1
|
Pegoraro F, Santangelo D, Santangelo A, Pelosio L, Jamshidi A, Camera L, Imbriaco M, Mainolfi CG, Insabato L, Accarino R, Giuliano M, Carlomagno N, D'Alessandro V, Santangelo ML. R0 surgical resection of giant dedifferentiated retroperitoneal liposarcomas in the COVID era with and without nephrectomy: A case report. Oncol Lett 2023; 26:410. [PMID: 37600332 PMCID: PMC10436160 DOI: 10.3892/ol.2023.13996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 06/13/2023] [Indexed: 08/22/2023] Open
Abstract
Retroperitoneal sarcomas (RPSs) are rare findings that can grow into large masses without eliciting severe symptoms. At present, surgical resection is the only radical therapy, whenever it can be performed with the aim to achieve a complete removal of the tumor. The present report describes two consecutive cases of RPSs that resulted in dedifferentiated liposarcomas (DDLPSs) and these patients underwent R0 surgical resection with and without a nephron-sparing procedure. The diagnostic workup, the surgical approach, the impact of late surgical management due to the COVID pandemic and the latest literature on the topic are discussed and analyzed. The patients, who refused to undergo any medical examination during the prior 2 years due to the COVID pandemic, were admitted to Federico II University Hospital (Naples, Italy) complaining about weight loss and general abdominal discomfort. In the first case, a primitive giant abdominal right neoplasm of retroperitoneal origin enveloping and medializing the right kidney was observed. The second patient had a similar primitive retroperitoneal giant left neoplasm, which did not affect the kidney. Given the characteristics of the masses and the absence of distant metastases, after a multidisciplinary discussion, radical surgical removal was carried out for both patients. The lesions appeared well-defined from the surrounding tissues, and markedly compressed all the adjacent organs, without signs of infiltration. In the first patient, the right kidney was surrounded and undetachable from the tumor and it was removed en bloc with the mass. The second patient benefited from a nephron-sparing resection, due to the existence of a clear cleavage plane. The postoperative courses were uneventful. Both the histological examinations were oriented towards a DDLPS and both patients benefited from adjuvant chemotherapy. In conclusion, the treatment of giant RPS is still challenging and requires multidisciplinary treatment as well as, when possible, radical surgical removal. The lack of tissue infiltration and the avoidance of excision or reconstruction of major organs (including the kidney) could lead to an easier postoperative course and an improved prognosis. When possible, surgical management of recurrences or incompletely resected masses must be pursued. Since the COVID pandemic caused limited medicalization of a number of population groups and delayed diagnosis of other oncologic diseases, an increased number of DDLPSs could be expected in the near future.
Collapse
Affiliation(s)
- Francesca Pegoraro
- Operative Unit of Hepato-Biliary-Pancreatic, Minimally Invasive and Robotic Surgery and Kidney Transplantation, Department of Clinical Medicine and Surgery, Federico II University Hospital, I-80131 Naples, Italy
| | - Domenico Santangelo
- Department of Radiology, ‘Scientific Hospitalization and Treatment Institute’ San Raffaele Hospital, I-20132 Milano, Italy
| | - Alfonso Santangelo
- Department of General Surgery and Emergency Surgery, ‘Scientific Hospitalization and Treatment Institute’ San Raffaele Hospital, I-20132 Milano, Italy
| | - Luigi Pelosio
- Operative Unit of General Surgery and Retroperitoneal Diseases, Department of Clinical Medicine and Surgery, Federico II University Hospital, I-80131 Naples, Italy
