Reduction of drug leakage by negative-balance isolated pelvic perfusion: correlation between leakage and in-out flow rate in a pig model

Stop-Flow Pelvic Chemoperfusion for the Treatment of Malignant Pelvic Bone Tumors: A Preliminary Study

Objective

To preliminarily study the efficacy and safety of stop‐flow pelvic chemoperfusion, a novel therapeutic strategy for treating pelvic malignancies.

Methods

Stop‐flow chemoperfusion was performed six times in 5 patients with primary pelvic malignancies. Aortic and vena cave balloons and tourniquets were used to isolate pelvic blood flow from systemic circulation. Cisplatin was then perfused through a transarterial catheter to achieve exposure to a higher drug concentration. Pelvic and peripheral blood samples were collected to determine drug concentration during perfusion. The efficacy of stop‐flow pelvic perfusion was assessed by measuring the change in tumor size, the visual analogue scale, and the tumor necrosis rate after perfusion. Safety was assessed by classifying adverse events according to CTCAE v4.03.

Results

The mean area under the curve (AUC) and maximum drug concentration in the pelvis during perfusion were 246.23 min μg/mL and 17.29 μg/mL, respectively. These measures were significantly higher than the peripheral mean AUC and maximum drug concentration of 52.08 min μg/mL and 5.14 μg/mL, respectively. All 5 patients showed stable disease in response, with changes in tumor size of −4.7%, −5.4%, +4.7%, −8.4%, and 0.0%. Among the 5 patients, 3 (60%) experienced significant pain relief after perfusion. Three patients underwent surgery, with tumor necrosis of 63%, <60%, and 93%. No severe complications were observed in this study.

Conclusions

Stop‐flow pelvic chemoperfusion resulted in exposure to drug higher concentration with fewer serious complications. These preliminary results suggest that further studies are required to comprehensively assess the therapeutic potential of stop‐flow pelvic chemoperfusion in pelvic malignancies.

Feasibility and Safety of Negative-Balance Isolated Pelvic Perfusion in Patients with Pretreated Recurrent or Persistent Uterine Cervical Cancer

BACKGROUND

Second-line therapy has limited activity in patients with recurrent or persistent uterine cervical cancer that has progressed after chemoradiation and palliative chemotherapy. The purpose of this study was to evaluate the efficacy of negative-balance isolated pelvic perfusion (NIPP) in patients with pretreated recurrent/persistent uterine cervical cancer.

METHODS

Between April 2004 and May 2013, a total of 26 patients with recurrent or persistent uterine cervical cancer previously treated with platinum-based systemic chemotherapy and/or chemoradiotherapy received NIPP therapy at our institution, consisting of a 30-min isolated pelvic perfusion with cisplatin and fluorouracil, followed by isolated pelvic dialysis. Primary endpoints were response rate (RR) and progression-free survival (PFS), while secondary endpoints were overall survival (OS) and safety. Platinum pharmacokinetics were also evaluated.

RESULTS

The RR was 57.7 % (complete response, five patients; partial response, ten patients). The median PFS and OS after NIPP therapy were 11.0 (95 % confidence interval [CI] 6.6-15.4) and 25.1 (95 % CI 17.1-33.1) months, respectively. PFS was significantly better in patients without intestinal involvement (p = 0.016) or dissemination (p < 0.001). Survival rates at 1, 2, and 3 years after initial NIPP therapy were 65.2, 50.4, and 13.4 %, respectively. The plasma pelvic-to-systemic exposure ratios were 15.4 and 15.8, based on the maximum concentration and the concentration-time curve, respectively. Most adverse events were mild (grade 1-2) (Common Terminology Criteria for Adverse Events, version 3.0). Severe neutropenia (grade 3 or higher) occurred in only 7.7 % of patients.

CONCLUSIONS

NIPP appears to be an effective and feasible method for patients with pretreated recurrent or persistent cervical cancer.

