Chemoembolization of oral and oropharyngeal cancer using a high-dose cisplatin crystal suspension and degradable starch microspheres

Transcatheter arterial chemoembolization is safe and effective for patients with late-stage or recurrent oral carcinoma

Objective

We reported the long-term outcomes of transcatheter chemoembolization (TACE) for patients with late-stage or recurrent oral carcinoma.

Methods

This retrospective study enrolled 18 patients with late-stage or recurrent oral carcinoma between December 2015 and April 2021. The tumor-feeding artery was catheterized, and cisplatin/oxaliplatin and 5-FU/raltitrexed were infused with embolization using polyvinyl alcohol or gelatin sponge. Computed tomography was performed at about 1, 3, and 6 months after the procedure, and every 6 months after that. During the procedure and follow-up, procedure outcomes, complications, treatment efficacy, and overall survival were analyzed.

Results

A total of 31 sessions of TACE were performed, with a technical success rate of 100%. Of 12 patients combined with oral hemorrhage, two patients showed rebleeding 35 and 37 days later, with a clinical efficiency of hemostasis of 88.9%. Mild complications were observed in 11 patients (61.1%). Severe complications or procedure-related deaths were not observed during or after the procedure. The objective response rate and disease control rate were 20.0% and 86.7%, 38.5% and 61.5%, and 25.0% and 50.0% at 1, 3, and 6 months later, respectively. Seventeen patients (94.4%) were followed up, with a median duration of 37.8 months (IQR 22.3–56.8). Nine patients died of tumor progression, one died of massive rebleeding, and one died of severe lung infection. The median overall survival was 23.8 months.

Conclusion

TACE is a safe and effective procedure with minimal invasiveness for treating late-stage or recurrent oral carcinoma. TACE can be recommended as a palliative treatment, particularly for patients with oral hemorrhage.

Feasibility of drug-eluting embolics chemoembolization for the management of recurrent/advanced head and neck cancer

PURPOSE

To characterize the safety, tolerability, and efficacy of chemoembolization with drug-eluting embolic (DEE) microspheres in patients with recurrent and advanced head and neck cancer.

MATERIALS AND METHODS

In this retrospective study, 32 patients (mean age, 57.2 ± 2.8 years; 17 women) with recurrent (n=16) and advanced (n=16) head and neck cancer were treated with chemoembolization with DEE microspheres loaded with doxorubicin. Treatment response, overall survival, local progression-free survival, and adverse events were evaluated.

RESULTS

At six months after the procedure, the objective response and disease control rates were 25% and 69%, respectively. The median overall survival and local progression-free survival were 14.5 and 13.6 months, respectively. Seven patients (22%) experienced adverse events after the chemoembolization procedure. All adverse events were related to post-embolization syndrome, including vomiting and nausea (n=1), pyrexia (n=2) and localized pain (n=7). No severe adverse events or procedure-related deaths were observed.

CONCLUSION

Chemoembolization with DEE microspheres was safe and tolerable in patients with recurrent and advanced head and neck cancer.

[It's a matter of time and dosage - intra arterial chemotherapy for carcinoma of the oropharynx]

INTRODUCTION

Advanced head and neck cancer (HNC) patients have good response rates with radiochemotherapy. However, quality of life is often severely affected and the main reason for high rates of suicide. For a deliberately milder treatment, there is an option to selectively treat the tumor region with chemotherapy. This study reports on the treatment of oropharyngeal carcinoma with intra arterial short-term infusion.

METHODS

55 patients, suffering from inoperable carcinoma of the oropharynx have been treated with intra-arterial short-term infusion chemotherapy via angiocatheters or implanted arterial port catheters. Infusion time of 7 to 12 minutes. Patients with high tumor load or lung metastases had additional treatment of isolated thoracic perfusion.

RESULTS

Divergent overall survival rates have been noted depending on the pretreatment of the patients. One-, two-, and three-year survival rates of 76 %, 54 % and 35 % for patients without prior irradiation and 40 %, 7 % und 7 % for priorly irradiated patients have been observed. Particularly long overall survival rates have been observed for the subgroup of patients with pretreatment but without irradiation suffering from relapsed cancer, who reached median survival rates of 33.5 months. In contrast, the median survival of irradiated patients suffering from recurrent cancer was 8.2 months. Tracheostomy and tube feeding could be avoided in any case.