| | - Akbar Jamshidi
- Operative Unit of General Surgery and Retroperitoneal Diseases, Department of Clinical Medicine and Surgery, Federico II University Hospital, I-80131 Naples, Italy
| | - Luigi Camera
- Operative Unit of Diagnostic Imaging and Radiotherapy, Federico II University Hospital, I-80131 Naples, Italy
| | - Massimo Imbriaco
- Operative Unit of Diagnostic Imaging and Radiotherapy, Federico II University Hospital, I-80131 Naples, Italy
| | - Ciro Gabriele Mainolfi
- Operative Unit of Diagnostic Imaging and Radiotherapy, Federico II University Hospital, I-80131 Naples, Italy
| | - Luigi Insabato
- Operative Unit of Pathology, Department of Advanced Biomedical Science, Federico II University Hospital, I-80131 Naples, Italy
| | - Rossella Accarino
- Operative Unit of Pathology, Department of Advanced Biomedical Science, Federico II University Hospital, I-80131 Naples, Italy
| | - Mario Giuliano
- Operative Unit of Medical Oncology, Department of Clinical Medicine and Surgery, Federico II University Hospital, I-80131 Naples, Italy
| | - Nicola Carlomagno
- Operative Unit of General Surgery and Kidney Transplantation, Department of Advanced Biomedical Science, Federico II University Hospital, I-80131 Naples, Italy
| | - Vincenzo D'Alessandro
- Operative Unit of General Surgery and Retroperitoneal Diseases, Department of Clinical Medicine and Surgery, Federico II University Hospital, I-80131 Naples, Italy
| | - Michele L. Santangelo
- Operative Unit of General Surgery and Kidney Transplantation, Department of Advanced Biomedical Science, Federico II University Hospital, I-80131 Naples, Italy
| |
Collapse
|
2
|
Wang H, Tang X, Xie L, Dong S, Chen C, Guo W. Stop-Flow Pelvic Chemoperfusion for the Treatment of Malignant Pelvic Bone Tumors: A Preliminary Study. Orthop Surg 2020; 12:741-748. [PMID: 32243077 PMCID: PMC7307261 DOI: 10.1111/os.12666] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 03/02/2020] [Accepted: 03/04/2020] [Indexed: 01/25/2023] Open
Abstract
Objective To preliminarily study the efficacy and safety of stop‐flow pelvic chemoperfusion, a novel therapeutic strategy for treating pelvic malignancies. Methods Stop‐flow chemoperfusion was performed six times in 5 patients with primary pelvic malignancies. Aortic and vena cave balloons and tourniquets were used to isolate pelvic blood flow from systemic circulation. Cisplatin was then perfused through a transarterial catheter to achieve exposure to a higher drug concentration. Pelvic and peripheral blood samples were collected to determine drug concentration during perfusion. The efficacy of stop‐flow pelvic perfusion was assessed by measuring the change in tumor size, the visual analogue scale, and the tumor necrosis rate after perfusion. Safety was assessed by classifying adverse events according to CTCAE v4.03. Results The mean area under the curve (AUC) and maximum drug concentration in the pelvis during perfusion were 246.23 min μg/mL and 17.29 μg/mL, respectively. These measures were significantly higher than the peripheral mean AUC and maximum drug concentration of 52.08 min μg/mL and 5.14 μg/mL, respectively. All 5 patients showed stable disease in response, with changes in tumor size of −4.7%, −5.4%, +4.7%, −8.4%, and 0.0%. Among the 5 patients, 3 (60%) experienced significant pain relief after perfusion. Three patients underwent surgery, with tumor necrosis of 63%, <60%, and 93%. No severe complications were observed in this study. Conclusions Stop‐flow pelvic chemoperfusion resulted in exposure to drug higher concentration with fewer serious complications. These preliminary results suggest that further studies are required to comprehensively assess the therapeutic potential of stop‐flow pelvic chemoperfusion in pelvic malignancies.
