Regional chemotherapy plus hemofiltration for the treatment of regionally advanced malignancy

Interventional neuro-oncology

Interventional neuro-oncology encompasses an array of image-guided therapies-intra-arterial chemotherapy, regional drug delivery, chemoembolization, tumor ablation-along with techniques to improve therapy delivery such as physical or chemical blood-brain barrier disruption and percutaneous catheter placement. Endovascular and percutaneous image-guided approaches to the treatment of the brain, eye, and other head and neck tumors will be discussed.

Stop-flow technique for loco-regional delivery of antiblastic agents: literature review and personal experience

AIMS

The therapeutic approach for primary or recurrent advanced solid tumours, particularly when unresectable, is still one of the main medical challenges in the management of cancer patients. The stop-flow (SF) technique has been recently proposed as a semi-invasive drug delivery system based on the blood supply blockage of the tumour-bearing area. Here, we discuss the principles underlying the SF technique as well as the worldwide experience published so far. We also report on the results of our pilot study on pelvic and limb SF perfusion.

METHODS

We reviewed the worldwide experience on SF as reported by the literature published on PubMed from 1990 through 2001. In our series, we treated 20 patients affected with locally advanced melanoma, soft tissue sarcoma or colorectal cancer.

RESULTS

This therapeutic modality - at least for some tumours - can achieve encouraging results in terms of clinical response even after conventional therapies have failed. Moreover, as a safe and relatively simple procedure, SF can be applied to patients for whom traditional treatments (i.e. surgery, systemic chemotherapy) are contraindicated because of poor general conditions.

CONCLUSIONS

At present, the SF technique should be considered an investigational approach to locally advanced cancers. The encouraging results obtained with this procedure should be validated by large phase III trials.

Hemodynamic changes during a new procedure for regional chemotherapy involving occlusion of the thoracic aorta and inferior vena cava

STUDY OBJECTIVE

To describe the hemodynamic consequences of a regional chemotherapy procedure involving occlusion of the thoracic aorta and inferior vena cava (IVC) by intraluminal balloons.

DESIGN

Prospective study.

SETTING

Operating rooms of an academic hospital.

PATIENTS

10 patients with inoperable intraabdominal malignancy.

INTERVENTIONS

After the induction of general anesthesia and the insertion of a pulmonary artery catheter the patients underwent the regional chemotherapy procedure.

MEASUREMENTS AND MAIN RESULTS

Occlusion of the thoracic aorta induced an increase in blood pressure (BP) and systemic vascular resistance (SVR) (41% +/- 8% and 80% +/- 15% from baseline, respectively), and a 30% +/- 7% decrease in cardiac output (CO). After aortic balloon deflation at the end of the procedure, we observed a decrease in BP to baseline values, decrease in SVR (to 62% +/- 12% below baseline), and increase in CO (to 80% +/- 15% above baseline). Those changes resemble those described during vascular surgery. Isolated occlusion of the IVC before aortic occlusion caused hemodynamic deterioration in only three of 10 patients, suggesting incomplete obstruction or collateral blood flow in others. Occluding the IVC while the aorta was occluded, caused minimal hemodynamic changes.

CONCLUSIONS

Independent inflation of the IVC balloon should not be performed routinely because of possible unpredicted hemodynamic instability. Inferior vena cava occlusion should always be performed after complete aortic occlusion, because it is then that it produces negligible hemodynamic consequences. It is possible that a better assessment of IVC occlusion after balloon inflation needs to be done by contrast injection to prevent a possible leak of chemotherapeutic drugs.

Hypopharyngeal carcinoma with clinical peritoneal carcinomatosis: a report of two patients

Most patients with hypopharyngeal carcinomas show advanced disease, either at the primary site or in the neck, at the time of diagnosis. Despite intensive therapy, a great number of recurrences and distant metastases can be observed. The most common metastatic sites are the lung and bone, and only in autopsy cases has peritoneum carcinomatosis been mentioned as a metastatic site. Since January 1992, two of 78 patients (2.3%) with advanced hypopharyngeal squamous cell carcinomas (SCCs) treated initially by chemotherapy in our department developed clinical peritoneal carcinomatosis during their natural courses. Both patients were man patients with advanced locoregional disease at stage T4N3. Their clinical peritoneal carcinomatosis appeared during chemotherapy, with good disease control above the clavicle. Both patients eventually died of sepsis within 1 month after diagnosis of the peritoneal carcinomatosis. The authors suggest that peritoneal carcinomatosis is not as rare as previously believed, and should be included in the differential diagnosis in patients with advanced hypopharyngeal SCC with abdominal symptoms. Peritoneal carcinomatosis appears to be refractory to chemotherapy, and carried a poor prognosis in patients in the present study.

Gastric cancer in Asia: progress and controversies in surgical management

Considerable controversy surrounds the management of gastric cancer and this has largely overshadowed recent progress in our understanding of the epidemiology and molecular pathogenesis of the disease, and improvements in diagnostic and staging techniques. Differences identifiable in the molecular pathogenesis of the 'intestinal' and 'diffuse' types of gastric cancer may help to unravel the biological behaviour of variants and ultimately influence therapeutic strategies. Endoscopic ultrasound is well established as being accurate for T staging and the introduction of laparoscopy, with or without ultrasound, is obviating unnecessary laparotomy in non-bleeding, non-obstructed patients. Controversies in surgery encompass the role of laparoscopic surgery in early gastric cancer, the extent of lymphadenectomy including para-aortic nodal dissection, resection of en bloc contiguous organ involvement, pancreatosplenectomy, left upper abdominal evisceration, and modes of reconstruction (pylorus-preserving gastrectomy, pouch formation) to enhance quality of life. Whereas adjuvant chemotherapy does not impact favourably on survival, emphasis has now shifted to neoadjuvant (induction) chemotherapy to downstage the disease. Preoperative regional chemotherapy and intra-operative hyperthermic chemotherapy or irradiation may prove to be of benefit in patients with resectable disease, but some scepticism still exists as to the usefulness of biological response modifiers (e.g. OK432, PSK) for adjuvant treatment. Ethical issues relating to cultural differences in Asia sometimes mitigate against adequate trial design (e.g. a surgery-alone control group or a no adjuvant therapy treatment group may be considered inappropriate) and this has understandably hindered acceptance in Western countries of the value of current management practices in Asia. These issues and the need for ongoing well-conducted randomized trials with prospective subset analysis are now being addressed.