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Bardet SM, Perrin ML, David V, Yardin C, Chaunavel A, Durand K, Maillan G, Rouchaud A, Durand Fontanier S, Taibi A. Feasibility of Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) in a Rabbit Model of Peritoneal Metastases: PIPALIM Project. Ann Surg Oncol 2025:10.1245/s10434-025-17251-7. [PMID: 40279057 DOI: 10.1245/s10434-025-17251-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2024] [Accepted: 03/09/2025] [Indexed: 04/26/2025]
Abstract
BACKGROUND Animal models are essential for testing new pressurized intraperitoneal aerosol chemotherapy (PIPAC) protocols; however, no immunocompetent animal model of peritoneal surface malignancies (PSMs) treated with PIPAC has been established. This study evaluated the feasibility, safety, and oncological efficacy of PIPAC in a rabbit PSM model. METHODS The study was conducted in two phases: (1) Feasibility Assessment: Three healthy rabbits underwent three consecutive PIPAC procedures (saline) at weekly intervals. The rabbits' well-being, morbidity, mortality, and histological changes were monitored. (2) Treatment Phase: Rabbits with PSM were treated with PIPAC using oxaliplatin, cisplatin-doxorubicin, or saline. Parameters such as animal well-being, ascites volume, morbidity, Peritoneal Cancer Index (PCI), histological response (Peritoneal Regression Grading Score [PRGS]), tumor cell proliferation/apoptosis, and circulating tumor DNA (ctDNA) levels were assessed. RESULTS PIPAC was feasible and safe, with no increased morbidity or mortality. PIPAC demonstrated antitumor efficacy with lower PCI (control 21.6 vs. oxaliplatin 9.2 vs. cisplatin-doxorubicin 10.2; p < 0.001), improved histological response (PRGS: control 3.38 vs. oxaliplatin 1.95 vs. cisplatin-doxorubicin 1.85; p = 0.01), and reduced tumor cell proliferation (control 5.3% vs. oxaliplatin 0.82% vs. cisplatin-doxorubicin 0.62%; p < 0.0001). ctDNA levels showed promise for monitoring treatment response, warranting further investigation. CONCLUSION This study confirms the feasibility and effectiveness of PIPAC with oxaliplatin or cisplatin-doxorubicin in rabbits with PSM. The model provides a foundation for future research on PIPAC protocols and related treatments.
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Affiliation(s)
| | | | - Valentin David
- Digestive Surgery Department, Dupuytren University Hospital, Limoges, France
| | - Catherine Yardin
- XLIM, UMR, CNRS 7252, University Limoges, Limoges, France
- Cytology and Histology Department, Dupuytren University Hospital, Limoges, France
- EMIS Research, Dupuytren University Hospital , Limoges, France
| | - Alain Chaunavel
- Translational Research and Innovation Platform in Oncology, Pathology Department, Dupuytren University Hospital, Limoges, France
| | - Karine Durand
- Translational Research and Innovation Platform in Oncology, Pathology Department, Dupuytren University Hospital, Limoges, France
| | - Gaelle Maillan
- Pharmacy Department, Dupuytren University Hospital, Limoges, France
| | - Aymeric Rouchaud
- XLIM, UMR, CNRS 7252, University Limoges, Limoges, France
- Radiology Department, Dupuytren University Hospital, Limoges, France
- EMIS Research, Dupuytren University Hospital , Limoges, France
| | - Sylvaine Durand Fontanier
- XLIM, UMR, CNRS 7252, University Limoges, Limoges, France
- Digestive Surgery Department, Dupuytren University Hospital, Limoges, France
- EMIS Research, Dupuytren University Hospital , Limoges, France
| | - Abdelkader Taibi
- XLIM, UMR, CNRS 7252, University Limoges, Limoges, France.
- Digestive Surgery Department, Dupuytren University Hospital, Limoges, France.
- EMIS Research, Dupuytren University Hospital , Limoges, France.
