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Nakasone ES, Bustillos HC, Gui X, Konnick EQ, Sham JG, Cohen SA. Multidisciplinary Approach for the Management of Metastatic Poorly Differentiated Neuroendocrine Carcinoma of the Pancreas: A Case Report of an Exceptional Responder. Pancreas 2024:00006676-990000000-00129. [PMID: 38460151 DOI: 10.1097/mpa.0000000000002322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/11/2024]
Abstract
ABSTRACT Poorly differentiated pancreatic neuroendocrine carcinomas (pNECs) are rare, highly aggressive neoplasms. Frequently metastatic at diagnosis, prognosis is poor with median overall survival estimated to be less than 1 year. Although multidisciplinary management, including systemic medications and locoregional therapies aimed at reducing and preventing symptoms caused by mass effect, is the mainstay of treatment for patients with metastatic well-differentiated pancreatic neuroendocrine tumors, rapid progression, organ dysfunction, and poor performance status often preclude initiation of even single-modality palliative chemotherapy for patients with metastatic pNEC, limiting the use of and recommendation for multidisciplinary management.We describe the case of a 51-year-old male patient diagnosed with pNEC metastatic to liver and lymph nodes presenting with impending cholestatic liver failure for whom we were able to successfully initiate and dose-escalate cytotoxic chemotherapy with excellent radiographic response. After multidisciplinary review of his case, the patient underwent pancreaticoduodenectomy and hepatic wedge biopsies, with pathology demonstrating a pathologic complete response to chemotherapy in both the pancreas and liver. Surveillance scans at 2 years from initial diagnosis and 1 year from surgery remain without evidence of locoregional or distant recurrence, highlighting the importance and utility of multidisciplinary management in select cases.
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Affiliation(s)
| | - Hannah C Bustillos
- Clinical Pharmacy, University of Washington/Fred Hutchinson Cancer Center
| | - Xianyong Gui
- Departments of Laboratory Medicine and Pathology, and
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Zhu Z, Hu K, Zhao F, Liu W, Zhou H, Zhu Z, Li H. Machine learning-based nomogram for 30-day mortality prediction for patients with unresectable malignant biliary obstruction after ERCP with metal stent: a retrospective observational cohort study. BMC Surg 2023; 23:260. [PMID: 37649027 PMCID: PMC10470194 DOI: 10.1186/s12893-023-02158-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 08/17/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND This study aimed to investigate the risk factors for 30-day mortality in patients with malignant biliary obstruction (MBO) after endoscopic retrograde cholangiopancreatography (ERCP) with endobiliary metal stent placement. Furthermore, we aimed to construct and visualize a prediction model based on LASSO-logistic regression. METHODS Data were collected from 245 patients who underwent their first ERCP with endobiliary metal stent placement for unresectable MBO between June 1, 2013, and August 31, 2021. Univariable and multivariable logistic regression analyses were conducted to identify the risk factors for 30-day mortality. We subsequently developed a logistic regression model that incorporated multiple parameters identified by LASSO regression. The model was visualized and the nomogram was plotted. Risk stratification was performed based on nomogram-derived scores. RESULTS The 30-day mortality rate was 10.7% (23/245 patients). Distant metastasis, total bilirubin, post-ERCP complications, and successful drainage were independent risk factors of 30-day mortality. The variables screened by LASSO regression, including distant metastasis, total bilirubin, post-ERCP complications, and successful drainage, were incorporated into the logistic model. The results were visualized through a nomogram based on the model. To assess the model's performance, discrimination was evaluated using the area-under-the-curve values obtained from receiver operating characteristic analyses with 10-fold cross-validation in the training group and validated in the testing group. The calibration curve showed the good predictive ability of the model. Decision curve analysis is used to evaluate the clinical application of nomogram. Finally, we performed risk stratification based on the risk calculated using the nomogram. Patients were assigned to the low-, moderate-, and high-risk groups based on their probability scores. The Kaplan-Meier survival curves for the different nomogram-based groups were significantly different (p < 0.001). CONCLUSIONS We developed a nomogram using the LASSO-logistic regression model to forecast the 30-day mortality rate in patients who had undergone ERCP with endobiliary metal stent placement due to MBO. This nomogram can assist in identifying individuals at high-risk of 30-day mortality following ERCP.
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Affiliation(s)
- Zongdong Zhu
- Jiaxing University Master Degree Cultivation Base, Zhejiang Chinese Medical University, Jiaxing, Zhejiang, China
- Department of Hepatobiliary and Pancreatic Surgery, First Hospital of Jiaxing, Affiliated Hospital of Jiaxing University, Jiaxing, Zhejiang, China
| | - Kaixin Hu
- Jiaxing University Master Degree Cultivation Base, Zhejiang Chinese Medical University, Jiaxing, Zhejiang, China
- Department of Hepatobiliary and Pancreatic Surgery, First Hospital of Jiaxing, Affiliated Hospital of Jiaxing University, Jiaxing, Zhejiang, China
| | - Fengqing Zhao
- Department of Hepatobiliary and Pancreatic Surgery, First Hospital of Jiaxing, Affiliated Hospital of Jiaxing University, Jiaxing, Zhejiang, China
| | - Wen Liu
- Department of Hepatobiliary and Pancreatic Surgery, First Hospital of Jiaxing, Affiliated Hospital of Jiaxing University, Jiaxing, Zhejiang, China
| | - Hongkun Zhou
- Department of Hepatobiliary and Pancreatic Surgery, First Hospital of Jiaxing, Affiliated Hospital of Jiaxing University, Jiaxing, Zhejiang, China
| | - Zongliang Zhu
- Henan University of Science and Technology, Luoyang, Henan, China
| | - Huangbao Li
- Jiaxing University Master Degree Cultivation Base, Zhejiang Chinese Medical University, Jiaxing, Zhejiang, China.
- Department of Hepatobiliary and Pancreatic Surgery, First Hospital of Jiaxing, Affiliated Hospital of Jiaxing University, Jiaxing, Zhejiang, China.
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The past, present, and future of chemotherapy with a focus on individualization of drug dosing. J Control Release 2022; 352:840-860. [PMID: 36334860 DOI: 10.1016/j.jconrel.2022.10.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 10/14/2022] [Accepted: 10/24/2022] [Indexed: 11/16/2022]
Abstract
While there have been rapid advances in developing new and more targeted drugs to treat cancer, much less progress has been made in individualizing dosing. Even though the introduction of immunotherapies such as CAR T-cells and checkpoint inhibitors, as well as personalized therapies that target specific mutations, have transformed clinical treatment of cancers, chemotherapy remains a mainstay in oncology. Chemotherapies are typically dosed on either a body surface area (BSA) or weight basis, which fails to account for pharmacokinetic differences between patients. Drug absorption, distribution, metabolism, and excretion rates can vary between patients, resulting in considerable differences in exposure to the active drugs. These differences result in suboptimal dosing, which can reduce efficacy and increase side-effects. Therapeutic drug monitoring (TDM), genotype guided dosing, and chronomodulation have been developed to address this challenge; however, despite improving clinical outcomes, they are rarely implemented in clinical practice for chemotherapies. Thus, there is a need to develop interventions that allow for individualized drug dosing of chemotherapies, which can help maximize the number of patients that reach the most efficacious level of drug in the blood while mitigating the risks of underdosing or overdosing. In this review, we discuss the history of the development of chemotherapies, their mechanisms of action and how they are dosed. We discuss substantial intraindividual and interindividual variability in chemotherapy pharmacokinetics. We then propose potential engineering solutions that could enable individualized dosing of chemotherapies, such as closed-loop drug delivery systems and bioresponsive biomaterials.
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Termsinsuk P, Charatcharoenwitthaya P, Pausawasdi N. Development and validation of a 90-day mortality prediction model following endobiliary drainage in patients with unresectable malignant biliary obstruction. Front Oncol 2022; 12:922386. [PMID: 36147905 PMCID: PMC9487418 DOI: 10.3389/fonc.2022.922386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 08/22/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundPalliative endobiliary drainage is the mainstay treatment for unresectable malignant biliary obstruction (MBO). Despite optimal drainage, the survival benefit is arguable. This study aimed to identify factors predicting post-endoscopic drainage mortality and develop and validate a mortality prediction model.MethodsWe retrospectively analyzed data for 451 patients with unresectable pancreatobiliary cancers undergoing first endoscopic retrograde cholangiopancreatography (ERCP)-guided endobiliary stent placement between 2007 and 2017. We randomly assigned patients in a 3:1 fashion into a derivation cohort (n=339) and validation cohort (n=112). Predictors for 90-day mortality post-stenting were identified from the derivation cohort. A prediction model was subsequently developed and verified with the validation cohort.ResultsThe overall 90-day mortality rate of the derivation cohort was 46.9%, and the mean age was 64.2 years. The 2 most common diagnoses were cholangiocarcinoma (53.4%) and pancreatic cancer (35.4%). In all, 34.2% had liver metastasis. The median total bilirubin (TB) level was 19.2 mg/dL, and the mean serum albumin was 3.2 g/dL. A metallic stent was used for 64.6% of the patients, and the median stent patency time was 63 days. A total of 70.8% had TB improvement of more than 50% within 2 weeks after stenting, and 14.5% were eligible for chemotherapy. Intrahepatic obstruction (OR=5.69; P=0.023), stage IV cancer (OR=3.01; P=0.001), pre-endoscopic serum albumin (OR=0.48; P=0.001), TB improvement within 2 weeks after stenting (OR=0.57; P=0.036), and chemotherapy after ERCP (OR=0.11; P<0.001) were associated with 90-day mortality after stenting. The prediction model was developed to identify the risk of death within 90 days post-stent placement. The AUROC was 0.76 and 0.75 in derivation and validation cohorts. Patients with a score ≥ 1.40 had a high likelihood of death, whereas those scoring < -1.50 had a low likelihood of death. Additionally, a score ≥ 0.58 provided a 75.2% probability of death, which highlights the usability of the model.ConclusionsThis study proposes a useful validated prediction model to forecast the 90-day mortality of unresectable MBO patients after stenting. The model permits physicians to stratify the death risk and may be helpful to provide a proper palliative strategy.
