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Kepenekian V, Bhatt A, Péron J, Alyami M, Benzerdjeb N, Bakrin N, Falandry C, Passot G, Rousset P, Glehen O. Advances in the management of peritoneal malignancies. Nat Rev Clin Oncol 2022; 19:698-718. [PMID: 36071285 DOI: 10.1038/s41571-022-00675-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2022] [Indexed: 11/09/2022]
Abstract
Peritoneal surface malignancies (PSMs) are usually associated with a poor prognosis. Nonetheless, in line with advances in the management of most abdominopelvic metastatic diseases, considerable progress has been made over the past decade. An improved understanding of disease biology has led to the more accurate prediction of neoplasia aggressiveness and the treatment response and has been reflected in the proposal of new classification systems. Achieving complete cytoreductive surgery remains the cornerstone of curative-intent treatment of PSMs. Alongside centralization in expert centres, enabling the delivery of multimodal and multidisciplinary strategies, preoperative management is a crucial step in order to select patients who are most likely to benefit from surgery. Depending on the specific PSM, the role of intraperitoneal chemotherapy and of perioperative systemic chemotherapy, in particular, in the neoadjuvant setting, is established in certain scenarios but questioned in several others, although more prospective data are required. In this Review, we describe advances in all aspects of the management of PSMs including disease biology, assessment and improvement of disease resectability, perioperative management, systemic therapy and pre-emptive management, and we speculate on future research directions.
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Affiliation(s)
- Vahan Kepenekian
- Surgical Oncology Department, Hôpital Lyon Sud, Hospices Civils de Lyon, Pierre Bénite, France.,CICLY - EA3738, Université Claude Bernard Lyon I (UCBL1), Lyon, France
| | - Aditi Bhatt
- Department of Surgical Oncology, Zydus hospital, Ahmedabad, Gujarat, India
| | - Julien Péron
- Medical Oncology Department, Hôpital Lyon Sud, Hospices Civils de Lyon, Pierre Bénite, France.,Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, UCBL1, Lyon, France
| | - Mohammad Alyami
- Department of General Surgery and Surgical Oncology, Oncology Center, King Khalid Hospital, Najran, Saudi Arabia
| | - Nazim Benzerdjeb
- CICLY - EA3738, Université Claude Bernard Lyon I (UCBL1), Lyon, France.,Department of Pathology, Institut de Pathologie Multisite, Hospices Civils de Lyon, UCBL1, Lyon, France
| | - Naoual Bakrin
- Surgical Oncology Department, Hôpital Lyon Sud, Hospices Civils de Lyon, Pierre Bénite, France.,CICLY - EA3738, Université Claude Bernard Lyon I (UCBL1), Lyon, France
| | - Claire Falandry
- Department of Onco-Geriatry, Hôpital Lyon Sud, Hospices Civils de Lyon, Lyon, France
| | - Guillaume Passot
- Surgical Oncology Department, Hôpital Lyon Sud, Hospices Civils de Lyon, Pierre Bénite, France.,CICLY - EA3738, Université Claude Bernard Lyon I (UCBL1), Lyon, France
| | - Pascal Rousset
- CICLY - EA3738, Université Claude Bernard Lyon I (UCBL1), Lyon, France.,Department of Radiology, Hôpital Lyon Sud, Hospices Civils de Lyon, UCBL1, Lyon, France
| | - Olivier Glehen
- Surgical Oncology Department, Hôpital Lyon Sud, Hospices Civils de Lyon, Pierre Bénite, France. .,CICLY - EA3738, Université Claude Bernard Lyon I (UCBL1), Lyon, France.
