Long-duration intracavitary infusion of methotrexate with systemic leucovorin protection in patients with malignant effusions

Review: Advances in Intraperitoneal (Intracavitary) Administration of Synthetic Polymers for Immunotherapy and Chemotherapy

Intraperitoneal (IP) catheters linked to subcutaneous portals have made routine intracavitary chemotherapy or immunotherapy safe and convenient. The IP route is anatomically appropriate for adjuvant or palliative treatment of intracavitary disease. IP chemotherapy has been successfully applied to ovarian, mesothelial, and gastrointestinal tumors.

Data shows that IP divinyl ether/maleic anhydride copolymer. MVE-2 (MW 15,000), has distinct localizing and toxicologic differences from that given intravenously (IV). When MVE-2 is given IV renal injury is observed; this is not seen on IP administration. The highest IP concentrations are found in mediastinal and mesenteric nodes, thymus and testis while the highest IV MVE-2 accumulation is found in the liver, spleen, adrenal, and kidney.

The IP route for treatment of tumors allows for high local tumoricidal drug concentrations or for regionalized immunostimulation with activating polymers or leukokines. The IP space can provide an antitumor, and antiviral immunizing site and/or a source of activated antitumor peritoneal exudate cells. The use of IP chemotherapy readily permits systemic neutralization of drug toxicity and can provide high portal venous concentrations of drug for the treatment of early liver metastasis.

This review speaks to the convenience and safety of the IP intracavitary route which provides a new option for the clinical utilization of polymers where regionalized abdominal effects and improved therapeutic index are warranted. The biologic application of IP polymers requires polymer distribution and kinetic studies which will provide unique tissue concentrations for application to immunization, cancer treatment and other diseases.

Comparison different methods of intraoperative and intraperitoneal chemotherapy for patients with gastric cancer: a meta-analysis

PURPOSE

To investigate the efficacy and safety of intraperitoneal chemotherapy (IPC) for patients with gastric cancer and to compare effects between different regimens of IPC.

METHOD

Randomized controlled trials comparing the effects of surgery plus intraperitoneal chemotherapy with surgery alone or comparing the efficacy between different regimens of intraperitoneal chemotherapy were searched for in Medline, Embase, Pubmed, the Cochrane Library and the Chinese BioMedical Disc and so on by two independent reviewers. After quality assessment and data extraction, data were pooled for meta-analysis using RevMan5.16 software. Tests of interaction were used to test for differences of effects among subgroups grouped according to different IPC regimens.

RESULTS

Fifteen RCTs with a total of 1713 patients with gastric cancer were included for quality assessment and data extraction. Ten studies were judged to be of fair quality and entered into meta-analysis. Hyperthermic intraoperative intraperitoneal chemotherapy (HR=0.60, P<0.01), hyperthermic intraoperative intraperitoneal chemotherapy plus postoperative intraperitoneal chemotherapy (HR=0.47, P<0.01) and normothermic intraoperative intraperitoneal chemotherapy (HR=0.70, P=0.01) were associated with a significant improvement in overall survival. Tests of interaction showed that hyperthermia and additional postoperative intraperitoneal chemotherapy did not impact on its effect. Further analysis revealed that intraperitoneal chemotherapy remarkably decrease the rate of postoperative hepatic metastasis by 73% (OR=0.27, 95% CI=0.12 to 0.67, P<0.01). However, intraperitoneal chemotherapy increased risks of marrow depression (OR=5.74, P<0.01), fever (OR=3.67, P=0.02) and intra-abdominal abscess (OR=3.57, P<0.01).

CONCLUSION

The present meta-analysis demonstrates that hyperthermic intraoperative intraperitoneal chemotherapy and normothermic intraoperative intraperitoneal chemotherapy should be recommended to treat patients with gastric cancer because of improvement in overall survival. However, it is noteworthy that intraperitoneal chemotherapy can increase the risks of marrow depression, intra-abdominal abscesses, and fever.