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Hao Y, Gkasti A, Managh AJ, Dagher J, Sifis A, Tiron L, Chriqui LE, Marie DN, De Souza Silva O, Christodoulou M, Peters S, Joyce JA, Krueger T, Gonzalez M, Abdelnour-Berchtold E, Sempoux C, Clerc D, Teixeira-Farinha H, Hübner M, Meylan E, Dyson PJ, Cavin S, Perentes JY. Hyperthermic Intrathoracic Chemotherapy Modulates the Immune Microenvironment of Pleural Mesothelioma and Improves the Impact of Dual Immune Checkpoint Inhibition. Cancer Immunol Res 2025; 13:185-199. [PMID: 39585317 DOI: 10.1158/2326-6066.cir-24-0245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 06/19/2024] [Accepted: 11/19/2024] [Indexed: 11/26/2024]
Abstract
Pleural mesothelioma is a fatal disease with limited treatment options. Recently, pleural mesothelioma management has improved with the development of immune checkpoint inhibitors (ICI). In first-line therapy, dual PD-1 and CTLA-4 blockade enhances tumor control and patient survival compared with chemotherapy. Unfortunately, only a fraction of patients is responsive to immunotherapy, and approaches to reshape the tumor immune microenvironment and make ICIs more effective are urgently required. In this study, we evaluated the effect of hyperthermic intrathoracic chemotherapy (HITOC), a treatment that combines fever-range hyperthermia with local intrapleural cisplatin chemotherapy, on the tumor immune microenvironment and response to ICIs. To do this, we developed a murine pleural mesothelioma model of HITOC. We found that HITOC significantly improved tumor control and animal survival through a mechanism involving the development of a cytotoxic immune response. Additionally, HITOC enhanced immune checkpoint expression by T lymphocytes and synergized with dual PD-1 and CTLA-4 inhibition, leading to further improvement in animal survival. Finally, the analysis of peritoneal mesothelioma patient samples treated by pressurized intraperitoneal aerosol chemotherapy revealed a similar immunomodulation. In conclusion, HITOC remodels the tumor immune microenvironment of pleural mesothelioma by promoting T-cell infiltration into the tumor and could be considered in combination with ICIs in the context of a clinical trial.
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Affiliation(s)
- Yameng Hao
- Department of Thoracic Surgery, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
- Agora Cancer Research Center Lausanne, Lausanne, Switzerland
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
| | - Aspasia Gkasti
- Swiss Institute for Experimental Cancer Research, School of Life Sciences, Ecole Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
| | - Amy J Managh
- Department of Chemistry, Loughborough University, Loughborough, United Kingdom
| | - Julien Dagher
- Institute of Pathology, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Alexandros Sifis
- Department of Thoracic Surgery, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
- Agora Cancer Research Center Lausanne, Lausanne, Switzerland
| | - Luca Tiron
- Department of Thoracic Surgery, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
- Agora Cancer Research Center Lausanne, Lausanne, Switzerland
| | - Louis-Emmanuel Chriqui
- Department of Thoracic Surgery, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
- Agora Cancer Research Center Lausanne, Lausanne, Switzerland
| | - Damien N Marie
- Department of Thoracic Surgery, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
- Agora Cancer Research Center Lausanne, Lausanne, Switzerland
| | - Olga De Souza Silva
- Department of Thoracic Surgery, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
- Agora Cancer Research Center Lausanne, Lausanne, Switzerland
| | | | - Solange Peters
- Department of Oncology, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Johanna A Joyce
- Agora Cancer Research Center Lausanne, Lausanne, Switzerland
- Department of Oncology, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
- Ludwig Institute for Cancer Research, University of Lausanne (UNIL), Lausanne, Switzerland
- Lundin Family Brain Tumor Research Center, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Thorsten Krueger
- Department of Thoracic Surgery, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Michel Gonzalez
- Department of Thoracic Surgery, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Etienne Abdelnour-Berchtold
- Department of Thoracic Surgery, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Christine Sempoux
- Institute of Pathology, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Daniel Clerc
- Department of Visceral Surgery, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Hugo Teixeira-Farinha
- Department of Visceral Surgery, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Etienne Meylan
- Lung Cancer and Immuno-Oncology Laboratory, Bordet Cancer Research Laboratories, Institut Jules Bordet, Hôpital Universitaire de Bruxelles, Faculty of Medicine, Université libre de Bruxelles, Anderlecht, Belgium
- Laboratory of Immunobiology, Faculty of Sciences, Université Libre de Bruxelles, Gosselies, Belgium
| | - Paul J Dyson
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
| | - Sabrina Cavin
- Department of Thoracic Surgery, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
- Agora Cancer Research Center Lausanne, Lausanne, Switzerland
| | - Jean Y Perentes
- Department of Thoracic Surgery, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
- Agora Cancer Research Center Lausanne, Lausanne, Switzerland
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Krell M, Ranjbar S, Gitlin S, Alvarez Vega DR, Wilson R, Thrasher K, Brown ZJ. Evolution in the Surgical Management of Gastric Cancer Peritoneal Metastases. Cancers (Basel) 2024; 17:100. [PMID: 39796727 PMCID: PMC11719528 DOI: 10.3390/cancers17010100] [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: 12/02/2024] [Revised: 12/26/2024] [Accepted: 12/27/2024] [Indexed: 01/13/2025] Open
Abstract
Despite therapeutic treatments and the growing utilization of multimodal therapies, gastric cancer (GC) remains a highly aggressive malignancy with high mortality worldwide. Much of the complexity in treating GC is due to the high incidence of peritoneal metastasis (PM), with mean overall survival typically ranging from 4 to 10 months. With current systemic therapy, targeted therapies, and immunotherapies continuing to remain ineffective for GC/PM, there has been a significant growing interest in intraperitoneal (IP) therapies for the treatment of GC/PM. In this review, we summarize the development of PM and evolving treatment strategies for GC/PM. Furthermore, we explore the various advancements and outcomes of IP therapies, including heated intraperitoneal chemotherapy (HIPEC), neoadjuvant HIPEC, and pressurized intraperitoneal aerosolized chemotherapy (PIPAC).