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2
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Seyfried N, Yurttas C, Burkard M, Oswald B, Tolios A, Herster F, Kauer J, Jäger T, Königsrainer I, Thiel K, Quante M, Rammensee HG, Venturelli S, Schwab M, Königsrainer A, Beckert S, Löffler MW. Prolonged Exposure to Oxaliplatin during HIPEC Improves Effectiveness in a Preclinical Micrometastasis Model. Cancers (Basel) 2022; 14:cancers14051158. [PMID: 35267468 PMCID: PMC8909393 DOI: 10.3390/cancers14051158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 02/01/2022] [Accepted: 02/12/2022] [Indexed: 12/13/2022] Open
Abstract
Simple Summary Absence of survival benefits when adding hyperthermic intraperitoneal chemotherapy (HIPEC) with oxaliplatin to cytoreductive surgery in peritoneal metastasis from colorectal cancer has recently been shown in the randomized controlled PRODIGE 7 trial. We therefore aimed to investigate the effects of this treatment modality in a preclinical micrometastasis model. Cancer cells were incubated with either patient samples obtained during HIPEC procedures or with defined oxaliplatin-containing solutions prepared according to clinically established HIPEC protocols. Our results demonstrate a limited effectiveness of short-term HIPEC in simulations with oxaliplatin to eliminate micrometastases, although we used platinum-sensitive cell lines for our model. Since these results are in line with findings from current research, our studies might offer further convincing evidence and potential explanations for HIPEC futility observed in clinical application. Abstract Cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (HIPEC) was considered a promising treatment for patients with peritoneal metastasis from colorectal cancer. However, the recently published randomized controlled PRODIGE 7 trial failed to demonstrate survival benefits through the addition of short-term oxaliplatin-based HIPEC. Constituting a complex multifactorial treatment, we investigated HIPEC in a preclinical model concerning the elimination of minimal tumor residues, thereby aiming to better understand the size of effects and respective clinical trial results. Patient samples of peritoneal perfusates obtained during HIPEC treatments and oxaliplatin-containing solutions at clinically relevant dosages, conforming with established HIPEC protocols, were assessed regarding their ability to eliminate modelled ~100 µm thickness cancer cell layers. Impedance-based real-time cell analysis and classical end-point assays were used. Flow cytometry was employed to determine the effect of different HIPEC drug solvents on tumor cell properties. Effectiveness of peritoneal perfusate patient samples and defined oxaliplatin-containing solutions proved limited but reproducible. HIPEC simulations for 30 min reduced the normalized cell index below 50% with peritoneal perfusates from merely 3 out of 9 patients within 72 h, indicating full-thickness cytotoxic effects. Instead, prolonging HIPEC to 1 h enhanced these effects and comprised 7 patients’ samples, while continuous drug exposure invariably resulted in complete cell death. Further, frequently used drug diluents caused approximately 25% cell size reduction within 30 min. Prolonging oxaliplatin exposure improved effectiveness of HIPEC to eliminate micrometastases in our preclinical model. Accordingly, insufficient penetration depth, short exposure time, and the physicochemical impact of drug solvents may constitute critical factors.
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Affiliation(s)
- Nick Seyfried
- Department of General, Visceral and Transplant Surgery, University Hospital Tübingen, Hoppe-Seyler-Str. 3, 72076 Tübingen, Germany; (N.S.); (I.K.); (K.T.); (M.Q.); (A.K.); (S.B.); (M.W.L.)
- Interfaculty Institute for Cell Biology, Department of Immunology, University of Tübingen, Auf der Morgenstelle 15, 72076 Tübingen, Germany; (B.O.); (F.H.); (J.K.); (H.-G.R.)
- Department of Surgery, Klinikum Rechts der Isar, Technical University of Munich (TUM), Ismaninger Str. 22, 81675 Munich, Germany
| | - Can Yurttas
- Department of General, Visceral and Transplant Surgery, University Hospital Tübingen, Hoppe-Seyler-Str. 3, 72076 Tübingen, Germany; (N.S.); (I.K.); (K.T.); (M.Q.); (A.K.); (S.B.); (M.W.L.)
- Correspondence:
| | - Markus Burkard
- Institute of Nutritional Sciences, Department of Nutritional Biochemistry, University of Hohenheim, Garbenstr. 30, 70599 Stuttgart, Germany; (M.B.); (S.V.)
| | - Benedikt Oswald
- Interfaculty Institute for Cell Biology, Department of Immunology, University of Tübingen, Auf der Morgenstelle 15, 72076 Tübingen, Germany; (B.O.); (F.H.); (J.K.); (H.-G.R.)
| | - Alexander Tolios
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria;
- Center for Physiology and Pharmacology, Institute of Vascular Biology and Thrombosis Research, Medical University of Vienna, Schwarzspanierstraße 17A, 1090 Vienna, Austria
- Center for Medical Statistics, Informatics and Intelligent Systems, Institute of Artificial Intelligence, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
| | - Franziska Herster
- Interfaculty Institute for Cell Biology, Department of Immunology, University of Tübingen, Auf der Morgenstelle 15, 72076 Tübingen, Germany; (B.O.); (F.H.); (J.K.); (H.-G.R.)