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Affiliation(s)
- Panotpol Termsinsuk
- Siriraj GI Endoscopy Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Gastroenterology Unit, School of Medicine, Institute of Medicine, Suranaree University of Technology, Nakhon Ratchasima, Thailand
| | - Phunchai Charatcharoenwitthaya
- Siriraj GI Endoscopy Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Nonthalee Pausawasdi
- Siriraj GI Endoscopy Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
- *Correspondence: Nonthalee Pausawasdi,
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Pausawasdi N, Termsinsuk P, Charatcharoenwitthaya P, Limsrivilai J, Kaosombatwattana U. Development and validation of a risk score for predicting clinical success after endobiliary stenting for malignant biliary obstruction. PLoS One 2022; 17:e0272918. [PMID: 35984773 PMCID: PMC9390920 DOI: 10.1371/journal.pone.0272918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 07/28/2022] [Indexed: 11/19/2022] Open
Abstract
Background Endoscopic drainage is the primary treatment for unresectable malignant biliary obstruction (MBO). This study developed and validated a pre-endoscopic predictive score for clinical success after stent placement. Methods Patients with unresectable MBO undergoing ERCP-guided endobiliary stent placement between 2007 and 2017 were randomly divided into derivation (n = 383) and validation (n = 128) cohorts. To develop the risk score, clinical parameters were built by logistic regression to predict (1) ≥ 50% total bilirubin (TB) resolution within 2 weeks and (2) bilirubin normalization (TB level <1.2 mg/dL) within 6 weeks following stenting. The scoring scheme was applied to the validation cohort to test its performance. Results A ≥ 50% TB resolution within 2 weeks was shown in 70.5% of cases. The risk scoring scheme had areas under the receiver operating characteristic curve (AUROC) of 0.70 (95% CI, 0.64–0.76) and 0.67 (95% CI, 0.57–0.77) in the derivation and validation cohorts, respectively. Thirty-one percent had TB normalization within 6 weeks after stenting. Significant predictors for TB normalization were extrahepatic biliary obstruction (odds ratio [OR] = 2.35), pre-endoscopic TB level (OR = 0.88), and stent type (OR = 0.42). The AUROC of a risk score for predicting TB normalization within 6 weeks was 0.78 (95% CI, 0.72–0.83) and 0.76 (95% CI, 0.67–0.86) in the derivation and validation cohorts, respectively. A score > 1.30 yielded a specificity of 98% and a positive predictive value of 84% for predicting TB normalization. A score of < -4.18 provided a sensitivity of 80%–90% and a negative predictive value of 90%–93% for predicting the absence of TB normalization. Conclusions The pre-endoscopic scoring system comprising biliary obstruction level, liver biochemistry, and type of stent provides prediction indices for TB normalization within 6 weeks after stenting. This scheme may help endoscopists identify patients with unresectable MBO suited for palliative stenting.
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Affiliation(s)
- Nonthalee Pausawasdi
- Siriraj GI Endoscopy Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
- * E-mail:
| | - Panotpol Termsinsuk
- Siriraj GI Endoscopy Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Phunchai Charatcharoenwitthaya
- Siriraj GI Endoscopy Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Julajak Limsrivilai
- Siriraj GI Endoscopy Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Uayporn Kaosombatwattana
- Siriraj GI Endoscopy Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Taggar AS, Mann P, Folkert MR, Aliakbari S, Myrehaug SD, Dawson LA. A systematic review of intraluminal high dose rate brachytherapy in the management of malignant biliary tract obstruction and cholangiocarcinoma. Radiother Oncol 2021; 165:60-74. [PMID: 34695521 DOI: 10.1016/j.radonc.2021.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 10/11/2021] [Accepted: 10/14/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE To conduct a systematic review evaluating the impact of high dose rate (HDR) intraluminal brachytherapy (ILBT) in the management of malignant biliary obstruction and cholangiocarcinoma with specific focus on stent patency, clinical outcomes and toxicities. METHODS AND MATERIALS A review of published articles was conducted using Medline, Embase and Cochrane databases using the search terms "bile duct carcinoma" or "cholangiocarcinoma" or "bile duct neoplasms" in combination with "brachytherapy" or "high dose rate brachytherapy" or "HDR brachytherapy". Studies published in English and reporting outcomes of ≥10 patients were included in the review. Only the most recent experience was included if same patients were included in sequential publications. RESULTS Seventeen studies were identified that met the inclusion criteria. Significant heterogeneity was observed in treatment regimens, which included use of surgery, external beam radiation (EBRT), and/or intra-arterial and intravenous chemotherapy in conjunction with ILBT. Nevertheless, among the included studies, use of ILBT appeared to result in longer duration of stent patency: 10 months with ILBT compared to 4-6 months without ILBT. A trend was observed towards prolonged local control and improved complete and partial response rates in patients treated with ILBT with or without EBRT. Weighted mean overall survival of patients treated with ILBT alone was 11.8 months compared to 10.5 months for those that received EBRT +/- chemotherapy in addition to ILBT. The included studies reported low complication rates and toxicity related to ILBT. CONCLUSION Brachytherapy can be an effective and safe tool in the management of malignant biliary tract obstruction in combination with stenting. Both retrospective and prospective studies have suggested improved outcomes when HDR ILBT is combined with percutaneous stenting.
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Affiliation(s)
- Amandeep S Taggar
- Sunnybrook Odette Cancer Centre, Toronto, Canada; University of Toronto, Canada.
| | - Paveen Mann
- Sunnybrook Odette Cancer Centre, Toronto, Canada
| | | | | | - Sten D Myrehaug
- Sunnybrook Odette Cancer Centre, Toronto, Canada; University of Toronto, Canada
| | - Laura A Dawson
- Princess Margaret Cancer Centre, Toronto, Canada; University of Toronto, Canada
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van Keulen A, Franssen S, van der Geest LG, de Boer MT, Coenraad M, van Driel LMJW, Erdmann JI, Haj Mohammad N, Heij L, Klümpen H, Tjwa E, Valkenburg‐van Iersel L, Verheij J, Groot Koerkamp B, Olthof PB. Nationwide treatment and outcomes of perihilar cholangiocarcinoma. Liver Int 2021; 41:1945-1953. [PMID: 33641214 PMCID: PMC8359996 DOI: 10.1111/liv.14856] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Revised: 02/06/2021] [Accepted: 02/17/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Perihilar cholangiocarcinoma (pCCA) is a rare tumour that requires complex multidisciplinary management. All known data are almost exclusively derived from expert centres. This study aimed to analyse the outcomes of patients with pCCA in a nationwide cohort. METHODS Data on all patients diagnosed with pCCA in the Netherlands between 2010 and 2018 were obtained from the Netherlands Cancer Registry. Data included type of hospital of diagnosis and the received treatment. Outcomes included the type of treatment and overall survival. RESULTS A total of 2031 patients were included and the median overall survival for the overall cohort was 5.2 (95% CI 4.7-5.7) months. Three-hundred-ten (15%) patients underwent surgical resection, 271 (13%) underwent palliative systemic treatment, 21 (1%) palliative local anti-cancer treatment and 1429 (70%) underwent best supportive care. These treatments resulted in a median overall survival of 29.6 (95% CI 25.2-34.0), 12.2 (95% CI 11.0-13.3), 14.5 (95%CI 8.2-20.8) and 2.9 (95% CI 2.6-3.2) months respectively. Resection rate was 13% in patients who were diagnosed in non-academic and 32% in academic centres (P < .001), which resulted in a survival difference in favour of academic centres. Median overall survival was 9.7 (95% CI 7.7-11.7) months in academic centres compared to 4.9 (95% CI 4.3-5.4) months in non-academic centres (P < .001). CONCLUSIONS In patients with pCCA, resection rate and overall survival were higher for patients who were diagnosed in academic centres. These results show population-based outcomes of pCCA and highlight the importance of regional collaboration in the treatment of these patients.