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Affiliation(s)
| | | | | | | | | | | | - Zachary J. Brown
- Department of Surgery, Division of Surgical Oncology, NYU Langone Health, NYU Grossman Long Island School of Medicine, Mineola, NY 11501, USA; (M.K.); (S.G.); (D.R.A.V.); (R.W.); (K.T.)
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Aulicino M, Santullo F, D’Annibale G, Abatini C, Attalla El Halabieh M, Orsini C, Barberis L, D’Agostino L, Tersigni I, Pacelli F, Lodoli C, Di Giorgio A, Ferracci F, Pacelli F. Efficacy and Insights from an Extensive Series of Cytoreductive Surgery for Peritoneal Neoplasms: A High-Volume Single-Center Experience. Cancers (Basel) 2024; 16:4229. [PMID: 39766128 PMCID: PMC11726991 DOI: 10.3390/cancers16244229] [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: 11/21/2024] [Revised: 12/13/2024] [Accepted: 12/17/2024] [Indexed: 01/15/2025] Open
Abstract
Background: Advances in cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) and pressurized intraperitoneal aerosol chemotherapy (PIPAC) have improved outcomes for selected patients with peritoneal surface malignancies (PSMs). Methods: This retrospective study analyzed 743 PSM patients treated at Fondazione Policlinico Universitario Agostino Gemelli from January 2016 to February 2024. The primary aim was to assess median overall survival (mOS), median disease-free survival (mDFS), and median progression-free survival (mPFS) stratified by tumor origin. Secondary outcomes examined the role of diagnostic laparoscopy in the management of PSMs and intra- and postoperative complications' rates. Results: A total of 1113 procedures were performed: 389 CRS, 370 PIPAC, and 354 diagnostic laparoscopies. Colorectal cancer was the predominant indication for CRS (52.4%), with a mOS of 52 months and mDFS of 22 months. Patients affected by gastric cancer undergoing CRS had a mOS of 18 months and a mDFS of 13 months, while PIPAC yielded a mOS of 9 months and a mPFS of 4 months. Among patients with pseudomyxoma peritonei undergoing CRS, the 5-year DFS rate was 64.1%, and OS rate was 89%. Patients affected by mesothelioma and treated with CRS exhibited a median OS of 43 months and a DFS of 26 months. Pancreatic and hepatobiliary cancers were treated with PIPAC, with a respective mOS of 12 and 8 months. Postoperative complications occurred in 12.6% of CRS, 3.2% of PIPAC, and 1.7% of diagnostic laparoscopies. High peritoneal cancer index (PCI), gastric resection, and blood loss over 500 mL were identified as risk factors for major complications in a multivariate analysis. Conclusions: Developing a highly experienced multidisciplinary team is crucial for delivering tailored treatment strategies which aim to achieve optimal oncological outcomes while preserving patients' quality of life.
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Affiliation(s)
- Matteo Aulicino
- General Surgery Department, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (M.A.); (C.O.); (L.B.); (L.D.); (I.T.); (F.F.); (F.P.)
| | - Francesco Santullo
- Surgical Unit of Peritoneum and Retroperitoneum Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (C.A.); (M.A.E.H.); (C.L.); (A.D.G.)
| | - Giorgio D’Annibale
- General Surgery Department, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (M.A.); (C.O.); (L.B.); (L.D.); (I.T.); (F.F.); (F.P.)
| | - Carlo Abatini
- Surgical Unit of Peritoneum and Retroperitoneum Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (C.A.); (M.A.E.H.); (C.L.); (A.D.G.)
| | - Miriam Attalla El Halabieh
- Surgical Unit of Peritoneum and Retroperitoneum Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (C.A.); (M.A.E.H.); (C.L.); (A.D.G.)
| | - Cecilia Orsini
- General Surgery Department, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (M.A.); (C.O.); (L.B.); (L.D.); (I.T.); (F.F.); (F.P.)
| | - Lorenzo Barberis
- General Surgery Department, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (M.A.); (C.O.); (L.B.); (L.D.); (I.T.); (F.F.); (F.P.)
| | - Luca D’Agostino
- General Surgery Department, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (M.A.); (C.O.); (L.B.); (L.D.); (I.T.); (F.F.); (F.P.)
| | - Ilaria Tersigni
- General Surgery Department, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (M.A.); (C.O.); (L.B.); (L.D.); (I.T.); (F.F.); (F.P.)