- Robert Bosch Center for Tumor Diseases (RBCT), Robert Bosch Hospital, Auerbachstr. 110, 70376 Stuttgart, Germany
| | - Joseph Kauer
- Interfaculty Institute for Cell Biology, Department of Immunology, University of Tübingen, Auf der Morgenstelle 15, 72076 Tübingen, Germany; (B.O.); (F.H.); (J.K.); (H.-G.R.)
- German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ) Partner Site Tübingen, 72076 Tübingen, Germany;
- Clinical Collaboration Unit Translational Immunology, German Cancer Consortium (DKTK), Department of Internal Medicine, University Hospital Tübingen, Otfried-Müller-Str. 10, 72076 Tübingen, Germany
- Department of Hematology, Oncology, and Rheumatology, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany
| | - Tarkan Jäger
- Department of Surgery, Paracelsus Medical University, Müllner Hauptstraße 48, 5020 Salzburg, Austria;
| | - Ingmar Königsrainer
- Department of General, Visceral and Transplant Surgery, University Hospital Tübingen, Hoppe-Seyler-Str. 3, 72076 Tübingen, Germany; (N.S.); (I.K.); (K.T.); (M.Q.); (A.K.); (S.B.); (M.W.L.)
- Department of General, Visceral and Thoracic Surgery, Landeskrankenhaus Feldkirch, Carinagasse 47, 6800 Feldkirch, Austria
| | - Karolin Thiel
- Department of General, Visceral and Transplant Surgery, University Hospital Tübingen, Hoppe-Seyler-Str. 3, 72076 Tübingen, Germany; (N.S.); (I.K.); (K.T.); (M.Q.); (A.K.); (S.B.); (M.W.L.)
| | - Markus Quante
- Department of General, Visceral and Transplant Surgery, University Hospital Tübingen, Hoppe-Seyler-Str. 3, 72076 Tübingen, Germany; (N.S.); (I.K.); (K.T.); (M.Q.); (A.K.); (S.B.); (M.W.L.)
| | - Hans-Georg Rammensee
- Interfaculty Institute for Cell Biology, Department of Immunology, University of Tübingen, Auf der Morgenstelle 15, 72076 Tübingen, Germany; (B.O.); (F.H.); (J.K.); (H.-G.R.)
- German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ) Partner Site Tübingen, 72076 Tübingen, Germany;
- Cluster of Excellence iFIT (EXC2180) ‘Image-Guided and Functionally Instructed Tumor Therapies’, University of Tübingen, 72076 Tübingen, Germany
| | - Sascha Venturelli
- Institute of Nutritional Sciences, Department of Nutritional Biochemistry, University of Hohenheim, Garbenstr. 30, 70599 Stuttgart, Germany; (M.B.); (S.V.)
- Department of Vegetative and Clinical Physiology, Institute of Physiology, University of Tübingen, Wilhelmstr. 56, 72074 Tübingen, Germany
| | - Matthias Schwab
- German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ) Partner Site Tübingen, 72076 Tübingen, Germany;
- Cluster of Excellence iFIT (EXC2180) ‘Image-Guided and Functionally Instructed Tumor Therapies’, University of Tübingen, 72076 Tübingen, Germany
- Department of Clinical Pharmacology, University Hospital Tübingen, Auf der Morgenstelle 8, 72076 Tübingen, Germany
- Dr. Margarete Fischer-Bosch-Institute of Clinical Pharmacology, Auerbachstr. 112, 70376 Stuttgart, Germany
- Departments of Pharmacy and Biochemistry, University of Tübingen, Auf der Morgenstelle 15, 72076 Tübingen, Germany
| | - Alfred Königsrainer
- Department of General, Visceral and Transplant Surgery, University Hospital Tübingen, Hoppe-Seyler-Str. 3, 72076 Tübingen, Germany; (N.S.); (I.K.); (K.T.); (M.Q.); (A.K.); (S.B.); (M.W.L.)