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Affiliation(s)
- Anne‐Marleen van Keulen
- Department of SurgeryErasmus MC Cancer InstituteRotterdamthe Netherlands
- Department of SurgeryReinier de Graaf GasthuisDelftthe Netherlands
| | - Stijn Franssen
- Department of SurgeryErasmus MC Cancer InstituteRotterdamthe Netherlands
| | - Lydia G. van der Geest
- Department of ResearchNetherlands Comprehensive Cancer Organization (IKNL)Utrechtthe Netherlands
| | - Marieke T. de Boer
- Department of SurgeryUniversity Medical Center GroningenGroningenthe Netherlands
| | - Minneke Coenraad
- Department of Gastroenterology and HepatologyLeiden University Medical CenterLeidenthe Netherlands
| | | | - Joris I. Erdmann
- Department of SurgeryAmsterdam University Medical CentersUniversity of AmsterdamAmsterdamthe Netherlands
| | - Nadia Haj Mohammad
- Department of Medical OncologyUniversity Medical Center Utrecht/ Regional Academic Cancer Center UtrechtUtrecht UniversityUtrechtthe Netherlands
| | - Lara Heij
- Institute of PathologyUniversity Hospital RWTH AachenAachenGermany
- Visceral and Transplant SurgeryUniversity Hospital RWTH AachenAachenGermany
- NUTRIM School of Nutrition and Translational Research in MetabolismMaastricht UniversityMaastrichtthe Netherlands
| | - Heinz‐Josef Klümpen
- Department of Medical OncologyAmsterdam University Medical CentersUniversity of AmsterdamAmsterdamthe Netherlands
| | - Eric Tjwa
- Department of GastroenterologyRadboud University Medical CenterNijmegenthe Netherlands
| | - Liselot Valkenburg‐van Iersel
- Department of Internal MedicineDivision of Medical OncologyGROW‐School for Oncology and Developmental BiologyMaastricht University Medical CenterMaastrichtthe Netherlands
| | - Joanne Verheij
- Department of PathologyAmsterdam University Medical CentersUniversity of AmsterdamAmsterdamthe Netherlands
| | - Bas Groot Koerkamp
- Department of SurgeryErasmus MC Cancer InstituteRotterdamthe Netherlands
| | - Pim B. Olthof
- Department of SurgeryErasmus MC Cancer InstituteRotterdamthe Netherlands
- Department of SurgeryAmsterdam University Medical CentersUniversity of AmsterdamAmsterdamthe Netherlands
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Rawat PS, Jaiswal A, Khurana A, Bhatti JS, Navik U. Doxorubicin-induced cardiotoxicity: An update on the molecular mechanism and novel therapeutic strategies for effective management. Biomed Pharmacother 2021; 139:111708. [PMID: 34243633 DOI: 10.1016/j.biopha.2021.111708] [Citation(s) in RCA: 243] [Impact Index Per Article: 81.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 05/04/2021] [Accepted: 05/05/2021] [Indexed: 12/06/2022] Open
Abstract
Doxorubicin (Dox) is a secondary metabolite of the mutated strain of Streptomyces peucetius var. Caesius and belongs to the anthracyclines family. The anti-cancer activity of Dox is mainly exerted through the DNA intercalation and inhibiting topoisomerase II enzyme in fast-proliferating tumors. However, Dox causes cumulative and dose-dependent cardiotoxicity, which results in increased risks of mortality among cancer patients and thus limiting its wide clinical applications. There are several mechanisms has been proposed for doxorubicin-induced cardiotoxicity and oxidative stress, free radical generation and apoptosis are most widely reported. Apart from this, other mechanisms are also involved in Dox-induced cardiotoxicity such as impaired mitochondrial function, a perturbation in iron regulatory protein, disruption of Ca2+ homeostasis, autophagy, the release of nitric oxide and inflammatory mediators and altered gene and protein expression that involved apoptosis. Dox also causes downregulation of DNA methyltransferase 1 (DNMT1) enzyme activity which leads to a reduction in the DNA methylation process. This hypomethylation causes dysregulation in the mitochondrial genes like peroxisome proliferator-activated receptor-gamma coactivator (PGC)-1-alpha (PGC-1α), nuclear respiratory factor 1 (NRF-1) and mitochondrial transcription factor A (TFAM) unit in the heart. Apart from DNA methylation, Dox treatment also alters the micro RNAs levels and histone deacetylase (HDAC) activity. Therefore, in the current review, we have provided a detailed update on the current understanding of the pathological mechanisms behind the well-known Dox-induced cardiotoxicity. Further, we have provided some of the most plausible pharmacological strategies which have been tested against Dox-induced cardiotoxicity.
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Affiliation(s)
- Pushkar Singh Rawat
- Department of Pharmacology, Central University of Punjab, Bathinda, Punjab, 151401, India
| | - Aiswarya Jaiswal
- Department of Pharmacology, Central University of Punjab, Bathinda, Punjab, 151401, India
| | - Amit Khurana
- Department of Veterinary Pharmacology and Toxicology, College of Veterinary Science, PVNRTVU, Rajendranagar, Hyderabad 500030, Telangana, India; Centre for Biomedical Engineering (CBME), Indian Institute of Technology (IIT), Delhi 110016, India.
| | - Jasvinder Singh Bhatti
- Department of human genetics and molecular medicine, School of health sciences, Central University of Punjab, Bathinda 151401, Punjab, India.
| | - Umashanker Navik
- Department of Pharmacology, Central University of Punjab, Bathinda, Punjab, 151401, India.
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Mashni O, Qasem K, Sara AA, Awad W. Etoposide dosage adjustment in two patients with neuroendocrine tumors and severe liver impairment. J Oncol Pharm Pract 2020; 26:500-506. [DOI: 10.1177/1078155219859630] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Introduction Limited data are available on dosing etoposide in patients with liver impairment. Case report We report the dosing strategies for etoposide utilized in two patients with neuroendocrine tumors and severe liver impairment. Management and outcomes Treatment consisted of platinum-based chemotherapy regimens, with the decision of whether to administer etoposide and at what doses being based on the liver function before each chemotherapy cycle. By the end of treatment, total bilirubin was normal, and the performance status of both patients had improved, with stable computed tomography scan findings. Discussion The reported two cases suggest that the administration of etoposide at reduced doses with close monitoring in patients with neuroendocrine tumors and severe liver impairment may still be considered as an option and may improve outcomes.
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Affiliation(s)
- Ola Mashni
- Department of Pharmacy, King Hussein Cancer Center, Amman, Jordan
| | - Khlood Qasem
- Department of Hematology and Medical Oncology, King Hussein Cancer Center, Amman, Jordan
| | - Aseel Abu Sara
- Department of Pharmacy, King Hussein Cancer Center, Amman, Jordan
| | - Wedad Awad
- Department of Pharmacy, King Hussein Cancer Center, Amman, Jordan
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Garattini S, Fuso Nerini I, D'Incalci M. Not only tumor but also therapy heterogeneity. Ann Oncol 2019; 29:13-19. [PMID: 29045538 DOI: 10.1093/annonc/mdx646] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Affiliation(s)
- S Garattini
- Department of Oncology, IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | - I Fuso Nerini
- Department of Oncology, IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | - M D'Incalci
- Department of Oncology, IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
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Ahmed HH, Galal AF, Shalby AB, Abd-Rabou AA, Mehaya FM. Improving Anti-Cancer Potentiality and Bioavailability of Gallic Acid by Designing Polymeric Nanocomposite Formulation. Asian Pac J Cancer Prev 2018; 19:3137-3146. [PMID: 30486601 PMCID: PMC6318406 DOI: 10.31557/apjcp.2018.19.11.3137] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Objective: In this study, we investigated the in vivo antitumor activity and pharmacokinetic characteristics of encapsulated GA-NC (gallic acid nanocomposite) in normal and hepatocellular carcinoma (HCC)-induced rats. Methods: Rats were distributed into 4 groups; negative control, HCC, gallic acid (GA), and GA-NC. Serum levels of alpha-fetoprotein (AFP), endoglin (ENG), heat shock protein-70 (HSP-70), pro-caspase 3, lipocalin-2 (LCN-2) and β-cell leukemia/lymphoma 2 (Bcl-2) were assayed by ELISA. The pharmacokinetic parameters for GA or GA-NC were determined by means of non-compartmental approach based on the serum– concentration profiles of free GA and GA-NC after oral administration. Also, histological procedures were used for examination of liver tissue sections. Results: Anaplastic changes in liver tissues were observed in untreated HCC group, as well as a significant increase in the serum AFP level. In addition, significant elevation in the serum ENG level as an angiogenic marker and the serum levels of the apoptotic mediators; HSP-70, Bcl-2 and pro-caspase 3 beside significant amplification in the serum inflammatory modulator, LCN-2 were recorded. Treatment with free GA or GA-NC markedly recovered the anaplastic changes in the rat liver tissues. In addition, they restored serum levels of AFP, ENG, HSP-70, Bcl-2, pro-caspase-3, and LCN-2. Pharmacokinetic analysis revealed that GA–NC displayed a characteristic sustained release profile with 4-fold increase in bioavailability in normal and HCC-induced rats. Conclusions: The results of this study suggest that encapsulation of GA into PLGA-CS-PEG enhances its oral bioavailability and anti-cancer activity. GA-NC may be a new therapeutic candidate for the mitigation of hepatocarcinogenesis.
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Affiliation(s)
- Hanaa H Ahmed
- Department of Hormones, Medical Research Division, National Research Centre, Dokki, Giza, Egypt.
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12
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Bellesoeur A, Thomas-Schoemann A, Allard M, Smadja D, Vidal M, Alexandre J, Goldwasser F, Blanchet B. Pharmacokinetic variability of anticoagulants in patients with cancer-associated thrombosis: Clinical consequences. Crit Rev Oncol Hematol 2018; 129:102-112. [DOI: 10.1016/j.critrevonc.2018.06.015] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 05/03/2018] [Accepted: 06/18/2018] [Indexed: 01/12/2023] Open
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13
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Myers CE, Hoelzinger DB, Truong TN, Chew LA, Myles A, Chaudhuri L, Egan JB, Liu J, Gendler SJ, Cohen PA. Chemotherapy can induce weight normalization of morbidly obese mice despite undiminished ingestion of high fat diet. Oncotarget 2018; 8:5426-5438. [PMID: 28076839 PMCID: PMC5354920 DOI: 10.18632/oncotarget.14576] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 12/05/2016] [Indexed: 02/06/2023] Open
Abstract
Morbidly obese patients who accomplish substantial weight loss often display a long-term decline in their resting metabolism, causing even relatively restrained caloric intake to trigger a relapse to the obese state. Paradoxically, we observed that morbidly obese mice receiving chemotherapy for cancer experienced spontaneous weight reduction despite unabated ingestion of their high fat diet (HFD). This response to chemotherapy could also be achieved in morbidly obese mice without cancer. Optimally dosed methotrexate (MTX) or cyclophosphamide (CY) enabled the mice to completely and safely normalize their body weight despite continued consumption of obesogenic quantities of HFD. Weight reduction was not attributable to decreased HFD intake, enhanced energy expenditure or malabsorption. MTX or CY dosing significantly depleted both adipose tissue and preadipocyte progenitors. Remarkably, however, despite continued high fat feeding, a compensatory increase in hepatocyte lipid storage was not observed, but rather the opposite. Gene microarray liver analyses demonstrated that HFD mice receiving MTX or CY experienced significantly inhibited lipogenesis and lipid storage, whereas Enho (energy homeostasis) gene expression was significantly upregulated. Further metabolic studies employing a human hepatocellular line revealed that MTX treatment preserved robust oxidative phosphorylation, but also promoted mitochondrial uncoupling with a surge in proton leak. This is the first report that certain optimally dosed chemotherapeutic agents can induce weight loss in morbidly obese mice without reduced dietary intake, apparently by depleting stores of adipocytes and their progenitors, curtailment of lipogenesis, and inconspicuous disposal of incoming dietary lipid via a steady state partial uncoupling of mitochondrial oxidative phosphorylation.