| | - Fiammetta Pacelli
- Department of Surgical and Medical Sciences and Translational Medicine, Sant ’Andrea University Hospital, Sapienza University of Rome, 00185 Rome, Italy;
| | - Claudio Lodoli
- Surgical Unit of Peritoneum and Retroperitoneum Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (C.A.); (M.A.E.H.); (C.L.); (A.D.G.)
| | - Andrea Di Giorgio
- Surgical Unit of Peritoneum and Retroperitoneum Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (C.A.); (M.A.E.H.); (C.L.); (A.D.G.)
| | - Federica Ferracci
- General Surgery Department, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (M.A.); (C.O.); (L.B.); (L.D.); (I.T.); (F.F.); (F.P.)
- Surgical Unit of Peritoneum and Retroperitoneum Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (C.A.); (M.A.E.H.); (C.L.); (A.D.G.)
| | - Fabio Pacelli
- General Surgery Department, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (M.A.); (C.O.); (L.B.); (L.D.); (I.T.); (F.F.); (F.P.)
- Surgical Unit of Peritoneum and Retroperitoneum Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (C.A.); (M.A.E.H.); (C.L.); (A.D.G.)
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Sundar R, Chia DKA, Zhao JJ, Lee ARYB, Kim G, Tan HL, Pang A, Shabbir A, Willaert W, Ma H, Huang KK, Hagihara T, Tan ALK, Ong CAJ, Wong JSM, Seo CJ, Walsh R, Chan G, Cheo SW, Soh CCC, Callebout E, Geboes K, Ng MCH, Lum JHY, Leow WQ, Selvarajan S, Hoorens A, Ang WH, Pang H, Tan P, Yong WP, Chia CSL, Ceelen W, So JBY. Phase I PIANO trial-PIPAC-oxaliplatin and systemic nivolumab combination for gastric cancer peritoneal metastases: clinical and translational outcomes. ESMO Open 2024; 9:103681. [PMID: 39288528 PMCID: PMC11421236 DOI: 10.1016/j.esmoop.2024.103681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Revised: 07/24/2024] [Accepted: 07/26/2024] [Indexed: 09/19/2024] Open
Abstract
INTRODUCTION Pressurized intraperitoneal aerosol chemotherapy-oxaliplatin (PIPAC-OX) induces direct DNA damage and immunogenic cell death in patients with gastric cancer peritoneal metastases (GCPM). Combining PIPAC-OX with immune checkpoint inhibition remains untested. We conducted a phase I first-in-human trial evaluating the safety and efficacy of PIPAC-OX combined with systemic nivolumab (NCT03172416). METHODS Patients with GCPM who experienced disease progression on at least first-line systemic therapy were recruited across three centers in Singapore and Belgium. Patients received PIPAC-OX at 90 mg/m2 every 6 weeks and i.v. nivolumab 240 mg every 2 weeks. Translational studies were carried out on GCPM samples acquired during PIPAC-OX procedures. RESULTS In total, 18 patients with GCPM were prospectively recruited. The PIPAC-OX and nivolumab combination was well tolerated with manageable treatment-related adverse events, although one patient suffered from grade 4 vomiting. At second and third PIPAC-OX, respectively, the median decrease in peritoneal cancer index (PCI) was -5 (interquartile range: -12 to +1) and -7 (interquartile range: -6 to -20) and peritoneal regression grade 1 or 2 was observed in 66.7% (6/9) and 100% (3/3). Translational analyses of 43 GCPM samples revealed enrichment of immune/stromal infiltration and inflammatory signatures in peritoneal tumors after PIPAC-OX and nivolumab. M2 macrophages were reduced in treated peritoneal tumor samples while memory CD4+, CD8+ central memory and naive CD8+ T-cells were increased. CONCLUSIONS The first-in-human trial combining PIPAC-OX and nivolumab demonstrated safety and tolerability, coupled with enhanced T-cell infiltration within peritoneal tumors. This trial sets the stage for future combinations of systemic immunotherapy with locoregional intraperitoneal treatments.
