A phase I study of gemcitabine given via intrahepatic pump for primary or metastatic hepatic malignancies

Saturable Hepatic Extraction of Gemcitabine Involves Biphasic Uptake Mediated by Nucleoside Transporters Equilibrative Nucleoside Transporter 1 and 2

Hepatic arterial infusion (HAI) chemotherapy with gemcitabine (GEM) is expected to be more effective and safer method to treat hepatic metastasis of pancreatic cancer compared with intravenous administration, because it affords higher tumor exposure with lower systemic exposure. Thus, a key issue for dose selection is the saturability of hepatic uptake of GEM. Therefore, we investigated GEM uptake in rat and human isolated hepatocytes. Hepatic GEM uptake involved high- and low-affinity saturable components with Km values of micromolar and millimolar order, respectively. The uptake was inhibited concentration dependently by S-(4-nitrobenzyl)-6-thioinosine (NBMPR) and was sodium-ion-independent, suggesting a contribution of equilibrative nucleoside transporters (ENTs). The concentration dependence of uptake in the presence of 0.1 μM NBMPR showed a single low-affinity binding site. Therefore, the high- and low-affinity sites correspond to ENT1 and ENT2, respectively. Our results indicate hepatic extraction of GEM is predominantly mediated by the low-affinity site (hENT2), and at clinically relevant hepatic concentrations of GEM, hENT2-mediated uptake would not be completely saturated. This is critical for HAI, because saturation of hepatic uptake would result in a marked increase of GEM concentration in the peripheral circulation, abrogating the advantage of HAI over intravenous administration in terms of severe adverse events.

Phase I trial of oral S-1 combined with hepatic arterial infusion of gemcitabine in unresectable biliary tract cancer

PURPOSE

S-1 and gemcitabine (GS) combination therapy is a promising treatment for advanced biliary tract cancer (BTC). However, systemic administration of GS is associated with a high rate of grade 3 and 4 neutropenia. Hepatic arterial infusion (HAI) of gemcitabine may overcome this problem. We conducted a prospective phase 1 trial to determine the maximum tolerated dose (MTD) of S-1 and rates of dose-limiting toxicities (DLTs) associated with HAI of gemcitabine in patients with unresectable BTC.

METHODS

BTC patients were treated with 21-day cycles of HAI of gemcitabine (1000 mg/m(2) on days 1 and 8) and oral S-1 (60, 70, or 80 mg/m(2) on days 1-14) until disease progression occurred.

RESULTS

Fifteen patients were enrolled in the study. Grade 3 and 4 neutropenia occurred in five of 15 (33%) patients. Among six patients who were treated with 60 mg/m(2) S-1, one developed grade 4 neutropenia. DLTs (grade 4 neutropenia and bladder infection) occurred in two of six patients who were treated with 70 mg/m(2) S-1. Two of the three patients who were treated with 80 mg/m(2) S-1 experienced DLTs (grade 4 leukopenia and neutropenia and grade 3 febrile neutropenia). Thus, 80 mg/m(2) was defined as the MTD of S-1.

CONCLUSION

The MTD of oral S-1 in GS therapy is 80 mg/m(2). Furthermore, HAI of gemcitabine may reduce the rate of grade 3 and 4 neutropenia in BTC patients receiving GS therapy.

Palliation: treating patients with inoperable biliary tract and primary liver tumors

This article summarizes the current literature in treatment of unresectable biliary tract and primary liver tumors. Locoregional therapies including radiofrequency ablation, percutaneous ethanol injection, cryoablation, microwave ablation, transarterial chemoembolization, hepatic artery infusion, radioembolization ((90)Y), and bland embolization are discussed and clinical trials compared. Palliative strategies including surgical, percutaneous, and endoscopic techniques to decompress the biliary system and improve symptoms are also summarized. Systemic chemotherapy and sorafenib used in conjunction with locoregional therapies or as sole therapeutic options are discussed.

Implantable arterial port-related bloodstream infection in patients with primary or metastatic hepatic malignancies

The incidence of implantable arterial post-related bloodstream infections (IAP-RBSI) among patients with unresectable hepatic malignancies is not well defined. We reviewed the 9-year incidence of implantable arterial post-related bloodstream infections in patients with hepatic malignancies, at a tertiary care center in Japan. The incidence was 1.9 infections per 10,000 catheter-days.

