Methodologic considerations in treatment using intraperitoneal chemotherapy

Intraperitoneal irinotecan with concomitant FOLFOX and bevacizumab for patients with unresectable colorectal peritoneal metastases: protocol of the multicentre, open-label, phase II, INTERACT-II trial

INTRODUCTION

The peritoneum is the second most affected organ for the dissemination of colorectal cancer (CRC). Patients with colorectal peritoneal metastases (CPM) face a poor prognosis, despite the majority of patients being treated with palliative systemic therapy. The efficacy of palliative systemic therapy is limited due to the plasma-peritoneum barrier. The poor prognosis of unresectable CPM patients has resulted in the development of new treatment strategies where systemic therapy is combined with local, intraperitoneal chemotherapy. In the recently published phase I study, the maximum tolerated dose and thus the recommended phase II dose of intraperitoneal irinotecan was investigated and determined to be 75 mg. In the present study, the overall survival after treatment with 75 mg irinotecan with concomitant mFOLFOX4 and bevacizumab will be investigated.

MATERIALS AND METHODS

In this single-arm phase II study in two Dutch tertiary referral centres, 85 patients are enrolled. Eligibility criteria are an adequate performance status and organ function, histologically confirmed microsatellite stable and unresectable CPM, no previous palliative therapy for CRC, no systemic therapy<6 months for CRC prior to enrolment and no previous cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS and HIPEC). Patients will undergo a diagnostic laparoscopy as standard work-up for CPM and if the peritoneal disease is considered unresectable (eg, Peritoneal Cancer Index (PCI)>20, too extensive small bowel involvement), a peritoneal access port and a port-a-cath are placed for administration of intraperitoneal and intravenous chemotherapy, respectively. Patients may undergo up to 12 cycles of study treatment. Each cycle consists of intravenous mFOLFOX4 with bevacizumab and concomitant intraperitoneal irinotecan (75 mg), which is repeated every 2 weeks, with a maximum of 12 cycles. Modified FOLFOX-4 regimen consists of 85 mg/m2 oxaliplatin plus 200 mg/m2 LV and 5-FU 400 mg/m2 bolus on day 1 followed by 1600 mg/m2 5-FU as a 46 hours infusion. Study treatment ends after the 12th cycle, or earlier in case of disease progression or unacceptable toxicity. The primary outcome is overall survival and key secondary outcomes are progression-free survival, safety (measured by the amount of grade ≥3 adverse events (Common Terminology Criteria for Adverse Events V.5.0)), patient-reported outcomes and pharmacokinetics of irinotecan. It is hypothesised that the trial treatment will lead to a 4 month increase in overall survival; from a median of 12.2 to 16.2 months.

ETHICS AND DISSEMINATION

This study is approved by the Dutch Authority (CCMO, the Hague, the Netherlands), by a central medical ethics committee (MEC-U, Nieuwegein, the Netherlands) and by the institutional research boards of both research centres. Results will be submitted for publication in peer-reviewed medical journals and presented to patients and healthcare professionals.

TRIAL REGISTRATION NUMBER

NCT06003998.

Ten-year treatment outcomes of consolidation hyperthermic intraperitoneal chemotherapy for ovarian cancer (HIPEC-KOV-03R)

OBJECTIVE

We aimed to evaluate the long-term efficacy of consolidation hyperthermic intraperitoneal chemotherapy (HIPEC) for patients with primary epithelial ovarian cancer.

METHODS

This retrospective cohort study included patients who underwent second-look surgery either with or without HIPEC after having complete or partial response to primary cytoreductive surgery and adjuvant platinum-based chemotherapy between January 1991 and December 2003 at Seoul St. Mary's Hospital. The 10-year progression-free survival (PFS), overall survival (OS), and toxicity within postoperative 28 days were investigated.