DISCUSSION

Randomized clinical trials are necessary to support these results. However, small dosages can generate high concentrations in limited volumes and therefore have an increased effect while keeping side effects low.

Management and prevention of acute bleedings in the head and neck area with interventional radiology

Background

The Interventional Neuroradiology is becoming more important in the interdisciplinary treatment of acute haemorrhages due to vascular erosion and vascular tumors in the head and neck area. The authors report on acute extracranial haemorrhage in emergency situations but also on preventive embolization of good vascularized tumors preoperatively and their outcome.

Methods

Retrospective analysis of 52 patients, who underwent an interdisciplinary approach of the ORL Department and the Interventional Neuroradiology over 5 ½ years at the Department of Otorhinolaryngology, Klinikum Rechts der Isar, Technical University of Munich, Germany. Their outcome was analysed in terms of success of the embolization, blood loss, survival rate and treatment failures.

Results

39/52 patients were treated for acute haemorrhage. Twenty-five of them attributable to vascular erosion in case of malignant tumors. Affected vessels were the common carotid artery as well as its internal and external parts with branches like the ascending pharyngeal, the facial and the superior thyroid artery.

Altogether 27/52 patients were treated for malignant tumors, 25/52 were attributable to acute haemorrhage due to epistaxis, after tonsillectomy, benign tumors and bleeding attributable to inflammations. Treatment of all patients consisted either of an unsuccessful approach via exposure, package of the bleeding, electrocoagulation or surgical ligature followed by embolization or the primary treatment via interventional embolization/stenting.

Conclusions

The common monitoring of patients at the ORL and interventional neuroradiology is an important alternative especially in the treatment of severe acute haemorrhage, following vascular erosion in malignant tumors or benign diseases. But also the preoperative embolization of good vascularized tumors must be taken into account to prevent severe blood loss or acute intraoperative bleeding.

Circumventing tumor resistance to chemotherapy by nanotechnology

Patient relapse and metastasis of malignant cells is very common after standard cancer treatment with surgery, radiation, and/or chemotherapy. Chemotherapy, a cornerstone in the development of present day cancer therapy, is one of the most effective and potent strategies to treat malignant tumors. However, the resistance of cancer cells to the drugs remains a significant impediment to successful chemotherapy. An additional obstacle is the inability of chemotherapeutic drugs to selectively target tumor cells. Almost all the anticancer agents have severe side effects on normal tissues and organs. The toxicity of currently available anticancer drugs and the inefficiency of chemotherapeutic treatments, especially for advanced stages of the disease, have limited the optimization of clinical drug combinations and effective chemotherapeutic protocols. Nanomedicine allows the release of drugs by biodegradation and self-regulation of nanomaterials in vitro and in vivo. Nanotechnologies are characterized by effective drug encapsulation, controllable self-assembly, specificity and biocompatibility as a result of their own material properties. Nanotechnology has the potential to overcome current chemotherapeutic barriers in cancer treatment, because of the unique nanoscale size and distinctive bioeffects of nanomaterials. Nanotechnology may help to solve the problems associated with traditional chemotherapy and multidrug resistance.

Chemoembolization of tongue carcinoma with ethylcellulose microcapsuled carboplatinum and its basic study

OBJECTIVE

By using lingual artery chemoembolization on the basis of detailed basic studies to search an additional way for treatment of certain tongue carcinoma.

METHODS

Study of lingual artery cast specimens in post-mortem human was processed. Patients with tongue carcinoma were chemoembolized with Carboplatinum microcapsules.

RESULTS

Microcapsule embolism located approximately at the fifth to the sixth branches level of deep lingual artery. Effective clinical outcomes complied with the anatomy.

CONCLUSION

Lingual artery chemoembolization with microcapsuled Carboplatinum of 214.0 +/- 48.0 microm showed nice efficacy in therapy of mid-tongue carcinoma.

Deep lingual arterial chemoembolization of tongue carcinoma with microcapsuled anticancer drug

OBJECTIVE

Microcapsule chemoembolism is a promising treatment of tumors. We describe a deep lingual arterial embolization of tongue carcinoma with microcapsuled carboplatinum.