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Affiliation(s)
- R Sundar
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Haematology-Oncology, National University Cancer Institute, Singapore; Cancer and Stem Cell Biology Program, Duke-NUS Medical School, Singapore; The N.1 Institute for Health, National University of Singapore, Singapore; Singapore Gastric Cancer Consortium, Singapore.
| | - D K A Chia
- Division of Upper Gastrointestinal Surgery, Department of Surgery, National University Hospital, National University Health System, Singapore
| | - J J Zhao
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Haematology-Oncology, National University Cancer Institute, Singapore; Department of Medicine, National University Hospital, Singapore, Singapore
| | - A R Y B Lee
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - G Kim
- Division of Upper Gastrointestinal Surgery, Department of Surgery, National University Hospital, National University Health System, Singapore
| | - H L Tan
- Department of Haematology-Oncology, National University Cancer Institute, Singapore
| | - A Pang
- Division of Upper Gastrointestinal Surgery, Department of Surgery, National University Hospital, National University Health System, Singapore
| | - A Shabbir
- Division of Upper Gastrointestinal Surgery, Department of Surgery, National University Hospital, National University Health System, Singapore
| | - W Willaert
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - H Ma
- Cancer and Stem Cell Biology Program, Duke-NUS Medical School, Singapore
| | - K K Huang
- Cancer and Stem Cell Biology Program, Duke-NUS Medical School, Singapore
| | - T Hagihara
- Cancer and Stem Cell Biology Program, Duke-NUS Medical School, Singapore
| | - A L K Tan
- Cancer and Stem Cell Biology Program, Duke-NUS Medical School, Singapore
| | - C-A J Ong
- Singapore Gastric Cancer Consortium, Singapore; Department of Sarcoma, Peritoneal and Rare Tumors (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore, Singapore
| | - J S M Wong
- Department of Sarcoma, Peritoneal and Rare Tumors (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore, Singapore
| | - C J Seo
- Department of Sarcoma, Peritoneal and Rare Tumors (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore, Singapore
| | - R Walsh
- Department of Haematology-Oncology, National University Cancer Institute, Singapore
| | - G Chan
- Department of Haematology-Oncology, National University Cancer Institute, Singapore
| | - S W Cheo
- Department of Haematology-Oncology, National University Cancer Institute, Singapore
| | - C C C Soh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - E Callebout
- Department of Digestive Oncology, Gastroenterology, Ghent University Hospital, Ghent, Belgium
| | - K Geboes
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - M C H Ng
- Division of Medical Oncology, National Cancer Centre, Singapore; Duke NUS Medical School, Singapore
| | - J H Y Lum
- Department of Pathology, National University Hospital, Singapore
| | - W Q Leow
- Department of Anatomical Pathology, Singapore General Hospital, Singapore, Singapore
| | - S Selvarajan
- Department of Anatomical Pathology, Singapore General Hospital, Singapore, Singapore
| | - A Hoorens
- Department of Pathology, Ghent University Hospital, Ghent, Belgium
| | - W H Ang
- Department of Chemistry, National University of Singapore, Singapore
| | - H Pang
- Department of Chemistry, National University of Singapore, Singapore
| | - P Tan
- Cancer and Stem Cell Biology Program, Duke-NUS Medical School, Singapore; Singapore Gastric Cancer Consortium, Singapore
| | - W P Yong
- Department of Haematology-Oncology, National University Cancer Institute, Singapore; Singapore Gastric Cancer Consortium, Singapore
| | - C S L Chia
- Department of Sarcoma, Peritoneal and Rare Tumors (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore, Singapore
| | - W Ceelen
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - J B Y So
- Singapore Gastric Cancer Consortium, Singapore; Division of Upper Gastrointestinal Surgery, Department of Surgery, National University Hospital, National University Health System, Singapore; Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Surgical Oncology, National University Cancer Institute of Singapore (NCIS), Singapore, Singapore.
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Göhler D, Oelschlägel K, Ouaissi M, Giger-Pabst U. Performance of different nebulizers in clinical use for Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC). PLoS One 2024; 19:e0300241. [PMID: 38696384 PMCID: PMC11065249 DOI: 10.1371/journal.pone.0300241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 02/23/2024] [Indexed: 05/04/2024] Open
Abstract
OBJECTIVE Technical ex-vivo comparison of commercial nebulizer nozzles used for Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC). METHODS The performance of four different commercial nebulizer nozzles (Nebulizer; HurriChemTM; MCR-4 TOPOL®; QuattroJet) was analysed concerning: i) technical design and principle of operation, ii) operational pressure as function of the liquid flow rate, iii) droplet size distribution via laser diffraction spectrometry, iv) spray cone angle, spray cone form as well as horizontal drug deposition by image-metric analyses and v) chemical resistance via exposing to a cytostatic solution and chemical composition by means of spark optical emission spectral analysis. RESULTS The Nebulizer shows quasi an identical technical design and thus also a similar performance (e.g., mass median droplet size of 29 μm) as the original PIPAC nozzles (MIP/ CapnoPen). All other nozzles show more or less a performance deviation to the original PIPAC nozzles. The HurriChemTM has a similar design and principle of operation as the Nebulizer, but provides a finer aerosol (22 μm). The principle of operation of MCR-4 TOPOL® and QuattroJet differ significantly from that of the original PIPAC nozzle technology. The MCR-4 TOPOL® offers a hollow spray cone with significantly larger droplets (50 μm) than the original PIPAC nozzles. The QuattroJet generates an aerosol (22 μm) similar to that of the HurriChemTM but with improved spatial drug distribution. CONCLUSION The availability of new PIPAC nozzles is encouraging but can also have a negative impact if their performance and efficacy is unknown. It is recommended that PIPAC nozzles that deviate from the current standard should be subject to bioequivalence testing and implementation in accordance with the IDEAL-D framework prior to routine clinical use.