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Affiliation(s)
- Cheryl E Myers
- Department of Biochemistry and Molecular Biology, Mayo Clinic, Scottsdale, AZ, USA
| | | | - Tiffany N Truong
- Department of Biochemistry and Molecular Biology, Mayo Clinic, Scottsdale, AZ, USA
| | - Lindsey A Chew
- Department of Biochemistry and Molecular Biology, Mayo Clinic, Scottsdale, AZ, USA
| | - Arpita Myles
- Department of Immunology, Mayo Clinic, Scottsdale, AZ, USA
| | | | - Jan B Egan
- Center for Individualized Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | - Jun Liu
- Department of Biochemistry and Molecular Biology, Mayo Clinic, Scottsdale, AZ, USA
| | - Sandra J Gendler
- Department of Biochemistry and Molecular Biology, Mayo Clinic, Scottsdale, AZ, USA.,Department of Immunology, Mayo Clinic, Scottsdale, AZ, USA.,Department of Hematology and Oncology, Mayo Clinic, Scottsdale, AZ, USA
| | - Peter A Cohen
- Department of Immunology, Mayo Clinic, Scottsdale, AZ, USA.,Department of Hematology and Oncology, Mayo Clinic, Scottsdale, AZ, USA
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14
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Khosla A, Xi Y, Toomay S. Predicting Success in Percutaneous Transhepatic Biliary Drainage. Cardiovasc Intervent Radiol 2017; 40:1586-1592. [DOI: 10.1007/s00270-017-1679-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Accepted: 04/28/2017] [Indexed: 12/12/2022]
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15
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Gong J, Cho M, Fakih M. Chemotherapy in patients with hepatobiliary cancers and abnormal hepatic function. J Gastrointest Oncol 2017; 8:314-323. [PMID: 28480070 DOI: 10.21037/jgo.2016.09.17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Sorafenib and cisplatin plus gemcitabine currently represent first-line treatment standards in advanced hepatocellular carcinoma and biliary cancer, respectively. Conventional cytotoxic agents (monotherapy or combination therapy) have demonstrated activity in the second-line setting or in those in which first-line agents are contraindicated. A strategy for safe yet effective administration of such systemic therapies in patients with advanced hepatobiliary cancer and abnormal liver function needs to be strongly considered. Here, we highlight the safety and tolerability of systemic therapies routinely used for the treatment of advanced hepatobiliary cancer in patients with hepatic dysfunction. Based on data from available clinical studies, we review dosing strategies recommended for chemotherapy and targeted therapy in those with liver dysfunction. Dose modifications for many agents in this population remain empiric due to limited clinical evidence. Future dedicated phase I studies are needed to provide further dosing considerations for combination therapy in those with abnormal liver function in which data is lacking.
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Affiliation(s)
- Jun Gong
- Department of Medical Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - May Cho
- Department of Medical Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Marwan Fakih
- Medical Oncology and Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
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16
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Abstract
Objective To develop a process which assists pharmacists in oncology order review, patient assessment, drug therapy monitoring, and documentation and evaluate whether it is useful in practice. Methods A process called the anDROIDs (Appendix A) is discussed. The acronym represents Antineoplastic Data Collection, Review of Systems, Oncology Target, Identification of drug-related problems, and Documentation System. A tool representing the process was created and introduced to a focus group in an oncology pharmacy workshop. Participants’ responses were measured using pre- and post-workshop assessments. Results. The focus group had positive responses in the post-workshop assessment compared to pre-workshop data. Participants found the anDROIDs tool to be easy to use and planned to incorporate it into their pharmacy practice. Conclusion The anDROIDs tool may have potential application in oncology pharmacy and can be modified to other pharmacy practice settings.
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Affiliation(s)
- Cathy D Duong
- Pharmacy Department, Cross Cancer Institute, Edmonton, Alberta, Canada
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17
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Abstract
Purpose. The primary objective of this paper is to provide a brief overview of docetaxel pharmacokinetics, pharmacodynamics, indications, and drug interactions, concentrating on their relationship with docetaxel use in patients with hepatic impairment. Data Sources. The literature was reviewed through a MEDLINE search from 1986 to 2000. Relevant articles cited in literature obtained by MEDLINE searching were also considered. The following terms were searched: hepatic impairment, liver failure, Taxotere, and docetaxel. The search was restricted to the English language. Data Extraction. The current literature is reviewed in regard to docetaxel pharmacokinetics, pharmacodynamics, dosing, efficacy, adverse effects, and drug interactions and with a special emphasis on docetaxel use in patients with hepatic impairment. Data Synthesis. Docetaxel has a wide spectrum of clinical activity and is used frequently in the treatment of metastatic breast cancer, NSCLC, ovarian cancer and cancer of the head and neck. The dose-limiting toxicity of docetaxel is neutropenia. Docetaxel is metabolized in the liver and elevations in hepatic enzymes can predict a reduced clearance of docetaxel, which is associated with an increased incidence of neutropenia. Based on population pharmacokinetic modeling, docetaxel can be safely administered in patients with elevated hepatic enzymes if the dose is reduced on the first cycle.
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Affiliation(s)
- Jill M Kolesar
- School of Pharmacy, University of Wisconsin-Madison, Madison, Wisconsin
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18
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Vincenzi B, Armento G, Spalato Ceruso M, Catania G, Leakos M, Santini D, Minotti G, Tonini G. Drug-induced hepatotoxicity in cancer patients - implication for treatment. Expert Opin Drug Saf 2016; 15:1219-38. [PMID: 27232067 DOI: 10.1080/14740338.2016.1194824] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
INTRODUCTION All anticancer drugs can cause idiosyncratic liver injury. Therefore, hepatoprotective agents assume particular importance to preserve liver function. Hepatic injury represents 10% of cases of acute hepatitis in adults; drug-related damage is still misjudged because of relative clinical underestimation and difficult differential diagnosis. Chemotherapeutic agents can produce liver toxicity through different pathways, resulting in different categories of liver injuries, but these drugs are not homogeneously hepatotoxic. Frequently, anticancer-induced hepatotoxicity is idiosyncratic and influenced by multiple factors. AREAS COVERED The aim of this paper is to perform a review of the literature regarding anticancer-induced liver toxicity. We described hepatotoxicity mechanisms of principal anticancer agents and respective dose reductions. Furthermore, we reviewed studies on hepatoprotectors and their optimal use. Tiopronin, magnesium isoglycyrrhizinate and S-Adenosylmethionine (AdoMet) demonstrated, in some small studies, a potential hepatoprotective activity. EXPERT OPINION Actually, in the literature only small experiences are reported. Even though hepatoprotective agents seem to be useful in the oncologic setting, the lack of well-designed prospective Phase III randomized controlled trials is a major limit in the introduction of hepatoprotectors in cancer patients and these kind of studies are warranted to support their use and to give further recommendations for the clinical practice.
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Affiliation(s)
- Bruno Vincenzi
- a Medical Oncology Department, Campus Bio-Medico , University of Rome , Rome , Italy
| | - Grazia Armento
- a Medical Oncology Department, Campus Bio-Medico , University of Rome , Rome , Italy
| | | | - Giovanna Catania
- a Medical Oncology Department, Campus Bio-Medico , University of Rome , Rome , Italy.,b Section of Medical Oncology, Department of Surgical, Oncological and Oral Sciences , University of Palermo , Palermo , Italy
| | - Mark Leakos
- a Medical Oncology Department, Campus Bio-Medico , University of Rome , Rome , Italy
| | - Daniele Santini
- a Medical Oncology Department, Campus Bio-Medico , University of Rome , Rome , Italy
| | - Giorgio Minotti
- c Clinical Pharmacology Department , Campus Bio-Medico, University of Rome , Rome , Italy
| | - Giuseppe Tonini
- a Medical Oncology Department, Campus Bio-Medico , University of Rome , Rome , Italy
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Levy JL, Sudheendra D, Dagli M, Mondschein JI, Stavropoulos SW, Shlansky-Goldberg RD, Trerotola SO, Teitelbaum U, Mick R, Soulen MC. Percutaneous biliary drainage effectively lowers serum bilirubin to permit chemotherapy treatment. Abdom Radiol (NY) 2016; 41:317-23. [PMID: 26867914 DOI: 10.1007/s00261-015-0580-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
PURPOSE For digestive tract cancers, the bilirubin threshold for administration of systemic chemotherapy can be 5 or 2 mg/dL (85.5 or 34.2 μmol/L) depending upon the regimen. We examined the ability of percutaneous biliary drainage (PBD) in patients with malignant biliary obstruction to achieve these clinically relevant endpoints. METHODS 106 consecutive patients with malignant biliary obstruction and a baseline serum bilirubin >2 mg/dL underwent PBD. Time to achieve a bilirubin of 5 mg/dL (85.5 μmol/L), 2 mg/dL (34.2 μmol/L), and survival was estimated by Kaplan-Meier analysis. Potential technical and clinical prognostic factors were subjected to univariate and multivariate analysis. Categorical variables were analyzed by the log rank test. Hazard ratios were calculated for continuous variables. RESULTS Median survival was 100 days (range 1-3771 days). Among 88 patients with a pre-drainage bilirubin >5 mg/dL, 62% achieved a serum bilirubin ≤5 mg/dL within 30 days and 84% within 60 days, median 21 days. Among 106 patients with a pre-drainage bilirubin >2 mg/dL, 37% achieved a serum bilirubin ≤2 mg/dL by 30 days and 70% within 60 days, median 43 days. None of the technical or clinical factors evaluated, including pre-drainage bilirubin, were significant predictors of time to achieve a bilirubin ≤2 mg/dL (p = 0.51). Size and type of biliary device were the only technical variables found to affect time to bilirubin of 5 mg/dL (p = 0.016). CONCLUSION PBD of malignant obstruction achieves clinically relevant reduction in serum bilirubin in the majority of patients within 1-2 months, irrespective of the pre-drainage serum bilirubin, sufficient to allow administration of systemic chemotherapy. However, the decision to undergo this procedure for this indication alone must be considered in the context of patients' prognosis and treatment goals.