RESULTS

A total of 87 patients were identified, 44 (50.6%) received second-look surgery with HIPEC whereas 43 (49.4%) received only second-look surgery. The 10-year PFS and OS were significantly longer in the HIPEC group compared with the control group (PFS, 53.6% vs. 34.9%, log-rank p=0.009; OS, 57.0% vs. 34.5%, log-rank p=0.025). Multivariable analysis identified HIPEC as an independent favorable prognostic factor for PFS (adjusted hazard ratio [HR]=0.42; 95% confidence interval [CI]=0.23-0.77; p=0.005) but not for OS (adjusted HR=0.58; 95% CI=0.32-1.07; p=0.079). The more common adverse events in the HIPEC group were thrombocytopenia (90.9% vs. 68.3%, p=0.005), elevated liver enzymes (65.9% vs. 29.3%, p=0.002), and wound complications (18.2% vs. 2.4%, p=0.032). However, these adverse events were reversible and did not delay subsequent consolidation chemotherapy.

CONCLUSION

The consolidation HIPEC demonstrated a significant improvement in 10-year PFS but not OS, with acceptable toxicity in patients with primary epithelial ovarian cancer. Further randomized controlled trials are warranted to confirm these results.

Intraperitoneal Chemotherapy for Unresectable Peritoneal Surface Malignancies

Malignancies of the peritoneal cavity are associated with a dismal prognosis. Systemic chemotherapy is the gold standard for patients with unresectable peritoneal disease, but its intraperitoneal effect is hampered by the peritoneal-plasma barrier. Intraperitoneal chemotherapy, which is administered repeatedly into the peritoneal cavity through a peritoneal implanted port, could provide a novel treatment modality for this patient population. This review provides a systematic overview of intraperitoneal used drugs, the performed clinical studies so far, and the complications of the peritoneal implemental ports. Several anticancer drugs have been studied for intraperitoneal application, with the taxanes paclitaxel and docetaxel as the most commonly used drug. Repeated intraperitoneal chemotherapy, mostly in combination with systemic chemotherapy, has shown promising results in Phase I and Phase II studies for several tumor types, such as gastric cancer, ovarian cancer, colorectal cancer, and pancreatic cancer. Two Phase III studies for intraperitoneal chemotherapy in gastric cancer have been performed so far, but the results regarding the superiority over standard systemic chemotherapy alone, are contradictory. Pressurized intraperitoneal administration, known as PIPAC, is an alternative way of administering intraperitoneal chemotherapy, and the first prospective studies have shown a tolerable safety profile. Although intraperitoneal chemotherapy might be a standard treatment option for patients with unresectable peritoneal disease, more Phase II and Phase III studies focusing on tolerability profiles, survival rates, and quality of life are warranted in order to establish optimal treatment schedules and to establish a potential role for intraperitoneal chemotherapy in the approach to unresectable peritoneal disease.

Pharmacokinetic problems in peritoneal drug administration: an update after 20 years

Intraperitoneal chemotherapy has demonstrated significant pharmacologic and clinical advantage over traditional intravenous administration for cancers that are restricted to the peritoneal cavity. The combination of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC) has become the standard technique used to fight ovarian and gastrointestinal cancers in many centers. However, challenges remain for HIPEC to contact the entire peritoneal surface, penetrate the tumor tissue, and transport to the lymphatics and other metastatic sites. New innovations in delivery technique, such as heated aerosol, and in delivery molecules, such as microparticles, nanoparticles, nanogels, and tumor-penetrating peptides are being tested in animal models and will likely soon be in human trials. Improvements in overall care, such as the recent clinical trial of an oral agent for maintenance therapy in ovarian carcinoma, will continue in this field for the next 20 years.

Treatment of ovarian cancer with paclitaxel- or carboplatin-based intraperitoneal hyperthermic chemotherapy during secondary surgery

OBJECTIVE

We aimed to evaluate the efficacy and feasibility of treating advanced ovarian cancer with paclitaxel or carboplatin in intraperitoneal hyperthermic chemotherapy (IPHC) during secondary surgery.

