Isolated thoracic perfusion with chemofiltration for progressive malignant pleural mesothelioma

Therapeutic Effect of Regional Chemotherapy in Diffuse Metastatic Cholangiocarcinoma

Simple Summary

Cholangiocarcinoma are mostly diagnosed at a late stage and early recurrence is also very common with 5-year survival rates of <5% in unresectable, and 33% in resectable disease. Systemic therapy options are limited with unsatisfactory outcome. The aim of our study was to assess the efficacy of regional chemotherapy in diffuse metastatic cholangiocarcinoma. In 36 diffuse metastatic cholangiocarcinoma patients 189 cycles of regional chemotherapy using arterial infusion and perfusion techniques have been applied. Regional chemotherapy provided an excellent outcome with a median therapy specific survival of 12 months. Regional chemotherapy is effective and superior to current available and proposed therapy options in diffuse metastatic cholangiocarcinoma.

Abstract

Background: Current therapeutic options in diffuse metastatic cholangiocarcinoma (CCC) are limited with unsatisfactory results. We evaluated the efficacy of regional chemotherapy (RegCTx) using arterial infusion (AI), hypoxic stop-flow abdominal perfusion (HAP), upper abdominal perfusion (UAP) and isolated-thoracic perfusion (ITP) in 36 patients with metastatic perihilar and intrahepatic CCC. Methods: Ten patients had previously undergone a liver resection and in 14 patients the previous systemic chemotherapy (sCTx) approach had failed. A total of 189 RegCTx cycles (90 AI, 74 UAP, 13 HAP and 12 ITP) were applied using cisplatin alone or with Adriamycin and Mitomycin C. A minimum of three cycles were applied in 75% of the study population. The response was evaluated using RECIST criteria with MediasStat 28.5.14. Mortality, morbidity and survival analysis were performed using a prospective follow-up database and SPSS–28.0. Results: No procedure related mortality occurred. The overall morbidity was 56% and dominated by lymph fistulas at the inguinal access site. No grade III or IV haematological complication occurred. The overall response rate was 38% partial response, 41% stable and 21% progressive disease. Median overall survival was 23 months (95%CI 16.3–29.7). The RegCTx specific survival was 12 months (95%CI 6.5–17.5) in completely therapy naive patients but also in patients who had failed a sCTx attempt previously. Conclusion: RegCTx is feasible, safe and superior to the current proposed therapeutic options in metastatic CCC. The role of RegCTx should be determined in a larger cohort of diffuse metastatic CCC patients but also at early stages especially in initially not resectable but potentially resectable patients.

Regional Chemotherapy Is a Valuable Second-Line Approach in Metastatic Esophageal Cancer after Failure to First-Line Palliative Treatment

Background: Therapeutic options in metastatic esophageal cancer (EC) are limited with unsatisfactory results. We evaluated the efficacy of regional chemotherapy (RegCTx) approach in diffuse metastatic EC using arterial infusion (AI), upper abdominal perfusion (UAP) and isolated-thoracic perfusion (ITP) in 14 patients (N = 8 adenocarcinoma (AC) and N = 6 squamous cell carcinoma (SQCC)) after failure to first-line palliative treatment. Methods: All patients had previously failed first-line palliative treatment attempt with systemic chemotherapy (sCTx). In total 51 RegCTx cycles (12 AI, 3 UAP and 36 ITP) were applied using cisplatin, Adriamycin and Mitomycin C. The outcome was evaluated using RECIST criteria with MediasStat 28.5.14 and SPSS–28.0. Results: No grade III or IV hematological complications occurred. The overall response rate was 41% partial response, 27% stable and 32% progressive disease. Median overall survival (OS) was 38 months (95%CI 10.1–65.9). The OS was better in SQCC with 51 months The RegCTx specific survival was 13 months (95%CI 2.9–23.1) in the entire cohort and 25 months in SQCC patients. Conclusion: RegCTx is a valuable safe approach and superior to the current proposed therapeutic options in metastatic EC after failure to first-line therapy.

Better effect of intrapleural perfusion with hyperthermic chemotherapy by video-assisted thoracoscopic surgery for malignant pleural effusion treatment compared to normothermic chemoperfusion of the pleural cavity

Objective

The aim of this study was to assess the efficacy and safety of intrapleural perfusion with hyperthermic chemotherapy (IPHC) in treating malignant pleural effusion (MPE) compared to normothermic chemoperfusion of the pleural cavity (NCPC), and to investigate the better treatment to control MPE.

Methods

Malignant pleural effusion patients were enrolled in the study and treated with NCPC or IPHC under video‐assisted thoracoscopic surgery (VATS). The chest drainage duration, clinical characteristics, and recurrence time of pleural effusion of patients were collected for statistical analysis. The chi‐squared test and the Fisher's exact test were applied to compare the distribution differences in categorical variables. Progression‐free survival (PFS) was estimated by the Kaplan–Meier method and was compared by the log‐rank test. The survival analysis was performed using the Cox proportional hazards method.