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Affiliation(s)
- Jennifer L Levy
- Division of Interventional Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Deepak Sudheendra
- Division of Interventional Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Mandeep Dagli
- Division of Interventional Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Jeffrey I Mondschein
- Division of Interventional Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | | | | | - Scott O Trerotola
- Division of Interventional Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Ursina Teitelbaum
- Division of Gastrointestinal Oncology, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA
| | - Rosemarie Mick
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael C Soulen
- Division of Interventional Radiology, University of Pennsylvania, Philadelphia, PA, USA.
- Department of Radiology, 1 Silverstein, 3400 Spruce Street, Philadelphia, PA, 19104, USA.
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20
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Pena MA, Horga JF, Zapater P. Variations of pharmacokinetics of drugs in patients with cirrhosis. Expert Rev Clin Pharmacol 2016; 9:441-58. [DOI: 10.1586/17512433.2016.1135733] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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21
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Papachristos A, Pippa N, Ioannidis K, Sivolapenko G, Demetzos C. Liposomal forms of anticancer agents beyond anthracyclines: present and future perspectives. J Liposome Res 2014; 25:166-73. [PMID: 25148295 DOI: 10.3109/08982104.2014.950277] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Liposomes are widely used as delivery systems of cytotoxic drugs. The encapsulation into liposomes improves pharmacological properties and as a result therapeutic index and outcomes. To date, liposomal vincristine and cytarabine are approved and marketed for intravenous and intrathecal administration, respectively. The main goal of this review is to examine the clinical use and pharmacological properties, as well as the safety of liposomal forms of less widely used liposomal forms of anticancer agents compared to their conventional forms and to present data regarding clinical development of other liposomal agents. Liposomal forms of cytarabine and vincristine are less widely used and unknown compared to liposomal anthracyclines, because they are approved only for specific indications and only in the United States.
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22
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Preparative regimen dosing for hematopoietic stem cell transplantation in patients with chronic hepatic impairment: analysis of the literature and recommendations. Biol Blood Marrow Transplant 2014; 20:622-9. [PMID: 24492142 DOI: 10.1016/j.bbmt.2014.01.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Accepted: 01/28/2014] [Indexed: 01/12/2023]
Abstract
Hematopoietic stem cell transplantation (HSCT) is a potentially life-saving therapy for patients with malignant and nonmalignant disease states. Transplant has been associated with high treatment-related morbidity and mortality, therefore limiting its usefulness in patients with baseline liver dysfunction. In the event that a patient with hepatic insufficiency is selected for HSCT, dosage adjustments may be considered; however, no reliable endogenous biomarkers can serve as a guide for adjustments. There is no clear standard or guideline for how to approach these patients, and most adjustments are made empirically on the basis of expert opinion. This article offers practical advice and outlines our personal approaches to provide dosing recommendations for commonly-used preparative agents in the setting of hepatic impairment with the aim to optimize dosing for this patient population.
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23
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Sonbol MB, Rana V, Kenderian SS, Finnes H, Witzig TE. Therapeutic options for patients with lymphoma and liver dysfunction or failure during mechlorethamine shortage. Leuk Lymphoma 2013; 55:1815-21. [DOI: 10.3109/10428194.2013.828349] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Lewis JH, Stine JG. Review article: prescribing medications in patients with cirrhosis - a practical guide. Aliment Pharmacol Ther 2013; 37:1132-56. [PMID: 23638982 DOI: 10.1111/apt.12324] [Citation(s) in RCA: 116] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Revised: 11/30/2012] [Accepted: 04/08/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND Most drugs have not been well studied in cirrhosis; recommendations on safe use are based largely on experience and/or expert opinion, with dosing recommendations often based on pharmacokinetic (PK) changes. AIM To provide a practical approach to prescribing medications for cirrhotic patients. METHODS An indexed MEDLINE search was conducted using keywords cirrhosis, drug-induced liver injury, pharmacodynamics (PDs), PKs, drug disposition and adverse drug reactions. Unpublished information from the Food and Drug Administration and industry was also reviewed. RESULTS Most medications have not been adequately studied in cirrhosis, and specific prescribing information is often lacking. Lower doses are generally recommended based on PK changes, but data are limited in terms of correlating PD effects with the degree of liver impairment. Very few drugs have been documented to have their hepatotoxicity potential enhanced by cirrhosis; most of these involve antituberculosis or antiretroviral agents used for HIV or viral hepatitis. Paracetamol can be used safely when prescribed in relatively small doses (2-3 g or less/day) for short durations, and is recommended as first-line treatment of pain. In contrast, NSAIDs should be used cautiously (or not at all) in advanced cirrhosis. Proton pump inhibitors have been linked to an increased risk of spontaneous bacterial peritonitis (SBP) in cirrhosis and should be used with care. CONCLUSIONS Most drugs can be used safely in cirrhosis, including those that are potentially hepatotoxic, but lower doses or reduced dosing frequency is often recommended, due to altered PKs. Drugs that can precipitate renal failure, gastrointestinal bleeding, SBP and encephalopathy should be identified and avoided.
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Affiliation(s)
- J H Lewis
- Division of Gastroenterology and Hepatology, Department of Medicine, Georgetown University Medical Center, Washington, DC 20007, USA.
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25
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Pharmacokinetics and tolerability of cediranib, a potent VEGF signalling inhibitor, in cancer patients with hepatic impairment. Anticancer Drugs 2013. [PMID: 23197081 DOI: 10.1097/cad.0b013e32835bd1d2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Vascular endothelial growth factor (VEGF) signalling plays a key role in tumour angiogenesis. Cediranib (AZD2171) is a small-molecule VEGF signalling inhibitor with potent activity against all three VEGF receptors. In this phase I, open-label, parallel-group study, adults with advanced solid tumours received a single 45 mg dose of cediranib, followed by 30 mg continuous once-daily oral dosing for 21 days after a 7-day washout period (clinicaltrials.gov identifier NCT00621725). The primary objective was to compare the single-dose pharmacokinetics (PK) of cediranib in patients with different levels of hepatic impairment classified according to the bilirubin level. Safety, tolerability, multiple-dose PK and PK stratified according to the Child-Pugh criteria were also assessed. Thirty patients received cediranib: 18 with normal-mild hepatic impairment and 12 with moderate hepatic impairment. Single-dose PK parameters were similar between the group with normal-mild hepatic impairment and the group with moderate hepatic impairment [ratio of geometric least square means: area under the curve (AUC) 1.12, 90% confidence interval (CI) 0.77-1.61; Cmax 0.95, 90% CI 0.69-1.31]. Hepatic impairment did not influence PK results in multiple dosing. After continuous once-daily dosing, the geometric least square means ratio was 0.72 (90% CI 0.51-1.03) for AUCSS and 0.67 (90% CI 0.47-0.94) for CSS,max. Similar results were obtained when patients were classified for hepatic impairment according to the Child-Pugh criteria. There was no clear difference in the incidence or the severity of adverse events between hepatic impairment groups. Moderate hepatic impairment does not appear to affect the PK profile or the tolerability of cediranib. Dose adjustments are not necessary in this patient population.
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Gemcitabine and docetaxel for hepatocellular carcinoma: a phase II North Central Cancer Treatment Group clinical trial. Am J Clin Oncol 2012; 35:418-23. [PMID: 21555932 DOI: 10.1097/coc.0b013e318219863b] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES Few effective options are available for the treatment of unresectable hepatocellular carcinoma (HCC). Several phase I trials suggest promising activity of a combination of gemcitabine and docetaxel. METHODS Patients with unresectable or metastatic HCC were treated with docetaxel 40 mg/m (later reduced to 30 mg/m) and gemcitabine 800 mg/m on days 1 and 8 every 3 weeks. Twenty-five patients were enrolled in 26 months. Median age was 64 (range, 27-078), 17 were male, 14 had liver-only disease, and 11 had extrahepatic disease. RESULTS Of 25 patients evaluable for the primary end point (response), 2 (8%) have a confirmed partial response. The median time to progression is 2.76 months (95% confidence interval, 1.84-6.64 mo). Median survival was 12.8 months (95% confidence interval, 5.26-28.00). Two patients died on study owing to adverse events (1 hepatic and 1 renal failure), neither of which were attributed to the study medications. Twenty patients (81%) have experienced grade 3+ adverse events, including 11 with grade 4+ adverse events, primarily neutropenia, thrombocytopenia, diarrhea, and fatigue. CONCLUSIONS Although this combination seems to have potential benefit, as measured by overall survival, its toxicity and the recent introduction of sorafenib has further limited the use of chemotherapy. Approaches other than chemotherapy are likely to be of the greatest potential benefit.
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Practical guidelines for dose individualization of anticancer targeted drugs. Clin Transl Oncol 2012; 14:812-9. [PMID: 23065600 DOI: 10.1007/s12094-012-0932-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Accepted: 08/22/2012] [Indexed: 10/27/2022]
Abstract
For drugs such as anticancer agents every effort should be made to minimize inter-patient variability in drug exposure in order to maximize the benefit while maintaining an acceptable risk level of serious adverse effects. Anticancer drugs generally have a preferential route of elimination, either in urine or in bile and feces. In consequence, dose individualization to renal and liver function permits excessive toxicity to be avoided and expected therapeutic benefit to be achieved. However, less is known about the most appropriate starting doses of antineoplastic agents in these individuals. In this review, we discuss trials that have specifically assessed new targeted agents dosing strategies (mainly monoclonal antibodies and tyrosine kinase inhibitors) in the setting of overt biochemical renal and liver dysfunction and we proportionate recommendations and practical guidelines for dose individualization.
