0).

CONCLUSIONS

For stop-flow perfusion, GA and SA are both effective, but SA provides faster recovery, superior analgesia, and less postoperative nausea and vomiting in the immediate postoperative period.

Pressure-suit combined with pelvic stop-flow: A feasibility study in a bovine model

BACKGROUND

Isolated pelvic perfusion exposes tissue to high drug doses and may benefit patients with advanced malignancy. However, leakage is a limit to this technique.

AIMS

The aim of the study is to increase the perfusion ratio between local and systemic compartments on isolated pelvic perfusion. We hypothesised that an inflated pressure-suit placed above the level of aortic and caval stop flow could decrease leakage from the regional to the systemic blood compartment in a bovine model.

METHOD

As the size of the pressure-suit was adapted for use in humans, we performed our experimental study on 6 calves which are big enough to fit into the suit. We used an inflated pressure-suit placed at low (40mmHg) and high pressures (125mmHg) above the level of aortic and caval stop-flow. A pharmacokinetic study with cisplatinum was performed in both compartments.

RESULTS

After injection of the drug, the mean ratio of drug concentration in the locoregional/systemic compartment was 43.1. After 30min, this mean ratio was 4 and 9.7 for a pressure-suit pressure of 40mmHg and 125mmHg, respectively. At pressure-suit pressures of 40mmHg and 125mmHg, pelvic perfusion achieved pelvic/systemic exposure ratios of 5.9 and 14.9 at 30min, respectively. Leakage at 30min was higher when the pressure-suit was inflated at low pressure (40mmHg, mean 18%). When the pressure-suit was inflated at high pressure, leakage was lower (125mmHg, mean 7%).

CONCLUSIONS

The pressure-suit increased the perfusion ratio between pelvic and systemic compartments in a bovine model.

Changes in pelvic and systemic platinum concentrations during negative-balance isolated pelvic perfusion: correlation between platinum concentration and method of administration in a pig model

PURPOSE

To assess the effect of altering the method of administration during negative-balance isolated pelvic perfusion (NIPP) on the platinum concentration in the pelvic or systemic circulation.

METHODS

Twenty female pigs were used in this study. The abdominal aorta and the infra-renal vena cava were occluded with two balloon catheters and blood in the extracorporeal circuit was circulated with twin rotary pumps. NIPP was then performed with cisplatin (5 mg/kg) in 15 pigs. Three types of NIPP administration method (group A: 1 bolus, B: 2 same doses boluses, C: 3 same doses boluses) were used, five pigs being subjected to each treatment. The remaining five pigs were administered cisplatin systemically as a control study (group D). The platinum concentrations in the pelvic and systemic circulation were measured and compared.

RESULTS

(1) Pelvic circulation: There was a tendency for the platinum concentration to increase as the bolus time decreased. The platinum concentration in groups A and B was significantly (P < 0.05) higher than that in group C. Significant differences (P < 0.05) between groups A and B until 10 min after the start of NIPP. (2) Systemic circulation: Significant differences (P < 0.05) were observed between NIPP groups and D during NIPP. The platinum concentration in group D was five times higher than that in group C. (3) Plasma pelvic to systemic exposure ratio: there were no significant differences among the three NIPP groups.

CONCLUSIONS

The platinum concentrations in the pelvic and systemic circulation increased as the bolus time decreased. The plasma pelvic to systemic exposure ratio was not influenced by bolus time.

Hypoxic abdominal stop-flow perfusion in the treatment of advanced pancreatic cancer: a phase II evaluation/trial