Pharmacologic principles of intraperitoneal chemotherapy for the treatment of ovarian cancer

Intraperitoneal therapy has now been demonstrated in multiple randomized trials to improve the outcome of chemotherapy for patients with optimally debulked or small volume ovarian carcinoma. This article reviews the basic pharmacologic principles that underlie the use of intraperitoneal therapy and identifies the key factors that determine the pharmacologic advantage of this route of administration. These include the relative peritoneal and plasma clearances and elements of tumor vascular permeability and blood flow that limit the penetration of drug entering tumor nodules by free-surface diffusion. New information about how cisplatin and carboplatin are transported into ovarian carcinoma cells points to novel strategies for further improving the therapeutic effectiveness of intraperitoneal chemotherapy

Development and Validation of Enzyme‐Linked Immunosorbent Assays for Quantification of Anti‐Methotrexate IgG and Fab in Mouse and Rat Plasma

This laboratory is investigating the use of anti-methotrexate IgG (AMI) and anti-methotrexate Fab fragments (AMF) within an inverse targeting strategy that is designed to enhance the pharmacokinetic selectivity of intraperitoneal (i.p.) chemotherapy. The goal of this study was to develop enzyme-linked immunosorbent assays (ELISAs) to determine concentrations of AMI and AMF in mouse and rat plasma. An antigen-specific ELISA was developed for AMI and AMF in mouse and rat plasma. The assay was validated with respect to precision and accuracy by evaluating the recovery of AMI and AMF from mouse and rat plasma samples. Preliminary pharmacokinetic studies of AMI and AMF were performed in Sprague-Dawley rats and Swiss Webster mice. The animals were instrumented with a jugular vein cannula and administered AMI or AMF, 15 mg kg(-1) via the cannula. Plasma samples were taken at various time points and analyzed using the ELISA, and the observed concentration vs. time profiles were subjected to non-compartmental pharmacokinetic analyses. Standard curves for the ELISAs were found to be linear over concentration ranges of 0-250 and 0-350 ng mL(-1) for AMI and AMF, respectively. Intra-assay and inter-assay recovery of AMI and AMF from plasma samples were found to be within 15% of theoretical values. Preliminary pharmacokinetic investigations of AMI allowed estimation of AMI clearance to be 0.017 mL kg(-1) min(-1) in the rat and 0.043 mL kg(-1) min(-1) in the mouse. AMF clearance was estimated to be 0.038 and 1.93 mL kg(-1) min(-1) in the mouse and rat, respectively. In conclusion, ELISAs have been developed and validated for quantitation of AMI and AMF in rat and mouse plasma. The assays will allow further investigations of AMI and AMF pharmacokinetics.

Intraperitoneal chemotherapy in ovarian cancer

From a theoretical viewpoint, intraperitoneal therapy (IP) in patients with ovarian cancer, a malignancy which remains mainly confined to the peritoneal cavity, is logical. Over the past decades this approach has evolved into a therapeutic strategy for a selected group of patients. Data available at present suggest a beneficiary role (for IP therapy) as first-line treatment in patients with small residual disease and possibly following initial reduction of tumor load by systemic chemotherapy. The theoretical basis, the present status of IP therapy in different settings, pharmacology, factors limiting its clinical utility and future directions are reviewed.

Transatrial access to the normal pericardial space: a novel approach for diagnostic sampling, pericardiocentesis, and therapeutic interventions

BACKGROUND

A nonsurgical means to access the normal pericardial space could provide opportunities for diagnostic sampling and therapeutic interventions. Because there are currently no approved nonsurgical methods to accomplish this, we tested a new approach in large animals.

METHODS AND RESULTS

A catheter system was employed in a percutaneous approach from a femoral vein to pierce the right atrial appendage. Pericardial access was confirmed by placement of a radiopaque guidewire visible under fluoroscopy (6 dogs, 13 pigs). In 7 of the pigs, pericardial tamponade, produced by injection of saline or heparinized blood into the pericardial space through this route, was confirmed by fluoroscopy and hemodynamic evidence. The feasibility and safety of this access route were tested with multiple repetitions in all 19 animals. At the end of each of the 17 acute experiments, direct inspection after thoracotomy revealed no hemopericardium, laceration, or bleeding on catheter withdrawal. In 24-hour survival studies performed in 2 of the 6 dogs, the animals exhibited no behavioral signs of discomfort or untoward consequences on recovery from anesthesia. Histology revealed only a small (approximately 1-mm) fibrinous plug at the site of puncture.

CONCLUSIONS

The percutaneous approach via the right atrial appendage provides a rapid, safe route to access the normal pericardial space for diagnostic sampling and to alleviate high-volume and low-volume (<200 mL) pericardial effusions. The access route is potentially useful for selective administration of therapeutic agents, growth factors, gene vectors, and cardioactive and vasoactive agents to the heart.