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28
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Phenotyping drug disposition in oncology. Cancer Treat Rev 2012; 38:715-25. [DOI: 10.1016/j.ctrv.2011.12.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2011] [Revised: 12/05/2011] [Accepted: 12/08/2011] [Indexed: 12/11/2022]
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Chen C, Chan A, Yap K. Visualizing clinical predictors of febrile neutropenia in Asian cancer patients receiving myelosuppressive chemotherapy. J Oncol Pharm Pract 2012; 19:111-20. [PMID: 23014897 DOI: 10.1177/1078155212457806] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Febrile neutropenia is a serious complication among cancer patients receiving myelosuppressive chemotherapy. Patient-specific risk factors, chemotherapy-related and disease-related characteristics can affect the clinical outcome and management of febrile neutropenia. Although many factors have been identified, they vary among different patient populations. We identified clinically-relevant febrile neutropenia predictors in Asian cancer patients through visualization of these factors. METHODS A single-centered, retrospective study was conducted from May to July 2011 at a local cancer center. Demographics and risk factor data were collated from electronic health records and four cancer registries. Data were summarized using descriptive statistics. Additionally, potential febrile neutropenia predictors were identified using categorical principal component and multiple correspondence analyses. RESULTS A total of 583 patients were analyzed. Majority was females (79%), Chinese (75%) and diagnosed with breast cancers (60%). Six risk factors were identified as potential predictors: types of cancer (16.9-19.8% of variance), chemotherapy regimen (anthracycline-based 11.8-12.9%, taxane-based 8.1%), liver function tests (alanine transaminase 8.6%, alkaline phosphatase 4.0%), renal function tests (serum creatinine 3.1%), prior granulocyte colony stimulating factor use (5.6%) and diabetes mellitus (6.6-6.9%). In terms of cancer types, lymphomas were more predictive than breast cancers. CONCLUSION From our knowledge, this is the first study that has identified clinically-relevant febrile neutropenia predictors in Asian cancer patients through visualization of their risk factors. The use of these predictors to identify patients at risk for adverse reactions, such as FN, can allow clinicians to optimize prophylactic granulocyte colony stimulating factor usage in these patients.
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Affiliation(s)
- Chao Chen
- School of Pharmacy, Fudan University, Shanghai, China
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30
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Devriese LA, Witteveen PO, Marchetti S, Mergui-Roelvink M, Reyderman L, Wanders J, Jenner A, Edwards G, Beijnen JH, Voest EE, Schellens JHM. Pharmacokinetics of eribulin mesylate in patients with solid tumors and hepatic impairment. Cancer Chemother Pharmacol 2012; 70:823-32. [DOI: 10.1007/s00280-012-1976-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Accepted: 09/12/2012] [Indexed: 11/24/2022]
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Delord JP, Ravaud A, Bennouna J, Fumoleau P, Favrel S, Pinel MC, Ferré P, Saliba F. Phase I and pharmacokinetic study of IV vinflunine in cancer patients with liver dysfunction. Invest New Drugs 2012; 31:724-33. [DOI: 10.1007/s10637-012-9878-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2012] [Accepted: 09/04/2012] [Indexed: 10/27/2022]
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Kim HS, Jung CO, Jeon HR, Sung LH. Rehabilitation for ataxia following chemotherapy for burkitt lymphoma involving the rectum. Ann Rehabil Med 2012; 36:578-83. [PMID: 22977788 PMCID: PMC3438429 DOI: 10.5535/arm.2012.36.4.578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2011] [Accepted: 10/17/2011] [Indexed: 11/13/2022] Open
Abstract
Burkitt lymphoma is a type of B-cell lymphoma that occurs mostly in children, and rarely in adults. The sporadic type is known to occur mostly at the ileum and cecum. Cytarabine, which is used for central nervous system prophylaxis during chemotherapy for Burkitt lymphoma, has known neurotoxicity, and its side effects include motor ataxia due to cerebellar injury, ataxic dysarthria, dysfunction of ocular movement, confusion, somnolence and lethargy. This case report is about a patient diagnosed with Burkitt lymphoma who manifested motor ataxia after chemotherapy that included cytarabine.
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Affiliation(s)
- Hyoung Seop Kim
- Department of Physical Medicine and Rehabilitation, National Health Insurance Corporation Ilsan Hospital, Korea
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Pharmacokinetics of the novel PAR-1 antagonist vorapaxar in patients with hepatic impairment. Eur J Clin Pharmacol 2012; 68:1501-8. [PMID: 22527342 DOI: 10.1007/s00228-012-1269-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2011] [Accepted: 03/07/2012] [Indexed: 12/29/2022]
Abstract
PURPOSE To determine whether hepatic impairment has an effect on the pharmacokinetics (PK) of vorapaxar or M20, its main pharmacologically active metabolite. METHODS This was an open-label study in which a single 40-mg oral dose of vorapaxar was administered to patients with mild (n = 6), moderate (n = 6), and severe (n = 4) hepatic impairment and healthy controls (n = 16) matched for age, gender, weight, and height. Blood samples for vorapaxar and M20 assay were collected predose and at frequent intervals up to 8 weeks postdose. RESULTS Plasma vorapaxar and M20 PK profiles were similar between patients with impaired liver function and healthy controls. Group mean values for vorapaxar C(max) and AUC(tf) were 206-279 ng/mL and 14,200-18,200 ng·h/mL, respectively, with the lowest values observed in patients with severe impairment. Vorapaxar median T(max) and mean t(1/2) values were 1.00-1.75 h and 298-366 h, respectively. There was no apparent correlation between vorapaxar or M20 exposure or t(1/2) values and disease severity. Vorapaxar was generally well tolerated; one serious adverse event (gastrointestinal bleeding secondary to ruptured esophageal varices) was reported in a patient with severe hepatic impairment. CONCLUSIONS Hepatic impairment had no clinically relevant effect on the PK of vorapaxar and M20. No dose or dosage adjustment of vorapaxar will be required in patients with mild to moderate hepatic impairment. Although systemic exposure to vorapaxar does not appear to increase in patients with severe hepatic impairment, administration of vorapaxar to such patients is not recommended given their bleeding diathesis.
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Outcomes of patients undergoing percutaneous biliary drainage to reduce bilirubin for administration of chemotherapy. J Vasc Interv Radiol 2011; 23:89-95. [PMID: 22115568 DOI: 10.1016/j.jvir.2011.09.022] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2010] [Revised: 09/21/2011] [Accepted: 09/23/2011] [Indexed: 01/28/2023] Open
Abstract
PURPOSE To describe outcomes in patients undergoing percutaneous biliary drainage to reduce total serum bilirubin level for administration of chemotherapy. MATERIALS AND METHODS A total of 647 consecutive patients underwent percutaneous biliary drainage between September 2001 and December 2008. In 168, the indication for biliary drainage was to decrease total serum bilirubin level to permit administration of chemotherapy. Of these, 20 were excluded because they had hepatic arterial infusion pumps, leaving 148 patients as the study group. The primary diagnoses for these patients were gallbladder cancer (n = 23), cholangiocarcinoma (n = 21), pancreatic cancer (n = 36), and other metastatic cancers (n = 68). Medical records and imaging studies were reviewed for demographic data, procedural information, pre- and postdrainage total serum bilirubin level levels, 30-day complications, and subsequent biliary procedures. RESULTS The probability of attaining a total serum bilirubin level of 1 mg/dL or lower by 100 days was 31% (95% CI, 23%-39%). Predrainage total serum bilirubin level of 9 mg/dL or lower (hazard ratio [HR], 3.27; 95% CI, 1.86-5.75; P < .001), 100% liver drainage (HR 2.73, 95% CI, 1.56-4.78; P <.001), and lower predrainage International Normalized Ratio (INR; HR, 0.80; 95% CI, 0.70-0.92; P = .002) were associated with an increased likelihood of attaining a total serum bilirubin level of 1 mg/dL or lower. The most common indication for follow-up was pericatheter leakage, which occurred in nearly one third of cases. During follow-up, patients required three visits per 100 catheter-days, or approximately one per month. Median overall survival in this population was approximately 3.5 months. CONCLUSIONS Only 31% of patients attained a normal serum bilirubin level by 100 days, and median overall survival was 107 days. Careful patient selection is warranted before biliary drainage for this indication. Maximal biliary drainage, a preprocedure total serum bilirubin of less than 9 mg/dL, and a lower INR were factors associated with serum bilirubin normalization in this cohort.
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Guilhaumou R, Solas C, Bourgarel-Rey V, Quaranta S, Rome A, Simon N, Lacarelle B, Andre N. Impact of plasma and intracellular exposure and CYP3A4, CYP3A5, and ABCB1 genetic polymorphisms on vincristine-induced neurotoxicity. Cancer Chemother Pharmacol 2011; 68:1633-8. [PMID: 21968951 DOI: 10.1007/s00280-011-1745-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2011] [Accepted: 09/13/2011] [Indexed: 10/17/2022]
Abstract
PURPOSE The aim of this study was to investigate the impact of plasma and intracellular exposure and CYP3A4, CYP3A5, and ABCB1 polymorphisms on vincristine neurotoxicity. We subsequently assessed the impact of ABCB1 polymorphisms on intracellular vincristine accumulation. METHODS Children treated for solid tumors were enrolled in the study (n = 26) and received 1.5 mg/m² of vincristine per course. Individual pharmacokinetic parameters and CYP3A4, CYP3A5, and ABCB1 genotypes were available from a previous analysis. A global toxicity score (pain, peripheral neurotoxicity, and gastrointestinal toxicity) was collected at each course. Vincristine in plasma and PBMCs were quantified by LC-MS/MS. RESULTS Vincristine plasma and intracellular concentrations ranged from 0.40 to 89.6 ng/ml and from 0.00225 to 1.85 ng/10(6) cells over a 24-h interval, respectively. The global toxicity score ranged from 0 to 6 and was not correlated with individual pharmacokinetics parameters. Neurotoxicity events (global score ≥ 3) were observed in 8 patients but the incidence was not influenced by the different studied polymorphisms. The global toxicity score was correlated with age, body surface area, and dose in mg. A trend to higher intracellular/plasma ratio of vincristine was found for patients with heterozygous diplotype (CGC-TTT) of ABCB1. CONCLUSIONS None of the different genetic covariates nor plasma and intracellular exposure was predictive of the observed neurotoxicity in our pediatric population. Nevertheless, the heterozygote diplotype of ABCB1 appears to influence the intracellular accumulation of vincristine. Owing to the small sample size, further evaluations are needed in a larger patient cohort.
