Multicenter Phase II Clinical Trial of Isolated Lung Perfusion in Patients With Lung Metastases

Preclinical experience with cisplatin, gemcitabine, and doxorubicin in pulmonary suffusion

Background

Because suffusion amplifies lung chemotherapy while limiting systemic toxicity, we tested candidate drugs for treating human lung cancers and pulmonary metastases.

Methods

Immature beagle dogs underwent thoracotomy for unilateral lung suffusion of cisplatin (0.125-2 mg/kg; n = 19), doxorubicin (3.75-7.5 mg/kg; n = 7), gemcitabine (168.75 mg/kg; n = 5), or saline (n = 3). After ipsilateral lung circulation isolation and drainage, pulmonary artery chemotherapy was injected, dwelled for 30 minutes, and then aspirated. Bilateral lung biopsies and serum samples assessed delivery and leak. After lung reperfusion, animals recovered for 30 days with scheduled monitoring of vital signs, weights, and behaviors. At experiment termination, necropsy histopathologic tissue analyses assessed tolerability.

Results

All 32 animals recovered, except 1 with lung torsion and 2 with pulmonary toxicity that required early euthanasia. Serum concentrations during suffusion for cisplatin (135 ng/mL), doxorubicin (undetectable), and gemcitabine (1452 ng/mL) indicated minimal systemic leakage. Cisplatin escalations showed uniform suffusion deliveries (100% fibrosis at a 100% systemic chemotherapy dose), which was then reduced to a nondamaging 25% threshold. When the equivalent dose of doxorubicin was used, toxicity occurred, but 12.5% (2.5-fold amplification of local delivery) was well tolerated. Gemcitabine, like cisplatin, caused minimal toxicity at 25% of the systemic dose (5-fold amplification). Optimized doses caused no hematologic or metabolic derangements and necropsies showed no gross organ injury other than adhesions. Histopathology demonstrated multifocal ipsilateral lung fibrotic changes without contralateral or extrapulmonary pathology.

Conclusions

While suffusion delivery of the vesicant doxorubicin was tolerated less well than cisplatin and gemcitabine, all appear to be safe and feasible for human trials.

Effects of Doxorubicin, Epirubicin, and Liposomal Doxorubicin (Anthracycline) on cardiac function in patients with osteosarcoma and their influencing factors

OBJECTIVE

The objective of this study was to investigate the impact of Doxorubicin, Epirubicin, and Liposomal Doxorubicin (Anthracycline) on cardiac function in osteosarcoma patients and analyze the factors influencing this effect.

METHODS

A retrospective study was conducted on 165 osteosarcoma patients admitted to our hospital from January 2020 to December 2022. Based on the chemotherapy regimen, the patients were divided into two groups: the control group (n = 62) treated with Cisplatin and cyclophosphamide, and the observation group (n = 103) treated with Doxorubicin, Epirubicin, and Liposomal Doxorubicin (Anthracycline). The general records of both groups were analyzed, and left ventricular ejection fraction (LVEF) was evaluated through echocardiography before and after chemotherapy. Blood cTnT and CK-MB levels were measured using immunoluminescence. The incidence of adverse reactions during chemotherapy was also analyzed. Univariate analysis was performed to identify patients with cardiotoxic events, and multiple logistic regression analysis was done to study the effects of Doxorubicin, Epirubicin, Liposomal Doxorubicin, and their dosages on cardiotoxicity in patients.

RESULTS

The general records between the two groups showed no significant differences (P > 0.05). However, at the fourth cycle of chemotherapy, the observation group exhibited a lower LVEF (P < 0.05), and a higher percentage of LVEF decrease compared to the control group (P < 0.05). Moreover, the observation group had higher levels of blood cTnT and CK-MB (P < 0.05). The incidence of cardiotoxicity in the observation group was also higher (P < 0.05), but no significant differences were seen in other adverse reaction rates (P > 0.05). The occurrence of cardiotoxicity was found to be related to the choice and dosage of chemotherapy drugs (P < 0.05), but not significantly correlated with age, sex, and mediastinal irradiation in patients (P > 0.05). Furthermore, the use of Doxorubicin, Epirubicin, and Liposomal Doxorubicin in chemotherapy, as well as an increase in their dosages, was found to elevate the risk of cardiotoxicity in osteosarcoma patients (P < 0.05). However, age, sex, and mediastinal radiation were not significantly associated with cardiotoxicity in osteosarcoma patients (P > 0.05).