Inverse targeting of peritoneal tumors: selective alteration of the disposition of methotrexate through the use of anti-methotrexate antibodies and antibody fragments

We have hypothesized that antidrug antibodies (ADAb) may be employed to impart site-specific alterations in the disposition of drug molecules, potentially allowing for targeted drug therapy. We are specifically interested in minimizing systemic exposure to free drug and systemic toxicities resultant from regional chemotherapy through the intravenous administration of ADAb. In this report, we present the production and purification of anti-methotrexate Fab fragments, and we present investigations of the effects of anti-methotrexate Fab and anti-methotrexate immunoglobulin G on the disposition of methotrexate in the rat. Pharmacokinetic studies revealed that intravenous anti-methotrexate immunoglobulin G (anti-MTX IgG) and anti-methotrexate Fab (anti-MTX Fab) administration produced dramatic alterations in the plasma pharmacokinetics of methotrexate (MTX), following intraperitoneal MTX administration (area under the total MTX concentration vs time curve for anti-MTX IgG relative to control, 420 +/- 90 (p < 0.05); for anti-MTX Fab relative to control, 46 +/- 6.1 (p < 0.05); area under the free MTX concentration vs time curve for anti-MTX IgG relative to control, 0.64 +/- 0.16; for anti-MTX Fab relative to control, 0.45 +/- 0.20 (p < 0.05)). Additional studies conducted in anesthetized rats revealed no significant alterations in the area under the total peritoneal MTX concentration vs time curves, free MTX peritoneal concentration vs time curves, or peritoneal exit rate of MTX in anti-MTX Fab treated animals relative to controls. Therefore, our pharmacokinetic studies demonstrate that ADAb may produce site-specific alterations in drug pharmacokinetics, potentially enhancing the site specificity of drug distribution and drug action following regional chemotherapy.

Pharmacokinetic and pharmacodynamic optimization of intraperitoneal chemotherapy

Intraperitoneal drug administration has been utilized to increase chemotherapeutic exposure to tumors confined to the peritoneal cavity, such as those found in ovarian, gastric, colo-rectal and mesotheliomal cancers. Extensive pre-clinical and clinical experimentation has been conducted to assess the pharmacokinetic and therapeutic benefits of this mode of therapy. Pharmacokinetic studies have shown that the barrier function of the peritoneal membrane may be utilized to produce large, favorable concentration gradients between peritoneal perfusate and blood. However, most clinical studies so far have demonstrated minimal increases in drug efficacy or decreases in drug toxicities from intraperitoneal drug therapy alone. This paper reviews the application of adjunctive therapies that have been rationally conceived to optimize intraperitoneal drug therapy through the alteration of antineoplastic pharmacokinetics and pharmacodynamics.

High-affinity rabbit antibodies directed against methotrexate: production, purification, characterization, and pharmacokinetics in the rat

We describe the production, purification, characterization, and disposition of rabbit polyclonal methotrexate antibodies. These antibodies are prepared for subsequent testing of a drug delivery approach to reduce systemic toxicity upon regional administration of methotrexate. The polyclonal antibodies were raised in New Zealand white female rabbits immunized with a methotrexate-bovine serum albumin conjugate. The anti-methotrexate antibodies were sequestered from rabbit serum through the use of a protein-G affinity column which allowed for purification of up to 100 mg of rabbit IgG in 30-40 min. The extent of purification was demonstrated through SDS-PAGE and calculation of specific binding activity relative to total protein concentration. The purified antibodies have been shown to have high affinity (Keq range: 1.8 x 10(8) to 8.75 x 10(9) M-1) and high selectivity for methotrexate. Preliminary pharmacokinetic studies of the purified antibodies in the rat following a 6 mg/kg intravenous infusion (n = 4) indicate a steady state volume of distribution of 38.0 +/- 11.2 mL kg-1, a systemic clearance of 0.92 +/- 0.67 mL kg-1 h-1 and an elimination half life of 28.9 +/- 7.9 h (mean +/- SD).

Deoxycytidine protects normal bone marrow progenitors against Ara-C and gemcitabine cytotoxicity without compromising their activity against cisplatin-resistant human ovarian cancer cells