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Wang Y, Katzenmeyer JB, Arriaga EA. Combination of micellar electrokinetic and high-performance liquid chromatographies to assess age-related changes in the in vitro metabolism of Fischer 344 rat liver. J Gerontol A Biol Sci Med Sci 2011; 66:935-43. [PMID: 21746738 DOI: 10.1093/gerona/glr074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
The metabolism of doxorubicin, a widely used anticancer drug, is different in young adult and old cancer patients. In this study, we demonstrate that micellar electrokinetic chromatography with laser-induced fluorescence detection is highly suited to monitor the metabolism of doxorubicin in subcellular fractions isolated from young adult (11 months, 100% survival rate) and old (26 months, ~25% survival rate) Fischer 344 rat livers. The relative amounts of doxorubicin metabolized in both mitochondria-enriched and postmitochondria fractions of young adult were larger than the respective fractions of old rat liver. 7-Deoxydoxorubicinolone and 7-deoxydoxorubicinone were identified using internal standard addition and structural elucidation by high-performance liquid chromatography with combined laser-induced fluorescence and mass spectrometry detection. Although high-performance liquid chromatography with combined laser-induced fluorescence and mass spectrometry detection is more useful in the identification of compounds, micellar electrokinetic chromatography with laser-induced fluorescence detection has low-sample requirements, simplified sample processing procedures, short analysis times and low limit of detection. Therefore, the combination of these two techniques provides a powerful approach to investigate metabolism of fluorescent drugs in aging studies.
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Affiliation(s)
- Yaohua Wang
- Department of Chemistry, University of Minnesota, Minneapolis, MN 55455, USA
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Phase I and pharmacokinetic study of trabectedin 3-hour infusion every three weeks in patients with advanced cancer and alteration of hepatic function. Med Oncol 2011; 29:2240-50. [PMID: 21660618 DOI: 10.1007/s12032-011-9979-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2011] [Accepted: 05/03/2011] [Indexed: 10/18/2022]
Abstract
Maximum tolerated dose (MTD), recommended dose (RD), and pharmacokinetics (PK) were evaluated for trabectedin 3-h every-3-weeks schedule in 33 cancer patients stratified according to liver dysfunction degree as per baseline alkaline phosphatase (AP). Stratification was as follows: stratum I [upper limit of normal (ULN) < AP ≤ 1.5 × ULN; n = 16], stratum II [1.5 × ULN < AP ≤ 2.5 × ULN; n = 12], and stratum III [AP >2.5 × ULN; n = 5] (bilirubin <2.5 × ULN for all 3 strata). In each stratum, patients were treated in sequential cohorts at escalating doses. Dose-limiting toxicities (DLTs) were grade 3 transaminase increases not recovering baseline values on day 21, febrile neutropenia/grade 4 neutropenia lasting >5 days and AP increase more than twice over baseline. The MTD and RD for stratum I (mild baseline AP) was 1.3 mg/m(2). Recruitment was stopped early in strata II/III (moderate/severe baseline AP) without reaching the MTD due to slow accrual and difficulty in finding patients. Biochemical parameters other than AP (bilirubin, AST or ALT) were similar between strata. No relevant PK differences were found between strata. In conclusion, the MTD and RD (1.3 mg/m(2)) were confirmed only for stratum I. Stratification criteria based on baseline AP apparently did not segregate the patients according to their liver dysfunction degree. Antitumor activity was found in patients with pretreated ovarian cancer.
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Horak J, White J, Harris AL, Verrill M, Carmichael J, Holt A, Cantarini M, Macpherson M, Swaisland A, Swaisland H, Twelves C. The effect of different etiologies of hepatic impairment on the pharmacokinetics of gefitinib. Cancer Chemother Pharmacol 2011; 68:1485-95. [DOI: 10.1007/s00280-011-1611-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2010] [Accepted: 03/04/2011] [Indexed: 10/18/2022]
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Ng T, Chan A. Dosing modifications of targeted cancer therapies in patients with special needs: evidence and controversies. Crit Rev Oncol Hematol 2011; 81:58-74. [PMID: 21429761 DOI: 10.1016/j.critrevonc.2011.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2010] [Revised: 02/07/2011] [Accepted: 02/18/2011] [Indexed: 12/18/2022] Open
Abstract
Targeted therapies have revolutionized the treatment of malignancies over the past decade. These agents are generally regarded to posses fewer systemic side effects than traditional cytotoxic chemotherapies. However, patients manifesting organ dysfunction or drug interactions with concurrent medications may require dosing modifications of their targeted therapies in order to reduce the risk of systemic toxicities or reduction of drug efficacies. Studies have shown that wide variations and controversies exist with regard to dosing modifications of drugs, due to the lack of well conducted studies and consensus. Hence, this review was conducted to review the literature on the dosing modification strategies, for 30 commercially available targeted cancer drugs, and to evaluate the current mainstay recommendations and controversies.
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Affiliation(s)
- T Ng
- Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore
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Bedikian AY, Silverman JA, Papadopoulos NE, Kim KB, Hagey AE, Vardeleon A, Hwu WJ, Homsi J, Davies M, Hwu P. Pharmacokinetics and safety of Marqibo (vincristine sulfate liposomes injection) in cancer patients with impaired liver function. J Clin Pharmacol 2010; 51:1205-12. [PMID: 20978276 DOI: 10.1177/0091270010381499] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Marqibo (vincristine sulfate liposome injection, VSLI) is a novel liposomal formulation of vincristine sulfate (VCR) being developed for the systemic treatment of cancer. This study evaluated the pharmacokinetics (PK) of Marqibo in subjects with melanoma and impaired hepatic function. Calculated PK parameters were similar in subjects with impaired liver function compared with those in subjects with adequate liver function. Subjects with impaired liver function universally had a monoexponential total plasma VCR concentration versus time decline, whereas two thirds of subjects with adequate liver function had a biexponential decline profile. Because one third of subjects with normal hepatic function demonstrated monoexponential disposition, lack of biexponential disposition in the hepatically impaired subjects cannot be clearly attributed to liver impairment. VSLI was generally well tolerated in all subjects.
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Affiliation(s)
- Agop Y Bedikian
- Department of Melanoma Medical Oncology, University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
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Biakhov MY, Kononova GV, Iglesias J, Desai N, Bhar P, Schmid AN, Loibl S. nab-Paclitaxel in patients with advanced solid tumors and hepatic dysfunction: a pilot study. Expert Opin Drug Saf 2010; 9:515-23. [PMID: 20500029 DOI: 10.1517/14740338.2010.487063] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE This pilot open-label clinical study evaluated the safety and pharmacokinetics of albumin-bound paclitaxel (nab-paclitaxel) in patients with advanced solid tumors and hepatic dysfunction. RESEARCH DESIGN/METHODS Dosing was determined according to baseline bilirubin levels as described in the package insert for Taxol((R)) (paclitaxel), and patients received 130, 200 or 260 mg/m(2) nab-paclitaxel every 3 weeks. RESULTS Thirty patients with elevated baseline bilirubin and aspartate aminotransferase levels received nab-paclitaxel. The most commonly-occurring grade 3/4 adverse events were neutropenia and fatigue. Grade 3/4 neutropenia occurred in 10, 30 and 30% of patients receiving 130, 200 and 260 mg/m(2) nab-paclitaxel, respectively. Grade 3 fatigue presented in 50 and 30% patients receiving 130 and 200 mg/m(2) nab-paclitaxel, respectively (no grade 4 event). Only one (10%) patient had a grade 3 sensory neuropathy in the 260 mg/m(2) nab-paclitaxel arm. Treatment-related grade 3 bilirubinemia and elevated aspartate aminotransferase was observed in patients receiving 130 mg/m(2) (30 and 10%, respectively) and 260 mg/m(2) nab-paclitaxel (20 and 10%, respectively). One patient had a grade 4 bilirubinemia in the 200 mg/m(2) nab-paclitaxel arm. Total bilirubin levels were inversely correlated to paclitaxel clearance (p < 0001). CONCLUSIONS nab-Paclitaxel has an acceptable tolerability profile in patients with solid tumors and hepatic dysfunction. The safety and pharmacokinetic results support the same dose modification scheme recommended for cremophor-based paclitaxel.
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Weil A, Martin P, Smith R, Oliver S, Langmuir P, Read J, Molz KH. Pharmacokinetics of Vandetanib in Subjects with Renal or Hepatic Impairment. Clin Pharmacokinet 2010; 49:607-18. [DOI: 10.2165/11534330-000000000-00000] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Abstract
The liver is fundamentally important in drug metabolism. In oncology, the astute clinician must not only understand the meaning and limitations of commonly ordered liver biochemical tests, but also be aware of which anticancer agents might induce liver dysfunction, and of the strategies for appropriate dosing of patients with pre-existing liver dysfunction. In part I of our Review, we highlighted both the importance and inadequacies of identifying serum biochemical liver abnormalities in oncology; we also discussed a lack of routine formal investigation of liver function. We summarised chemotherapy-related hepatotoxicity and other causes of liver toxic effects in patients with cancer. Here in part II, we discuss trials that have specifically assessed chemotherapy dosing strategies in the setting of overt biochemical liver dysfunction and we note their recommendations. Furthermore, we review other assessments of liver metabolic and excretory function, particularly in the setting of chemotherapy drug handling. We discuss the potential use of these metabolic probes in practice.