- German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ) Partner Site Tübingen, 72076 Tübingen, Germany;
- Cluster of Excellence iFIT (EXC2180) ‘Image-Guided and Functionally Instructed Tumor Therapies’, University of Tübingen, 72076 Tübingen, Germany
| | - Stefan Beckert
- Department of General, Visceral and Transplant Surgery, University Hospital Tübingen, Hoppe-Seyler-Str. 3, 72076 Tübingen, Germany; (N.S.); (I.K.); (K.T.); (M.Q.); (A.K.); (S.B.); (M.W.L.)
- Department of General and Visceral Surgery, Schwarzwald-Baar Hospital, Klinikstr. 11, 78052 Villingen-Schwenningen, Germany
| | - Markus W. Löffler
- Department of General, Visceral and Transplant Surgery, University Hospital Tübingen, Hoppe-Seyler-Str. 3, 72076 Tübingen, Germany; (N.S.); (I.K.); (K.T.); (M.Q.); (A.K.); (S.B.); (M.W.L.)
- Interfaculty Institute for Cell Biology, Department of Immunology, University of Tübingen, Auf der Morgenstelle 15, 72076 Tübingen, Germany; (B.O.); (F.H.); (J.K.); (H.-G.R.)
- German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ) Partner Site Tübingen, 72076 Tübingen, Germany;
- Cluster of Excellence iFIT (EXC2180) ‘Image-Guided and Functionally Instructed Tumor Therapies’, University of Tübingen, 72076 Tübingen, Germany
- Department of Clinical Pharmacology, University Hospital Tübingen, Auf der Morgenstelle 8, 72076 Tübingen, Germany
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3
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Yurttas C, Horvath P, Fischer I, Meisner C, Nadalin S, Königsrainer I, Königsrainer A, Beckert S, Löffler MW. A Prospective, Phase I/II, Open-Label Pilot Trial to Assess the Safety of Hyperthermic Intraperitoneal Chemotherapy After Oncological Resection of Pancreatic Adenocarcinoma. Ann Surg Oncol 2021; 28:9086-9095. [PMID: 34131821 PMCID: PMC8205203 DOI: 10.1245/s10434-021-10187-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 05/01/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pancreatic ductal adenocarcinoma (PDAC) is a common fatal disease with unfavorable prognosis, even after oncological resection. To improve survival, adding hyperthermic intraperitoneal chemotherapy (HIPEC) has been suggested. Whether HIPEC entails disproportional short-term mortality is unknown and a prospectively determined adverse events profile is lacking. Since both pancreatic resection and HIPEC may relevantly influence morbidity and mortality, this uncontrolled single-arm, open-label, phase I/II pilot trial was designed to assess the 30-day mortality rate, treatment feasibility, and adverse events connected with HIPEC after oncological pancreatic surgery. METHODS This trial recruited patients scheduled for PDAC resection. A sample size of 16 patients receiving study interventions was estimated to establish a predefined margin of treatment-associated short-term mortality with a power of > 80%. Patients achieving complete macroscopic resection received HIPEC with gemcitabine administered at 1000 mg/m2 body surface area heated to 42 °C for 1 hour. RESULTS Within 30 days after intervention, no patient died or experienced any adverse events higher than grade 3 that were related to HIPEC. Furthermore, treatment-related adverse events were prospectively documented and categorized as expected or unexpected. This trial supports that the actual mortality rate after PDAC resection and HIPEC is below 10%. HIPEC treatment proved feasible in 89% of patients allocated to intervention. Pancreatic fistulas, as key complications after pancreas surgery, occurred in 3/13 patients under risk. CONCLUSION Combined pancreas resection and gemcitabine HIPEC proved feasible and safe, with acceptable morbidity and mortality. Based on these results, further clinical evaluation can be justified. REGISTRATION NUMBER NCT02863471 ( http://www.clinicaltrials.gov ).
