Pharmacokinetics of intra-arterial chemotherapy

Recent Advancements in Hyperthermia-Driven Controlled Drug Delivery from Nanotherapeutics

Previous reviews of the works on magnetic nanoparticles for hyperthermia-induced treatment concentrated mostly on magnetic fluid hyperthermia (MFH) employing monometallic/metal oxide nanocomposites. In the literature, the word "hyperthermia" was also limited to the use of heat for medicinal purposes. A number of articles have recently been published demonstrating that magnetic nanoparticle-based hyperthermia may produce restricted high temperatures, resulting in the release of medicines that are either connected to the magnetic nanoparticles or encased in polymer matrices. In this debate, we propose broadening the concept of "hyperthermia" to encompass temperature-based treatment as well as magnetically controlled medication delivery. The review also addresses core-shell magnetic nanomaterials, particularly nanoshells made by stacked assembly, for the use of hyperthermia- based treatment and precise administration of drugs. The primary objective of this review article is to demonstrate how the combination of hyperthermia-induced therapy and on-demand' drug release models may lead to effective applications in personalized medicine.

Hyperthermia and smart drug delivery systems for solid tumor therapy

Chemotherapy is a cornerstone of cancer therapy. Irrespective of the administered drug, it is crucial that adequate drug amounts reach all cancer cells. To achieve this, drugs first need to be absorbed, then enter the blood circulation, diffuse into the tumor interstitial space and finally reach the tumor cells. Next to chemoresistance, one of the most important factors for effective chemotherapy is adequate tumor drug uptake and penetration. Unfortunately, most chemotherapeutic agents do not have favorable properties. These compounds are cleared rapidly, distribute throughout all tissues in the body, with only low tumor drug uptake that is heterogeneously distributed within the tumor. Moreover, the typical microenvironment of solid cancers provides additional hurdles for drug delivery, such as heterogeneous vascular density and perfusion, high interstitial fluid pressure, and abundant stroma. The hope was that nanotechnology will solve most, if not all, of these drug delivery barriers. However, in spite of advances and decades of nanoparticle development, results are unsatisfactory. One promising recent development are nanoparticles which can be steered, and release content triggered by internal or external signals. Here we discuss these so-called smart drug delivery systems in cancer therapy with emphasis on mild hyperthermia as a trigger signal for drug delivery.

Palliative hepatic intraarterial chemotherapy (HIC) using a novel combination of gemcitabine and mitomycin C: results in hepatic metastases

To evaluate repeated hepatic intraarterial chemotherapy (HIC) as a palliative treatment option for unresectable cholangiocarcinoma and liver metastases of various origins that were progressive under systemic chemotherapy. Between 2002 and 2006, 55 patients were treated in 4-week intervals (mean five sessions). Combined gemcitabine/mitomycin was administered intraarterially within 1 h. Tumor response was evaluated after the third session according to RECIST. Treated tumor entities were colorectal carcinoma (CRC) (n = 12), breast cancer (BC) (n = 12), cholangiocarcinoma (CCC) (n = 10), pancreatic (n = 4), ovarian (n = 3), gastric, cervical, papillary (each n = 2), prostate, esophageal carcinoma, leiomyosarcoma (each n = 1), cancer of unknown primacy (CUP) (n = 5). All patients tolerated the treatment well without any major side effects or complications. In total, there were 1 complete response (CR), 19 partial responses (PR), 19 stable (SD) and 16 progressive diseases (PD). We observed 5 PR, 3 SD and 4 PD in CRC; 1 CR, 4 PR, 6 SD in BC; and 2 PR, 2 SD and 6 PD in CCC. Median survival after first HIC was 9.7 months for CRC, 11.4 months for BC and 6.0 months for CCC. HIC with gemcitabine/mitomycin is a safe, minimally invasive, palliative treatment for hepatic metastases that are progressive under systemic chemotherapy. The treatment yields respectable tumor control rates in CRC and BC patients.