METHODS

Lingual artery cast specimens from cadavers were microscopically examined, and 78 patients with tongue cancer were recruited and treated with the deep lingual arterial embolization therapy.

RESULTS

Microcapsule embolism occurred approximately at the fifth or sixth level of the deep lingual artery branches. The five-year survival rate was 88.5% (69 out of 78), and the ten-year survival rate 52.6% (41 out of 78).

CONCLUSION

The deep lingual arterial embolization of tongue carcinoma with microcapsuled carboplatinum is an effective therapy to treat carcinoma in mid-margin or mid-body of the tongue.

Anatomical and clinical study of lingual arterial chemoembolization for tongue carcinoma

OBJECTIVE

The aim of this study was to develop an alternative treatment approach using lingual artery chemoembolization for certain tongue carcinomas.

STUDY DESIGN

Fifty-three lingual artery, postmortem, cast human specimens were studied. Seventy-eight patients with tongue carcinoma were chemoembolized with Car-platinum microcapsules.

RESULTS

The deposition of the microcapsule embolism was approximately at the fifth- to the sixth-branch level of the deep lingual artery. The results complied with the anatomy, and the clinical outcomes were effective.

CONCLUSIONS

Lingual artery chemoembolization showed efficacy for curing carcinoma in the midmargin and midbody areas of the tongue, within the limitations of this study.

Diaphragmatic Weakness after Transcatheter Arterial Chemoembolization of Inferior Phrenic Artery for Treatment of Hepatocellular Carcinoma

PURPOSE

To prospectively assess the diaphragmatic anatomic and functional consequences of transcatheter arterial chemoembolization (TACE) of the inferior phrenic artery in patients with hepatocellular carcinoma.

MATERIALS AND METHODS

Informed consent and institutional review board approval were obtained. Fifteen patients (13 men, two women; mean age, 52 years; age range, 22-61 years) who underwent TACE of the inferior phrenic artery for treatment of hepatocellular carcinoma were enrolled. The right inferior phrenic artery was embolized in 14 patients, and the left inferior phrenic artery was embolized in one patient. Chest radiography, fluoroscopy, computed tomography (CT), and pulmonary function tests were performed before and after TACE of the inferior phrenic artery. The post-TACE examinations were performed 2-3 months after TACE, and the results were compared with those of the pre-TACE examinations. A paired t test or the Wilcoxon signed rank test was used for statistical analyses.

RESULTS

At chest radiography and fluoroscopy, six of 15 patients (40%) had both elevation and movement abnormality of the ipsilateral hemidiaphragm after TACE of the inferior phrenic artery. The mean (+/- standard deviation) diaphragmatic thickness on CT scans changed from 9.11 mm +/- 3.02 to 7.67 mm +/- 2.27 after TACE (P = .048). The mean vital capacity also was significantly decreased after TACE, from 91.87% +/- 18.52 to 82.27% +/- 16.94 of the predicted value (P = .006). The decreases in diaphragmatic thickness and vital capacity were most pronounced in the patients with abnormal findings at chest radiography and fluoroscopy.

CONCLUSION

After TACE of the inferior phrenic artery, a substantial portion of patients showed functional and anatomic evidence of diaphragmatic weakness.

Comorbidity in patients with cancer of the head and neck: Prevalence and impact on treatment and prognosis

At the time of diagnosis, many patients with head and neck cancer have other medical conditions, referred to as comorbidity. These other medical conditions may affect treatment and prognosis. Several valid instruments are available to capture the individual comorbid ailments and their prognostic impact. Inclusion of comorbidity information will assist in the analysis of treatment effectiveness, quality of care assessment, and outcomes studies based on observational studies.

[Local chemotherapy for squamous cell cancer of the oral cavity and oropharynx]

BACKGROUND

Modern treatment concepts for patients suffering from oral and oropharyngeal cancer include more and more adjuvant therapeutic options. Local chemotherapy offers the possibility to apply an extremely high drug concentration at the tumor site while minimizing possible side effects by systemic neutralization at the same time.

PATIENTS AND METHODS

A total of 289 patients with histologically proven carcinoma of the oral cavity and the oropharynx underwent neoadjuvant intra-arterial chemotherapy with high-dosage cisplatin within a multimodal therapeutic setting. Concerning the TNM classification, more than 70% of the patients were classified as stages III and IV. The mean age at the time of intervention was 60 years, and 71% of the patients were male.

