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Guadagni S, Fiorentini G, Palumbo P, Masedu F, Ricevuto E, Bruera G, Deraco M, Kusamura S, Sarti D, Fiorentini C, Gailhofer S, Clementi M. Hypoxic pelvic perfusion with cisplatin and mitomycin C in multidisciplinary palliative treatment of patients with unresectable recurrent rectal cancer: a retrospective study. MINERVA CHIR 2019; 74:304-312. [PMID: 31062943 DOI: 10.23736/s0026-4733.19.07896-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
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.
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Affiliation(s)
- Stefano Guadagni
- Section of General Surgery, Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, L'Aquila, Italy -
| | - Giammaria Fiorentini
- Unit of Medical Oncology, Department of Oncology and Hematology, Ospedali Riuniti Marche Nord, Pesaro, Italy
| | - Paola Palumbo
- Laboratory of Immunopathology, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Francesco Masedu
- Section of Biostatistics and Epidemiology, Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, L'Aquila, Italy
| | - Enrico Ricevuto
- Section of Oncology, Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, L'Aquila, Italy
| | - Gemma Bruera
- Section of Oncology, Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, L'Aquila, Italy
| | - Marcello Deraco
- Unit of Peritoneal Surface Malignancies, Colon and Rectal Surgery, National Cancer Institute Foundation, Milan, Italy
| | - Shigeki Kusamura
- Unit of Peritoneal Surface Malignancies, Colon and Rectal Surgery, National Cancer Institute Foundation, Milan, Italy
| | - Donatella Sarti
- Unit of Medical Oncology, Department of Oncology and Hematology, Ospedali Riuniti Marche Nord, Pesaro, Italy
| | - Caterina Fiorentini
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Sabine Gailhofer
- Department of Surgical Oncology, Medias Klinikum, Burghausen, Germany
| | - Marco Clementi
- Section of General Surgery, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
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Guadagni S, Clementi M, Bencivenga M, Kusamura S, Fiorentini C, Masedu F. Palliation with a multimodality treatment including hypoxic pelvic perfusion for unresectable recurrent rectal cancer: outcomes based on a retrospective study. Updates Surg 2018; 70:441-447. [PMID: 30191532 DOI: 10.1007/s13304-018-0592-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 08/29/2018] [Indexed: 01/19/2023]
Abstract
Patients with unresectable recurrent rectal cancer that progresses after systemic chemotherapy and radiotherapy are 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. From a cohort of 77 patients with unresectable recurrent rectal cancer in progression after standard treatments and submitted to HPP, 21 patients underwent repeat HPP using mitomycin C (MMC) at the dose of 25 mg/m2. After the last HPP, 7 patients received a targeted-therapy with cetuximab according to overexpression of epidermal growth factor receptor in recurrence cancer cells. The median overall survival of these 21 patients from the diagnosis of unresectable recurrent rectal cancer was 23 months (iqr 18-24). After the first HPP, the median survival of the 21 patients until death or end of follow-up was 10 months (iqr 9-13). The 1-year and 2-year survival rates were 71.4%, and 4.8%, respectively. From the first HPP, age > 60 years, a recurrence shrinkage of at least 30% (partial response), and the addition of a post-HPP targeted-therapy with cetuximab significantly affected survival (P < 0.04). In conclusion, repeated MMC-HPP followed by targeted-therapy seems to be an effective palliative treatment for patients with unresectable recurrent rectal cancer in progression after systemic chemotherapy and radiation but the results of this study have to be confirmed by a larger phase III trial.
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Affiliation(s)
- Stefano Guadagni
- Department of Applied Clinical Sciences and Biotechnology, Section of General Surgery, University of L'Aquila, Via Vetoio, 67100, L'Aquila, Italy.
| | - Marco Clementi
- Department of Life, Health and Environmental Sciences, University of L'Aquila, 67100, L'Aquila, Italy
| | - Maria Bencivenga
- General and Upper GI Surgery Division, University of Verona, Piazzale Aristide Stefani 1, 37126, Verona, Italy
| | - Shigeki Kusamura
- Fondazione IRCCS, Istituto Nazionale dei Tumori Milano, Via Venezian 1, 20133, Milan, Italy
| | - Caterina Fiorentini
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, 53100, Siena, Italy
| | - Francesco Masedu
- Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, 67100, L'Aquila, Italy
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Guadagni S, Palumbo G, Fiorentini G, Clementi M, Marsili L, Giordano AV, Masedu F, Valenti M. Surgical versus percutaneous isolated pelvic perfusion (IPP) for advanced melanoma: comparison in terms of melphalan pharmacokinetic pelvic bio-availability. BMC Res Notes 2017; 10:411. [PMID: 28810925 PMCID: PMC5558752 DOI: 10.1186/s13104-017-2738-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 08/07/2017] [Indexed: 01/19/2023] Open
Abstract
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 (AUC0 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 AUC0 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.
