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Pinkiewicz M, Pinkiewicz M, Walecki J, Zawadzki M. A systematic review on intra-arterial cerebral infusions of chemotherapeutics in the treatment of glioblastoma multiforme: The state-of-the-art. Front Oncol 2022; 12:950167. [PMID: 36212394 PMCID: PMC9539841 DOI: 10.3389/fonc.2022.950167] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 09/02/2022] [Indexed: 12/24/2022] Open
Abstract
Objective To provide a comprehensive review of intra-arterial cerebral infusions of chemotherapeutics in glioblastoma multiforme treatment and discuss potential research aims. We describe technical aspects of the intra-arterial delivery, methods of blood-brain barrier disruption, the role of intraoperative imaging and clinical trials involving intra-arterial cerebral infusions of chemotherapeutics in the treatment of glioblastoma multiforme. Method 159 articles in English were reviewed and used as the foundation for this paper. The Medline/Pubmed, Cochrane databases, Google Scholar, Scielo and PEDro databases have been used to select the most relevant and influential papers on the intra-arterial cerebral infusions of chemotherapeutics in the treatment of glioblastoma multiforme. Additionally, we have included some relevant clinical trials involving intra-arterial delivery of chemotherapeutics to other than GBM brain tumours. Conclusion Considering that conventional treatments for glioblastoma multiforme fall short of providing a significant therapeutic benefit, with a majority of patients relapsing, the neuro-oncological community has considered intra-arterial administration of chemotherapeutics as an alternative to oral or intravenous administration. Numerous studies have proven the safety of IA delivery of chemotherapy and its ability to ensure higher drug concentrations in targeted areas, simultaneously limiting systemic toxicity. Nonetheless, the scarcity of phase III trials prevents any declaration of a therapeutic benefit. Given that the likelihood of a single therapeutic agent which will be effective for the treatment of glioblastoma multiforme is extremely low, it is paramount to establish an adequate multimodal therapy which will have a synergistic effect on the diverse pathogenesis of GBM. Precise quantitative and spatial monitoring is necessary to guarantee the accurate delivery of the therapeutic to the tumour. New and comprehensive pharmacokinetic models, a more elaborate understanding of glioblastoma biology and effective methods of diminishing treatment-related neurotoxicity are paramount for intra-arterial cerebral infusion of chemotherapeutics to become a mainstay treatment for glioblastoma multiforme. Additional use of other imaging methods like MRI guidance during the procedure could have an edge over X-ray alone and aid in selecting proper arteries as well as infusion parameters of chemotherapeutics making the procedure safer and more effective.
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Affiliation(s)
- Mateusz Pinkiewicz
- Department of Diagnostic Imaging, Mazowiecki Regional Hospital in Siedlce, Siedlce, Poland
| | - Milosz Pinkiewicz
- English Division, Faculty of Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Jerzy Walecki
- Division of Interventional Neuroradiology of the Central Clinical Hospital of the Ministry of Interior and Administration, Department of Radiology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Michał Zawadzki
- Division of Interventional Neuroradiology of the Central Clinical Hospital of the Ministry of Interior and Administration, Department of Radiology, Centre of Postgraduate Medical Education, Warsaw, Poland
- *Correspondence: Michał Zawadzki,
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Oatess TL, Chen PH, Daniels AB, Himmel LE. Severe Periocular Edema after Intraarterial Carboplatin Chemotherapy for Retinoblastoma in a Rabbit ( Oryctolagus cuniculus) Model. Comp Med 2020; 70:176-182. [PMID: 32160941 DOI: 10.30802/aalas-cm-18-000146] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Endovascular microcatheter-based intraarterial (ophthalmic artery) chemotherapy is becoming widely used for the clinical treatment of intraocular retinoblastoma due to its apparent increased efficacy compared with traditional intravenous chemotherapy; however local ocular complications are not uncommon. Carboplatin is a chemotherapeutic agent used in both intravenous and intraarterial chemotherapy. We used rabbits to assess pharmacokinetics and ocular and systemic toxicity after intraarterial carboplatin infusion. Subsequent to unilateral intraarterial administration of carboplatin, severe unilateral or bilateral periocular edema occurred in 6 adult male New Zealand white rabbits. Time to onset varied from less than 4 h after administration (n = 3, 50 mg) to approximately 24 h afterward (n = 3, 25 mg). After becoming symptomatic, 5 of the 6 animals were promptly euthanized, and the remaining animal (25 mg treatment) was medically managed for 4 d before being euthanized due to intractable edema-related lagophthalmos. Globes and orbits from all 6 euthanized rabbits were harvested en bloc; whole-mount sections were prepared for histologic evaluation, which revealed drug-induced vasogenic edema in confined spaces as the main underlying pathogenesis. Transient and self-limiting periocular edema is a common side effect of intraarterial chemotherapy but is thought to occur predominantly with melphalan monotherapy or combination therapy using melphalan, carboplatin, and topotecan. The severity of this adverse consequence in rabbits was unexpected, and its use in the study was subsequently discontinued. Although the definitive cause for this vasotoxicity and striking clinical presentation is unknown, we suspect species-specific anatomic features and sensitivity might have contributed to amplified complications after intraarterial carboplatin chemotherapy of the eye. Due to the adverse effects of intraarterial carboplatin chemotherapy that we observed in 2 experimental cohorts of rabbits, we recommend caution regarding its use in this species.