Collapse
Affiliation(s)
- Han Wang
- Musculoskeletal Tumor Centre, Peking University People's Hospital, Beijing, China
| | - Xiaodong Tang
- Musculoskeletal Tumor Centre, Peking University People's Hospital, Beijing, China
| | - Lu Xie
- Musculoskeletal Tumor Centre, Peking University People's Hospital, Beijing, China
| | - Sen Dong
- Musculoskeletal Tumor Centre, Peking University People's Hospital, Beijing, China
| | - Chen Chen
- Department of Radiology, Peking University People's Hospital, Beijing, China
| | - Wei Guo
- Musculoskeletal Tumor Centre, Peking University People's Hospital, Beijing, China
| |
Collapse
|
3
|
Peluso G, Incollingo P, Calogero A, Tammaro V, Rupealta N, Chiacchio G, Sandoval Sotelo ML, Minieri G, Pisani A, Riccio E, Sabbatini M, Bracale UM, Dodaro CA, Carlomagno N. Current Tissue Molecular Markers in Colorectal Cancer: A Literature Review. BIOMED RESEARCH INTERNATIONAL 2017; 2017:2605628. [PMID: 29214162 PMCID: PMC5682052 DOI: 10.1155/2017/2605628] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Revised: 09/18/2017] [Accepted: 10/03/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND Colorectal cancer (CRC) is one of the most spread neoplasia types all around the world, especially in western areas. It evolves from precancerous lesions and adenomatous polyps, through successive genetic and epigenetic mutations. Numerous risk factors intervene in its development and they are either environmental or genetic. AIM OF THE REVIEW Alongside common screening techniques, such as fecal screening tests, endoscopic evaluation, and CT-colonography, we have identified the most important and useful biomarkers and we have analyzed their role in the diagnosis, prevention, and prognosis of CRC. CONCLUSION Biomarkers can become an important tool in the diagnostic and therapeutic process for CRC. But further studies are needed to identify a noninvasive, cost-effective, and highly sensible and specific screening test for their detection and to standardize their use in clinical practice.
Collapse
Affiliation(s)
- Gaia Peluso
- Department of Advanced Biomedical Science, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Paola Incollingo
- Department of Advanced Biomedical Science, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Armando Calogero
- Department of Advanced Biomedical Science, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Vincenzo Tammaro
- Department of Advanced Biomedical Science, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Niccolò Rupealta
- Department of Advanced Biomedical Science, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Gaetano Chiacchio
- Department of Advanced Biomedical Science, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Maria Laura Sandoval Sotelo
- Department of Advanced Biomedical Science, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Gianluca Minieri
- Department of Advanced Biomedical Science, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Antonio Pisani
- Department of Public Health, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Eleonora Riccio
- Department of Public Health, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Massimo Sabbatini
- Department of Public Health, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Umberto Marcello Bracale
- Department of Public Health, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Concetta Anna Dodaro
- Department of Advanced Biomedical Science, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Nicola Carlomagno
- Department of Advanced Biomedical Science, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| |
Collapse
|
4
|
Mitomycin C hypoxic pelvic perfusion for unresectable recurrent rectal cancer: pharmacokinetic comparison of surgical and percutaneous techniques. Updates Surg 2017; 69:403-410. [PMID: 28791628 PMCID: PMC5591364 DOI: 10.1007/s13304-017-0480-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 07/12/2017] [Indexed: 01/19/2023]
Abstract
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 (AUC0–20). The mean values ± SD for the ratios between the MMC AUC0–20 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.
Collapse
|
5
|
Facchini G, Della Pepa C, Cavaliere C, Cecere SC, Di Napoli M, D'Aniello C, Crispo A, Iovane G, Maiolino P, Tramontano T, Piscitelli R, Pisconti S, Montella M, Berretta M, Sorrentino D, Perdonà S, Pignata S. From Clinical Trials to the Front Line: Vinflunine for Treatment of Urothelial Cell Carcinoma at the National Cancer Institute of Naples. Front Pharmacol 2016; 7:110. [PMID: 27199753 PMCID: PMC4853416 DOI: 10.3389/fphar.2016.00110] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 04/11/2016] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The efficacy of Vinflunine, after failure of platinum-based chemotherapy in patients with metastatic or recurrent Transitional Cell Cancer of the Urothelial Tract, TCCU, has been demonstrated in an international, randomized, phase III trial comparing Vinflunine plus Best Supportive Care, BSC, with BSC alone. On the basis of that study vinflunine has been approved by the European Medicine Association, EMA, for treatment of TCCU patients after failure of a platinum treatment. However, since data in clinical trials often differ from routine clinical practice due to unselected population and less strict monitoring, "real life" experiences are very helpful to verify the efficacy of a new therapy. METHODS This was a spontaneous, observational, retrospective study involving 43 patients with metastatic TCCU treated with vinflunine at our cancer center, data about demographics, disease characteristics, and previous treatments were collected and outcome and toxicities of vinflunine were analyzed. RESULTS 41 of 43 patients were eligible for RR analysis, the Overall RR was 12%, the Disease Control Rate was 29%; when including only patients treated in II line the DCR rose to 33%; the median PFS and the median OS were 2.2 and 6.9 months, respectively. CONCLUSION Our findings were consistent with the outcome data emerged in the phase III randomized trial and in the other observational studies conducted all around Europe in the last 2-3 years. This experience supports the use of vinflunine in patients with advanced TTCU as effective and manageable antineoplastic drug.