In the past decade, some authors have reported objective responses and prolonged median survival times using hypoxic abdominal perfusion (HAP) for the treatment of advanced pancreatic cancer. However, these promising results have not been confirmed by others, making it difficult to define the effectiveness of this loco-regional chemotherapy. The aim of this study, therefore, was to evaluate the response rate, time to disease progression and overall survival following HAP treatment of 22 consecutive patients with advanced pancreatic tumors. Within the period from 1999 to 2003, 22 patients with histological diagnosis of unresectable stage III/IV pancreatic cancer, not responsive to systemic chemotherapy, were treated with mitomycin C 30mg/m(2) and cisplatin 60mg/m(2) by HAP (stop flow technique). Immediately after perfusion, hemofiltration was performed to reduce systemic side toxic effects. Responses were assessed by CT-scan 30days from the end of treatment. Minor or partial responses were confirmed by a second CT-scan 4weeks later. Following 26 treatment cycles no death or technical complications were recorded; four patients (18.2%) achieved a partial response, 2 (9.1%) a minimal response and 13 (59.1%) stable disease. The remaining 3 patients (13.6%) showed progression of the disease. The median time to disease progression was 3 months (range 1-10). The median survival time from the start of regional chemotherapy was 6 months (range 1.9-16), with a 1-year survival rate of 9%. Our data show that HAP is a relatively effective second-line treatment for advanced stage pancreatic cancer with a low complication rate. We do not concur with the opinion of others that HAP is an inactive treatment approach. However, taking into account the invasiveness of this procedure, and associated morbidity and cost, HAP would not appear to be preferable to less invasive loco-regional chemotherapeutic alternatives.

Results of regional chemotherapy using the aortic stop-flow technique in advanced pancreatic carcinoma

PURPOSE

Systemic palliative chemotherapy provides only a disappointing response and almost no prolongation of the survival time in patients with pancreatic carcinoma. Isolated perfusion may lead to a higher concentration of cytostatics within the target tissue, which can be associated with a high response rate and longer survival in addition to a low rate of side effects. The aim of the study was to investigate the feasibility of the aortic stop-flow technique using commercially available tools in patients with advanced pancreatic carcinoma.

METHODS

Seventeen patients with either unresectable or metastasized pancreatic carcinoma (diagnosed by histologic investigation) were enrolled in the study. In total, a 20-min hypoxic perfusion of the isolated abdominal compartment with 20 mg/m2 of mitomycin C (Medac, Hamburg, Germany) was carried out 22 times. The cytostatic concentration was determined intrainterventionally within the systemic and regional compartment. The tumor response was assessed using computed tomography and a tumor marker (CA19-9) every 4 weeks.

RESULTS

While 12 patients underwent one cycle, in 5 patients two complete perfusions were performed. Mitomycin C concentration was 10-fold higher within the regional compared with the systemic compartment at its maximum. The area under the curve (AUC) was 4.02 times larger. The degree of toxicity was considerable: World Health Organization grade I/II in 8/17, III/IV in 9/17 cases. Three treatment-related deaths were documented. The objective response rate was 17.6% (3 of 17 cases; 1 complete remission [CR], 2 partial remissions [PR]). In 3 subjects, a stable disease (SD) and in 11 individuals tumor progression (PD) was registered. The median survival was 4.1 months.

CONCLUSION

The aortic stop-flow technique was associated with a high toxicity rate but no improvement in the tumor response and survival was seen in comparison to the systemic chemotherapy of the historical group. Despite detectable pharmacokinetic advantages, the aortic stop-flow technique is therefore not considered to be feasible for palliative chemotherapy in patients with pancreatic carcinoma for routine use.

Reduction of drug leakage by negative-balance isolated pelvic perfusion: correlation between leakage and in-out flow rate in a pig model

PURPOSE

Isolated pelvic perfusion (IPP) therapy exposes target tissues to high doses of anticancer drugs with low systemic concentrations, but the major drawback is drug leakage into the systemic circulation, which often thwarts the increased drug concentration. In this study, the efficacy of altering the in-out flow rate during IPP in order to decrease the leakage was assessed in adult pigs.

METHODS

The abdominal aorta and the infrarenal vena cava were occluded with two balloon catheters, blood in the extracorporeal circuit was circulated with twin rotary pumps, and the IPP was performed with platinum. Three sets of in-out flow rates were used, and the degree of drug leakage into the systemic circulation was evaluated. The volume of blood withdrawn was equal to the volume returned (300 ml/min; group A), 5% higher (group B), or 10% higher (group C). The platinum concentrations in the pelvic circulation, systemic circulation, and urine were measured and compared.

