Pharmacokinetics and results of dose escalation in cis-platin hyperthermic isolation limb perfusion

Emerging hyperthermia applications for pediatric oncology

Local application of hyperthermia has a myriad of effects on the tumor microenvironment as well as the host's immune system. Ablative hyperthermia (typically > 55 °C) has been used both as monotherapy and adjuvant therapy, while mild hyperthermia treatment (39-45 °C) demonstrated efficacy as an adjuvant therapy through enhancement of both chemotherapy and radiation therapy. Clinical integration of hyperthermia has especially great potential in pediatric oncology, where current chemotherapy regimens have reached maximum tolerability and the young age of patients implies significant risks of late effects related to therapy. Furthermore, activation of both local and systemic immune response by hyperthermia suggests that hyperthermia treatments could be used to enhance the anticancer effects of immunotherapy. This review summarizes the state of current applications of hyperthermia in pediatric oncology and discusses the use of hyperthermia in the context of other available treatments and promising pre-clinical research.

The role of hyperthermic intraperitoneal chemotherapy (HIPEC) and isolated perfusion (ILP) interventions in sarcoma

Locally advanced sarcomas in the extremity and in the retroperitoneum/abdominal cavity (peritoneal sarcomatosis, PS) can be managed administering chemotherapy locally using isolated limb perfusion (ILP) and hyperthermic intraperitoneal chemotherapy (HIPEC), respectively. In this review, the authors discuss the pros and cons of the use of these locoregional therapies in locally advanced soft tissue sarcoma, with a view to establishing their role in the multidisciplinary approach to these difficult diseases.

Hyperthermic isolated regional perfusion with CDDP for bone and soft-tissue sarcoma of the lower limb: pharmacokinetics, thermal dose, toxicity, and feasibility

The objectives of this study were to investigate the pharmacokinetics of cisplatin (CDDP) and the thermal dose, toxicity, and feasibility of hyperthermic isolated regional perfusion (HIRP) with CDDP for bone and soft-tissue sarcomas of the lower limb. A total of 43 patients were treated with HIRP using CDDP. The dose of CDDP administered was 62.9+/-11.8 mg/limb (20 mg/m(2) +20 approximately 30 mg). The mean highest CDDP concentration was 56.9 microg/ml as total platinum (tPt) and 49.0 microg/ml as free platinum (fPt). The tPt concentration remained higher than 10 microg/ml. The highest temperature within tumor was 42.3+/-1.4 degrees C on average. The complications of HIRP were grade II toxicity in 30 patients, grade III in 9, and grade IV in 4. The mean necrotic ratio in the resected specimen was 84.5%, and the effect was grade IV (no viable tumor cells) in 13 patients, grade III(>90% necrosis) in 12, grade II (50 to <90%) in 9, and grade I (<50%) in 4. We obtained favorable levels of platinum concentration of the perfusate using a lower CDDP dosage compared with previous studies of HIRP. Considering our results of the pharmacokinetics of CDDP and clinical efficacy, we propose a lower dosage of CDDP for HIRP in the treatment of osteosarcoma. Multimodality treatment of HIRP with preoperative chemotherapy and surgery is a relatively safe and reliable therapeutic option for patients with limb sarcomas, and our method offers excellent local control.

Isolated limb perfusion in locally advanced cutaneous melanoma

Isolated limb perfusion (ILP) is a well-established locoregional procedure to deliver high doses of cytostatics to an extremity with multiple in-transit lesions from cutaneous melanoma, with minimal systemic and mild local toxicity. This approach is quite sophisticated and requires accurate monitoring of systemic leakage and of the temperature of the affected limb in order to avoid major systemic and local side effects. Mephalan (L-PAM) is considered the reference drug, although complete responses are reported in only about 50% of patients. Since the early 1990s, tumor necrosis factor-alpha (TNF-alpha) was administered with melphalan in ILP aiming to improve the therapeutic index of this procedure. However, despite the impressive results reported, its role still remains controversial, seemingly confined to large tumor bulk. Fotemustine ILP was proposed as a less toxic alternative to L-PAM, after the results of a pilot experience claiming similar response rates with less local toxicity. A formal phase 1-2 study is now underway to confirm these findings. More straightforward procedures, such as isolated limb infusion, are appealing, as they seem capable of achieving good response rates, are easily repeatable, and are less costly. Larger series are required to validate such results. As potential agents to be delivered through ILP, new vasoactive drugs and agents with new mechanisms of action that interplay with chemotherapy, as well as virus-mediated gene therapy, are being developed.