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Affiliation(s)
- Can Yurttas
- Department of General, Visceral and Transplant Surgery, University Hospital Tübingen, Tübingen, Germany
| | - Philipp Horvath
- Department of General, Visceral and Transplant Surgery, University Hospital Tübingen, Tübingen, Germany
| | - Imma Fischer
- Institute for Clinical Epidemiology and Applied Biometry, University Hospital Tübingen, Tübingen, Germany
| | - Christoph Meisner
- Institute for Clinical Epidemiology and Applied Biometry, University Hospital Tübingen, Tübingen, Germany
| | - Silvio Nadalin
- Department of General, Visceral and Transplant Surgery, University Hospital Tübingen, Tübingen, Germany
| | - Ingmar Königsrainer
- Department of General, Visceral and Transplant Surgery, University Hospital Tübingen, Tübingen, Germany.,Department of General, Visceral and Thoracic Surgery, Landeskrankenhaus Feldkirch, Feldkirch, Austria
| | - Alfred Königsrainer
- Department of General, Visceral and Transplant Surgery, University Hospital Tübingen, Tübingen, Germany.,German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ), Partner Site Tübingen, Tübingen, Germany.,Cluster of Excellence iFIT (EXC2180) 'Image-Guided and Functionally Instructed Tumor Therapies', University of Tübingen, Tübingen, Germany
| | - Stefan Beckert
- Department of General, Visceral and Transplant Surgery, University Hospital Tübingen, Tübingen, Germany.,Department of General and Visceral Surgery, Schwarzwald-Baar Klinikum Villingen-Schwenningen, Villingen-Schwenningen, Germany
| | - Markus W Löffler
- Department of General, Visceral and Transplant Surgery, University Hospital Tübingen, Tübingen, Germany. .,German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ), Partner Site Tübingen, Tübingen, Germany. .,Cluster of Excellence iFIT (EXC2180) 'Image-Guided and Functionally Instructed Tumor Therapies', University of Tübingen, Tübingen, Germany. .,Interfaculty Institute for Cell Biology, Department of Immunology, University of Tübingen, Tübingen, Germany. .,Department of Clinical Pharmacology, University Hospital Tübingen, Tübingen, Germany.
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4
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de Jong LAW, Elekonawo FMK, Lambert M, de Gooyer JM, Verheul HMW, Burger DM, de Wilt JHW, Chatelut E, Ter Heine R, de Reuver PR, Bremers AJA, van Erp NP. Wide variation in tissue, systemic, and drain fluid exposure after oxaliplatin-based HIPEC: results of the GUTOX study. Cancer Chemother Pharmacol 2020; 86:141-150. [PMID: 32594200 PMCID: PMC7338818 DOI: 10.1007/s00280-020-04107-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 06/24/2020] [Indexed: 01/02/2023]
Abstract
Purpose In this exploratory study, the effect of postprocedural flushing with crystalloids after oxaliplatin-based hyperthermic intraperitoneal chemotherapy (HIPEC) on platinum concentrations in peritoneal tissue, blood, and drain fluid was studied. Interpatient variability in oxaliplatin pharmacokinetics and the relation between platinum concentration in peritoneal fluid and platinum exposure in tissue and blood was explored. Methods Ten patients with peritoneal carcinomatosis of colorectal origin were treated with HIPEC including postprocedural flushing, followed by ten patients without flushing afterwards. Tissue, peritoneal fluid, blood, and drain fluid samples were collected for measurement of total and ultrafiltered platinum concentrations. Results Peritoneal tissue concentration and systemic ultrafiltered platinum exposure showed large inter individual variability, ranging from 65 to 1640 µg/g dry weight and 10.5 to 28.0 µg*h/ml, respectively. No effect of flushing was found on geometric mean platinum concentration in peritoneal tissue (348 vs. 356 µg/g dry weight), blood (14.8 vs. 18.1 µg*h/ml), or drain fluid (day 1: 7.6 vs. 7.7 µg/ml; day 2: 1.7 vs. 1.9 µg/ml). The platinum concentration in peritoneal fluid at the start of HIPEC differed twofold between patients and was positively correlated with systemic exposure (p = .04) and peak plasma concentration (p = .04). Conclusion In this exploratory study, no effect was found for postprocedural flushing on platinum concentrations in peritoneal tissue, blood, or drain fluid. BSA-based HIPEC procedure leads to large interpatient variability in platinum exposure in all compartments. The study was registered at ClinicalTrials.gov on 7 December 2017 under registration number NCT03364907.