The intracellular metabolism and cytotoxic effects of Ara-C and 2'-difluorodeoxycytidine (dFdC or Gemcitabine) administered with or without deoxycytidine (dCyd) were examined in cisplatin-resistant (2008/C13) and -sensitive (2008) human ovarian cystadenocarcinoma cells. Compared to 2008 cells, 2008/C13 cells possess 2.1-fold higher glutathione (GSH) levels, enhanced expressions of GSH S-transferase (GST)-pi mRNA and protein, and significantly greater activity of GST, GSH peroxidase, and GST reductase. Although 2008/C13 cells were slightly cross-resistant to 4-hydroperoxycyclophosphamide, the drug displayed a steep dose-response (colony growth inhibition) effect toward these cells. 2008/C13 cells expressed greater sensitivity toward Ara-C and Gemcitabine. This was associated with intracellular Ara-CTP and dFdCtriphosphate levels in 2008/C13 significantly higher than those in 2008 cells. Against bone marrow progenitor cells, the cytotoxic effects of submicromolar levels of Ara-C or dFdC, produced in plasma following intraperitoneal administration of the drugs, were significantly reversed by cotreatment with high levels of dCyd achieved in plasma following intravenous administration. In contrast, the metabolism and cytotoxic effects of Ara-C and dFdC in 2008 and 2008/C13 cells were not significantly altered by dCyd concentrations that are reached in the peritoneum following intravenous administration. These in vitro data suggest that systematically administered dCyd might protect bone marrow progenitor cells against Ara-C cytotoxicity without impairing antitumor activity of intraperitoneal Ara-C.

Intrapleural etoposide for malignant effusion

The pharmacology, toxicity, and therapeutic effectiveness of etoposide (VP-16) given by the intrapleural route were examined in a phase I trial. Ten patients with malignant pleural effusion received 100, 150, or 225 mg/m2 VP-16 infused over 2 h into the pleural space after drainage of pleural fluid. The administration of VP-16 was tolerated well, with no local pain, increase in cough, dyspnea, or infection. Myelosuppression was mild at doses of 150 mg/m2 or less but severe at 225 mg/m2. Drug levels were followed in both plasma and pleural fluid for up to 12 h. Clearance of VP-16 from the pleural cavity was low at 2 ml/min m2. Peak pleural-fluid drug levels in patients receiving 225 mg/m2 exceeded 300 micrograms/ml, whereas peak drug concentrations in corresponding plasma samples obtained at the same time amounted to less than 10 micrograms/ml. Serial chest X-rays showed no disappearance of pleural effusion in nine evaluable patients. However, follow-up investigation of pleural fluid characteristics [carcinoembryonic antigen (CEA), lactic dehydrogenase (LDH), and cytologic examination] suggested some evidence of local therapeutic benefit.

Anti-tumor effect of cisplatin, carboplatin, mitoxantrone, and doxorubicin on peritoneal tumor growth after intraperitoneal and intravenous chemotherapy: a comparative study

Tumor growth was studied in a peritoneal tumor model in the rat after intravenous and intraperitoneal administration of doxorubicin (4 mg/kg), mitoxantrone (2.5 mg/kg) and cisplatin (4 mg/kg) and after intraperitoneal administration of carboplatin (20 mg/kg). All treatments delayed tumor growth and intraperitoneal treatment was more effective initially than intravenous treatment for all drugs tested. Regrowth occurred between 2 and 7 weeks after treatment and was less pronounced after intravenous treatment. Tumor sizes in cisplatin treated rats 7 weeks after treatment were comparable after intraperitoneal and intravenous treatments. Intraperitoneal carboplatin even with a dose 5 times higher than cisplatin resulted in a less tumor growth delay in all stages of the treatment, compared to cisplatin. All cytostatic drugs, except carboplatin, induced loss of body weight. Weight loss was similar for intraperitoneal and intravenous treatment with both cisplatin and mitoxantrone while for doxorubicin the weight loss was significantly higher after intravenous treatment than after intraperitoneal therapy. Considering the "therapeutic index", defined as the ratio of tumor growth delay to weight loss, cisplatin had the highest "therapeutic index", 1.5 (intraperitoneal) and 1.7 (intravenous) compared to 0.3 (intraperitoneal) and 0.6 (intravenous) for Mitoxantrone and 0.4 (intraperitoneal) and 0.5 (intravenous) for doxorubicin. This indicated that cisplatin was the most favorable drug to use in this peritoneal tumor model for both intraperitoneal and intravenous treatment. The tumor growth delay was initially more pronounced after intraperitoneal cisplatin compared with intravenous.