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Affiliation(s)
- Tai L Oatess
- Department of Pathology, Microbiology, and Immunology, Division of Comparative Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Patty H Chen
- United States Army Laboratory Animal Medicine Residency Program, Animal Care and Use Review Office, Office of Research Protections, Medical Research and Development Command, Fort Detrick, Maryland
| | - Anthony B Daniels
- Department of Ophthalmology and Visual Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lauren E Himmel
- Department of Pathology, Microbiology, and Immunology, Division of Comparative Medicine, Vanderbilt University Medical Center, Nashville, Tennessee;,
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Overview of Current Drug Delivery Methods Across the Blood-Brain Barrier for the Treatment of Primary Brain Tumors. CNS Drugs 2020; 34:1121-1131. [PMID: 32965590 PMCID: PMC7658069 DOI: 10.1007/s40263-020-00766-w] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/05/2020] [Indexed: 01/05/2023]
Abstract
Existing drug delivery methods have not led to a significant increase in survival for patients with malignant primary brain tumors. While the combination of conventional therapies consisting of surgery, radiotherapy, and chemotherapy has improved survival for some types of brain tumors (e.g., WNT medulloblastoma), other types of brain tumors (e.g., glioblastoma and diffuse midline glioma) still have a poor prognosis. The reason for the differences in response can be largely attributed to the blood-brain barrier (BBB), a specialized structure at the microvasculature level that regulates the transport of molecules across the blood vessels into the brain parenchyma. This structure hampers the delivery of most chemotherapeutic agents for the treatment of primary brain tumors. Several drug delivery methods such as nanoparticles, convection enhanced delivery, focused ultrasound, intranasal delivery, and intra-arterial delivery have been developed to overcome the BBB in primary brain tumors. However, prognosis of most primary brain tumors still remains poor. The heterogeneity of the BBB in primary brain tumors and the distinct vasculature of tumors make it difficult to design a drug delivery method that targets the entire tumor. Drug delivery methods that combine strategies such as focused ultrasound and nanoparticles might be a more successful approach. However, more research is needed to optimize and develop new drug delivery techniques to improve survival of patients with primary brain tumors.
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Joshi S, Ellis JA, Emala CW. Revisiting intra-arterial drug delivery for treating brain diseases or is it "déjà-vu, all over again"? JOURNAL OF NEUROANAESTHESIOLOGY AND CRITICAL CARE 2018; 1:108-115. [PMID: 25478580 DOI: 10.4103/2348-0548.130386] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
For over six decades intra-arterial (IA) drugs have been sporadically used for the treatment of lethal brain diseases. In recent years considerable advance has been made in the IA treatment of retinoblastomas, liver and locally invasive breast cancers, but relatively little progress has been made in the treatment of brain cancers. High resting blood flow and the presence of the blood-brain barrier (BBB), makes IA delivery to the brain tissue far more challenging, compared to other organs. The lack of advance in the field is also partly due to the inability to understand the complex pharmacokinetics of IA drugs as it is difficult to track drug concentrations in sub-second time frame by conventional chemical methods. The advances in optical imaging now provide unprecedented insights into the pharmacokinetics of IA drug and optical tracer delivery. Novel delivery methods, improved IA drug formulations, and optical pharmacokinetics, present us with untested paradigms in pharmacology that could lead to new therapeutic interventions for brain cancers and stroke. The object of this review is to bring into focus the current practice, problems, and the potential of IA drug delivery for treating brain diseases. A concerted effort is needed at basic sciences (pharmacology and drug imaging), and translational (drug delivery techniques and protocol development) levels by the interventional neuroradiology community to advance the field.