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Affiliation(s)
- Loek A W de Jong
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center (RUMC), P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Fortuné M K Elekonawo
- Department of Radiology and Nuclear Medicine, Radboud Institute for Health Sciences, Radboud University Medical Center (RUMC), P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.,Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center (RUMC), P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Marie Lambert
- Institut Claudius‑Regaud, IUCT‑Oncopole, and CRCT, Université de Toulouse, Inserm, 1, avenue Irène Joliot‑Curie, Toulouse, France
| | - Jan Marie de Gooyer
- Department of Radiology and Nuclear Medicine, Radboud Institute for Health Sciences, Radboud University Medical Center (RUMC), P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.,Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center (RUMC), P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Henk M W Verheul
- Department of Medical Oncology, Radboud Institute for Health Sciences, Radboud University Medical Center (RUMC), P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - David M Burger
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center (RUMC), P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Johannes H W de Wilt
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center (RUMC), P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Etienne Chatelut
- Institut Claudius‑Regaud, IUCT‑Oncopole, and CRCT, Université de Toulouse, Inserm, 1, avenue Irène Joliot‑Curie, Toulouse, France
| | - Rob Ter Heine
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center (RUMC), P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Philip R de Reuver
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center (RUMC), P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Andre J A Bremers
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center (RUMC), P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Nielka P van Erp
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center (RUMC), P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
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Nadiradze G, Horvath P, Sautkin Y, Archid R, Weinreich FJ, Königsrainer A, Reymond MA. Overcoming Drug Resistance by Taking Advantage of Physical Principles: Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC). Cancers (Basel) 2019; 12:cancers12010034. [PMID: 31877647 PMCID: PMC7016575 DOI: 10.3390/cancers12010034] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 12/17/2019] [Accepted: 12/18/2019] [Indexed: 12/24/2022] Open
Abstract
Theoretical considerations as well as comprehensive preclinical and clinical data suggest that optimizing physical parameters of intraperitoneal drug delivery might help to circumvent initial or acquired resistance of peritoneal metastasis (PM) to chemotherapy. Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) is a novel minimally invasive drug delivery system systematically addressing the current limitations of intraperitoneal chemotherapy. The rationale behind PIPAC is: (1) optimizing homogeneity of drug distribution by applying an aerosol rather than a liquid solution; (2) applying increased intraperitoneal hydrostatic pressure to counteract elevated intratumoral interstitial fluid pressure; (3) limiting blood outflow during drug application; (4) steering environmental parameters (temperature, pH, electrostatic charge etc.) in the peritoneal cavity for best tissue target effect. In addition, PIPAC allows repeated application and objective assessment of tumor response by comparing biopsies between chemotherapy cycles. Although incompletely understood, the reasons that allow PIPAC to overcome established chemoresistance are probably linked to local dose intensification. All pharmacological data published so far show a superior therapeutic ratio (tissue concentration/dose applied) of PIPAC vs. systemic administration, of PIPAC vs. intraperitoneal liquid chemotherapy, of PIPAC vs. Hyperthermic Intraperitoneal Chemotherapy (HIPEC) or PIPAC vs. laparoscopic HIPEC. In the initial introduction phase, PIPAC has been used in patients who were quite ill and had already failed multiple treatment regimes, but it may not be limited to that group of patients in the future. Rapid diffusion of PIPAC in clinical practice worldwide supports its potential to become a game changer in the treatment of chemoresistant isolated PM of various origins.