CONCLUSION

We demonstrated that Doxorubicin, Epirubicin, Liposomal Doxorubicin (Anthracycline), and other drugs adversely affected cardiac function in osteosarcoma patients, increasing the risk of cardiac toxicity. Therefore, close monitoring of cardiac function during chemotherapy is crucial, and timely adjustments to the chemotherapy regimen are necessary. In addition, rational control of drug selection and dosage is essential to minimize the occurrence of cardiac toxicity.

Transvenous Pulmonary Chemoembolization and Optional Microwave Ablation for Colorectal Lung Metastases

(1) Purpose: To evaluate tumor response and survival of patients with colorectal pulmonary metastases treated by transvenous pulmonary chemoembolization (TPCE) alone with palliative intent or TPCE followed by microwave ablation (MWA) with potentially curative intent. (2) Material and methods: A total of 164 patients (64 women and 100 men; mean age: 61.8 ± 12.7 years) with unresectable colorectal lung metastases and not responding to systemic chemotherapy, who either received repetitive TPCE (Group A) or TPCE followed by MWA (Group B), were retrospectively enrolled. The revised response evaluation criteria in solid tumors were used to assess treatment response in Group A. The oncological response in Group B was divided into local tumor progression (LTP) and intrapulmonary distant recurrence (IDR) after MWA. (3) Results: The 1-, 2-, 3-, and 4-year survival rates were 70.4%, 41.4%, 22.3%, and 5%, respectively, for all patients. In Group A; the rates of stable disease; progressive disease; and partial response were at 55.4%, 41.9%, and 2.7%, respectively. The rates of LTP and IDR were 3.8%, and 63.5%, respectively, in Group B. Conclusion: TPCE is an effective treatment for colorectal lung metastases, which can be performed alone or combined with MWA.

Innovative Invasive Loco-Regional Techniques for the Treatment of Lung Cancer

Surgical resection is still the standard treatment for early-stage lung cancer. A multimodal treatment consisting of chemotherapy, radiotherapy and/or immunotherapy is advised for more advanced disease stages (stages IIb, III and IV). The role of surgery in these stages is limited to very specific indications. Regional treatment techniques are being introduced at a high speed because of improved technology and their possible advantages over traditional surgery. This review includes an overview of established and promising innovative invasive loco-regional techniques stratified based on the route of administration, including endobronchial, endovascular and transthoracic routes, a discussion of the results for each method, and an overview of their implementation and effectiveness.

The Nitrogen Mustards

The nitrogen mustards are powerful cytotoxic and lymphoablative agents and have been used for more than 60 years. They are employed in the treatment of cancers, sarcomas, and hematologic malignancies. Cyclophosphamide, the most versatile of the nitrogen mustards, also has a place in stem cell transplantation and the therapy of autoimmune diseases. Adverse effects caused by the nitrogen mustards on the central nervous system, kidney, heart, bladder, and gonads remain important issues. Advances in analytical techniques have facilitated the investigation of the pharmacokinetics of the nitrogen mustards, especially the oxazaphosphorines, which are prodrugs requiring metabolic activation. Enzymes involved in the metabolism of cyclophosphamide and ifosfamide are very polymorphic, but a greater understanding of the pharmacogenomic influences on their activity has not yet translated into a personalized medicine approach. In addition to damaging DNA, the nitrogen mustards can act through other mechanisms, such as antiangiogenesis and immunomodulation. The immunomodulatory properties of cyclophosphamide are an area of current exploration. In particular, cyclophosphamide decreases the number and activity of regulatory T cells, and the interaction between cyclophosphamide and the intestinal microbiome is now recognized as an important factor. New derivatives of the nitrogen mustards continue to be assessed. Oxazaphosphorine analogs have been synthesized in attempts to both improve efficacy and reduce toxicity, with varying degrees of success. Combinations of the nitrogen mustards with monoclonal antibodies and small-molecule targeted agents are being evaluated. SIGNIFICANCE STATEMENT: The nitrogen mustards are important, well-established therapeutic agents that are used to treat a variety of diseases. Their role is continuing to evolve.