METHODS

We reviewed clinical data of 96 eligible patients with stage Ic-IIIc epithelial ovarian cancer. After primary staging operation and 6-12 cycles of adjuvant chemotherapy, 22 patients were treated with IPHC-paclitaxel (175 mg/m(2)) and 45 patients were treated with IPHC-carboplatin (350 mg/m(2)) during secondary surgery. Survival rates were compared with those of 29 patients treated with only conventional therapy (control group).

RESULTS

In stage III diseases, 5-year survival rates were 84.6% in IPHC-paclitaxel, 63.0% in IPHC-carboplatin (P=0.4098) and 32.8% in control group (vs. IPHC, P=0.0003). Three-year progression-free survival rates in stage III diseases were both 56.3% in IPHC-paclitaxel and IPHC-carboplatin (P=0.8911) and 16.7% in control group (vs. IPHC, P=0.0028). For the relative risk of disease progression yielded from multivariate analyses, hazard ratio of IPHC-paclitaxel was 0.281 (P=0.0039) and that of IPHC-carboplatin was 0.443 (P=0.0083). Like carboplatin (hazard ratio: 0.396, P=0.0004), IPHC-paclitaxel considerably decreased the risk of death (hazard ratio: 0.197, P=0.0253).

CONCLUSION

In advanced ovarian cancer, IPHC using paclitaxel or carboplatin during secondary surgery could be a candidate for regional consolidation therapy to prolong survival and hinder disease progression.

Gastrectomy, peritonectomy, and perioperative intraperitoneal chemotherapy: the evolution of treatment strategies for advanced gastric cancer

Gastric cancer disseminates by hematogenous, lymphatic, and transcoelomic routes. For maximal containment of the malignant process, perioperative intraperitoneal chemotherapy is necessary in two groups of patients in whom the primary cancer can be resected. Those patients who have been resected for cure and have a high likelihood of microscopic residual disease require intraperitoneal chemotherapy. This includes all T3 and T4 patients, and patients with N2 nodes present. A series of randomized and nonrandomized clinical studies have established the benefits of perioperative intraperitoneal chemotherapy in this group of patients. Patients with stage IV disease who are able to undergo a palliative resection require these treatments if peritoneal seeding is observed. Systemic chemotherapy is largely ineffective for peritoneal seeding, while intraperitoneal chemotherapy is most likely to produce a response with small volume, surgically debulked carcinomatosis. In addition, intraperitoneal chemotherapy can eliminate the future development of debilitating ascites. Sufficient data are available from the gastric cancer literature to support the use of these combined treatments on a routine basis if the primary cancer is resectable and gastrointestinal function can be reestablished.

Cytoreductive surgery and intraoperative hyperthermic intrathoracic chemotherapy in patients with malignant pleural mesothelioma or pleural metastases of thymoma

STUDY OBJECTIVES

No established curative treatment is available for pleural thymoma metastases and malignant pleural mesothelioma (MPM). Recently, peritoneal malignancies have been treated by cytoreductive surgery and intraoperative hyperthermic intracavitary perfusion chemotherapy (HIPEC). We investigated the feasibility and safety of this multimodality treatment in the thoracic cavity.

DESIGN

Patients with pleural thymoma metastases or early-stage MPM were enrolled in a feasibility study. Morbidity, recurrence, and survival rates were recorded.

SETTING

The Netherlands Cancer Institute.

PATIENTS

Three patients with pleural thymoma metastases and 11 patients with pleural mesothelioma were treated.

INTERVENTIONS

Cytoreductive surgery and intraoperative hyperthermic intrathoracic perfusion chemotherapy (HITHOC) with cisplatin and adriamycin were performed. The mesothelioma patients received adjuvant radiotherapy on the thoracotomy wound and drainage tracts.