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6
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Petrillo M, Zucchetti M, Cianci S, Morosi L, Ronsini C, Colombo A, D'Incalci M, Scambia G, Fagotti A. Pharmacokinetics of cisplatin during open and minimally-invasive secondary cytoreductive surgery plus HIPEC in women with platinum-sensitive recurrent ovarian cancer: a prospective study. J Gynecol Oncol 2019; 30:e59. [PMID: 31074245 PMCID: PMC6543101 DOI: 10.3802/jgo.2019.30.e59] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 11/01/2018] [Accepted: 01/29/2019] [Indexed: 12/17/2022] Open
Abstract
Objective Evidences from animal models seem to suggest that minimally invasive surgery may enhance cisplatin diffusion when the drug is administered in the context of post-operative hyperthermic intraperitoneal chemotherapy (HIPEC). The present study evaluates the cisplatin pharmacokinetic profile in a prospective series of women with platinum sensitive recurrent epithelial ovarian cancer treated with open secondary cytoreductive surgery (O-SCS) or minimally-invasive secondary cytoreductive surgery (MI-SCS). Methods Cisplatin levels were assessed at 0, 20, 40, 60, and 120 minutes in: 1) blood samples, 2) peritoneal perfusate, and 3) peritoneal biopsies at the end of HIPEC. Median Cmax has been used to identify women with high and low drug levels. Progression-free survival (PFS) was calculated as the time elapsed between SCS+HIPEC and secondary recurrence or last follow-up visit. Results Nine (45.0%) women received MI-SCS, and 11 (55.0%) O-SCS. At 60 minutes, median cisplatin Cmax in peritoneal tissue was higher in patients treated with MI-SCS compared to O-SCS (Cmax=8.262 µg/mL vs. Cmax=4.057 µg/mL). Furthermore, median cisplatin plasma Cmax was higher in patients treated with MI-SCS compared to O-SCS (Cmax=0.511 vs. Cmax=0.254 µg/mL; p-value=0.012) at 120 minutes. With a median follow-up time of 24 months, women with higher cisplatin peritoneal Cmax showed a longer PFS compared to women with low cisplatin peritoneal levels (2-years PFS=70% vs. 35%; p-value=0.054). Conclusions We demonstrate for the first time that minimally invasive route enhances cisplatin peritoneal tissue uptake during HIPEC, further evaluations are needed to confirm the correlation between peritoneal cisplatin levels after HIPEC and survival. Trial Registration ClinicalTrials.gov Identifier: NCT01539785
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Affiliation(s)
- Marco Petrillo
- Department of Clinical and Experimental Medicine, Gynecologic and Obstetric Clinic, University of Sassari, Sassari, Italy.,PhD School in Biomedical Sciences, University of Sassari, Sassari, Italy.
| | - Massimo Zucchetti
- Department of Oncology, Cancer Pharmacology Laboratory at IRCCS - Mario Negri Institute for Pharmacological Research, Milan, Italy
| | - Stefano Cianci
- Fondazione Policlinico Universitario A. Gemelli, IRCCS, Gynecologic Oncology, Department of Woman, Child and Public Health, Rome, Italy
| | - Lavinia Morosi
- Department of Oncology, Cancer Pharmacology Laboratory at IRCCS - Mario Negri Institute for Pharmacological Research, Milan, Italy
| | - Carlo Ronsini
- Fondazione Policlinico Universitario A. Gemelli, IRCCS, Gynecologic Oncology, Department of Woman, Child and Public Health, Rome, Italy
| | - Andrea Colombo
- Department of Environmental Health Sciences, at IRCCS - Mario Negri Institute for Pharmacological Research, Milan, Italy
| | - Maurizio D'Incalci
- Department of Oncology, Cancer Pharmacology Laboratory at IRCCS - Mario Negri Institute for Pharmacological Research, Milan, Italy
| | - Giovanni Scambia
- Fondazione Policlinico Universitario A. Gemelli, IRCCS, Gynecologic Oncology, Department of Woman, Child and Public Health, Rome, Italy
| | - Anna Fagotti
- Fondazione Policlinico Universitario A. Gemelli, IRCCS, Gynecologic Oncology, Department of Woman, Child and Public Health, Rome, Italy
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7
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Systematic Review of Variations in Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for Peritoneal Metastasis from Colorectal Cancer. J Clin Med 2018; 7:jcm7120567. [PMID: 30572653 PMCID: PMC6306814 DOI: 10.3390/jcm7120567] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 12/05/2018] [Accepted: 12/10/2018] [Indexed: 02/07/2023] Open
Abstract