Application of Different Ventilation Modes Combined with AutoFlow Technology in Thoracic Surgery

To investigate the effect of AutoFlow on airway pressure and hemodynamics in mechanical ventilation constant volume-control ventilation mode, 100 patients receiving mechanical ventilation were randomly divided into observation group (SIMV-PSV-PEEP + AutoFlow) and control group (SIMV-PSV-PEEP). The results showed that the peak airway pressure and average airway pressure decreased with different flow rate settings and automatic flow conversion (P < 0.05). The peak airway pressure and mean airway pressure decreased with different resistance settings (P < 0.05). With different compliance settings, the peak airway pressure and average airway pressure decreased after being assisted with an automatic converter (P < 0.05). Adding AutoFlow on the basis of SIMV-PSV mode can significantly reduce peak inspiratory pressure (PIP), mean airway pressure (Pmean), and airway resistance (R). There was no significant difference in hemodynamic monitoring results between the observation group and the control group. It is proved that the SIMV constant volume-controlled ventilation mode combined with AutoFlow can not only ensure tidal volume but also avoid excessive airway pressure, which has little effect on hemodynamics.

Pulmonary metastasectomy in colorectal carcinoma

Colorectal cancer (CRC) is one of the leading causes of cancer-related deaths worldwide. It is estimated that 50% of all patients with CRC develop metastases, most commonly in the liver and the lung. Lung metastases are seen in approximately 10–15% of all patients with CRC. A large number of these patients with metastatic CRC can only receive palliative treatment due to invasion of other organs and disseminated disease. However, a subset of these patients present with potentially resectable metastases. Pulmonary metastasectomy is considered to be a potentially curative treatment for selected patients with resectable metastatic CRC. Current data suggest that patients that undergo pulmonary metastasectomy have 5-year survival rates of approximately 40%. However, the majority of data published regarding lung metastasectomy is based on small, retrospective case series. Due to this lack of prospective data, it is still unclear which subset of patients will benefit most from curative-intent surgery. Furthermore, there is also controversy regarding which prognostic and genetic factors are related to survival outcomes and whether there is a difference between open and thoracoscopic approaches in terms of overall and disease-free survival. In this review, we aim to summarize the latest data on prognostic factors and survival outcomes after pulmonary metastasectomy in patients with metastatic CRC.

Two Hours of In Vivo Lung Perfusion Improves Lung Function in Sepsis-Induced Acute Respiratory Distress Syndrome

Sepsis is the leading cause of acute respiratory distress syndrome (ARDS) in adults and carries a high mortality. Utilizing a previously validated porcine model of sepsis-induced ARDS, we sought to refine our novel therapeutic technique of in vivo lung perfusion (IVLP). We hypothesized that 2 hours of IVLP would provide non-inferior lung rehabilitation compared to 4 hours of treatment. Adult swine (n = 8) received lipopolysaccharide to develop ARDS and were placed on central venoarterial extracorporeal membrane oxygenation. Animals were randomized to 2 vs 4 hours of IVLP. The left pulmonary vessels were cannulated to IVLP using antegrade Steen solution. After IVLP treatment, the left lung was decannulated and reperfused for 4 hours. Total lung compliance and pulmonary venous gases from the right lung (control) and left lung (treatment) were sampled hourly. Biochemical analysis of tissue and bronchioalveolar lavage was performed along with tissue histologic assessment. Throughout IVLP and reperfusion, treated left lung PaO2/FiO2 ratio was significantly higher than the right lung control in the 2-hour group (332.2 ± 58.9 vs 264.4 ± 46.5, P = 0.01). In the 4-hour group, there was no difference between treatment and control lung PaO2/FiO2 ratio (258.5 ± 72.4 vs 253.2 ± 90.3, P = 0.58). Wet-to-dry weight ratios demonstrated reduced edema in the treated left lungs of the 2-hour group (6.23 ± 0.73 vs 7.28 ± 0.61, P = 0.03). Total lung compliance was also significantly improved in the 2-hour group. Two hours of IVLP demonstrated superior lung function in this preclinical model of sepsis-induced ARDS. Clinical translation of IVLP may shorten duration of mechanical support and improve outcomes.