Efficacy of two-route chemotherapy using intraperitoneal neocarzinostatin and its antidote, intravenous tiopronin, for peritoneally disseminated tumors in mice

We assessed the efficacy of "two-route chemotherapy (TRC)" using neocarzinostatin (NCS) given ip and its antidote, N-(2-mercaptopropionyl)-glycine (tiopronin), given iv for peritoneally disseminated tumors in mice. Whether or not the single iv administration of tiopronin (800 mg/kg) at various times after NCS ip would decrease the lethal toxicity induced by NCS ip was given attention. When compared with the LD50 (4.4 mg/kg) of NCS ip alone, simultaneous or postadministration of tiopronin together with NCS ip increased the LD50 of NCS ip by 2.8 to 7.6 fold in a time-dependent manner. Chemotherapy experiments on ip disseminated tumors in mice were done to compare the antitumor effects of the following treatments, at two dose levels (75 and 100% of LD10) of NCS, with or without tiopronin: treatment with NCS ip alone and combined chemotherapy using NCS ip plus tiopronin iv, simultaneously or postadministered. Based on the survival time of the treated mice, the groups given NCS plus tiopronin (postadministration, 15 or 25 min later) showed a significantly superior survival time to that of the group given NCS ip alone. The side effects, evaluated in terms of the changes in body weight and number of WBC of the mice, were not significantly different among the groups treated with 100% of LD10 of NCS.

Pharmacologic basis for the use of dipyridamole to increase the selectivity of intraperitoneally delivered methotrexate

Dipyridamole (DP) is an attractive agent with which to increase the selectivity of intraperitoneally delivered methotrexate (MTX). We demonstrated that DP synergistically increased the cytotoxicity of MTX to the human OV 2008 ovarian carcinoma cell line in vitro and that this synergy was highly concentration-dependent. DP did not alter MTX binding in plasma, and vice versa. We found that the two drugs were chemically compatible at concentrations of less than 400 microM, which was well above the concentration needed to make continuous i.p. infusion feasible. The ability of OV 2008 cells to accumulate uridine was used as a bioassay for the in vivo activity of DP. When this drug was infused i.p. at 12 mg/m2 per day, the steady-state peritoneal DP concentrations attained in patients were sufficient for maximal inhibition of uridine uptake, indicating concentrations high enough for synergism with MTX. We found no correlation between total peritoneal protein concentration and either free DP concentration or biologic activity. On the basis of these preclinical and pharmacologic measurements, we conclude that it should be possible to produce selective i.p. biochemical modulation of MTX with DP.

Intraperitoneal therapy in the management of ovarian carcinoma

The intraperitoneal administration of chemotherapeutic and biological agents as therapy of ovarian carcinoma is based on both theoretical considerations and experimental evaluations which suggest that tumor present in the cavity can be exposed to higher concentrations of certain antineoplastic drugs than can be accomplished if the agents are administered systemically. Recent clinical data have confirmed both the safety and pharmacokinetic advantage associated with this approach. Surgically defined responses have been observed in patients with small-volume residual refractory ovarian carcinoma treated with several single-agent and combination intraperitoneal therapeutic programs. While significant activity has been noted in this clinical setting, a clearly defined role for intraperitoneal treatment in the standard management of ovarian carcinoma remains to be determined.

Tenckhoff catheter cytology in patients with ovarian cancer

In order to expose malignant cells to high concentrations of cytotoxic chemotherapeutic agents, drugs can be instilled directly into the peritoneal cavity of patients with ovarian carcinomas through a Tenckhoff catheter. The peritoneal dialysate removed during such therapy can be examined cytologically for the presence of carcinoma cells. The cytologic specimens from Tenckhoff catheters from 40 consecutive patients with primary ovarian (39) and tubal (1) cancer who received intraperitoneal chemotherapy have been reviewed retrospectively. A total of 237 specimens yielded 78 (33%) positive, 138 (58%) negative, and 21 (9%) inconclusive or suspicious fluids. The major diagnostic problem was the marked mesothelial atypia, which may be related to the high concentrations of cytotoxic agents intimately in contact with the peritoneum. Of the 15 patients who had tissue examined after placement of the catheter (mean interval, 5 months), results agreed with those of the catheter cytologic specimens in ten patients. The catheter cytologic specimen was never positive when histology was negative. Of the 36 patients with evaluable follow-up (mean, 19 months), agreement between the clinical course and the catheter cytologic results was found in 27 patients (75%). Again, interpretation of the catheter specimens was never positive in the face of a benign clinical course. Thus, evaluation of catheter specimens by cytologic examination has a diagnostic sensitivity and specificity of 59% and 100%, respectively. Tenckhoff catheter cytology has proven to be a rather valuable tool to monitor persistent or recurrent intraperitoneal ovarian carcinoma.