Background: Cytoreductive surgery (CRS), followed by hyperthermic intraperitoneal chemotherapy (HIPEC), combines radical surgery with abdominal heated chemotherapy, constituting a multimodal treatment approach. Since clear standards for HIPEC conduct in colorectal carcinoma (CRC) are lacking, we aimed to provide a comprehensive structured survey. Data sources and study eligibility criteria: A systematic literature search was performed in PubMed, with keywords “HIPEC” and “colorectal cancer”, according to established guidelines. Articles were systematically screened, selecting 87 publications complemented by 48 publications identified through extended search for subsequent synthesis and evaluation, extracting inter alia details on used drugs, dosage, temperature, exposure times, and carrier solutions. Results: Compiled publications contained 171 reports on HIPEC conduct foremost with mitomycin C and oxaliplatin, but also other drugs and drug combinations, comprising at least 60 different procedures. We hence provide an overview of interconnections between HIPEC protocols, used drugs and carrier solutions as well as their volumes. In addition, HIPEC temperatures and dosing benchmarks, as well as an estimate of in vivo resulting drug concentrations are demonstrated. Conclusions and implications: Owing to recent developments, HIPEC conduct and practices need to be reassessed. Unfortunately, imprecise and lacking reporting is frequent, which is why minimal information requirements should be established for HIPEC and the introduction of final drug concentrations for comparability reasons seems sensible.
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8
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de Jong LAW, Elekonawo FMK, de Reuver PR, Bremers AJA, de Wilt JHW, Jansman FGA, Ter Heine R, van Erp NP. Hyperthermic intraperitoneal chemotherapy with oxaliplatin for peritoneal carcinomatosis: a clinical pharmacological perspective on a surgical procedure. Br J Clin Pharmacol 2018; 85:47-58. [PMID: 30255585 DOI: 10.1111/bcp.13773] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 09/17/2018] [Accepted: 09/18/2018] [Indexed: 01/07/2023] Open
Abstract
Cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (HIPEC) has become the standard of care in the treatment of patients with peritoneal carcinomatosis of colorectal origin. The use of oxaliplatin for HIPEC has gained popularity. Although the HIPEC procedure is adopted throughout the world, major differences exist between treatment protocols regarding the carrier solution, perfusate volume, use of an open or closed technique, duration of the perfusion and application of additional flushing. These differences can influence the pharmacokinetics and pharmacodynamics of oxaliplatin and might thereby have an impact on the efficacy and/or safety of the treatment. Clinicians should be aware of the clinical importance of oxaliplatin pharmacology when performing HIPEC surgery. This review adds new insights into the complex field of the pharmacology of HIPEC and highlights an important worldwide problem: the lack of standardization of the HIPEC procedure.
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Affiliation(s)
- Loek A W de Jong
- Radboudumc, Department of Pharmacy, Radboud Institute for Health Sciences, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands
| | - Fortuné M K Elekonawo
- Radboudumc, Department of Surgery, Radboud Institute for Health Sciences, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands
| | - Philip R de Reuver
- Radboudumc, Department of Surgery, Radboud Institute for Health Sciences, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands
| | - Andre J A Bremers
- Radboudumc, Department of Surgery, Radboud Institute for Health Sciences, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands
| | - Johannes H W de Wilt
- Radboudumc, Department of Surgery, Radboud Institute for Health Sciences, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands
| | - Frank G A Jansman
- Department of Clinical Pharmacy, Deventer Teaching Hospital, Nico Bolkesteinlaan 75, 7416 SE, Deventer, the Netherlands.,University of Groningen, Groningen Research Institute of Pharmacy, PharmacoTherapy, -Epidemiology & -Economics, P.O. Box 196, 9700 AD, Groningen, the Netherlands
| | - Rob Ter Heine
- Radboudumc, Department of Pharmacy, Radboud Institute for Health Sciences, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands
| | - Nielka P van Erp
- Radboudumc, Department of Pharmacy, Radboud Institute for Health Sciences, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands
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