Negative-balance isolated pelvic perfusion in patients with incurable symptomatic rectal cancer: results and drug dose correlation to adverse events

BACKGROUND

Drug leakage and lack of a drug-removal system have prevented clinical application of isolated pelvic perfusion (IPP). These barriers were overcome with negative-balance IPP (NIPP) in experimental pig models. Here, a phase 1 clinical study of NIPP was performed in patients with incurable symptomatic rectal cancer.

PURPOSE

To establish a safe regimen of high-dose regional chemotherapy with NIPP using cisplatin in patients with incurable rectal cancer.

MATERIAL AND METHODS

Between June 2004 and January 2007, NIPP therapy was performed for 23 patients (11 women, 12 men; mean age, 58 years). NIPP was routinely performed twice over a 4-week interval. Dose-limiting toxicities (DLTs) were defined using a 5 + 3 design, and cisplatin doses were escalated from 170 mg/m(2), with a fixed 5-fluorouracil dose of 1000 mg/m(2). The grade of adverse events (AEs) at the first and second sessions of NIPP therapy, pharmacokinetics, and antitumor response were evaluated.

RESULTS

No DLTs were observed during the first session of NIPP. However, at the second session, two patients experienced the DLT of neuropathy after administration of 200 mg/m(2) cisplatin. Therefore, 190 mg/m(2) cisplatin was indicated as the maximum tolerated dose (MTD). The plasma pelvic-to-systemic exposure ratio was 18.4 based on the maximum concentration and 19.0 based on the concentration-time curve. Solid tumor responses included complete response in two patients, partial response in five patients, stable disease in 15 patients, and progressive disease in one patient.

CONCLUSION

NIPP may offer the safe delivery of high-dose regional chemotherapy (MTD of 190 mg/m(2) cisplatin) with negligible AEs and effective control of tumor growth in patients with incurable rectal cancer.

Comparative study of transcatheter renal arterial embolization with and without closed renal circuit: pharmacokinetic and histologic assessment in pigs

PURPOSE

To assess the degree of renal necrosis and the leakage of absolute ethanol by using two methods: transcatheter renal artery embolization (TAE) and TAE performed with a closed renal circuit (CRC) (TAE/CRC), both performed by using ethanol and iodized oil, in a pig model.

MATERIALS AND METHODS

All animal experiments were conducted in accordance with our university guidelines for animal care and experimentation. Fourteen pigs were classified in two groups: standard TAE and TAE/CRC groups. In the TAE/CRC group, the renal artery and vein were occluded with balloon catheters; in the TAE group, only the renal artery was occluded. An emulsion of absolute ethanol (0.5 mL per kilogram of body weight) and iodized oil (emulsion ratio, 4:1) was injected in the renal artery in both groups. In the TAE/CRC group, we aspirated the blood containing the emulsion via the renal vein during arterial infusion. We measured the ethanol concentrations of the systemic circulation. Four days after embolization, the kidneys in both groups were removed and histopathologic examination was performed and results were compared.

RESULTS

The mean systemic ethanol concentration was less than 0.1 mg/mL in the TAE/CRC group and 0.28 mg/mL +/- 0.15 (standard deviation) in the TAE group (P < .002). In both groups, about 90% of the kidney was shown histopathologically to have undergone coagulation necrosis (no significant difference). The frequency of venous thrombus formation was significantly lower (P = .009) in the TAE/CRC group.

CONCLUSION

TAE/CRC dramatically reduces ethanol leakage to the systemic circulation without a decrease in embolization effect in the normal swine kidney, and it also reduces the likelihood of venous thrombus formation.