Pharmacokinetics of cis-dichloro-trans-dihydroxy-bis-isopropylamine platinum IV (iproplatinum, CHIP) in patients with normal and impaired renal function and following intraperitoneal administration

CHIP is a quadrivalent platinum (Pt) complex, introduced clinically as a less toxic alternative to cis-platinum. The drug's major route of excretion is via the kidneys, and in this study the pharmacokinetics of unchanged CHIP, filterable Pt and total Pt have been determined following intravenous administration to patients with a range of renal function. Total Pt and filterable Pt in plasma decayed biexponentially and was fitted to a two-compartment model, whereas unchanged CHIP declined monoexponentially and was best fitted to a one-compartment model, according to Akaike's information criteria. There is a correlation between the unchanged CHIP clearance and 51Cr-EDTA clearance. The pharmacokinetics of CHIP was determined following intraperitoneal (i.p.) administration (dose, 150-300 mg m-2 4 h dwell time) and a regional advantage (peritoneal peak concentration/plasma peak concentration) of approximately 30 fold was seen. It is likely that the dose of CHIP will need to be reduced in patients with impaired renal function, and the use of i.p. CHIP in ovarian carcinoma warrants further study.

Intraperitoneal chemotherapy and immunotherapy

1. The predictive model is validated empirically; a kinetic advantage for i.p. administration of certain antineoplastic drugs exist. 2. The concentrations achieved in the peritoneum are orders of magnitude greater than those found in the plasma, so rate-limiting systemic toxicities may be avoided. 3. The aspirin principle--if one is good, two are better--may not be applicable unless we can utilize this advantage to improve survival.

Ovarian cancer

A comprehensive research effort has been focused on ovarian cancer during the past decade and this research focus has resulted in substantial improvements in accurate staging and effective treatment. On the basis of prospectively performed clinical trials in well-staged early ovarian cancer patients, a subset can be identified in whom no further therapy is necessary. Consequently, these patients can be spared the toxicities associated with long-term use of adjuvant chemotherapy. For patients with advanced disease, cisplatin-based combination chemotherapy regimens have produced higher complete response rates, prolongation of disease-free survival, and, in several large studies, a statistically significant prolongation of overall survival. In addition, recent clinical and laboratory data has confirmed the importance of dose and dose intensity in the optimum management of patients with ovarian cancer, and preliminary results of high-dose regimens are encouraging. Unfortunately, high-dose cisplatin-based chemotherapy regimens are associated with increased toxicity. However, pharmacologic techniques to decrease toxicity have been proven effective in murine models and clinical trials in patients have recently been initiated. Furthermore, the development of new cisplatin analogs may also permit further dose escalations with decreased long-term toxicities. There are also new promising clinical approaches that may be useful in treatment of patients who are left with small volume residual disease. It seems that approximately 30% of these patients can achieve disease-free status with intraperitoneal cisplatin therapy. While these results need to be confirmed in larger prospective trials, they do suggest that some patients with residual disease can be salvaged with intraperitoneal chemotherapy. Our understanding of the biology of ovarian cancer has been greatly facilitated by the development of relevant experimental model systems. These model systems have been used to help unravel the mechanisms associated with broad cross-resistance that currently limits the effectiveness of combination chemotherapy. In addition, pharmacologic techniques have already been shown to be capable of reversing resistance both in vitro and in vivo and these exciting new approaches will be entering clinical trial in the not too distant future. Finally, biological agents have also shown marked efficacy in these model systems of human ovarian cancer.(ABSTRACT TRUNCATED AT 400 WORDS)

Pharmacokinetics and efficacy of i.v. and i.p. VM26 chemotherapy in mice bearing Krebs II ascitic tumors

The pharmacokinetics and the efficacy of VM26 are studied following i.p. or i.v. administration in mice bearing Krebs II ascitic tumors. The i.p. inoculation of 30.10(6) Krebs II cells in Swiss mice leads to the formation of ascites. The effects of VM26 were dependent upon the route of administration. A 2 mg/kg i.p. single dose induces an equivalent per cent increase of median survival time than a 20 mg/kg i.v. single dose. The survival advantage of i.p. VM26 was found to be related to the pharmacologic benefit of i.p. administration. If local toxicity does not prove to be a major problem, i.p. VM26 may constitute a safe and practical mode of therapy in patients with intraabdominal tumors.