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Affiliation(s)
- Kathryn M Field
- Division of Haematology and Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
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Seol YM, Song MK, Choi YJ, Kim GH, Shin HJ, Song GA, Chung JS, Cho GJ. Oral fluoropyrimidines (capecitabine or S-1) and cisplatin as first line treatment in elderly patients with advanced gastric cancer: a retrospective study. Jpn J Clin Oncol 2008; 39:43-8. [PMID: 18997184 DOI: 10.1093/jjco/hyn119] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND This study aimed to evaluate the safety and efficacy of oral fluoropyrimidines and cisplatin therapy in elderly patients with untreated advanced gastric cancer (AGC) retrospectively. In addition, we evaluated the relative activity and toxicity of these agents in this patient population. METHODS Clinical data from 72 patients with previously untreated AGC, who were treated with capecitabine/cisplatin and S-1/cisplatin, were reviewed. Oral fluoropyrimidines were administered orally twice a day on Days 1-14. The dose of capecitabine was 1250 mg/m(2) and that of S-1 was 50 mg [body surface area (BSA) < 1.5 m(3)] or 60 mg (BSA > 1.5 m(3)) twice a day. Cisplatin was administered intravenously on Day 1 (before the first dose of capecitabine or S-1) at a dose of 70 mg/m(2) over a 2 h period. The chemotherapy cycle was of 3 weeks (with oral capecitabine or S-1). RESULTS Thirty-two and 40 patients received the S-1 and capecitabine regimens, respectively, and were included in the analysis. The S-1 protocol had a response rate of 40.6%, a median time-to-progression (TTP) of 5.4 months and a median survival of 9.6 months. The capecitabine had a response rate of 55%, a median TTP of 5.9 months and a median survival of 10.2 months. Each protocol had a similar incidence of Grade 3 or 4 adverse events. However, there was a higher rate of the hand-foot syndrome (6 versus 37%) and diarrhea (25 versus 32%) in the capecitabine group. CONCLUSION Oral fluoropyrimidines and cisplatin in elderly patients with untreated AGC showed encouraging results. The treatment was well tolerated with a manageable toxicity profile. The comparison of S-1 with capecitabine showed that capecitabine had a slightly higher response rate (statistically not significant) in addition to a higher rate of adverse events such as the hand-foot syndrome and diarrhea. These data should be warranted with further prospective studies.
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Affiliation(s)
- Young Mi Seol
- Hematology-Oncology Division, Department of Internal Medicine, Pusan National University Hospital, Seo-Gu, Busan, Korea
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Weston BR, Ross WA, Wolff RA, Evans D, Lee JE, Wang X, Xiao LC, Lee JH. Rate of bilirubin regression after stenting in malignant biliary obstruction for the initiation of chemotherapy: how soon should we repeat endoscopic retrograde cholangiopancreatography? Cancer 2008; 112:2417-23. [PMID: 18404695 DOI: 10.1002/cncr.23454] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND This study was conducted to evaluate the rate of regression of bilirubin after stent placement for malignant biliary obstruction. METHODS Records were reviewed from October 2002 to September 2005 for patients who underwent endoscopic retrograde cholangiopancreatography with stent placement. The time to achieve a bilirubin level <or=2 mg/dL was the primary endpoint because this is the level required by most chemotherapy protocols. Patient variables included type of cancer, liver metastasis, recent chemotherapy, baseline creatinine, and international normalized ratio (INR). Stent variables included type, dimension, stricture location, and sphincterotomy. RESULTS In total, 156 patients were included in the analysis: Ninety-three patients achieved a poststent bilirubin level <or=2 mg/dL, 29 patients failed because of stent failure, and 34 patients failed because of inadequate follow-up. The time required for 80% of patients to achieve normalization was more than doubled in those who had prestent bilirubin levels >or=10 mg/dL (6 weeks) compared with those who had prestent bilirubin levels <10 mg/dL (3 weeks). The following variables were identified as statistically significant: prestent bilirubin level, stricture location, liver metastasis, and INR. The cancer type, recent chemotherapy, stent type and diameter, and sphincterotomy were not statistically significant variables. CONCLUSIONS The rate of bilirubin normalization after biliary stenting was highly dependent on the prestent bilirubin level. Endoscopic intervention should be considered in patients who fail to achieve adequate normalization of serum bilirubin in 6 weeks if prestent bilirubin level was >or=10 mg/dL and in 3 weeks if their prestent bilirubin level was <10 mg/dL. Independent variables, such as diffuse liver metastases, stricture outside the common bile duct, and elevated INR had predictive value for bilirubin normalization.
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Affiliation(s)
- Brian R Weston
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA
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Pharmacology and Pharmacotherapy. CONCISE MANUAL OF HEMATOLOGY AND ONCOLOGY 2008. [PMCID: PMC7119909 DOI: 10.1007/978-3-540-73277-8_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Superfin D, Iannucci AA, Davies AM. Commentary: Oncologic drugs in patients with organ dysfunction: a summary. Oncologist 2007; 12:1070-83. [PMID: 17914077 DOI: 10.1634/theoncologist.12-9-1070] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
There are few prospective data regarding the pharmacokinetics and clinical toxicity of commonly used chemotherapeutics in cancer patients with organ dysfunction. Although increasing numbers of studies are investigating newer chemotherapeutics in patients with liver or kidney dysfunction, most guidelines for dosing, especially for established agents, remain empiric. This review describes the available data (both prospective and case study) evaluating the impact of renal and hepatic dysfunction on toxicity and dosing of commonly used chemotherapeutics and provides a practical summary for their use in this setting.
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Affiliation(s)
- Diana Superfin
- University of California Davis Cancer Center, 4501 X Street, Sacramento, California 95817, USA
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Zamboni WC, Strychor S, Joseph E, Parise RA, Egorin MJ, Eiseman JL. Tumor, tissue, and plasma pharmacokinetic studies and antitumor response studies of docetaxel in combination with 9-nitrocamptothecin in mice bearing SKOV-3 human ovarian xenografts. Cancer Chemother Pharmacol 2007; 62:417-26. [PMID: 17957368 DOI: 10.1007/s00280-007-0620-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2007] [Accepted: 09/24/2007] [Indexed: 11/28/2022]
Abstract
PURPOSE We evaluated the antitumor activity of two different schedules of docetaxel and 9-nitrocamptothecin (9NC) in mice bearing human SKOV-3 ovarian carcinoma xenografts and evaluated the plasma, tissue, and tumor disposition of each agent alone and in combination. EXPERIMENTAL DESIGN The following treatment groups were evaluated: (1) docetaxel 10 mg/kg IV on days 0 and 7; (2) 9NC 0.67 mg/kg PO qdx5dx2wk; (3) 9NC 0.67 mg/kg PO qdx5dx2wk in combination with docetaxel 10 mg/kg IV on days 0 and 7; and (4) 9NC 0.67 mg/kg PO qdx5dx2wk in combination with docetaxel 10 mg/kg IV on days 4 and 11; (5) vehicle controls for each agent; and (6) no treatment controls. RESULTS All treatment regimens produced significant antitumor activity as compared with control groups (P < 0.05). Docetaxel administered on days 0 and 7 or on days 4 and 11 in combination with 9NC resulted in similar antitumor activity (P > 0.05). High docetaxel concentrations in tumor were maintained at late time points as compared with plasma and tissues with the retention of docetaxel at 24 h being 132-fold and 15-fold higher in tumor than in plasma and liver, respectively. After administration of 9NC alone, the ratio of the 9-aminocamptothecin (9AC) area under the concentration versus time curve (AUC) to 9NC AUC in plasma and tumor was 0.15 and 1.34, respectively. CONCLUSIONS The combination of docetaxel and 9NC was effective against SKOV-3 xenografts. The lack of a difference in sequence-dependent antitumor activity may reflect the sensitivity of the SKOV-3 xenograft to 9NC. The factors associated with tumor-specific retention of docetaxel and the ratio of 9NC to 9AC in tumors is unknown.
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Affiliation(s)
- William C Zamboni
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA 15213, USA.
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Mbue JE, Solimando DA, Waddell JA. Doxorubicin, Cisplatin, High-dose Methotrexate, and Ifosfamide for Osteosarcoma. Hosp Pharm 2007. [DOI: 10.1310/hpj4209-801] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The increasing complexity of cancer chemotherapy now requires that pharmacists be familiar with these highly toxic agents. This column will review various issues related to preparation, dispensing, and administration of cancer chemotherapy, and review various agents, both commercially available and investigational, used to treat malignant diseases.
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Affiliation(s)
- John E. Mbue
- Medical Service Corps, Hematology-Oncology Service, Department of Pharmacy, Walter Reed Army Medical Center, Washington DC
| | - Dominic A. Solimando
- Oncology Pharmacy Services, Inc., 4201 Wilson Blvd #110-545, Arlington, VA 22203
| | - J. Aubrey Waddell
- University of Tennessee College of Pharmacy; Pharmacy Department, Blount Memorial Hospital, 907 E. Lamar Alexander Parkway, Maryville, TN 37804
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Lichtman SM, Wildiers H, Chatelut E, Steer C, Budman D, Morrison VA, Tranchand B, Shapira I, Aapro M. International Society of Geriatric Oncology Chemotherapy Taskforce: evaluation of chemotherapy in older patients--an analysis of the medical literature. J Clin Oncol 2007; 25:1832-43. [PMID: 17488981 DOI: 10.1200/jco.2007.10.6583] [Citation(s) in RCA: 180] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
The elderly comprise the majority of patients with cancer and are the recipients of the greatest amount of chemotherapy. Unfortunately, there is a lack of data to make evidence-based decisions with regard to chemotherapy. This is due to the minimal participation of older patients in clinical trials and that trials have not systematically evaluated chemotherapy. This article reviews the available information with regard to chemotherapy and aging provided by a task force of the International Society of Geriatric Oncology (SIOG). Due to the lack of prospective data, the conclusions and recommendations made are a consensus of the participants. Extrapolation of data from younger to older patients is necessary, particularly to those patients older than 80 years, for which data is almost entirely lacking. The classes of drugs reviewed include alkylators, antimetabolites, anthracyclines, taxanes, camptothecins, and epipodophyllotoxins. Clinical trials need to incorporate an analysis of chemotherapy in terms of the pharmacokinetic and pharmacodynamic effects of aging. In addition, data already accumulated need to be reanalyzed by age to aid in the management of the older cancer patient.
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Affiliation(s)
- Stuart M Lichtman
- Memorial Sloan-Kettering Cancer Center, Commack, New York 11725, USA.
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