Hepatic arterial infusion chemotherapy with gemcitabine and 5-fluorouracil or oral S-1 improves the prognosis of patients with postoperative liver metastases from pancreatic cancer

Hepatic metastasis is a common cause of treatment failure following resection of pancreatic cancer. In this study, we report our results of hepatic arterial infusion (HAI) chemotherapy with gemcitabine (GEM) plus 5-fluorouracil (5-FU) or oral S-1 treatment for postoperative liver metastases from pancreatic cancer. Seven patients with postoperative liver metastases from pancreatic cancer received HAI with GEM plus 5-FU or oral S-1 between October, 2008 and September, 2010 at Kanazawa University Hospital (Kanazawa, Japan). Three out of the 7 cases exhibited a partial response (PR) according to Response Evaluation Criteria in Solid Tumors (RECIST) and stable disease (SD) was achieved in 3 out of the 7 cases (response rate, 85.7%). A decrease in serum tumor marker CA 19-9 levels was observed after 10 HAI treatment cycles in 5 out of the 7 cases. The median time to treatment failure was 8 months (range, 0–17 months). Adverse events included grade 3 leukocytopenia in 1 case and anemia in all 7 cases, although 5 out of the 7 patients were anemic prior to HAI therapy. Grade 2 thrombocytopenia was also observed in 2 cases. Non-hematological events, such as nausea, diarrhea, liver injury or neuropathy and life-threatening toxicities were not reported; however, 6 patients (85.7%) developed catheter-related complications and the HAI catheter and subcutaneous implantable port system had to be removed. These findings demonstrated that HAI may deliver high doses of chemotherapeutic agents directly into the tumor vessels, producing increased regional levels with greater efficacy and a lower incidence/severity of systemic side effects. In conclusion, HAI chemotherapy is a safe and effective treatment for liver metastases from pancreatic cancer.

Phase I trial of hepatic arterial infusion of nanoparticle albumin-bound paclitaxel: toxicity, pharmacokinetics, and activity

Because liver involvement in patients with metastatic cancer has limited options and poor outcomes, we conducted a phase I study to determine the safety, activity, and pharmacokinetic characteristics of hepatic arterial infusion of nanoparticle albumin-bound paclitaxel (HAI nab-paclitaxel). Cohorts of three patients having predominant hepatic metastases received HAI nab-paclitaxel at three dose levels (180, 220, and 260 mg/m(2), respectively) infused for more than 1 hour every 3 weeks (3 + 3 design). Some patients participated in comparative pharmacokinetic studies (i.v. vs. HAI), receiving their first course i.v., to determine peak concentrations and effect of first-pass hepatic extraction compared with subsequent courses administered by HAI. The highest dose level was expanded to determine the safety and activity of HAI nab-paclitaxel. Thirty-eight patients were treated. There were no dose-limiting toxicities at doses up to 260 mg/m(2). Common adverse events included alopecia, fatigue, myelosuppresion, nausea, and vomiting. Three patients had stable disease for 4 or more months and 2 patients (1 of 12 with breast cancer and 1 of 1 with cervical cancer) achieved a partial response lasting for 5 and 15 months, respectively. Peak concentrations were lower (∼50%) with greater hepatic extraction of drug (∼42%) following HAI than i.v. infusion based on area under the curve comparison of drug exposure. HAI nab-paclitaxel showed partial hepatic extraction. At doses 260 mg/m(2) or less given for 1 hour every 3 weeks, the treatment was well-tolerated and showed activity in advanced cancer patients with predominant liver metastases.

Pilot study of hepatic arterial infusion chemotherapy with gemcitabine and 5-fluorouracil for patients with postoperative liver metastases from pancreatic cancer