Clinical pharmacology of anticancer agents in relation to formulations and administration routes

In the past years, alternative administration routes and pharmaceutical formulations of anticancer agents have been investigated in order to improve conventional chemotherapy treatment. The impact of these adjustments on the pharmacokinetics and pharmacodynamics is discussed. A review of the literature shows many examples of alternative administration forms of anticancer agents with improved pharmacokinetics. Local administration routes have been investigated in order to reduce the systemic toxicity and to enhance the local efficacy of conventional chemotherapy. Oral administration of anticancer agents is preferred by patients for its convenience and its potential for outpatient treatment. In addition, oral administration facilitates a prolonged exposure to the cytotoxic agent. However, poor bioavailability and substantial interpatient variability are noted as limitations for oral chemotherapy. Increased tumour selectivity can also be achieved by the use of specific pharmaceutical formulations, such as liposomes and macromolecular drug conjugates. The composition of these formulations often determine the pharmacokinetic behaviour of the formulated drug. In conclusion, several alternative administration forms of anticancer agents have been designed in the past years, with the potential for improvement of conventional chemotherapy, however, more extensive clinical evaluation of these novel strategies is warranted to prove their real clinical value.

Transcatheter arterial embolization as a method of cisplatin-retention enhancement on the VX2 tumor uterus transplants

PURPOSE

Enhanced cisplatin (Pt) retention using transcatheter arterial chemoembolization (TAE) with Gelfoam particles was studied in rabbit uterine tumors.

METHODS

Ten rabbit uteri were inoculated with 5 x 10(7) cells of VX2 carcinoma. Three to four weeks later cisplatin, 1 mg/kg, was injected, either with (TAE group) or without (IA group) being mixed with small Gelfoam particles, into the aortic bifurcation over 5 s. Blood and tissue concentration of cisplatin were determined.

RESULTS

Slower arterial blood clearance of Pt was observed in the TAE group compared with the IA group, whereas the venous blood Pt clearance curves were similar for both groups. The uterine tumor Pt concentration at 80 min was found to be 2.52-fold higher after TAE compared with IA (p < 0.01). In the pelvic metastatic lymph nodes, the Pt concentration was 4.63 times higher after TAE than after IA (p < 0.01).

CONCLUSION

These data indicate that TAE is an effective means of increasing tissue concentration in uterine tumors.

Comparison of intra-arterial versus intravenous 5-fluorouracil administration on epidermal squamous cell carcinoma in sheep

Clinical evidence that intra-arterial chemotherapy is more effective in regressing head and neck cancers than equivalent intravenous doses is lacking. Intra-arterial versus intravenous 5-fluorouracil infusion was compared in a naturally occurring, auricular epidermal squamous cell cancer in sheep. Of 18 lesions infused intra-arterially and of 18 infused intravenously with the same dose, 39 and 11%, respectively responded objectively (over 50% regression); mean (S.E.) tumour volume reduction was 37(23) and 18(22)%, respectively. There was a statistically significant difference in the mean tumour response and in numbers of tumours regressing by at least 40% of tumour volume (50% of intra-arterial treated tumours compared with 11% of intravenous treated lesions) after the 16 day total infusion time in favour of intra-arterial treatment. Technically, the intra-arterial route in this model was an improvement on previous small animal models. These findings lend support to the need for continuing clinical study of intra-arterial infusion.

Developments in surgical oncology--past, present, and future trends

The historical development of integrated treatment programs for locally advanced or aggressive cancers, for which the results of surgical excision or radiotherapy are unsatisfactory, is reviewed. Chemotherapy should be used first (induction chemotherapy), while tumour vasculature is intact; intra-arterial infusion gives a greater regional effect. Central residual tumour may be eradicated by subsequent radiotherapy and/or surgery. Regional induction chemotherapy is particularly useful in treating locally advanced stage III breast cancer, locally advanced head and neck cancer, gastric cancer, and locally advanced sarcomas and melanomas of the limbs. A team approach, involving surgical and medical oncologists, radiotherapists, immunologists, and others should improve the results in these patients.