Cytotoxic intracavitary chemotherapy

The intracavitary administration of chemotherapeutic agents for their cytotoxic properties as therapy for tumors confined to body cavities has significant theoretical appeal. Pharmacokinetic evaluation of several clinically useful antineoplastic drugs has confirmed modeling predictions that suggested a major advantage for cavity exposure to the agents compared with that of the plasma when the drugs are delivered directly into the body cavity. As the direct penetration of the agents into tissue is quite limited, the greatest potential utility of this therapeutic approach would be in patients with microscopic residual disease following debulking surgery or as therapy for patients with a high risk of intraperitoneal recurrence. Major toxicities of this innovative technique include abdominal pain (chemical serositis) and infection. Additional clinical evaluation will be required to define a role for cytotoxic intracavitary chemotherapy in the management of malignant disease.

Peritoneal access for intracavitary chemotherapy

Direct intraperitoneal instillation of many chemotherapeutic agents can markedly increase total peritoneal drug exposure and may be useful for the treatment of ovarian carcinoma and mesothelioma. The use of a totally implanted access system (Port-a-CathTM) reduces the risk of inadvertent bowel damage, and infection associated with repeated intraperitoneal instillation of drugs. In addition, patient acceptance is better in comparison to catheters that protrude through the skin. Catheter failure due to the formation of adhesions around the outside of the catheter remains a major problem.

Intracavitary chemotherapy for malignant disease confined to body cavities

The direct administration of cytotoxic chemotherapeutic agents into the peritoneal or pleural cavities to treat malignant disease principally involving these regions is based on modeling studies suggesting a major pharmacokinetic advantage for the exposed cavity compared with the plasma. The safety and clinical efficacy of several agents administered directly into body cavities either singly or in combination have now been shown. Additional studies are needed to define optimal drugs, dosages and treatment schedules for the various tumors confined to body cavities. Whether this form of therapy will prove to be superior to standard systemic drug administration will require controlled clinical trials comparing the two treatment methods.

Maintenance of peritoneal catheter function by the intraperitoneal administration of 32% dextran 70

Thirty-two percent dextran 70 was administered to 53 patients receiving intraperitoneal (i.p.) chemotherapy in an attempt to better maintain catheter function. One hundred milliliters of 32% dextran 70 was administered i.p. at the time of catheter placement and at the completion of each course of chemotherapy (every 3 to 4 weeks). Analysis of the functional survival of the dextran treated catheters and 20 historical controls was performed. The cumulative probabilities of catheters maintaining bi-directional function in the dextran treated and control groups were 0.75 and 0.50 respectively. This difference was statistically significant at p = 0.051 by two-tailed Wilcoxon analysis. The difference between survival of dextran treated and control catheters increased if patients who received intraperitoneal doxorubicin were factored out (p = 0.035 by two-tailed Wilcoxon analysis). Plasma and peritoneal dextran levels were measured on 9 courses in 8 patients. Dextran was detectable in the peritoneal cavity up to 7 days after administration. The "apparent half-life" of dextran 70 in the peritoneal cavity was 36 hours. Plasma dextran concentrations increased for 2 days following i.p. administration and then decreased with an apparent half-life of 36 hours. One patient experienced chills and another had an anaphylactoid reaction following administration of the dextran. This study suggests that i.p. administration of 32% dextran 70 may be an effective means of minimizing peritoneal catheter failures.

The intraoperative intraperitoneal administration of cisplatin: a case report

A 63-year-old female with endometrial carcinoma who had received prior extensive systemic chemotherapy and pelvic radiotherapy was administered intraoperative cisplatin (100 mg/m2) by the i.p. route. The method and timing of chemotherapy administration were chosen to optimize delivery of the antineoplastic agent to tumor remaining following debulking surgery. There was no evidence of excessive or unexpected local or systemic toxicity. The intraoperative i.p. instillation of chemotherapeutic agents has the theoretical potential of improving to a limited degree the problem of insuring adequate drug distribution over i.p. chemotherapy.

Intracavitary chemotherapy

Pharmacokinetic modeling has suggested, and clinical investigations have confirmed, that intracavitary drug administration can result in a much greater drug exposure for the cavity into which the agent is instilled compared to the plasma. Both the safety and the efficacy of several agents administered individually or in combination have now been demonstrated. Several malignancies, in particular ovarian carcinoma and malignant mesothelioma, which remain confined to body cavities for much of their natural history, might be most rationally treated by the intracavitary treatment approach. Early clinical trials have demonstrated significant activity of intracavitary chemotherapy in both of these malignancies. Optimal drugs and dosages as well as appropriate scheduling for the various tumors involving body cavities remain to be defined. Whether or not combination intracavitary chemotherapy will significantly improve survival of patients with malignant disease confined to body cavities must await carefully controlled clinical trials comparing this treatment approach to standard systemically administered chemotherapy.