Collapse
Affiliation(s)
- Gaetano Facchini
- Division of MedicalOncology, Department of Uro-Gynaecological Oncology, Istituto Nazionale Tumori Fondazione G. Pascale Naples, Italy
| | - Chiara Della Pepa
- Division of MedicalOncology, Department of Uro-Gynaecological Oncology, Istituto Nazionale Tumori Fondazione G. Pascale Naples, Italy
| | - Carla Cavaliere
- Division of MedicalOncology, Department of Uro-Gynaecological Oncology, Istituto Nazionale Tumori Fondazione G. Pascale Naples, Italy
| | - Sabrina C Cecere
- Division of MedicalOncology, Department of Uro-Gynaecological Oncology, Istituto Nazionale Tumori Fondazione G. Pascale Naples, Italy
| | - Marilena Di Napoli
- Division of MedicalOncology, Department of Uro-Gynaecological Oncology, Istituto Nazionale Tumori Fondazione G. Pascale Naples, Italy
| | - Carmine D'Aniello
- Department of Onco-Ematology Medical Oncology, S.G. Moscati Hospital of Taranto Taranto, Italy
| | - Anna Crispo
- Unit of Epidemiology, Struttura Complessa di Statistica Medica, Biometria e Bioinformatica, Fondazione Istituto Nazionale Tumori Naples, Italy
| | - Gelsomina Iovane
- Division of MedicalOncology, Department of Uro-Gynaecological Oncology, Istituto Nazionale Tumori Fondazione G. Pascale Naples, Italy
| | - Piera Maiolino
- Pharmacy Unit, Istituto Nazionale Tumori, Istituto Nazionale Tumori-Fondazione G. Pascale Naples, Italy
| | - Teresa Tramontano
- Pharmacy Unit, Istituto Nazionale Tumori, Istituto Nazionale Tumori-Fondazione G. Pascale Naples, Italy
| | - Raffaele Piscitelli
- Pharmacy Unit, Istituto Nazionale Tumori, Istituto Nazionale Tumori-Fondazione G. Pascale Naples, Italy
| | - Salvatore Pisconti
- Department of Onco-Ematology Medical Oncology, S.G. Moscati Hospital of Taranto Taranto, Italy
| | - Maurizio Montella
- Unit of Epidemiology, Struttura Complessa di Statistica Medica, Biometria e Bioinformatica, Fondazione Istituto Nazionale Tumori Naples, Italy
| | | | - Domenico Sorrentino
- Division of Urology, Department of Uro-Gynaecological Oncology, Istituto Nazionale Tumori Fondazione G. Pascale Naples, Italy
| | - Sisto Perdonà
- Division of Urology, Department of Uro-Gynaecological Oncology, Istituto Nazionale Tumori Fondazione G. Pascale Naples, Italy
| | - Sandro Pignata
- Division of MedicalOncology, Department of Uro-Gynaecological Oncology, Istituto Nazionale Tumori Fondazione G. Pascale Naples, Italy
| |
Collapse
|
6
|
Santangelo ML, Criscitiello C, Renda A, Federico S, Curigliano G, Dodaro C, Scotti A, Tammaro V, Calogero A, Riccio E, Pisani A, Carlomagno N. Immunosuppression and Multiple Primary Malignancies in Kidney-Transplanted Patients: A Single-Institute Study. BIOMED RESEARCH INTERNATIONAL 2015; 2015:183523. [PMID: 26185750 PMCID: PMC4491567 DOI: 10.1155/2015/183523] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Revised: 08/21/2014] [Accepted: 09/30/2014] [Indexed: 12/14/2022]
Abstract