Ex vivo lung perfusion in lung transplantation

Lung transplantation is an established life-saving intervention for patients with end-stage lung diseases. The success of lung transplantation mainly depends on the quality and function of the implanted donor lungs, which are frequently subject to brain-death-induced lung injuries and intensive care unit (ICU)-related complications before transplantation. Recent innovations, particularly the development of ex vivo lung perfusion (EVLP), in which donor lungs are ventilated and perfused under normothermic conditions outside the body, have allowed clinicians to more accurately assess the donor lung function prior to transplantation. Therefore, EVLP has been successfully translated into clinical practice with the expansion of the donor lung pool, leading to favorable post-transplant outcomes in a growing number of transplant centers worldwide. The EVLP system and techniques, following the Toronto protocol, have recently been applied for the assessment of extended criteria brain-death donors in clinical lung transplantation in Japan. The advancement of EVLP from organ assessment to organ treatment will be the next challenging stage not only to expand donor lung pool, but also to improve graft survival and long-term outcomes after transplantation.

Isolated Lung Perfusion in the Management of Acute Respiratory Distress Syndrome

Acute respiratory distress syndrome (ARDS) is associated with high morbidity and mortality, and current management has a dramatic impact on healthcare resource utilization. While our understanding of this disease has improved, the majority of treatment strategies remain supportive in nature and are associated with continued poor outcomes. There is a dramatic need for the development and breakthrough of new methods for the treatment of ARDS. Isolated machine lung perfusion is a promising surgical platform that has been associated with the rehabilitation of injured lungs and the induction of molecular and cellular changes in the lung, including upregulation of anti-inflammatory and regenerative pathways. Initially implemented in an ex vivo fashion to evaluate marginal donor lungs prior to transplantation, recent investigations of isolated lung perfusion have shifted in vivo and are focused on the management of ARDS. This review presents current tenants of ARDS management and isolated lung perfusion, with a focus on how ex vivo lung perfusion (EVLP) has paved the way for current investigations utilizing in vivo lung perfusion (IVLP) in the treatment of severe ARDS.

Targeting aggressive osteosarcoma with a peptidase-enhanced cytotoxic melphalan flufenamide

Background:

Low survival rates in metastatic high-grade osteosarcoma (HGOS) have remained stagnant for the last three decades. This study aims to investigate the role of aminopeptidase N (ANPEP) in HGOS progression and its targeting with a novel lipophilic peptidase-enhanced cytotoxic compound melphalan flufenamide (melflufen) in HGOS.

Methods:

Meta-analysis of publicly available gene expression datasets was performed to determine the impact of ANPEP gene expression on metastasis-free survival of HGOS patients. The efficacy of standard-of-care anti-neoplastic drugs and a lipophilic peptidase-enhanced cytotoxic conjugate melflufen was investigated in patient-derived HGOS ex vivo models and cell lines. The kinetics of apoptosis and necrosis induced by melflufen and doxorubicin were compared. Anti-neoplastic effects of melflufen were investigated in vivo.

Results:

Elevated ANPEP expression in diagnostic biopsies of HGOS patients was found to significantly reduce metastasis-free survival. In drug sensitivity assays, melflufen has shown an anti-proliferative effect in HGOS ex vivo samples and cell lines, including those resistant to methotrexate, etoposide, doxorubicin, and PARP inhibitors. Further, HGOS cells treated with melflufen displayed a rapid induction of apoptosis and this sensitivity correlated with high expression of ANPEP. In combination treatments, melflufen demonstrated synergy with doxorubicin in killing HGOS cells. Finally, Melflufen displayed anti-tumor growth and anti-metastatic effects in vivo.

