Isolated lung perfusion for the treatment of pulmonary metastases current mini-review of work in progress

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

Background

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

Methods

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

Results

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

Conclusions

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

Intravaskuläre Therapieverfahren zu lokoregionalen Therapien von Lungentumoren

Hintergrund Die Inzidenz von Lungenkarzinomen hat im letzten Jahrhundert stark zugenommen. Darüber hinaus ist die Lunge der häufigste Ort der Metastasierung. Trotz der verbesserten Diagnostik und Therapie von Lungenmalignomen ist die Prognose der Patienten noch immer unbefriedigend. Lokoregionäre chemotherapeutische Techniken zur Behandlung von Lungenmalignomen haben heutzutage die Aufmerksamkeit der Forschung auf sich gezogen. Ziel dieses Übersichtsartikels ist es, verschiedene lokoregionale intravaskuläre Techniken und deren Behandlungsprinzipien vorzustellen und die jeweiligen Vor- und Nachteile als palliative und neoadjuvante Behandlungsmethode bei der Behandlung von Lungenmalignomen zu evaluieren.

Methode Die verschiedenen Verfahren bei der Behandlung von Lungenmalignomen wie isolierte Lungenperfusion (ILP), selektive pulmonale Arterienperfusion (SPAP), transpulmonale Chemoembolisation (TPCE), Bronchialarterieninfusion (BAI), Bronchialarterienchemoembolisation (BACE) und intraarterielle Chemoperfusion (IACP) werden vergleichend bewertet.

Ergebnisse Lokoregionale intravaskuläre Chemotherapieverfahren erweisen sich als vielversprechende Behandlungsoptionen bei der Behandlung von malignen Lungentumoren. Um optimale Ergebnisse zu erreichen, sollte mittels lokoregionaler Technik eine möglichst hohe Aufnahme des Chemotherapeutikums in das Zielgewebe mit schneller systemischer Clearance erzielt werden.

Schlussfolgerung Unter den verschiedenen Behandlungsoptionen bei Lungenmalignomen ist die TPCE das am besten evaluierte Behandlungskonzept. Allerdings sind weitere Studien nötig, um das optimale Behandlungskonzept mit den besten klinischen Ergebnissen zu definieren.

Kernaussagen 

Zitierweise

Intravascular Treatment Techniques for Locoregional Therapies of Lung Tumors

BACKGROUND

Lung cancer incidence has greatly increased over the past century. Moreover, the lung is the most common site of metastatic involvement. Despite improvements in the diagnosis and treatment of lung malignancies, patient prognosis is still unsatisfactory. Locoregional chemotherapeutic techniques for the treatment of lung malignancies are the current focus of research. The aim of this review article is to present different locoregional intravascular techniques and their treatment principles and to assess the pros and cons of each of them as a palliative and neoadjuvant treatment method in the treatment of lung malignancy.

METHOD

The different methods for the treatment of malignant lung lesions such as isolated lung perfusion (ILP), selective pulmonary artery perfusion (SPAP), transpulmonary chemoembolization (TPCE), bronchial artery infusion (BAI), bronchioarterial chemoembolization (BACE), and intraarteriel chemoperfusion (IACP) are evaluated comparatively.

RESULTS

Locoregional intravascular chemotherapy procedures are proving to be promising treatment options in the management of malignant lung tumors. In order to achieve optimal results, the locoregional technique should be used to achieve the highest possible uptake of the chemotherapeutic agent into the target tissue with rapid systemic clearance.

CONCLUSION

Among the various treatment options for lung malignancies, TPCE is the best evaluated treatment concept. However, further studies are necessary to define the optimal treatment concept with the best clinical outcomes.

KEY POINTS

· There are various intravascular chemotherapy methods for the treatment of lung malignancies.. · Transpulmonary chemoembolization (TPCE) is currently the most extensively evaluated treatment method for lung malignancies.. · Thermoablation after neoadjuvant chemoperfusion is a promising therapy for treating lung malignancies..

CITATION FORMAT

· Vogl TJ, Mekkawy A, Thabet DB. Intravascular Treatment Techniques for Locoregional Therapies of Lung Tumors. Fortschr Röntgenstr 2023; 195: 579 - 585.

Transvenous Pulmonary Chemoembolization and Optional Microwave Ablation for Colorectal Lung Metastases

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

Transcatheter Arterial Chemoembolization with Spherical Embolic Agent in Patients with Pulmonary or Mediastinal Metastases from Breast Cancer

PURPOSE

To evaluate safety and feasibility of transcatheter arterial chemoembolization with superabsorbent polymer microspheres (SAP-MS) for patients with pulmonary or mediastinal metastasis from breast cancer.