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Affiliation(s)
- Stefano Guadagni
- Department of Applied Clinical Sciences and Biotecnology, University of L'Aquila, via Vetoio, 67100, L'Aquila, Italy.
| | - Giancarlo Palumbo
- Department of Life, Health and Environmental Sciences, University of L'Aquila, via Vetoio, 67100, L'Aquila, Italy
| | - Giammaria Fiorentini
- Medical Oncology Unit, Department of Oncology and Hematology, Azienda Ospedaliera "Ospedali Riuniti Marche Nord", Pesaro, Italy
| | - Marco Clementi
- Department of Life, Health and Environmental Sciences, University of L'Aquila, via Vetoio, 67100, L'Aquila, Italy
| | - Luca Marsili
- Department of Applied Clinical Sciences and Biotecnology, University of L'Aquila, via Vetoio, 67100, L'Aquila, Italy
| | - Aldo Victor Giordano
- Department of Applied Clinical Sciences and Biotecnology, University of L'Aquila, via Vetoio, 67100, L'Aquila, Italy
| | - Francesco Masedu
- Department of Applied Clinical Sciences and Biotecnology, University of L'Aquila, via Vetoio, 67100, L'Aquila, Italy
| | - Marco Valenti
- Department of Applied Clinical Sciences and Biotecnology, University of L'Aquila, via Vetoio, 67100, L'Aquila, Italy
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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.
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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.
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Affiliation(s)
- Eelco de Bree
- Department of Surgical Oncology, Medical School of Crete University Hospital, Herakleion, Greece.
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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.
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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.
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Affiliation(s)
- S Bonvalot
- Department of Surgery, Institut Gustave Roussy, 94805 Villejuif, France.
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van Ijken MGA, van Etten B, Brunstein F, ten Hagen TLM, Guetens G, de Wilt JHW, de Bruijn EA, Eggermont AMM. Bio-chemotherapeutic strategies and the (dis) utility of hypoxic perfusion of liver, abdomen and pelvis using balloon catheter techniques. Eur J Surg Oncol 2005; 31:807-16. [PMID: 15951150 DOI: 10.1016/j.ejso.2005.02.032] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2004] [Revised: 02/03/2005] [Accepted: 02/14/2005] [Indexed: 01/07/2023] Open
Abstract
AIMS To review the development and current status of balloon catheter mediated hypoxic perfusion of abdomen, pelvis and liver for treatment of locally advanced malignancies. Within this context we focus on the addition of tumour necrosis factor-alpha (TNF) to these minimal invasive perfusion procedures. METHODS A literature search on these topics was carried out in PubMed for indexed articles and in all issues of Regional Cancer Treatment. The findings were related to our own experiences. RESULTS Hypoxic abdominal (HAP) and hypoxic pelvic perfusion (HPP) using balloon catheters, are currently applied modalities for treatment of a wide variety of abdominal and pelvic tumours, yet scientific validation of these procedures is poor. Following the results of several Phase I-II trials, both treatments are associated with severe systemic toxicity, significant morbidity and even mortality. The degree of systemic leakage associated with these procedures prohibits addition of TNF. For leakage free liver perfusion surgery is still required, as with current balloon catheter techniques it is not possible to perform leakage free isolated hypoxic hepatic perfusion (IHHP), using either orthograde or retrograde hepatic flow. Experimental and clinical observations suggest that within any perfusion setting, the utilization of TNF is only indicated for treatment of highly vascularised tumours and not for treatment of colorectal tumours. CONCLUSION Balloon catheter technology in its present form does not provide adequate leakage control in any of these settings and is therefore associated with considerable toxicity. It is associated with poor response rates and cannot be considered in any setting as a standard of care.
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Affiliation(s)
- M G A van Ijken
- Department of Surgical Oncology, Erasmus Medical Center, Daniel den Hoed Cancer Center, Groene Hilledijk 301, 3075 EA Rotterdam, The Netherlands
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