Hepatic metastasis is a common cause of treatment failure after curative resection of pancreatic cancer. We report a pilot study of hepatic arterial infusion (HAI) chemotherapy with gemcitabine and 5-fluorouracil (5-FU) for postoperative liver metastases from pancreatic cancer. Five patients who had undergone curative resection of liver metastases from pancreatic cancer received HAI of gemcitabine and 5-FU between October 2008 and September 2010 at Kanazawa University Hospital. Gemcitabine at a dose of 800 mg was infused over 30 min via a bedside pump. After gemcitabine administration, 250 mg of 5-FU was infused continuously over 24 h on days 1-5, comprising one cycle of therapy. These treatment cycles were continued biweekly. In the evaluation according to RECIST criteria, a partial response was obtained in 2 of the 5 cases, with stable disease being achieved in the remaining 3 cases (response rate, 100%). In 4 of the 5 cases, a decrease in serum tumor marker CA19-9 was observed after 10 HAI treatment cycles. The median time to treatment failure was 10 months (range 3-17). As to adverse events, leukocytopenia was grade 3 in 1 of 4 affected cases and all 5 were anemic, although 4 of the 5 cases had anemia prior to HAI therapy. Grade 2 thrombocytopenia was observed in 2 cases. No nonhematologic events, such as nausea, diarrhea, liver injury and neuropathy, occurred. There were no life-threatening toxicities, but 4 cases (80%) developed catheter complications, and the HAI catheter and subcutaneous implantable port system had to be removed. HAI delivers high doses of chemotherapeutic agents directly into tumor vessels, producing increased regional levels with greater efficacy and a lower incidence/severity of systemic side effects. In conclusion, HAI chemotherapy is useful and safe for the treatment of malignancies confined to the liver.

Hepatic arterial infusion chemotherapy for post-operative liver metastases from pancreatic cancer in a patient with leukocytopenia: A case report

Here, we present a case of post-operative liver metastases from pancreatic head cancer in a patient with leukocytopenia, who was safely treated by hepatic arterial infusion (HAI) chemotherapy consisting of gemcitabine and 5-FU. The patient was a 61-year-old woman who underwent pancreaticoduodenectomy for pancreatic head cancer, but was found to be an unsuitable candidate for adjuvant systemic chemotherapy due to the presence of leukocytopenia. Five months after surgery, a follow-up CT revealed two liver metastases. Intravenous systemic chemotherapy was also contraindicated due to the leukocytopenia. In the apparent absence of recurrence, excepting the liver metastases, we decided to administer HAI chemotherapy, which had already been administered following the curative surgery. HAI chemotherapy has been shown to be associated with a lower incidence of systemic side effects. Gemcitabine at a dose of 400 mg was administered via a bedside pump and infused over 30 min. After gemcitabine infusion, 250 mg of 5-FU was infused continuously over 24 h from days 1 to 5. This comprised 1 cycle of therapy. The treatment cycles were continued biweekly. After 10 cycles without severe side effects, it was found that though the size of the metastatic tumors was not reduced, tumor vascularity was. However, after the 13th treatment cycle, local recurrence and lymph node metastases were detected. By this time, the patient had recovered from the leukocytopenia, and could thus be administered systemic chemotherapy. In conclusion, HAI chemotherapy is useful and safe for the treatment of malignancies confined to the liver, even in cases where the patient is in a reduced physical condition.

Long-term clinical outcomes of hepatic arterial infusion chemotherapy with cisplatin with or without 5-fluorouracil in locally advanced hepatocellular carcinoma

PURPOSE

Hepatic arterial infusion chemotherapy (HAIC) has often been used as a therapeutic option for patients with advanced hepatocellular carcinoma (HCC). This study aimed to evaluate the efficacy and safety of HAIC using cisplatin with or without 5-fluorouracil in patients with advanced HCC.

METHODS

Between January 2002 and December 2007, we enrolled patients with advanced HCC who underwent HAIC via implantable port systems with cisplatin (60 mg/m(2) on Day 1) with or without 5-fluorouracil (500 mg/m(2) on Days 1-3) every 4 weeks. Tumor response was assessed every two cycles.

RESULTS

During follow-up (median 9.5 months), we recorded patient (n = 138) and disease characteristics including median age (53 years), Child-Pugh class A/B (n = 103/35, respectively), portal vein thrombosis (n = 115), and death (n = 121). In total, 561 cycles of HAIC were administered (median four cycles, range 1-14). Ninety-one patients received cisplatin plus 5-fluorouracil, while 47 received only cisplatin. The median progression-free survival (PFS) and overall survival (OS) were 6.0 and 9.5 months, respectively, while the overall disease control rate was 62.3% (3 complete responses, 29 partial responses and 54 stable diseases). Patients treated with cisplatin plus 5-fluorouracil had longer median PFS (7.0 vs. 4.6 months in those given cisplatin only; p = 0.004) and OS (12.0 vs. 7.5 months in those given cisplatin only; p = 0.001). Adverse reactions were tolerable and successfully managed with conservative treatment.

CONCLUSIONS

Repetitive HAIC seems well-tolerated and effective in treating advanced HCC, with more therapeutic benefit when treated with cisplatin plus 5-fluorouracil. Future randomized comparative studies are warranted for its efficacy.