MEASUREMENTS AND RESULTS

Morbidity and mortality rates were 47% and 0%, respectively. Reoperation was necessary in four cases. Severe chemotherapy-related complications were not observed. A solitary mediastinal and a contralateral pleural thymoma recurrence were successfully treated by radiotherapy and a contralateral HITHOC procedure. All thymoma patients were alive and free of disease after a mean follow-up period of 18 months. After a mean follow-up period of 7.4 months, nine mesothelioma patients are alive. Two mesothelioma patients died of contralateral pleural and peritoneal recurrent disease, while one patient is alive with locoregional recurrence.

CONCLUSIONS

Cytoreductive surgery and HITHOC with cisplatin and adriamycin is feasible in patients with pleural thymoma metastases and early-stage MPM, and is associated with acceptable morbidity rates. Early data on locoregional disease control are encouraging, and a phase II study will be conducted.

Intraperitoneal chemotherapy for colorectal cancer

The peritoneal surface remains an important failure site for patients with colorectal cancer. Peritoneal metastases of colorectal cancer are at present considered equal to distant metastatic disease. Consequently, peritoneal carcinomatosis is treated with systemic chemotherapy and surgery only to palliate complications such as obstruction. Despite the development of new chemotherapeutic agents and combinations, the results remain disappointing with a limited impact on survival. Colorectal carcinoma cells are relatively resistant to chemotherapy. Intraperitoneal chemotherapy seems to be an attractive approach in the treatment of high-risk colorectal cancer and peritoneal carcinomatosis from colorectal origin providing high local drug concentration with limited systemic side effects. Adjuvant early postoperative intraperitoneal chemotherapy is worthwhile for consideration as treatment option after resection of high-risk colorectal cancer. In the treatment of peritoneal carcinomatosis postoperative intraperitoneal chemotherapy leads to inadequate exposure of the peritoneal surface. Only an intraoperative intraperitoneal chemotherapy performed with direct cytotoxic drugs such as MMC and cisplatin overcome this problem. The limited drug penetration in tissue implies the need for extensive cytoreductive surgery. The results of phase II studies suggest that an increased median survival can be achieved with this approach. The natural history of this disease and the heterogeneity of the patients are such that only a randomized trial design will adequately answer the question whether regional treatment of patients with peritoneal dissemination of colorectal cancer actually prolongs survival. The results of such a study are to be expected in approximately 2 years time.

Rationale and techniques of intra-operative hyperthermic intraperitoneal chemotherapy

BACKGROUND

In recent years surgical cytoreduction followed by intra-operative hyperthermic intraperitoneal chemotherapy (HIPEC) was introduced as treatment modality in patients with peritoneal surface malignancy. In the current review the rational for this approach, the prerequisites and the different techniques used are discussed.

METHODS

A literature search through PubMed was performed.

RESULTS

Pharmacokinetic studies have shown an important dose advantage for intraperitoneal versus intravenous application. Hyperthermia enhances the penetration of cytostatic drugs into tumour tissue and also shows synergism with various cytostatic drugs. The penetration depth of drugs into tissue is limited, therefore HIPEC can only be effective in patients with minimal residual disease after (aggressive) surgery. HIPEC can be conducted in various ways, without clear proven advantage of one method over the others. Local complications after this combined treatment approach are mainly surgery related. Intraperitoneal chemotherapy may cause systemic toxicity, dependent on the drug used. In randomised studies cytoreductive surgery followed by HIPEC has proven its value in the prevention of peritoneal dissemination in gastric cancer. Phase II data on HIPEC in peritoneal carcinomatosis of colorectal origin and pseudomyxoma peritonei are promising, but randomised studies are still not available.

CONCLUSION

Aggressive surgical cytoreduction and HIPEC in patients with peritoneal surface malignancy has a clear rational and seems to have clinical value.

Prospective randomized trial of early postoperative intraperitoneal chemotherapy as an adjuvant to resectable gastric cancer

OBJECTIVE

Surgeons have postulated on numerous occasions that cancer resection may participate in the dissemination of a malignancy. This randomized trial sought to determine whether a large volume of chemotherapy solution used perioperatively to flood the peritoneal cavity could eliminate microscopic residual disease and thereby improve survival of patients with gastric cancer.