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Affiliation(s)
- Daniel Göhler
- Topas GmbH, Dresden, Germany
- Research Group Mechanical Process Engineering, Institute of Process Engineering and Environmental Technology, Technische Universität Dresden, Dresden, Germany
| | | | - Mehdi Ouaissi
- EA4245 Transplantation, Immunology, Inflammation, Université de Tours, Tours, France
- Department of Digestive, Oncological, Endocrine, Hepato-Biliary, Pancreatic and Liver Transplant Surgery, University Hospital of Tours, Tours, France
| | - Urs Giger-Pabst
- EA4245 Transplantation, Immunology, Inflammation, Université de Tours, Tours, France
- Fliedner Fachhochschule, University of Applied Sciences Düsseldorf, Düsseldorf, Germany
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Daniel SK, Sun BJ, Lee B. PIPAC for Gastrointestinal Malignancies. J Clin Med 2023; 12:6799. [PMID: 37959264 PMCID: PMC10650315 DOI: 10.3390/jcm12216799] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/19/2023] [Accepted: 10/23/2023] [Indexed: 11/15/2023] Open
Abstract
The peritoneum is a common site of metastases for gastrointestinal tumors that predicts a poor outcome. In addition to decreased survival, peritoneal metastases (PMs) can significantly impact quality of life from the resulting ascites and bowel obstructions. The peritoneum has been a target for regional therapies due to the unique properties of the blood-peritoneum barrier. Cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) have become accepted treatments for limited-volume peritoneal disease in appendiceal, ovarian, and colorectal malignancies, but there are limitations. Pressurized intraperitoneal aerosolized chemotherapy (PIPAC) improves drug distribution and tissue penetration, allowing for a minimally invasive application for patients who are not CRS/HIPEC candidates based on high disease burden. PIPAC is an emerging treatment that may convert the patient to resectable disease, and may increase survival without major morbidity, as indicated by many small studies. In this review, we discuss the rationale and benefits of PIPAC, as well as sentinel papers describing its application for gastric, colorectal, appendiceal, and pancreatobiliary PMs. While no PIPAC device has yet met FDA approval, we discuss next steps needed to incorporate PIPAC into neoadjuvant/adjuvant treatment paradigms, as well as palliative settings. Data on active clinical trials using PIPAC are provided.
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Affiliation(s)
- Sara K. Daniel
- Department of Surgery, Stanford University, Stanford, CA 94305, USA
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Ramos Arias G, Sindayigaya R, Ouaissi M, Buggisch JR, Schmeding M, Giger-Pabst U, Zieren J. Safety and Feasibility of High-Pressure/High-Dose Pressurized Intraperitoneal Aerosol Chemotherapy (HP/HD-PIPAC) for Primary and Metastatic Peritoneal Surface Malignancies. Ann Surg Oncol 2023; 30:2497-2505. [PMID: 36400887 DOI: 10.1245/s10434-022-12698-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 10/04/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the feasibility and perioperative safety of high-pressure/high-dose pressurized intraperitoneal aerosol chemotherapy (HP/HD-PIPAC) to manage peritoneal surface malignancies (PSM). METHODS Retrospective analysis of a prospective database of about 130 consecutive patients scheduled for HP/HD-PIPACs for PSM. Doxorubicin plus cisplatin (PIPAC-C/D) or oxaliplatin (PIPAC-Ox) were nebulized into a constant capnoperitoneum of 20 mmHg at doses of 6, 30, or 120 mg/m2 of body surface area (BSA). Outcome criteria were perioperative complications (Clavien-Dindo). RESULTS The median age of patients was 62 years (range 9-82), and the primary tumor site was of colorectal (CRC), upper gastrointestinal tract (UGI), unknown primary (CUP), malignant epithelioid mesothelioma of the peritoneum (MPM), hepato-pancreatic-biliary tract (HPB), and other origin in 30 (23.1%), 27 (20.8%), 16 (12.3%), 16 (12.3%), 6 (4.6%), and 35 (26.9%) patients, respectively. Abdominal access failed for a first, second, third, and fourth or more HP/HD-PIPAC in 12/130 (9.2%), 4/64 (6.3%), 6/40 (15.0%), and 2/33 (6.1%) patients. A total of 243 procedures were performed in 118 patients. No intraoperative complications related to increased capnoperitoneal pressure occurred, but an intraoperative bleeding complication was observed in 1/243 (0.4%) patients. The overall rate of postoperative procedure-related complications was 19.3% (47/243), while 15.3% (37/243), 1.6% (6/243), 1.6% (1/243), 0.4% (1/243), and 0.4% (1/243) were Grade I, II, III, IV, and V complications, respectively. CONCLUSIONS Perioperative complications of HP/HD-PIPAC are comparable with standard pressure/dose PIPAC treatment protocols. Prospective studies are warranted to examine potential improvement in therapy outcomes.