Drug targeting in cancer chemotherapy: a clinical perspective

Drug targeting is a phenomenon which maneuvers the distribution of drug in the body in such a manner that the major fraction of the drug interacts exclusively with the target tissue at a cellular or subcellular level. Numerous strategies have been developed to accomplish this goal; some of them have been tried clinically for improving cancer chemotherapy. This review updates the current status of research in the area of targeted drug delivery, with particular emphasis on its application in the clinical management of carcinomas.

Indications for surgical or radiological placement of cannulas for intra-arterial induction chemotherapy

Intra-arterial chemotherapy achieves a higher concentration and increased total dose of drugs to a locally advanced cancer. This principle is increasingly being applied for pretreatment of advanced or aggressive localised tumours to make them more curable by subsequent radiotherapy. This is sometimes called "neo-adjuvant" chemotherapy but better called INDUCTION chemotherapy (Stephens 1989).

Developments in surgical oncology: induction (neoadjuvant) chemotherapy--the state of the art

The three established modalities for treatment of cancer are operative surgery, radiotherapy and chemotherapy. In the past, patients have been referred to clinics where experts in the appropriate discipline have usually advised management by one or other of the three modalities. In recent years it has become apparent that for some cancers in which good results have not been forthcoming by one therapeutic modality alone, improvements may well be made by integrating management using two or three forms of treatment, in a planned approach. Management of localized cancers in which a surgical operation is likely to play a major part has traditionally been carried out by surgeons. However, operative surgery alone may not provide optimal care so that surgical oncology has developed as a discipline often embracing combined treatment with either chemotherapy or radiotherapy or both. In managing advanced but localized cancers for which a surgical operation alone is unlikely to produce tumour eradication (or for which tumour eradication can only be achieved with a mutilating operation such as amputation) it has become increasingly recognized that reduction of tumour size and viability by using chemotherapy first may render many tumours more susceptible to total eradication by subsequent radiotherapy and/or surgical operation. Such treatment is often referred to as 'induction' or 'neo-adjuvant' chemotherapy. This paper summarizes the principles of use of induction chemotherapy with integrated follow-up radiotherapy and/or surgical operation.

Regional chemotherapy of liver metastases from colorectal carcinoma: hepatic artery or portal vein infusion?

Hepatic artery infusion (HAI) chemotherapy has been well developed and is commonly used in the treatment of unresectable hepatic colorectal metastases. However, several important questions are unanswered, such as survival advantage over conventional systemic intravenous chemotherapy, long-term effects on the liver function, and prevention of complications, in particular cholangiosclerosis. Recent investigation into the blood supply of liver tumors challenges the adage that arterial flow is dominant. This review of the merits of regional HAI compared with portal venous infusion (PVI) chemotherapy shows a lack of conclusive data to favor either treatment modality, although a larger experience exists for HAI. Further studies need to be conducted.

Regional chemotherapy with the use of cisplatin and doxorubicin as primary treatment for advanced sarcomas in shoulder, pelvis, and thigh

Eight patients who had large sarcomas in the hip, thigh, or shoulder girdle have been described. Three had osteogenic sarcomas, and one each had Ewing's sarcoma, biphasic synovial sarcoma, pleomorphic liposarcoma, undifferentiated spindling sarcoma, and malignant fibrous histiocytoma. All eight tumors showed evidence of regression after intraarterial infusion of cisplatin and Adriamycin (doxorubicin) given over 48 hours at 3-week intervals, for a total of between three and seven courses. Tru-cut needle biopsy specimens of five of the lesions were normal after chemotherapy. However, after resection of the regressed fibrotic tumor in seven of the patients, four contained foci of probably viable malignant cells. These cell foci were intraosseous in three cases and in the wall of a cyst in one case. In the remaining case, tumor in the distribution of the infused artery regressed, but tumor in a region supplied by an artery that was not infused continued to enlarge. In one patient with osteogenic sarcoma in the pelvis, despite a good response to intraarterial chemotherapy that was followed by surgical resection and radiotherapy, tumor recurred in an adjacent area in tissues supplied by an artery not infused. A hindquarter amputation subsequently was required. With the exception of the two cases in which adequate tumor arterial infusion was not achieved, local primary tumor control was accomplished by intraarterial infusion chemotherapy followed by local resection or radiotherapy and local resection in all patients. Four patients are well without evidence of residual or metastatic sarcoma 3.5 years after presentation in the case of an osteogenic sarcoma of shoulder, 2.5 years after presentation in the case of a large pleomorphic liposarcoma of thigh and groin, 20 months after presentation in the case of lower-thigh malignant fibrous histiocytoma, and 1 year after presentation in a child with an osteogenic sarcoma of lower femur.