SUMMARY BACKGROUND DATA

Surgical treatment failures in patients with gastric cancer are confined to the abdomen in most patients. Resection site and peritoneal surface spread, along with liver metastases, are the most common areas of recurrence. Survival and quality of life of patients with gastric cancer would be improved if disease progression at these anatomic sites was reduced.

METHODS

In a prospective randomized trial of 248 patients, intraperitoneal mitomycin C on day 1 and intraperitoneal 5-fluorouracil on days 2 through 5 were administered after gastric cancer resection. Patients who were thought to have stage II or stage III disease were randomized after resection to surgery alone versus surgery plus early postoperative intraperitoneal chemotherapy. After final pathologic examinations, there were 39 patients with stage I, 50 with stage II 95 with stage III, and 64 with resected stage IV cancer.

RESULTS

The 5-year survival of the surgery-only group was 29.3%, and the surgery-plus-intraperitoneal chemotherapy group was 38.7% (p = 0.219). In a subset analysis, the patients with stage I, stage II, and stage IV disease showed no statistically significant difference in survival. The 5-year survival rate of patients with stage III disease who underwent surgery only was 18.4% versus a survival rate of 49.1% for patients who underwent surgery plus intraperitoneal chemotherapy (p = 0.011).

CONCLUSIONS

In a subset analysis, patients with stage III gastric cancer have shown a statistically significant improvement in survival when treated with perioperative intraperitoneal chemotherapy. Further studies in patients with gastric cancer with surgically directed chemotherapy are suggested.

Intraperitoneal chemotherapy and cytoreductive surgery for the prevention and treatment of peritoneal carcinomatosis and sarcomatosis

Intraperitoneal chemotherapy and cytoreductive surgery have been combined to reach treatment objectives in patients with peritoneal carcinomatosis or sarcomatosis that neither modality by itself can achieve. These treatments must be combined with the proper selection of patients in order to observe "high value" results from therapy. There are three principles of management to support treatments for peritoneal carcinomatosis and sarcomatosis. First, the clinician must select patients who have isolated disease distributed on the surfaces of abdominal and pelvic structures. Patients treated for peritoneal implants who have persistent disease at other sites will profit little or not at all. Second, this disease must be reduced to its lowest possible mass by peritonectomy procedures and resections of viscera. Third, maximal intraperitoneal and systemic chemotherapy are utilized to eradicate the disease on peritoneal surfaces as well as control the primary or recurrent tumor. These principles of management and a presentation of the results achieved to date are reviewed.

Ligand-targeted liposomes

Liposomes have gained increased attention as systemic drug delivery vehicles following recent regulatory approvals of several vesicle-formulated drugs. These products have demonstrated improved therapeutic indices over their corresponding conventional drugs by avoiding sensitive tissues and/or increasing delivery to specific targets in vivo. They have achieved these improvements primarily through physical means: (1) by retaining drug within vesicles while in the circulation, thus avoiding or minimizing uptake by sensitive normal tissues; and (2) by selectively extravasating into target tissues, releasing active drug. In order to improve upon these therapies in the future, clinically active liposome delivery systems most likely will need to include site-directed surface ligands to further enhance their selective delivery. This may be crucial for the in vivo transport and delivery of macromolecules, including antisense, oligonucleotide aptamers, and genes, which-unlike most conventional drugs-do not circulate well and often require cellular uptake by fusion, endocytosis, or other processes to reach their active sites. This manuscript reviews technologies applicable to directing liposomes and their contents to selected in vivo targets using surface-bound, site-specific ligands. Presented are the biological barriers to be overcome, criteria for selecting the determinants to be targeted, various targeting ligands and overall delivery system design considerations. Several novel targets as well as novel ligand constructs for site-directed therapy are reviewed and discussed. Systemic liposome therapy, which currently must be administered by the intravenous route, is the principal focus of this analysis.