RESULTS

After the first cycle 19.3% of the patients presented with complete remission (grade I); 35.4% and 41.5% showed partial remissions (grade II) or stable disease (grade III), respectively. The mean observation time after treatment was 28 months (median: 24.2 months). Of the 137 patients who completed the full multimodal therapeutic scheme, 11% developed local recurrence, and 12.4% developed lymph node or distant metastasis. At the time of evaluation, 72.5% of these patients were still alive.

CONCLUSION

Intra-arterial chemotherapy is a safe and highly effective procedure that should be considered as an important option in multimodal therapeutic concepts for oral and oropharyngeal cancer.

Chemoembolization Using Cisplatin Crystals as Neoadjuvant Treatment of Oral Cancer

Chemoembolization for cancer of the head and neck has been used very rarely in the past owing to local characteristics and risks. By combining the antineoplastic activity and embolizing effect in the same drug, a more routine use seems possible. A cisplatin suspension in normal saline (5 mg in 1 mL) with precipitation of microembolizing cisplatin crystals and without additional drugs was prepared. The cisplatin dosage was 150 mg/m2, the maximum absolute dose 300 mg, and the maximum amount of fluid 60 mL. One hundred and three consecutive patients with previously untreated squamous cell carcinomas of the oral cavity and the anterior oropharynx were treated in a neoadjuvant setting with superselective chemoembolization using the cisplatin suspension. Acceptance by the patients has been excellent with no refusal. Overall response after one intervention has been 73%, with 18.5% showing pathological complete remissions. The highest response rates could be seen in T1-3 tumors and tumors of the oral tongue and floor of the mouth. Measurable acute systemic toxicity has been low. Postembolization syndrome, especially swelling, had to be observed carefully. There have been 3.5% interventional and 10% local complications, which could be significantly reduced by the use of this procedure only in cancers of the oral tongue, floor of the mouth, and mandibular alveolar ridge. Chemoembolization of cancer in the head and neck area can be carried out regularly and safely using this method, and it is highly effective. It could be used as an induction before definitive surgery or radiotherapy. Further investigation is mandatory to assess the potential of chemoembolization for the improvement of local control and survival.

Biodistribution of 10B in a rat liver tumor model following intra-arterial administration of sodium borocaptate (BSH)/degradable starch microspheres (DSM) emulsion

We reported that intra-arterial administration of borocaptate sodium (BSH)/lipiodol emulsion provided selectively high (10)B concentrations (approximately 200 ppm 6 h after administration) in experimental liver tumors. In the present study, we investigated the pharmacokinetics of BSH following intra-arterial administration of BSH with other embolizing agent, degradable starch microspheres (DSM). The (10)B concentration in the tumor at 1 h after administration of BSH with DSM was 231 ppm. At 6 h, the (10)B concentration in the tumor in BSH with DSM group was 81.5 ppm. The (10)B concentration in the liver at 1 h after administration of BSH with DSM was 184 ppm. At 6 h, the(10)B concentration in the liver in BSH with DSM group was 78 ppm. The tumor/liver (10)B concentration ratios (T/L ratio) in the "BSH+DSM" group were significantly smaller than those in the "BSH+lipiodol" group at 1 h (1.4 vs. 3.6) and 6h (1.1 vs. 14.9). BSH/DSM-boron neutron capture therapy (BNCT) was not suitable for treatment of multiple liver tumors due to the low T/L (10)B concentration ratio. However, the high (10)B accumulation in the liver tumors following intra-arterial administration of BSH/DSM emulsion suggests that BSH/DSM-BNCT has the potential for application to malignant tumors in other sites.