METHODS

Between November 2002 and January 2015, 14 patients with 29 unresectable pulmonary or mediastinal breast cancer metastases underwent transcatheter arterial chemoembolization using SAP-MS (50-100 μm) after injection of a combination of 2-4 types of anticancer drugs (eg, cisplatin [30 mg] + fluorouracil [500 mg], or epirubicin [40 mg] + mitomycin C [4 mg] + fluorouracil [500 mg]). As a primary endpoint, local tumor response and adverse events were evaluated 1 month after the first transcatheter arterial chemoembolization, according to Response Evaluation Criteria In Solid Tumors Version 1.1 and Common Terminology Criteria for Adverse Events Version 4 criteria. Transcatheter arterial chemoembolization was repeated as needed. Overall survival was analyzed as a secondary endpoint.

RESULTS

Response rate was 28.6% (partial response, 4 patients; stable disease, 10 patients). Median progression rate was -12.7%. No cases of hematologic toxicity of grade 3 or higher were observed. A grade 3 maculopapular rash was observed in 1 patient. After the first transcatheter arterial chemoembolization sessions, 63 additional transcatheter arterial chemoembolization sessions were performed (average, 5.5 sessions per patient; range, 2-10 sessions). The median overall survival time after the first session was 29 months, and the 5-year survival rate was 49.5%.

CONCLUSIONS

Transcatheter arterial chemoembolization with SAP-MS is a well-tolerated and feasible palliative treatment option for patients with pulmonary or mediastinal metastasis from breast cancer.

Laboratory models of regional chemotherapy

Development of new treatment strategies and agents is a difficult and costly matter in oncology. Routinely drugs are tested in vitro on tumor cells which, however, may have limited predictive value for their activity in patients. Also, the pharmacokinetic behavior, intratumoral distribution, as well as toxic side effects, binding to other compounds and stability of an agent are very important in determining activity in the patient. More so, development and evaluation of surgical delivery methods, i.e. regional treatment strategies, cannot be tested in cell systems. Therefore animal models are crucial for the development of regional chemotherapy methodologies. To allow translation of the animal data to patients it is important that the animal model closely mimics the clinical setting as for instance is achieved with isolated limb perfusion. However, animal models remain limited in their use, as eventually the efficacy of the approach may be different in animals compared to patients. Here we describe the use of animal models for regional treatment of solid tumors.

Transpulmonary chemoembolization: a novel approach for the treatment of unresectable lung tumors

This article describes the technique of transpulmonary chemoembolization for the palliative treatment of unresectable lung tumors. Early utilization of this method has resulted in reduction in tumor volume and alleviation of patient symptoms. After superselective catheterization, cytotoxic agents are administered, and the pulmonary arterial supply of the tumor is occluded by injection of microspheres and ethiodized oil. Emerging data suggest that this approach is well tolerated.

Pharmacokinetics after Endovascular Lung Perfusion with Cisplatin

PURPOSE

Endovascular lung perfusion (ELP) is a technique designed to deliver high doses of cisplatin via the pulmonary artery for the treatment of lung tumors. The purpose of the current study was to evaluate variables that affect adduct formation.

MATERIALS AND METHODS

Thirteen swine underwent ELP. The first group (n = 6) underwent infusion of 150 mg cisplatin diluted to 0.5 mg/mL via a balloon occlusion catheter in the left pulmonary artery. Uptake was compared with that seen with systemic infusion. A second group (n = 7) underwent bilateral sequential infusion of the left pulmonary artery, followed by the right. Cisplatin (150 mg) was infused at one of three concentrations: 1 mg/mL (n = 5 lungs), 0.67 mg/mL (n = 5 lungs), or 0.5 mg/mL (n = 4 lungs). The Pearson coefficient was used to correlate uptake with infusion time, infusate concentration, animal weight, and initial mean pulmonary artery pressure.

RESULTS

In the first group, cisplatin uptake in the control lung was less than 8% of that in the study lung. Infusion times for both groups ranged from 3 minutes to 56 minutes. Increases in infusion time correlated with increased adduct levels (r = 0.831; P < .0001). Mean uptake at concentrations of 0.5, 0.67, and 1 mg/mL were 25.79, 12.43, and 13.12 fmol/mug, respectively. There was no significant correlation between pulmonary adduct levels and infusate concentration (r = 0.106; P = .72). Animal weight and initial mean pulmonary artery pressure were not correlated with adduct formation.

CONCLUSIONS

ELP with longer infusions of cisplatin may lead to greater adduct formation in pulmonary tissues. Changes in concentration of the infusate do not affect uptake of cisplatin. Hemodynamic parameters do not affect cisplatin uptake.