Isolated limb reperfusion with tumor necrosis factor and melphalan in patients with extremity melanoma after failure of isolated limb perfusion with chemotherapeutics

BACKGROUND

This retrospective study evaluated the benefit of using tumor necrosis factor (TNF) and melphalan administered via an isolated limb perfusion (ILP) in a series of patients with metastatic melanoma who failed initial ILP with chemotherapeutics.

METHODS

Seventeen patients with extremity melanoma who underwent prior ILP with conventional chemotherapeutics (10 with melphalan; 4 with platinum; 2 with platinum, dacarbazine, thiotepa, actinomycin D, and nitrogen mustard; and 1 with thiotepa, actinomycin D, and nitrogen mustard) and had local recurrences were treated with a 90-minute isolated hyperthermic limb reperfusion with melphalan (10 mg/L limb volume) plus TNF (2-6 mg). Five prior ILPs were adjuvant and 12 were therapeutic.

RESULTS

Reperfusion was associated with an overall 94% response rate and a 65% complete response (CR) rate. Of the patients who failed an initial ILP with melphalan alone the overall response rate was 90% after the reperfusion with TNF and melphalan. In patients who failed an initial ILP with agents other than melphalan the CR rate was 100% after ILP with TNF and melphalan. TNF/melphalan isolated limb reperfusion was found to be more effective in terms of CR after initial ILP regimens that did not utilize melphalan (100% CR after nonmelphalan ILP vs. 50% CR after melphalan ILP [P = 0.04]). Regional toxicity was comprised of mild skin blistering and peeling in 47% of patients. One patient developed Grade 3 (based on National Cancer Institute Common Toxicity Criteria) skin necrosis, and one developed Grade 5 muscle and nerve toxicity, requiring an amputation.

CONCLUSIONS

Isolated limb reperfusion with TNF and melphalan can be performed safely with response rates similar to those of other trials of single perfusions. Repeat ILP using TNF and melphalan in patients with melanoma who have failed prior ILP with chemotherapeutics is justified. The utility of TNF (vs. melphalan alone) will be defined in ongoing Phase III trials.

Tissue toxicity of doxorubicin in first and second hyperthermic isolated limb perfusion--an experimental study in dogs

The aim of this experimental study in dogs was to assess the tissue toxicity of doxorubicin (DOX) and the impact of dose and pharmacokinetics after double isolated limb perfusion (ILP). Fifteen beagle dogs were assigned to three groups of five animals each. In the first ILP 0.75 mg/kg bodyweight (bw) DOX was given to all animals. In the second perfusion after an interval of 6 to 8 weeks the dosage was 0.5 mg/kg bw in group I, 0.75 mg/kg bw in group II, and 1.0 mg/kg bw in group III. At the same dosage tissue toxicity increased in comparison to the first ILP. At the second ILP there was a dose-toxicity relationship. At a dose of 0.75 mg/kg bw pharmacokinetics of DOX in the perfusate showed no significant differences between first and second perfusion. The mean muscle tissue levels during the second ILP were lower than during the first perfusion. However, in contrast to the first perfusion, they showed a further increase after perfusate eluation. A disturbed microcirculation caused by intima proliferations in arteries and arterioles fter the first ILP may impair the removal of DOX from the intravasal and interstitial compartment and can be assumed as a reason for increased tissue toxicity. Therefore, we recommend a reduction of DOX dose in the second ILP for clinical use.

Rhabdomyolysis and renal function impairment after isolated limb perfusion--comparison between the effects of perfusion with rhTNF alpha and a 'triple-drug' regimen

The aim of this study was to monitor serum and perfusate levels of myoglobin (MB) and creatine kinase (CK) during isolated limb perfusion (ILP) in order to identify those at risk of renal failure. We investigated the release of MB and CK in 40 patients who underwent ILP for melanoma (n = 15) or sarcoma (n = 25) using rhTNF alpha/melphalan (n = 28) or a triple-drug regimen (n = 12). Serial determinations of CK and MB were performed in both perfusate and systemic circulation during and after ILP and renal function was assessed. A significant increase of MB could be detected in the perfusate during ILP. After ILP, an up to 100-fold increase with a double peak of MB at 4 h and 24 h postoperatively was observed. The maximum elevation of serum activity of CK was at 30 h. The increase for both proteins was highly significant (P < 0.001). ILP with rhTNF alpha/melphalan yielded significantly (P < 0.001) higher serum values of MB and CK and also the impairment of the renal function was more pronounced. The peak values of MB after ILP occur early and allow the patients most at risk of developing renal failure to be identified. Rhabdomyolysis can be detected early by determination of MB from the perfusate. Further measurements twice daily for 2-3 days post ILP from serum samples as well as daily assessment of MB in the urine is helpful for detecting myoglobinuria and imminent renal failure.