Cancer chemotherapy: alternative routes of drug administration. A review

This review covers recent developments in regional cancer chemotherapy, including the pharmacological background, technical progress, and clinical experience. Intrathecal chemotherapy is an approach that has acquired an established place, although its ultimate potentials are not known yet. The therapeutic value of hepatic intraarterial drug infusion is still unclear, although this route has been used for more than 20 years. Furthermore, the evaluation of alternative routes via the pleural and peritoneal cavities and other arteries is still in an experimental phase. Interest in these treatment modalities has been stimulated by a number of recent developments in separate fields. Major technical advances have been made, including surgically placed and totally implantable elastic catheters and subcutaneous portals and pumps. In addition, a pharmacokinetic model describing the fate of drugs administered via an artery or cavity has been developed. These developments have made it possible not only to design randomized studies and treat a larger number of patients in a relatively short time with reduced morbidity, but also to improve greatly the selection of drugs, target organs, and administration schedules. Ongoing clinical studies can be expected to lead to improved treatment results as well as provide data on dose-response relationships and drug schedule dependency for specific tumor types.

Combination Intracavitary Chemotherapy for Malignant Pleural Disease

Seven previously heavily pretreated patients with malignant pleural disease and effusions were treated with 12 courses of combination intrapleural chemotherapy with cisplatin, cytarabine, and doxorubicin. Two patients with ovarian cancer metastatic to the pleura demonstrated dramatic clinical improvement following therapy. Local pain, nephrotoxicity, or bone marrow suppression were not observed during this trial. Further investigation of intrapleural therapy utilizing an escalated dose of cytarabine is warranted.

Antirheumatic drug concentrations in human synovial fluid and synovial tissue. Observations on extravascular pharmacokinetics

Antirheumatic drug concentrations have been measured in human synovial fluid and synovial tissue, and provide insights on: (1) extravascular pharmacokinetics; (2) articular pathophysiology; and (3) the factors which modify drug levels in inflamed tissues. Concentrations of free drug in synovial fluid and plasma are the same in all conditions except rheumatoid and infectious arthritis, where the most severely afflicted joints may contain lower synovial fluid drug concentrations. This finding may be relevant to the chronicity and intractability of chronic arthritis. After single-dose therapy and a characteristic 'equilibration time', higher concentrations are found in synovial fluid than in plasma - a phenomenon which results from relative drug sequestration across the trans-synovial diffusion barrier away from the organs of elimination. Studies of oral, parenteral, topical and intra-articular antirheumatic drug therapy are reviewed, and recommendations are made for the conduct of future studies.

Clinical pharmacokinetics of commonly used anticancer drugs

The quantitative aspects of drug disposition in man of the commonly used antineoplastic agents, including cyclophosphamide, the nitrosoureas, cisplatin, methotrexate, cytarabine, 5-fluorouracil, doxorubicin, daunorubicin, bleomycin, vincristine, vinblastine, and vindesine are reviewed. Although the pharmacokinetic behaviour of these drugs has been adequately described in man, the chemical reactivity, the complexity of metabolism and disposition, the lack of simple, rapid and sensitive assays to measure plasma concentration, and the lack of defined therapeutic and toxic plasma concentrations have limited the application of routine drug monitoring in clinical oncology. With the exception of high dose methotrexate, drug doses and administration schedules remain empirical with a standard starting dose and subsequent dosage modifications determined by ensuing drug toxicities. However, many of the pharmacological characteristics of the drugs, such as their low therapeutic index, potentially life-threatening toxicities and wide individual variability in drug disposition, necessitate pharmacological monitoring. Comprehensive pharmacokinetic analysis of new and established antineoplastic agents does play a role in defining dosage, administration schedule, route of administration, and dosage modification in the presence of organ dysfunction. Consideration of the kinetics of these drugs in planning treatment regimens could lead to more rational, safer and possibly more efficacious use.

Pharmacology of intraperitoneal chemotherapy

In this review of the pharmacology and clinical application of intraperitoneal drug administration, we have tried to acquaint the reader with the current state of the art. At this juncture it is important to outline briefly some of the major remaining questions. First, as we have discussed, the analysis of tumor penetration is at present poorly formulated and needs more detailed analysis. Second, the current catheter arrangements are adequate but certainly not ideal. Third, there is need for Phase I and pharmacologic data on additional drugs to provide greater flexibility in terms of combination chemotherapy. Finally, and most importantly, there is a need for a series of careful randomized clinical trials to be done which will assess the clinical value of this form of treatment in the situations listed in Table 3.