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Affiliation(s)
- Gabriel Ramos Arias
- Department of Surgery, Städtisches Krankenhaus Dortmund, University Hospital of the University Witten/Herdecke, Wuppertal, Germany
| | - Rémy Sindayigaya
- Department of Digestive, Oncological, Endocrine, Hepato-Biliary, Pancreatic and Liver Transplant Surgery, Trousseau Hospital, Chambray les Tours, Tours, France
| | - Mehdi Ouaissi
- Department of Digestive, Oncological, Endocrine, Hepato-Biliary, Pancreatic and Liver Transplant Surgery, Trousseau Hospital, Chambray les Tours, Tours, France
- University of Münster, Medizinische Fakultät, Münster, Germany
| | | | - Maximilian Schmeding
- Department of Surgery, Städtisches Krankenhaus Dortmund, University Hospital of the University Witten/Herdecke, Wuppertal, Germany
| | - Urs Giger-Pabst
- EA4245 Transplantation, Immunologie, Inflammation, Université de Tours, Tours, France.
- Fliedner Fachhochschule, University of Applied Science Düsseldorf, Düsseldorf, Germany.
| | - Jürgen Zieren
- Department of Surgery, Städtisches Krankenhaus Dortmund, University Hospital of the University Witten/Herdecke, Wuppertal, Germany
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Baggaley AE, Lafaurie GBRC, Tate SJ, Boshier PR, Case A, Prosser S, Torkington J, Jones SEF, Gwynne SH, Peters CJ. Pressurized intraperitoneal aerosol chemotherapy (PIPAC): updated systematic review using the IDEAL framework. Br J Surg 2022; 110:10-18. [PMID: 36056893 PMCID: PMC10364525 DOI: 10.1093/bjs/znac284] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 06/28/2022] [Accepted: 07/19/2022] [Indexed: 12/31/2022]
Affiliation(s)
- Alice E Baggaley
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, London, UK
| | | | - Sophia J Tate
- Department of Anaesthesia, Swansea Bay University Health Board, Swansea, UK
| | - Piers R Boshier
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, London, UK
| | - Amy Case
- Department of Cancer Services, Swansea Bay University Health Board, Swansea, UK
| | - Susan Prosser
- Department of Library Services, Swansea Bay University Health Board, Swansea, UK
| | - Jared Torkington
- Department of Surgery, University Hospital of Wales, Cardiff, UK
| | - Sadie E F Jones
- Department of Obstetrics and Gynaecology, University Hospital of Wales, Cardiff, UK
| | - Sarah H Gwynne
- Department of Cancer Services, Swansea Bay University Health Board, Swansea, UK
| | - Christopher J Peters
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, London, UK
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Feasibility of pressurized intra peritoneal aerosol chemotherapy using an ultrasound aerosol generator (usPIPAC). Surg Endosc 2022; 36:7848-7858. [PMID: 36038646 PMCID: PMC9485099 DOI: 10.1007/s00464-022-09525-y] [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: 09/12/2021] [Accepted: 07/31/2022] [Indexed: 11/23/2022]
Abstract
Background
We tested the feasibility of ultrasound technology for generating pressurized intraperitoneal aerosol chemotherapy (usPIPAC) and compared its performance vs. comparator (PIPAC). Material and methods A piezoelectric ultrasound aerosolizer (NextGen, Sinaptec) was compared with the available technology (Capnopen, Capnomed). Granulometry was measured for water, Glc 5%, and silicone oil using laser diffraction spectrometry. Two- and three-dimensional (2D and 3D) spraying patterns were determined with methylene blue. Tissue penetration of doxorubicin (DOX) was measured by fluorescence microscopy in the enhanced inverted Bovine Urinary Bladder model (eIBUB). Tissue DOX concentration was measured by high-performance liquid chromatography (HPLC). Results The droplets median aerodynamic diameter was (usPIPAC vs. PIPAC): H20: 40.4 (CI 10–90%: 19.0–102.3) vs. 34.8 (22.8–52.7) µm; Glc 5%: 52.8 (22.2–132.1) vs. 39.0 (23.7–65.2) µm; Silicone oil: 178.7 (55.7–501.8) vs. 43.0 (20.2–78.5) µm. 2D and 3D blue ink distribution pattern of usPIPAC was largely equivalent with PIPAC, as was DOX tissue concentration (usPIPAC: 0.65 (CI 5-95%: 0.44–0.86) vs. PIPAC: 0.88 (0.59–1.17) ng/ml, p = 0.29). DOX tissue penetration with usPIPAC was inferior to PIPAC: usPIPAC: 60.1 (CI 5.95%: 58.8–61.5) µm vs. PIPAC: 1172 (1157–1198) µm, p < 0.001). The homogeneity of spatial distribution (top, middle and bottom of the eIBUB) was comparable between modalities. Discussion usPIPAC is feasible, but its performance as a drug delivery system remains currently inferior to PIPAC, in particular for lipophilic solutions.