Interventional neuroradiology of the head and neck

Vascular interventions are important and helpful for treatment of various pathologies of the head and neck. Interventional neuroradiology of the head and neck includes image-guided biopsies, vessel occlusion, and local chemotherapy. Knowledge of anatomy, functional relationships between intra- and extracranial vessels, and pathology are the basis for therapeutic success. The interventional neuroradiologist is responsible for appropriate selection of patients based on clinical information, indications, and risk assessment. Neuroradiologic imaging, especially CT and MR imaging, and appropriate analysis of angiographic findings help ensure indication for treatment and plan an intervention. Technical equipment, including an angiographic unit, catheters, needles, embolizing materials, and so forth, are important. Knowledge of hemodynamics is relevant to avoid complications and to find the optimal technique for solving the clinical problem. Indications for image-guided biopsies are preverterbal fluid-collections, spinal and paraspinal inflammations and abscesses, deep cervical malignancies, vertebral body, and skull base tumors. Special care should be taken to preserve critical structures in this region, including spinal nerve roots, cervical plexus, main peripheral nerves, and vessels. Indications for vessel occlusion are emergency situations to stop bleeding in vascular lesions (traumatic, malformation, or tumors) by reduction of pressure, preoperative reduction of blood flow to minimize the surgical risk, palliative occlusion of feeding vessels to produce tumor necrosis, or potential curative (or presurgical) occlusion of vascular malformations. Pressure reduction to support normal coagulation, such as epistaxis, in hereditary hemorrhagic telangiectasia can be achieved by proximal vessel occlusion with large particles or platinum coils. Prevention of intraoperative bleeding requires occlusion of the microvascular bed with small particles. Examples of these interventions are: a hemangioma of the hard palate, a juvenile angiofibroma, a hemangiopericytoma, a malignant meningioma, a malignant fibrous histiocytoma, and a glomus tumor. Effective treatment of vascular malformations, such as AV fistulas or angiomas, needs exact occlusion of the fistula or the angiomatous nidus, which is demonstrated in the case of an AV angioma of the base of the tongue. Chemotherapy with local intra-arterial cisplatin combined with intravenous administration of sodium thiosulfate as antidote is indicated as an adjuvant modality in a multimodal regimen of oropharyngeal squamous cell carcinoma or as palliative treatment of recurrent and otherwise untreatable malignant tumors of the head and neck. Examples are a carcinoma of the alveolar ridge, a squamous cell carcinoma of the floor of the mouth, and a nasopharyngeal lymphoepithelioma. Palliative treatment of a bleeding oropharyngeal cancer is another example of interventional treatment. Selective treatment, either occluding or pharmacologic, may be preoperative, palliative, or curative. The objective is reduction of surgical risk, improvement of quality of life, or curative therapy of a lesion. Thus, the interventional treatment should not be associated with morbidity or mortality. Major complications, such as cerebral stroke, blindness, or cranial nerve palsies, can result from application of inappropriate techniques or poor evaluation of angiographic findings and should be avoided in the majority of cases. Sometimes collateral lesions are unavoidable. These include inflammation, necrosis, and nerve damage. Based on neuroradiologic experience, most of those risks are predictable. The benefits, risks, and expected damages of neuroradiologic interventions must be balanced during the informed consent procedure with the patient. Avoiding complications, handling unavoidable problems, and dealing with complications is a skill founded on knowledge and experience. Continuing education is a firm basis to push the limits of interventions and expand benefits without increasing risk for the patient. Nevertheless, state-of-the-art external carotid intervention should, in skilled hands, have a permanent morbidity far below 1% and no mortality.

Improved method of recombinant AAV2 delivery for systemic targeted gene therapy

A major hurdle in most current gene therapy modalities is the ability to transduce target tissues at very high efficiencies that ultimately lead to therapeutic levels of transgene expression. We have developed a novel method of recombinant adeno-associated virus 2 (rAAV) delivery that results in increased vector transduction efficiencies using microspheres reversibly conjugated to rAAV vectors. We hypothesize that conjugation to microspheres should result in a higher effective concentration of vector as well as longer relative exposure time of vector to target cells as it moves through the tissue vasculature. In vitro experiments demonstrate that the same level of transduction seen with free vector can be achieved using 1% of vector when conjugated to microspheres. In addition, using magnetic microspheres, the region of infection can be targeted. In vivo, we demonstrate that microsphere-mediated delivery of rAAV vector results in higher transduction efficiencies than delivery with free vector alone when administered either intramuscularly or intravenously. Furthermore, we demonstrate targeting of transgene expression to specific tissues by retention of microsphere-bound vector in the capillary bed. These studies demonstrate a novel method to deliver rAAV vectors more effectively that could prove to be a successful alternative mode of virus-mediated human gene therapy.