RESULTS

The average and maximum plasma platinum concentrations in the pelvic circulation did not significantly differ among the three groups. The plasma platinum concentrations in the systemic venous circulation of the three groups significantly (P<0.01) decreased as the volume withdrawn during IPP increased. The percentage of platinum eliminated in the urine during IPP was significantly (P<0.01) lower in group B and C than in group A.

CONCLUSIONS

Setting the volume withdrawn higher than the volume returned decreased leakage into the systemic circulation under isolated pelvic perfusion.

Pharmacokinetics of the Antineoplastic Drug Mitomycin C in Regional Chemotherapy Using the Aortic Stop Flow Technique in Advanced Pancreatic Carcinoma

BACKGROUND

An isolated perfusion may lead to a higher concentration of cytostatics within the target tissue, which can be associated with a high response rate and longer survival in addition to a low rate of side effects in comparison with systemic palliative chemotherapy. The aim of the present study was to investigate the pharmacokinetics of mitomycin C utilizing the aortic stop flow technique with commercially available tools in patients with advanced pancreatic carcinoma.

METHODS

Seventeen patients with unresectable or metastasized pancreatic carcinoma (diagnosed by histological investigation) underwent a 20-min hypoxic perfusion of the isolated abdominal compartment with 20 mg/m2 mitomycin C (Mitomedac, medac, Hamburg, Germany) 22 times. Cytostatic concentration was determined intrainterventionally within the systemic and regional compartment.

RESULTS

The mitomycin C concentration was 10 times higher within the regional compared with the systemic compartment at its maximum. The area under the curve was 4.02 times greater. Toxicity was considerable, i.e. WHO grade I/II in 8 of 17 cases, and III/IV in 9 of 17 cases. Two treatment-related deaths were documented. The objective response rate was 17.6% (3 of 17 cases; 1 complete remission, 2 partial remissions). In 3 subjects, stable disease was registered, and in 11 individuals, tumor progression. The median survival was 4.1 months.

CONCLUSION

Though high concentrations of the cytostatic drug were achieved within the regional compartment, the aortic stop flow technique was associated with a high toxicity rate but no improvement of tumor response and survival in comparison with systemic chemotherapy. Despite its pharmacokinetic advantages, the aortic stop flow technique is currently not recommendable for routine use.

Stop-flow technique for loco-regional delivery of high dose chemotherapy in the treatment of advanced pelvic cancers

AIM

To verify the rationale of a pelvic stop-flow technique for the perfusion of high-doses of mitomycin C and anthacyclines in patients with inoperable, recurrent pelvic cancer.

METHODS

The stop-flow technique was realized by using percutaneous double-balloon arterial-venous catheters that selectively isolate the pelvic vascular section and a perfusion provided by an extracorporeal pump for 20 min. Ten patients (pts) with unresectable pelvic recurrence from colon-rectal cancer were treated with a combination of Mitomycin C (MMC, 20 mg/sqm) plus doxorubicin (DOXO, 75 mg/sqm; 8pts) or epirubicin (EPI, 75 mg/sqm; 2pts) infused into the isolated pelvic compartment. Blood samples were collected from the extracorporeal vascular flow and from peripheral plasma, and analysed for drug quantitation.

RESULTS

During the procedure, there were no technical or hemodynamic complications, and no deaths occurred during surgery or in the postoperative period. MMC and DOXO peak levels measured in the extracorporeal system which irrotates the tumor area, were on average 21.6 (range: 4.3-44.3, MMC) and 17.2 (range: 1.8-48.4, DOXO) times higher than those observed in the peripheral blood. Similarly; the area under concentration (AUC) versus time curves measured in the pelvic compartment during stop-flow perfusion were 19.9 (range: 3.8-45.0, MMC) and 13.4 (range: 1.2-26.6, DOXO) times higher than the corresponding value in peripheral circulation. The drug percentage eliminated in the ultra filtrate was only 7.7% (MMC) and 0.9% (DOXO), and the plasmatic AUC(0-24) were similar to those observed with iv bolus of equivalent drug doses. Minimal systemic and local toxicities were observed. One complete pathological and 2 partial responses were observed; pain remission in 8/10 patients. median survival was 12 months (8-31).