Hyperthermic isolated limb perfusion with cisplatin in four patients with sarcomas of soft tissue and bone

The value of hyperthermic isolated limb perfusion (HILP) with cisplatin in the management of locally advanced soft tissue sarcomas or metastatic bone sarcoma was studied. Four patients were treated with HILP under mild hyperthermia (39-40 degrees C) with 20-30 mg cisplatin/l perfused limb volume. Toxicity in the perfused limbs was moderate, and the erythema and oedema that occurred resolved spontaneously within 7-14 days as did the slight motor and sensory neuropathy over a longer period of time. Clinically, a reduction of pain was observed in all patients. Two weeks after perfusion, tumour biopsies were taken to evaluate tumour response. Two patients showed a pathological complete response, one patient showed >90% necrosis and one patient showed no response. Currently patients are treated with tumour necrosis factor and melphalan as perfusion agents. The above-mentioned results make the combination of tumour necrosis factor with cisplatin in the isolated limb perfusion setting an interesting option.

Intracompartmental pressure during hyperthermic isolated limb perfusion for melanoma and sarcoma

Side effects of isolated limb perfusion (ILP) include rhabdomyolysis, paresthesia, or nerve palsy. The increase in intracompartmental pressure during ILP is thought to be linked to neuro- and muscular toxicity, and fasciotomy is recommended for protection. In 24 patients, intracompartmental pressure was measured. A flexible 5 F probe was placed into the non-tumour-bearing compartment of the perfused limb. Interstitial fluid pressure was measured using a piezoresistant tip. Compartmental pressure values were continuously recorded during and after ILP. The drugs used were a combination of doxorubicin, cisplatinum and melphalan or rhTNF-alpha combined with melphalan. The median overall compartmental pressure prior to ILP was 13 mmHg (range: 11-21 mmHg); during the heat-up phase the median pressure rose to 28 mmHg. During therapeutic perfusion a further increase could be documented and the maximum pressure measured was 90 mmHg; the median of the pressure maxima of all patients was 34 mmHg. During wash-out, at the end of the perfusion, a clear reduction in compartment pressures could be observed and the median dropped to a value of 27 mmHg. In all patients a continuous decrease in compartmental pressure could be recorded, reaching the pre-ILP values by 48 h post-operatively. A dramatic increase in compartmental pressure during ILP can be observed by continuous monitoring. Because of our observation that during the wash-out phase elevated compartmental pressures return to normal, there is no general indication for a fasciotomy. However, for patients maintaining a peak compartmental pressure above a critical threshold of 35 to 40 mmHg fasciotomy may be indicated.

Hyperthermic isolated regional perfusion with cisplatin in the local treatment of spontaneous canine osteosarcoma: assessment of short-term effects

To increase the effect of cisplatin on locoregional osteosarcoma, the short-term effect of hyperthermic isolated regional perfusion (HIRP) with cisplatin (30 mg/L extremity volume) was studied in 28 dogs with spontaneous osteogenic sarcoma, using clinical, radiological, and histological parameters. Thirty days postoperatively, mortality was 14.3%. Total platinum levels at the start of perfusion were 28.2 +/- 14.3 mg/L. A significant improvement (P < 0.001) in clinical score was observed in the overall group at 6 and 12 weeks after perfusion. The radiological parameter showed a stationary X-ray 2 weeks after perfusion and an improved X-ray 6 weeks after perfusion. Overall histological scores showed a moderate effect according to the Huvos classification. No additional therapeutic effect, according to the three parameters, could be demonstrated by increasing the perfusate temperature by 1 degrees C. HIRP with cisplatin is feasible in the local treatment of spontaneous osteosarcoma in dogs with acceptable locoregional toxicity. However, the histological results were modest, with none of the dogs showing a complete response 6 weeks after perfusion. Therefore, the search for the ideal perfusion agent with substantial contribution to the limb-sparing treatment in human osteosarcoma continues.