Immunodeficiency is associated with higher cancer incidence. However, it is unknown whether there is a link between immunodeficiency and development of multiple primary malignancies. In the present study we analyse this link focusing on kidney-transplanted patients, as they are at higher risk of developing cancer due to the chronic assumption of immunosuppressants. We followed up 1200 patients who underwent kidney transplantation between 1980 and 2012. A total of 77/1200 kidney-transplanted patients developed cancer and 24 of them developed multiple cancers. Most multiple cancers were synchronous with a nonsignificant association between cancer and rejection episodes. In the general cancer population, one-ninth of patients are at higher risk of developing a second tumor over a lifetime; hence it would be reasonable to conclude that, from a merely theoretical and statistical viewpoint, long-term transplanted patients potentially have a higher risk of developing MPMs. However, data did not confirm this assumption, probably because these patients die before a second primary malignancy appears. Despite many observations on the increased incidence of different tumor types in immunodeficient patients and despite immunosuppression certainly being a predisposing factor for the multicancer syndrome, data so far are not robust enough to justify a correlation between immunodeficiency and multiple primary malignancies in transplanted patients.
Collapse
Affiliation(s)
- Michele L. Santangelo
- Department of Advanced BioMedical Sciences, Operative Unit of General Surgery & Transplants, University of Naples Federico II, 80131 Naples, Italy
| | - Carmen Criscitiello
- Division of Early Drug Development for Innovative Therapies, European Institute of Oncology, 20141 Milan, Italy
| | - Andrea Renda
- Department of Advanced BioMedical Sciences, Operative Unit of General Surgery & Transplants, University of Naples Federico II, 80131 Naples, Italy
| | - Stefano Federico
- Department of Public Medicine, Operative Unit of Nephrology, University of Naples Federico II, 80131 Naples, Italy
| | - Giuseppe Curigliano
- Division of Early Drug Development for Innovative Therapies, European Institute of Oncology, 20141 Milan, Italy
| | - Concetta Dodaro
- Department of Advanced BioMedical Sciences, Operative Unit of General Surgery & Transplants, University of Naples Federico II, 80131 Naples, Italy
| | - Alessandro Scotti
- Department of Advanced BioMedical Sciences, Operative Unit of General Surgery & Transplants, University of Naples Federico II, 80131 Naples, Italy
| | - Vincenzo Tammaro
- Department of Advanced BioMedical Sciences, Operative Unit of General Surgery & Transplants, University of Naples Federico II, 80131 Naples, Italy
| | - Armando Calogero
- Department of Advanced BioMedical Sciences, Operative Unit of General Surgery & Transplants, University of Naples Federico II, 80131 Naples, Italy
| | - Eleonora Riccio
- Department of Public Medicine, Operative Unit of Nephrology, University of Naples Federico II, 80131 Naples, Italy
| | - Antonio Pisani
- Department of Public Medicine, Operative Unit of Nephrology, University of Naples Federico II, 80131 Naples, Italy
| | - Nicola Carlomagno
- Department of Advanced BioMedical Sciences, Operative Unit of General Surgery & Transplants, University of Naples Federico II, 80131 Naples, Italy
| |
Collapse
|
7
|
Uzan C, Goere D, Dumont F, Gouy S, Muret J, Hakime A, De Baere T, Bonvalot S. Isolated pelvic perfusion in irradiated unresectable recurrence of pelvic tumor: preliminary outcome and ongoing study. J Visc Surg 2014; 151 Suppl 1:S11-5. [PMID: 24582274 DOI: 10.1016/j.jviscsurg.2014.01.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
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.