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Affiliation(s)
- Shailendra Joshi
- Departments of Anesthesiology, and Neurosurgery, College of Physicians and Surgeons of Columbia University, New York, NY
| | - Jason A Ellis
- Departments of Anesthesiology, and Neurosurgery, College of Physicians and Surgeons of Columbia University, New York, NY
| | - Charles W Emala
- Departments of Anesthesiology, and Neurosurgery, College of Physicians and Surgeons of Columbia University, New York, NY
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Zeng XT, Bi WJ, Li P, Deng AP, Zhang L, Li YC, Dong Z. Intra-arterial chemotherapy for high-grade gliomas. Hippokratia 2017. [DOI: 10.1002/14651858.cd010549.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Xian Tao Zeng
- Zhongnan Hospital of Wuhan University; Center for Evidence-Based and Translational Medicine; 169 Donghu Road Wuhan City Hubei Province China 430071
| | - Wei Jing Bi
- West China Healthcare Hospital of Sichuan University; Department of Medicine; No.8 Lin Yin Street Chengdu Sichuan China 610041
| | - Ping Li
- Sichuan University; The Department of Head, Neck and Breast Oncology, Cancer Center, West China Hospital; The State Key Laboratory of Biotherapy; West China Hospital Wai Nan Guo Xue Line, No.37 Chengdu Sichuan China 610041
| | - Ai Ping Deng
- Taihe Hospital, Hubei University of Medicine; Department of Neurosurgery; 32 South Renmin Road Shiyan Hubei China 442000
| | - Li Zhang
- Taihe Hospital, Hubei University of Medicine; Department of Neurosurgery; 32 South Renmin Road Shiyan Hubei China 442000
| | - Yan Chu Li
- Sichuan University; The Department of Head, Neck and Breast Oncology, Cancer Center, West China Hospital; The State Key Laboratory of Biotherapy; West China Hospital Wai Nan Guo Xue Line, No.37 Chengdu Sichuan China 610041
| | - Zhiyong Dong
- The First Affiliated Hospital of Jinan University; Department of Surgery; No.613, HuangPu Avenu West Guangzhou Guangdong China 510630
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Warren KE. Novel therapeutic delivery approaches in development for pediatric gliomas. CNS Oncol 2015; 2:427-35. [PMID: 24511389 DOI: 10.2217/cns.13.37] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Pediatric gliomas are a heterogeneous group of diseases, ranging from relatively benign pilocytic astrocytomas with >90% 5-year survival, to glioblastomas and diffuse intrinsic pontine gliomas with <20% 5-year survival. Chemotherapy plays an important role in the management of these tumors, particularly in low-grade gliomas, but many high-grade tumors are resistant to chemotherapy. A major obstacle and contributor to this resistance is the blood–brain barrier, which protects the CNS by limiting entry of potential toxins, including chemotherapeutic agents. Several novel delivery approaches that circumvent the blood–brain barrier have been developed, including some currently in clinical trials. This review describes several of these novel approaches to improve delivery of chemotherapeutic agents to their site of action at the tumor, in attempts to improve their efficacy and the prognosis of children with this disease.
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Chen W, Wu Q, Mo L, Nassi M. Intra-Arterial Chemotherapy Is Not Superior to Intravenous Chemotherapy for Malignant Gliomas: A Systematic Review and Meta-Analysis. Eur Neurol 2013; 70:124-32. [DOI: 10.1159/000346580] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Accepted: 12/14/2012] [Indexed: 11/19/2022]
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Abstract
Intra-arterial (IA) chemotherapy is a form of regional delivery to brain tumors, designed to enhance the intra-tumoral concentrations of a given drug, in comparison with the intravenous route. Drugs that are likely to benefit from IA delivery have a rapid systemic clearance and include carmustine and other nitrosoureas, cisplatin, carboplatin, etoposide, and methotrexate. Clinical studies have demonstrated activity of IA chemotherapy approaches for low- and high-grade gliomas, and for cerebral lymphomas. However, a survival benefit for IA drug delivery, in comparison with intravenous administration, has not been proven in phase III trials. The technique is limited by the potential for significant vascular and neurologic toxicity, including visual loss, stroke, and leukoencephalopathy. More recent studies suggest that toxicity can be reduced by the use of carboplatin- and methotrexate-based regimens. Further clinical studies will be needed to determine the appropriate role for IA chemotherapy in the treatment of primary brain tumors.
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Affiliation(s)
- Herbert B Newton
- Dardinger Neuro-Oncology Center and Division of Neuro-Oncology, Department of Neurology, The Ohio State University Medical Center and James Cancer Hospital and Solove Research Institute, 1654 Upham Drive, Columbus, OH 43210, USA.
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