Treatment of advanced and inaccessible sarcomas with continuous intra-arterial chemotherapy prior to definitive surgery or radiotherapy--a possible alternative to amputation or disabling radical surgery

Four patients with advanced and inaccessible soft tissue sarcomas were treated with a regimen of intra-arterial chemotherapy followed by radiotherapy and/or surgical excision. Two of the patients had advanced sarcomas in the buttock and thigh regions which would otherwise have required hindquarter amputation in one case or disarticulation of the hip in the other case. These sarcomas responded significantly to intra-arterial chemotherapy to the extent that subsequent local surgery was effective in eradicating the residual tumours. No viable tumour cells were found in the resected specimens. In both patients amputation was avoided and local tumour eradication was achieved. In the other two patients, advanced and non-resectable sarcomas in the head were first treated with a similar regimen of intra-arterial chemotherapy. In both cases the tumours regressed in size prior to administration of local radiotherapy. After completion of chemotherapy and radiotherapy no viable tumour cells were detected in either lesion. In one case (originally a very extensive sarcoma of the jaw in a 5 year old child) a residual lump was resected but no viable tumour was detected in the resected specimen. These four patients represent our total experience with this plan of management. All responded well and there has been no evidence of local disease recurrence in any of the four patients. One patient (Case 2) did develop pulmonary and bone metastases from which she died 2 years later but the other three patients remain well with no evidence of residual disease, 11 years, 4 years and 20 months after presentation.

A preliminary report on the suitability of sheep epidermal squamous cell carcinoma as a solid tumor model in the evaluation of intra-arterial methotrexate administration

A preliminary study was undertaken to assess the sensitivity of sheep epidermal squamous cell carcinoma, in the head and neck region, to intra-arterial (IA) methotrexate (MTX) infusion. There was an objective tumor response (40-56% regression) in all three IA-infused sheep, whereas tumor progression was observed in all three animals treated intravenously (IV). Regional and systemic side effects were negligible in all cases. Technically, IA drug infusion in the sheep was an improvement on previous small animal models, with no problems related to arterial catheter insertion, blockage, or dislodgement, and tolerable infusion times being of markedly longer duration. The histological differentiation of moderately differentiated stage II lesions improved during therapy irrespective of clinical response, whilst the histology of well-differentiated stage III and IV tumors remained unchanged. Tumor cell cycle stage and ploidy characteristics, as determined by flow cytometric DNA analysis, were little affected by either mode of drug administration. It is concluded that sheep epidermal carcinoma is responsive to IA MTX, and that this animal model is the most appropriate yet utilised to study the comparative effects of IA and IV chemotherapy in the head and neck region.

Experiments on the efficacy and toxicity of locoregional chemotherapy of liver tumors with 5-fluoro-2'-deoxyuridine (FUDR) and 5-fluorouracil (5-FU) in an animal model

For the investigation of locoregional chemotherapy of liver neoplasms we developed a standardized animal model in the rat. Continuous infusion therapy or repeated bolus injections of FUDR or 5-FU were given via the hepatic artery, the portal vein or the vena cava in tumor-bearing animals. The efficacy of the treatment was determined by measuring the tumor volume 3 weeks after tumor cell implantation. For the evaluation of the local and systemic toxicity serum GOT, GPT, and total bilirubin were determined. DNA single strand breaks were assessed in isolated liver and bone marrow cells. Inhibition of colony formation of bone marrow stem cells was determined by CFU-C and CFU-S bioassay. A significant reduction of tumor growth was observed only after continuous infusion of FUDR via the hepatic artery. Systemic toxicity was lowest in this group for both compounds while the local liver toxicity was only slightly elevated.