Collapse
Affiliation(s)
- C Uzan
- Département de chirurgie, institut Gustave-Roussy, 114, rue Édouard-Vaillant, 94805 Villejuif, France.
| | - D Goere
- Département de chirurgie, institut Gustave-Roussy, 114, rue Édouard-Vaillant, 94805 Villejuif, France
| | - F Dumont
- Département de chirurgie, institut Gustave-Roussy, 114, rue Édouard-Vaillant, 94805 Villejuif, France
| | - S Gouy
- Département de chirurgie, institut Gustave-Roussy, 114, rue Édouard-Vaillant, 94805 Villejuif, France
| | - J Muret
- Département d'anesthésie, institut Gustave-Roussy, 114, rue Édouard-Vaillant, 94805 Villejuif, France
| | - A Hakime
- Département de radiologie interventionnelle, institut Gustave-Roussy, 114, rue Édouard-Vaillant, 94805 Villejuif, France
| | - T De Baere
- Département de radiologie interventionnelle, institut Gustave-Roussy, 114, rue Édouard-Vaillant, 94805 Villejuif, France
| | - S Bonvalot
- Département de chirurgie, institut Gustave-Roussy, 114, rue Édouard-Vaillant, 94805 Villejuif, France
| |
Collapse
|
8
|
de Bree E, Romanos J, Tsogkas J, Askoxylakis J, Metaxari M, Michalakis J, Volakakis E, Melissas J, Tsiftsis DD. Complications and toxicity after abdominal and pelvic hypoxic stop-flow perfusion chemotherapy: incidence and assessment of risk factors. Ann Surg Oncol 2012; 19:3591-7. [PMID: 22576062 DOI: 10.1245/s10434-012-2383-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2011] [Indexed: 01/19/2023]
Abstract
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.
Collapse
Affiliation(s)
- Eelco de Bree
- Department of Surgical Oncology, Medical School of Crete University Hospital, Herakleion, Greece.
| | | | | | | | | | | | | | | | | |
Collapse
|
9
|
Abstract
Isolated pelvic perfusion (IPP) is a form of intra-arterial local-regional treatment of tumor-bearing organs. IPP using a simplified balloon occlusion technique has shown promise in palliation of resectability of advanced rectal cancer in patients not amenable to treatment with conventional chemoradiation. This article reviews technique criteria and the response to IPP from seven literature studies of isolated pelvic perfusion with colorectal cancer. Current efforts should be directed to improving anti-tumor responses by optimizing chemotherapeutic protocols and modifying perfusion parameters, so that hopefully, this will lead to a more standardized and improved procedure for the isolated pelvic perfusion technique.
Collapse
|
10
|
Kuemmerle A, Decosterd LA, Buclin T, Liénard D, Stupp R, Chassot PG, Mosimann F, Lejeune F. A phase I pharmacokinetic study of hypoxic abdominal stop-flow perfusion with gemcitabine in patients with advanced pancreatic cancer and refractory malignant ascites. Cancer Chemother Pharmacol 2008; 63:331-41. [PMID: 18587581 DOI: 10.1007/s00280-008-0743-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2007] [Accepted: 03/17/2008] [Indexed: 01/02/2023]
Abstract
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.
Collapse
Affiliation(s)
- Andrea Kuemmerle
- Division de Pharmacologie Clinique, Département de Médecine, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | | | | | | | | | | | | | | |
Collapse
|
11
|
Recovery profiles of general anesthesia and spinal anesthesia for chemotherapeutic perfusion with circulatory block (stop-flow perfusion). Anesth Analg 2007; 105:1500-3, table of contents. [PMID: 17959989 DOI: 10.1213/01.ane.0000281051.24740.93] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
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.