Conclusion:

This study may pave the way for use of melflufen as an adjuvant to doxorubicin in improving the therapeutic efficacy for the treatment of metastatic HGOS.

A model to assess acute and delayed lung toxicity of oxaliplatin during in vivo lung perfusion

OBJECTIVES

To determine the dose-limiting toxicity of oxaliplatin chemotherapy delivered by in vivo lung perfusion (IVLP). To allow assessment of subacute toxicities, we aimed to develop a 72-hour porcine IVLP survival model.

METHODS

In total, 12 Yorkshire male pigs were used. Left lung IVLP was performed for 3 hours. At 72 hours postoperatively, computed tomography imaging of the lungs was performed before the pigs were killed. Lung physiology, airway dynamics, gross appearance, and histology were assessed before and during IVLP, at reperfusion, and when the pigs were euthanized. An accelerated titration dose-escalation study design was employed whereby oxaliplatin doses were sequentially doubled provided no clinically significant toxicity was observed, defined as an arterial partial pressure of oxygen to fraction of inspired oxygen ratio <300 mm Hg or severe acute lung injury on biopsy.

RESULTS

After an initial training phase, no mortality or adverse events related to the procedure were observed. There was no lung injury observed at the time of IVLP for any case. At sacrifice, clinically significant lung injury was observed at 80 mg/L oxaliplatin, with an arterial partial pressure of oxygen to fraction of inspired oxygen ratio of 112 mm Hg. Mild and subclinical lung injury was observed at 40 mg/L, with this dose being repeated to confirm safety.

CONCLUSIONS

A stable and reproducible porcine 3-day IVLP survival model was established that will allow toxicity assessment of agents delivered by IVLP. Oxaliplatin delivered by IVLP showed delayed-onset toxicity that was not apparent at the time of reperfusion, with a maximal-tolerated dose of 40 mg/L. This information will inform initiation of a clinical trial examining IVLP delivery of oxaliplatin at our institution.

A population-based propensity-matched study of regional dissections in patients with metastatic osteosarcoma

Background

The survival rates of patients with metastatic osteosarcoma are poor, and the prognosis is closely related to the choice of treatment, especially surgery. This study aimed to evaluate the survival outcomes of patients with metastatic osteosarcoma undergoing regional dissections.

Methods

We collected data on patients with metastatic osteosarcoma between 2004 and 2014 from the Surveillance, Epidemiology, and End Results (SEER) database. Kaplan–Meier curves were used to compare overall survival (OS) and cancer-specific survival (CSS), while univariate and multivariate Cox regression analyses were used to evaluate outcomes. Propensity score matching (PSM) was used to minimize the effects of confounding factors.

Results

The SEER database had records of 2768 patients diagnosed with osteosarcoma, of whom 398 were included in our study. Of the included patients, 116 (29.15%) underwent regional dissections, while 282 (70.85%) underwent non-regional dissections. The univariate and multivariate Cox regression analyses, prior to PSM, showed that OS (hazard ratio (HR): 0.34, 95% confidence interval (CI): 0.26–0.44, P<0.001 and HR: 0.47, 95% CI: 0.35–0.64, P<0.001, respectively) and CSS (HR: 0.33, 95% CI: 0.25–0.43, P<0.001 and HR: 0.46, 95% CI: 0.34–0.63, P<0.001, respectively) were better in patients who underwent regional dissections than those who underwent non-regional dissections. Compared with non-regional dissections, regional dissections, which included both primary tumour resection (PTR) and primary tumour and metastatic site resection (PTMR), were associated with better OS (P<0.001) and CSS (P<0.001) . However, the survival outcomes following PTR and PTMR showed no significant difference. After PSM, patients in the regional dissection group still had a higher OS (P<0.001) and CSS (P<0.001) than those in the non-regional dissection group.

Conclusions

Compared with non-regional dissection, regional dissection resulted in better survival in patients with metastatic osteosarcoma.