Pilot study of transcatheter arterial ethanol embolization under closed renal circuit for large renal cell carcinomas

The safety of a new technique, designated "transcatheter arterial embolization (TAE) with aspiration via a balloon-occluded renal drainage vein" (TAE-ABOD), for the management of large renal cell carcinomas (RCCs). The subjects were 25 patients with RCC who underwent a total of 27 sessions of TAE-ABOD. This TAE-ABOD technique incorporates two procedures: balloon occlusion of renal drainage vein and infusion of absolute ethanol into the tumor-feeding arteries during aspiration of blood via a balloon catheter, thereby reducing leakage of absolute ethanol into the systemic circulation. Our primary endpoint was to establish a safe regimen for high-dose ethanol injection therapy, and our secondary endpoint was to assess global survival of the patients. The administered dose of ethanol ranged from 0.2 to 0.5 ml/kg [median: 0.34 (SD: 0.10) ml/kg], increased in a stepwise manner. The systemic ethanol concentration was measurable in 14 patients, and was less than 0.1 mg/ml in 12 and from 0.1 to less than 0.2 mg/ml in two. There were no major complications such as renal failure or renal abscess. TAE-ABOD can safely deliver a high dose of absolute ethanol for the treatment of large RCCs.

Large volume loading to prevent cisplatin-induced nephrotoxicity during negative-balance isolated pelvic perfusion

PURPOSE

Negative-balance isolated pelvic perfusion (NIPP) is used to administer high doses of anticancer drugs such as cisplatin to patients with advanced cancer of the pelvic region. Although the drugs are intended to be specifically delivered to the pelvis, their leakage into the systemic circulation can cause acute renal failure. This study examines the loading volume required for preservation of renal function during anesthesia of NIPP.

METHODS

Pelvic cancer patients were assigned to NIPP according to its enrollment criteria. Patients with heart failure, uncontrollable hypertension, renal failure, pulmonary disease or contraindication for the contrast media were excluded. We compared the current anesthesia management regime with a previous protocol, with regard to the loading volume and renal function as assessed by the calculated glomerular filtration rate (GFR). The correlation between the total loading volume and the GFR ratio (GFR after NIPP/GFR before NIPP) was evaluated to define adequate volume loading.

RESULTS

The GFR ratios were 0.86 +/- 0.29 and 1.12 +/- 0.25 for the previous and current procedures, respectively. The regression line showed that a minimum loading volume of 28.8 ml kg(-1) h(-1) was required to maintain a GFR ratio of > or =1.

CONCLUSIONS

A large volume infusion preserves the GFR despite high-dose cisplatin administration by NIPP.

Changes in pelvic and systemic platinum concentrations during negative-balance isolated pelvic perfusion: correlation between platinum concentration and method of administration in a pig model

PURPOSE

To assess the effect of altering the method of administration during negative-balance isolated pelvic perfusion (NIPP) on the platinum concentration in the pelvic or systemic circulation.

METHODS

Twenty female pigs were used in this study. The abdominal aorta and the infra-renal vena cava were occluded with two balloon catheters and blood in the extracorporeal circuit was circulated with twin rotary pumps. NIPP was then performed with cisplatin (5 mg/kg) in 15 pigs. Three types of NIPP administration method (group A: 1 bolus, B: 2 same doses boluses, C: 3 same doses boluses) were used, five pigs being subjected to each treatment. The remaining five pigs were administered cisplatin systemically as a control study (group D). The platinum concentrations in the pelvic and systemic circulation were measured and compared.

RESULTS

(1) Pelvic circulation: There was a tendency for the platinum concentration to increase as the bolus time decreased. The platinum concentration in groups A and B was significantly (P < 0.05) higher than that in group C. Significant differences (P < 0.05) between groups A and B until 10 min after the start of NIPP. (2) Systemic circulation: Significant differences (P < 0.05) were observed between NIPP groups and D during NIPP. The platinum concentration in group D was five times higher than that in group C. (3) Plasma pelvic to systemic exposure ratio: there were no significant differences among the three NIPP groups.

CONCLUSIONS

The platinum concentrations in the pelvic and systemic circulation increased as the bolus time decreased. The plasma pelvic to systemic exposure ratio was not influenced by bolus time.