A pilot phase I/II study of combination chemotherapy with nafamostat mesilate and gemcitabine for unresectable pancreatic cancer

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Background: To improve chemoresistance of gemcitabine (GEM) caused by GEM-induced nuclear factor kappa B (NF- κB) activation, we have conducted combination chemotherapy of GEM with NF-κB inhibitor, nafamostat mesilate (NAM) which is commercially approved as an effective therapeutic agent for disseminated intravascular coagulation, systemic response syndrome, or pancreatitis in Japan for patients with unresectable pancreatic cancer patients through phase 1/2 study. Methods: Study treatment consists of GEM 1,000 mg/m2 on d 8, 15 and 22 plus NAM 2.4∼4.8 mg/kg on d 8, 15 and 22. NAM was administered intra-arterially by continuous regional infusion for 24 hours via an infusion port system one hour before administration of GEM. Overall survival, response rate (RECIST), serum CA19–9 and clinical benefit response (body weight, pain alleviation) were assessed. Results: Between Feb 2007 and Oct 2008, 20 patients with unresectable pancreatic cancer were included in this study. Pts characteristics: male/female: 18/2, median age 63.5 (range 38–79) yrs, median Karnofsky PS 80% (range 70–90%), stage III/IV: 8/12, serum CA19–9 4,662 U/ml (range 88–32,100), baseline visual analogue scale 0–1/2–4/5–7/8–10; 9/4/7/0, baseline analgesic consumption (morphine-equivalent, mg/day) 0/10–100/100>; 10/7/3. The combination of NAM with GEM is well tolerated and MTD has not been reached. The recommended dose was GEM 1,000 mg/m2; NAM 4.8 mg/kg. Overall survival was 8.0 (range 4.7–17) months. CR/PR/NC/PD/not evaluated; 0/3/14/2/1. Serum CA19–9 reduction rate; 89%. Three pts. could become off and 1pt. could reduce oral morphine sulfate, and 5 pts. gained weight. Conclusions: The GEM/NAM regimen is safe, and the clinical data, including overall survival and clinical benefit response, suggest that the initial clinical outcome of this trial has been encouraging. An expanded cohort of the combination chemotherapy is underway.

No significant financial relationships to disclose.

A phase I study of full-dose gemcitabine and regional arterial infusion of nafamostat mesilate for advanced pancreatic cancer

BACKGROUND

The primary end points of this study were to determine the dose-limiting toxic effects (DLTs), maximum tolerated dose, and a recommended phase II dose of a synthetic serine protease inhibitor, nafamostat mesilate, in combination with full-dose gemcitabine in patients with unresectable locally advanced or metastatic pancreatic cancer. The secondary end point was to assess therapeutic response.

PATIENTS AND METHODS

Patients with previously untreated pancreatic cancer received gemcitabine (1 000 mg/m(2) i.v. for 30 min) on days 1, 8, and 15, with nafamostat mesilate (continuous regional arterial infusion for 24 h through a port-catheter system) on days 1, 8, and 15; this regimen was repeated at 28-day intervals. The initial dose of nafamostat mesilate was 2.4 mg/kg and was escalated in increments of 1.2 mg/kg until a dose of 4.8 mg/kg was achieved. A standard '3+3' phase I dose-escalation design was used. Therapeutic response and clinical benefit response were assessed.

RESULTS

Twelve patients were enrolled in this study. None of the patients experienced DLTs, and nafamostat mesilate was well tolerated at doses up to 4.8 mg/kg in combination with full-dose gemcitabine. This combination chemotherapy yielded a reduction of a high serum level of the tumor marker CA19-9. Pain was reduced in three of seven patients without oral morphine sulfate. Overall survival was 7.1 months for all patients.

CONCLUSION

This phase I study was carried out safely. This combination chemotherapy showed beneficial improvement in health-related quality of life. The recommended phase II dose of nafamostat mesilate in combination with full-dose gemcitabine is 4.8 mg/kg.

Balloon Test Occlusion with Perfusion CT Imaging Utilizing Intraarterial Contrast Injection

SUMMARY

Balloon Test Occlusion (BTO) is performed to evaluate the collateral flow when a permanent therapeutic occlusion of unilateral carotid artery is planned. BTO with neurological evaluation alone, however, has a rather high false negative rate. In order to improve the sensitivity, several adjunctive procedures such as induced hypotension or cerebral blood flow (CBF) measurement with various modalities have been combined. Perfusion CT (PCT) is another imaging modality that is mainly used for the diagnosis of acute stroke. In this study, we evaluate the efficacy and the safety of BTO combined with PCT in the same procedure utilizing intraarterial contrast injection from the catheter. Seven patients underwent BTO with PCT in our institution. All the procedures were performed in the angio/CT combination suite. BTO was performed in the usual fashion and when the patient passed the 30 minutes' BTO clinically, PCT was performed subsequently. Contrast material was injected from a Pig Tail catheter placed in the ascending aorta. The obtained data were transferred to a workstation and perfusion maps of CBF, cerebral blood volume (CBV), and time to peak (TTP) were generated using software. In three patients, single photon emission CT (SPECT) was also obtained with administering 99 mTc-ethyl cysteinate dimer (99 mTc-ECD) intravenously during BTO. Although all the patients had passed the BTO clinically, the CBF maps of three patients revealed significant decrease in the occluded hemisphere. There was no procedure-related morbidity. PCT using intraarterial contrast injection during BTO was performed successfully and safely. Intraarterial injection allowed us to obtain excellent time-attenuation curves by utilizing less contrast material and less radiation doze.

[Comparative study of the physical properties of microcatheters frequently used for abdominal IVR]

The purpose of this study was to determine the physical properties of commercially available microcatheters through basic experiments. The materials included eleven different types of widely used microcatheters, ten of which were 135 cm in length and the remaining one 113 cm. Five samples of each catheter were examined. For each catheter, we measured the flow rate, flexibility of the tip, rigidity of the proximal part, smoothness of the outer and inner surfaces, kink resistance of the tip, and pressure resistance of the whole catheter. In conclusion, an ideal microcatheter should satisfy the following criteria: 1) the internal lumen must be large enough to allow high flow volume, and the wall must be enforced by braiding to withstand higher injection pressure; 2) the tip of the catheter must be soft, but must increase in hardness as it approaches the proximal end; 3) it must have a hydrophilic coating on the surface for an appropriate length.

Extended intraarterial cisplatin infusion for treatment of gynecologic cancer after alteration of intrapelvic blood flow and implantation of a vascular access device

PURPOSE

Twenty-two patients with advanced gynecologic cancer underwent extended intraarterial cisplatin infusion after alteration of the intrapelvic blood flow and implantation of a vascular access device (VAD).

METHODS

To maximize concentrations of cisplatin at the target lesion, the superior and inferior gluteal arteries were embolized with steel coils. The tip of the catheter was inserted into the internal iliac artery; the opposite end of the catheter was connected to the VAD.

RESULTS

Intensive radioisotope accumulation was demonstrated in the anterior division of the pelvis, seen by scintigraphy performed with technetium 99m macroaggregated albumin via the VAD. Local perfusion in the tumor was well seen by ultrasonographic angiography with CO2 microbubbles via the VAD. Continuous consecutive infusion of cisplatin at a rate of 12.5 mg/day via the VAD minimized the toxicity. The overall response rate was 73%. Radical surgery was possible in 16 of the 22 patients after this intraarterial infusion.

CONCLUSION

This method was useful for treating advanced gynecologic cancer without significant toxicity.