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Buggisch JR, Göhler D, Sobilo J, Lerondel S, Rezniczek GA, Stintz M, Rudolph A, Tabchouri N, Roger S, Ouaissi M, Giger-Pabst U. Development and technical validation of an ultrasound nebulizer to deliver intraperitoneal pressurized aerosols in a rat colon cancer peritoneal metastases model. BMC Cancer 2022; 22:570. [PMID: 35597921 PMCID: PMC9124413 DOI: 10.1186/s12885-022-09668-0] [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: 10/04/2021] [Accepted: 05/11/2022] [Indexed: 11/15/2022] Open
Abstract
Background/aim To develop and validate a nebulizer device for anti-cancer research on pressurized intraperitoneal aerosol supply in a preclinical peritoneal metastases (PM) rat model. Material and methods For aerosol generation, an ultrasonic nebulizer (USN) was modified. Aerosol analyses were performed ex-vivo by laser diffraction spectrometry (LDS). Intraperitoneal (IP) 99mtechnetium sodium pertechnetate (99mTc) aerosol distribution and deposition were quantified by in-vivo single photon emission computed tomography (SPECT/CT) and compared to liquid IP instillation of equivalent volume/doses of 99mTc with and without capnoperitoneum. PM was induced by IP injection of HCT116-Luc2 human colon cancer cells in immunosuppressed RNU rats. Tumor growth was monitored by bioluminescence imaging (BLI), 18F-FDG positron emission tomography (PET) and tissues examination at necropsy. Results The USN was able to establish a stable and reproducible capnoperitoneum at a pressure of 8 to 10 mmHg. LDS showed that the USN provides a polydisperse and monomodal aerosol with a volume-weighted diameter of 2.6 μm. At a CO2 flow rate of 2 L/min with an IP residence time of 3.9 s, the highest drug deposition efficiency was found to be 15 wt.-%. In comparison to liquid instillation, nebulization showed the most homogeneous IP spatial drug deposition. Compared to BLI, 18F-FDG-PET was more sensitive to detect smaller PM nodules measuring only 1–2 mm in diameter. BLI, 18F-FDG PET and necropsy analyses showed relevant PM in all animals. Conclusions The USN together with the PM rat model are suitable for robust and species-specific preclinical pharmacological studies regarding intraperitoneal delivery of pressurized aerosolized drugs and cancer research.
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Affiliation(s)
- Jonathan R Buggisch
- University of Münster, Medizinische Fakultät, Münster, Germany.,CNRS UPS44, CIPA, PHENOMIN-TAAM, Orléans, France
| | - Daniel Göhler
- Research Group Mechanical Process Engineering, Institute of Process Engineering and Environmental Technology, Technische Universität Dresden, Dresden, Germany.,Technologie-orientierte Partikel-, Analysen- und Sensortechnik, Topas GmbH, Dresden, Germany
| | | | | | - Günther A Rezniczek
- Department of Obstetrics and Gynecology, Marien Hospital Herne, Ruhr-Universität Bochum, Bochum, Germany
| | - Michael Stintz
- Research Group Mechanical Process Engineering, Institute of Process Engineering and Environmental Technology, Technische Universität Dresden, Dresden, Germany
| | - Andreas Rudolph
- Technologie-orientierte Partikel-, Analysen- und Sensortechnik, Topas GmbH, Dresden, Germany
| | - Nicolas Tabchouri
- Department of Digestive, Oncological, Endocrine, Hepato-Biliary, Pancreatic and Liver Transplant Surgery, University Hospital of Tours, Lille, France
| | - Sébastien Roger
- EA4245 Transplantation, Immunologie, Inflammation, Université de Tours, France.,Institut Universitaire de France, Paris, France
| | - Mehdi Ouaissi
- Department of Digestive, Oncological, Endocrine, Hepato-Biliary, Pancreatic and Liver Transplant Surgery, University Hospital of Tours, Lille, France.,EA4245 Transplantation, Immunologie, Inflammation, Université de Tours, France
| | - Urs Giger-Pabst
- EA4245 Transplantation, Immunologie, Inflammation, Université de Tours, France. .,University of Applied Science Düsseldorf, 40489, Düsseldorf, Germany.
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