CONCLUSION

The endo-arterial administration into the local vasculature produces high pelvic-systemic concentration gradients during the stop-flow perfusion with limited local and systemic toxicity. The encouraging clinical results suggest further evaluation.

Hemodynamic variations during thoracic and abdominal stop-flow regional chemotherapy

AIMS

The aim of this study was to study hemodynamic modifications during thoracic and abdominal stop-flow regional chemotherapy and to evaluate the need for routine hemodynamic monitoring during such kind of procedures.

METHODS

Thirty patients, aged 17-67 years, ASA physical status II-III, scheduled for thoracic (group A, n = 15), and abdominal (group B, n = 15) stop-flow regional chemotherapy were enrolled. Heart rate (HR), electrocardiogram lead I and V(5), end tidal carbon dioxide (ETCO(2)), arterial oxygen saturation (SaO(2)), systolic, diastolic and mean arterial pressure (SBP, DBP, MAP), mean pulmonary arterial pressure (MPAP), pulmonary capillary wedge pressure (PCWP), central venous pressure (CVP), cardiac output (CO), stroke volume (SV), stroke index (SI), systemic vascular resistance (SVR), pulmonary vascular resistance (PVR), left cardiac work (LCW), right cardiac work (RCW), left cardiac work index (LCWI), right cardiac work index (RCWI), cardiac index (CI), and body O(2) consumption (VO(2)) were recorded.

RESULTS

After aortic and inferior vena cava endovascular occlusion (T(1)), a significant reduction of CO and SV, associated with an increase of CVP, MAP, PAPM and PCWP were observed. A concomitant reduction of CI and increase of SVR and PVR were registered. The VO(2) was significantly reduced compared to basal values in both groups. After deflating aortic and vena cava balloons (T(2)), CO, SV and CI increased with respect to basal value p < 0.05) whereas MAP, CVP, PAPM, PCWP and calculated parameters (SVR, PVR) showed a significant reduction compared to T(1). The oxygen consumption was significantly higher than that of basal values p < 0.05. After hemofiltration (T(3)), all hemodynamic variables were comparable with the basal values. Modifications of direct and calculated parameters, during the stop-flow period, showed a similar trend in both study groups, without any statistically significant difference. No ST modifications at ECG were noted during all perioperative period.

CONCLUSIONS

The results of this study have confirmed in both groups, the safety of stop-flow regional chemotherapy procedure, despite endovascular occlusion of the aorta and inferior cava vein. The hemodynamic and oxygenation changes are reversible and did not produce any ST modifications at ECG during all perioperative period. Routine pulmonary artery catheterization is thus unnecessary, except in high cardiac risk patients.

Stop-flow technique for loco-regional delivery of antiblastic agents: literature review and personal experience

AIMS

The therapeutic approach for primary or recurrent advanced solid tumours, particularly when unresectable, is still one of the main medical challenges in the management of cancer patients. The stop-flow (SF) technique has been recently proposed as a semi-invasive drug delivery system based on the blood supply blockage of the tumour-bearing area. Here, we discuss the principles underlying the SF technique as well as the worldwide experience published so far. We also report on the results of our pilot study on pelvic and limb SF perfusion.

METHODS

We reviewed the worldwide experience on SF as reported by the literature published on PubMed from 1990 through 2001. In our series, we treated 20 patients affected with locally advanced melanoma, soft tissue sarcoma or colorectal cancer.

RESULTS

This therapeutic modality - at least for some tumours - can achieve encouraging results in terms of clinical response even after conventional therapies have failed. Moreover, as a safe and relatively simple procedure, SF can be applied to patients for whom traditional treatments (i.e. surgery, systemic chemotherapy) are contraindicated because of poor general conditions.

CONCLUSIONS

At present, the SF technique should be considered an investigational approach to locally advanced cancers. The encouraging results obtained with this procedure should be validated by large phase III trials.