Short-term intra-arterial mitomycin C in hepatic metastases

Superselective intra-arterial chemotherapy with mitomycin C in hepatic metastases from colorectal cancer

BACKGROUND

Mitomycin C has been found clinically useful in the treatment of colorectal cancer when administered via the hepatic artery. In a prospective therapeutic trial, we studied the effect of superselective intra-arterial chemotherapy with mitomycin C in patients with hepatic metastases from colorectal cancer.

METHODS

Forty-six patients with hepatic metastases from colorectal cancer received intra-arterial chemotherapy with mitomycin C (SIAC) between 1981 and 1991. The results of a 5-year follow-up were compared with 46 control patients standardized by sex, age, and tumor distribution.

RESULTS

The overall response rate to intra-arterial chemotherapy was 20%. The median survival time for responders was 26 months and that for nonresponders 12 months (P < 0.003). The median survival period after intra-arterial chemotherapy was 15 months, compared with 9 months in controls (P < 0.004). The cumulative 5-year survival rate was 6% for patients treated by SIAC and 5% for controls. Cessation of chemotherapy was necessary in 39 of the 46 patients: in 28 because of tumor progression, in 9 because of toxicity, in 1 because of catheterization difficulties, and in 1 because of patient refusal.

CONCLUSIONS

Superselective intra-arterial mitomycin C therapy had a poor effect on hepatic metastases from colorectal cancer because of the low response and long-term survival rates.

Superselective intra-arterial chemotherapy with mitomycin C for hepatocellular carcinoma

Thirty-six patients with primary hepatocellular carcinoma were treated by superselective intra-arterial chemotherapy with mitomycin C (SIAC) between 1981 and 1990, either as primary chemotherapy without operation (28) or as additional therapy after resective surgery (8). During the same period 10 patients were resected radically and 26 patients treated conservatively. The overall response rate to SIAC was 25% (9/36), comprising two complete and seven partial responses. The cumulative 5-year survival rate was significantly related to the percentage of hepatic replacement (PHR) (P < 0.01) and to resective surgery (P < 0.01). Overall 5-year survival was only 4% and all the patients with PHR over 75% died within 2 or 3 years. Cessation of chemotherapy was necessary in 72% of cases (26/36), because of tumour progression in 20 cases, chemotherapy toxicity in four and one technical error in one and patient refusal in one. The results of the use of SIAC as a chemotherapeutic agent for hepatocellular cancer may be regarded as disappointing, as the response rate remained low and the medication was unable to prevent tumour progression in most cases. We intend to use SIAC only for stage I-II tumours and as additional therapy after surgery when the radicality remains uncertain.

Regional treatment of hepatic metastases and hepatocellular carcinoma

Hepatic metastases represent a common site of dissemination for a number of primary malignancies related in part to the dual blood supply, large blood flow, and receptive environment of the hepatic parenchyma. Although this review focuses on regional therapy, we have included sections on systemic therapy to better interpret the results with intrahepatic therapy. We will also discuss the efficiency of hepatic arterial ligation, embolization, and radiotherapy of hepatic metastases. Primary gastrointestinal neoplasms are particularly prone to produce hepatic metastases. Because colorectal carcinoma metastasizes to the liver in up to 70% of patients with advanced disease, the treatment of hepatic metastases is a relevant topic. We will discuss the systemic and regional therapy of colorectal, gastric, and gallbladder cancers. Breast carcinoma and malignant melanoma frequently metastasize to the liver, and we have described systemic and regional treatments of these diseases. Because sarcomas are often treated by regional therapy, we have included a section on the treatment of hepatic sarcomas. Neuroendocrine tumors (carcinoid and islet cell), although often slow growing, frequently metastasize to the liver and then cause symptomatic problems. Much of the work done with embolization and hepatic ligation in the treatment of hepatic metastases has been performed in neuroendocrine tumors, and these studies, as well as the systemic and regional chemotherapy of hepatic metastases, will be described. The last section concerns the treatment of hepatocellular carcinoma. We have outlined the staging systems used. We then detail the results of systemic and intrahepatic therapy, embolization, and hepatic ligation in the treatment of hepatocellular carcinoma. Because hepatic metastases are a frequent problem, many patients are available for clinical investigation. It is hoped that newer strategies for the treatment of liver metastases will lead to higher response rates and perhaps control of local disease. These therapeutic approaches may also give us leads to the treatment of systemic disease.

Preclinical toxicity study of mitomycin C infused into the internal carotid artery of beagle dogs

Young adult male and female beagle dogs were infused with single doses of 0.5 (2 dogs) or 0.25 mg (5 dogs) Mitomycin C (MMC)/kg body weight directly into the internal carotid artery. Serial hematology and serum chemistry profiles, electrocardiograms and physical observations were made, the animals necropsied at varying times after dosage, and the major organs examined histologically. Results indicate that the dose limiting toxicity of this treatment regimen is myelosuppression. No ocular or neurologic toxicity was detected in any test animal. The findings suggest that infusion of MMC can be safely attempted in humans for the treatment of brain tumors that derive their blood supply from the internal carotid artery.