Collapse
|
12
|
Nakazato K, Kim C, Terajima K, Murata S, Fujitani H, Nakanishi K, Tajima H, Kumazaki T, Sakamoto A. Large volume loading to prevent cisplatin-induced nephrotoxicity during negative-balance isolated pelvic perfusion. J Cancer Res Clin Oncol 2007; 133:741-7. [PMID: 17503082 DOI: 10.1007/s00432-007-0217-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2006] [Accepted: 03/23/2007] [Indexed: 10/23/2022]
Abstract
PURPOSE Negative-balance isolated pelvic perfusion (NIPP) is used to administer high doses of anticancer drugs such as cisplatin to patients with advanced cancer of the pelvic region. Although the drugs are intended to be specifically delivered to the pelvis, their leakage into the systemic circulation can cause acute renal failure. This study examines the loading volume required for preservation of renal function during anesthesia of NIPP. METHODS Pelvic cancer patients were assigned to NIPP according to its enrollment criteria. Patients with heart failure, uncontrollable hypertension, renal failure, pulmonary disease or contraindication for the contrast media were excluded. We compared the current anesthesia management regime with a previous protocol, with regard to the loading volume and renal function as assessed by the calculated glomerular filtration rate (GFR). The correlation between the total loading volume and the GFR ratio (GFR after NIPP/GFR before NIPP) was evaluated to define adequate volume loading. RESULTS The GFR ratios were 0.86 +/- 0.29 and 1.12 +/- 0.25 for the previous and current procedures, respectively. The regression line showed that a minimum loading volume of 28.8 ml kg(-1) h(-1) was required to maintain a GFR ratio of > or =1. CONCLUSIONS A large volume infusion preserves the GFR despite high-dose cisplatin administration by NIPP.
Collapse
Affiliation(s)
- Keiko Nakazato
- Department of Anesthesiology, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, 113-8602, Tokyo, Japan.
| | | | | | | | | | | | | | | | | |
Collapse
|
13
|
Bonvalot S, Bonnay M, Drouard-Troalen L, Cavalcanti A, Le Péchoux C, Le Cesne A, Blay JY, Laborde F. Pressure-suit combined with pelvic stop-flow: A feasibility study in a bovine model. Eur J Surg Oncol 2007; 33:114-8. [PMID: 17088039 DOI: 10.1016/j.ejso.2006.09.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2006] [Accepted: 09/29/2006] [Indexed: 10/23/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- S Bonvalot
- Department of Surgery, Institut Gustave Roussy, 94805 Villejuif, France.
| | | | | | | | | | | | | | | |
Collapse
|
14
|
van Ijken MGA, van Etten B, Guetens G, de Bruijn EA, Ten Hagen TLM, Wiggers T, Eggermont AMM. Balloon catheter hypoxic pelvic perfusion with mitomycin C and melphalan for locally advanced tumours in the pelvic region: A phase I—II trial. Eur J Surg Oncol 2005; 31:897-904. [PMID: 16084053 DOI: 10.1016/j.ejso.2005.06.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2004] [Revised: 05/18/2005] [Accepted: 06/16/2005] [Indexed: 10/25/2022] Open
Abstract
AIMS To investigate the feasibility of hypoxic pelvic perfusion (HPP), using balloon catheter techniques as treatment modality for locally advanced pelvic malignancies. METHODS In a phase I--II study, 16 patients with various non-resectable pelvic tumours were treated with two HPP with MMC and melphalan, followed by radiotherapy (25 Gy) and surgical resection if feasible. Toxicity and procedure related complications were documented. Tumour responses were assessed by MRI or CT. Pain reductive effects were assessed by evaluation of pain registration forms. RESULTS HPP resulted in augmented regional drug concentrations with relatively low systemic levels. Some severe systemic toxicity was observed. One procedure related death occurred. Pain reduction effects were short-lived. Ten patients had radiological NC, two PD and one PR. In 11 patients surgical resection was performed, which was microscopically radical in six cases. Mean survival was 26.8 months (range 1--86). CONCLUSION The seemingly favorable pharmacokinetic profiles observed with HPP in this and other studies can still lead to severe systemic toxicity. In terms of survival, local (re-)recurrence and pain reduction there seems no benefit of addition of HPP to pre-operative radiotherapy. HPP with MMC and melphalan, does not seem a therapeutic option in patients with locally advanced pelvic tumours.
Collapse
Affiliation(s)
- M G A van Ijken
- Department of Surgical Oncology, Erasmus Medical Center Rotterdam, Daniel den Hoed Cancer Center, Groene Hilledijk 301, 3075 EA Rotterdam, The Netherlands
| | | | | | | | | | | | | |
Collapse
|