A pharmacokinetic study of adriamycin and 4'epi-adriamycin after simultaneous intra-arterial liver administration

The plasma pharmacokinetics of adriamycin and 4'epi-adriamycin were studied in patients with malignant tumors of the liver after simultaneous regional administration of equal amounts of the two anthracyclines by the arterial route. The use of a highly selective liquid chromatographic analytical method permitted quantification of plasma concentrations of the two drugs as well as their corresponding 13-hydroxy metabolites. The plasma concentrations of each drug followed a three-compartment open model. On average the area under the plasma concentration time curve (AUC) and the maximum plasma concentration (Cmax) were 2.1 and 1.7 times larger for adriamycin than for 4'epi-adriamycin, respectively. 4'Epi-adriamycin was eliminated faster than adriamycin, the terminal half-life time being on the average 1.5 times higher for adriamycin. These findings are in agreement with what has previously been observed after intravenous administration. The plasma concentrations of the 13-hydroxy metabolites did not exceed 30 ng ml-1. The AUC values of these metabolites were on average 20% of the AUC values of the intact drugs.

Intra-arterial infusion of mitomycin C in treatment of breast cancer: occurrence of skin necrosis in irradiated patients

Eight previously irradiated breast cancer patients with local recurrences were treated with intra-arterial infusions of 8 mg/m2 mitomycin C given at 3-week intervals. The mean time interval between radiotherapy and intra-arterial chemotherapy was 38 months (range 2-60). In five cases a temporary reduction in tumour size was observed. However, in 3 of the 8 patients severe local pain, starting immediately after the third course of treatment, was followed 4 weeks later by the development of deep necrotic ulcers of the chest wall. These cases are reported here and discussed in relation to the results of previous studies.

Intrahepatic and intravenous administration of adriamycin--a comparative pharmacokinetic study in patients with malignant liver tumours

The pharmacokinetics of adriamycin in patients with malignant tumours of the liver were studied after peripheral intravenous treatment and after regional administration of the drug either by the arterial route or by the portal vein, with or without hepatic artery ligation. The plasma concentration of adriamycin after intravenous as well as after intrahepatic administration followed a three-compartment open model. The results in the present study confirm previous reports of a large inter-individual variation of the pharmacokinetics of adriamycin. After intravenous administration the individual variations in AUC/mg/m2 and Cp,max/mg/m2 (dose normalized area under plasma concentration time curve and dose normalized maximum plasma concentration, respectively) were more than 5-fold. The area under the plasma concentration time curve (AUC) was on the average 1.5 times higher after the peripheral intravenous administration than after intrahepatic administration. The reduction of maximum plasma concentration (Cp,max) of adriamycin after intrahepatic administration was even more pronounced than the reduction in AUC (mean value Cp,max iv/Cp,max ihep = 1.7). The plasma concentration of adriamycinol did not exceed 20 ng/ml. The AUC values of adriamycinol were 20% (median value) of the AUC values of adriamycin, indicating the importance of adriamycinol in the adriamycin therapy.

Angiography of the internal mammary artery

The anatomy and catheterization techniques of the internal mammary artery (i.m.a.) are described. The diagnostic criteria and importance of i.m.a. angiography in thymoma, lymphoma, carcinoma, parathyroid adenoma, diseases of the breast, and trauma are discussed. The role of i.m.a. catheterization for i.a. infusion therapy in lung carcinoma, mesothelioma and chest wall metastases of breast carcinoma and embolization of i.m.a. in bleeding following trauma or tumour ulceration are described. Transcatheter treatment of mediastinal parathyroid adenoma is also described.

The effect of vasopressin and hepatic artery ligation on the blood supply to normal and metastatic liver tissue

The effect of low (0.08 microU g-1 body wt min-1) and high (0.16 microU g-1 body wt min-1) rates of vasopressin infusion on blood flow to normal liver tissue and to liver metastases derived from azoxymethane induced colorectal carcinomas was studied in 36 male Wistar rats. Portal venous flow was measured by electromagnetic flowmetry and blood flow to normal and metastatic liver tissue by the clearance of xenon-133 injected directly into the liver parenchyma or metastasis. The low rate of vasopressin infusion decreased portal venous flow but increased blood flow to normal and metastatic liver tissue while at the higher rate of infusion these effects were reversed. Hepatic artery ligation (HAL) immediately following a low rate of vasopressin infusion abolished the observed increase in blood flow to both normal liver tissue and metastases. HAL immediately following the higher rate of vasopressin infusion further reduced blood flow to metastases but did not further alter blood flow to normal liver tissue. HAL prior to the infusion of the vasoactive drug significantly reduced blood flow to metastatic liver tissue, increased portal venous flow and was without effect on blood flow to normal liver tissue. Following HAL, blood flow to metastatic liver tissue was not further altered by either the low or high rates of vasopressin infusion. However, blood flow to normal liver tissue after HAL was reduced by a low rate of infusion of vasopressin and increased by the higher rate of infusion. The results of this study indicate that blood flow to normal or metastatic liver tissue can be increased or decreased by differential rates of infusion of vasopressin. These observations may have important implications in the treatment of liver metastases in man where different rates of vasopressin infusion may potentiate the effects of hepatic artery ligation or cytotoxic therapy.