Results

A total of 37 MPE patients were enrolled in this study. Twenty‐seven patients received NCPC and 10 patients received IPHC under VATS. Significant differences were found in pathological types (p = 0.011), chest drainage duration (p = 0.005), and remission rate (p = 0.009) between two different treatment groups. The chest drainage duration of IPHC under VATS was shorter than the NCPC group (t = 2.969, p = 0.005). The remission rate of MPE in IPHC group was better than the NCPC one (OR = 0.031, 95% CI: 0.002–0.507, p = 0.015). The result of the Kaplan–Meier method showed that IPHC group could significantly prolong the PFS of patients with MPE compared to NCPC group (log‐rank p = 0.002). Univariate cox regression analysis showed that patients with MPE in the IPHC group presented significant longer PFS than the NCPC group (HR = 0.264, 95% CI: 0.098–0.713, p = 0.009). Multivariate cox regression analysis further verified this conclusion (HR = 0.268, 95% CI: 0.096–0.753, p = 0.012).

Conclusion

Compared to the NCPC, the IPHC under VATS presents a better control effect on MPE, shorter tube placement time, and longer complete remission time. For this reason, we recommend IPHC under VATS as the first‐line treatment for patients with MPE those who can tolerate minimally invasive surgery.

Approaching 10 years disease-free survival after isolated thoracic perfusion for advanced stage IV tonsil carcinoma: A case report

INTRODUCTION

This is a report about the first case of an advanced stage IV tonsil carcinoma treated with isolated thoracic perfusion and chemofiltration.

PRESENTATION OF CASE

The tumor extended beyond the midline with bilateral lymphnode metastases. Playing on wind instruments was impossible. As a professional Jazz saxophonist he refused mutilating surgery and chemoradiotherapy. After one isolated thoracic perfusion there was substantial tumor shrinkage. After three additional cycles of carotid artery infusion with chemofiltration a complete remission has been noted without systemic or local toxicity since 9 ½ years.

DISCUSSION

Knowing the often considerable long-term damage after surgery and chemoradiotherapy of head and neck tumors, some patient reject conventional therapy. Because of the steep dose response curve in cancer chemotherapy, an increased drug exposure in terms of intra-arterial short-term infusions or isolated perfusion can induce rapid remission induction without significantly affecting the quality of life. Further studies comparing regional chemotherapies with conventional chemoradiotherapy are warranted.

CONCLUSION

Intra-arterially applied short-term chemotherapy may generate rapid and onlasting remissions at low side-effects.

Primary malignant pericardial mesothelioma presenting with cardiac tamponade

INTRODUCTION

Primary malignant pericardial mesothelioma is a rare tumor that is very difficult to diagnose. Furthermore, it is a lethal disease, because patients usually have progressed at the time of referral.

PRESENTATION OF THE CASE

We report a 44-year-old man with primary malignant pericardial mesothelioma. He was referred to our hospital for the diagnosis and treatment of a massive pericardial effusion and huge tumor. Pericardiocentesis was performed, but we could not obtain definitive diagnosis, and the cardiac tamponade continued along with the signs/symptoms. He required surgical intervention for the diagnosis and treatment. After surgery, his signs/symptoms improved. He received adjuvant therapy, although he died 7 months after surgery.

DISCUSSION

Primary malignant pericardial mesothelioma is a rare tumor. The most common signs and symptoms are related to constriction of the heart by the tumor and/or effusion. Even if the pericardial fluid specimen obtained by pericardiocentesis is negative for malignant cells, primary malignant pericardial mesothelioma should be included in the differential diagnosis. Because the malignancy is usually advanced at the time of diagnosis, it has been difficult to cure. Radiation and chemotherapy have been used in addition to surgery, but have been minimally effective.

CONCLUSION

The outcome of our patient with pericardial malignant mesothelioma was dismal. The indications for surgical intervention should be carefully considered except for critical cases requiring alleviation of immediate life-threating conditions.

Isolated thoracic perfusion in lung metastases from breast cancer: a retrospective observational study

The median overall survival of metastatic breast cancer (MBC) patients is still approximately 2 years. This is even lower in triple-negative breast cancer (TNBC) patients with concomitant lung metastases. These patients are often not suitable for surgery and not responsive to systemic chemotherapy. Isolated thoracic perfusion (ITP) followed by chemofiltration has been used for palliation in selected specialised centres. A retrospective observational study evaluating 162 MBC patients who underwent 407 ITP procedures was performed. The primary objective was the evaluation of the feasibility, safety, tolerability and efficacy of ITP in the complete cohort of 162 patients with LM from breast cancer. The secondary objective of the study was the evaluation of responses and median survivals in 43 TNBC patients with LM. In the 162 patients, ITP appeared safe and well tolerated with MST from LM diagnosis to death or last contact of 19.5 months. In the subgroup of patients treated with systemic chemotherapy followed by ITP at progression, the MST from LM diagnosis to death or last contact was 29 months. In the subgroup of TNBC patients treated with systemic chemotherapy followed by ITP at progression, the MST from LM diagnosis to death or last contact was 19 months (ITP overall response rate was 65.52%). ITP followed by chemofiltration could be adopted in the sequential palliation treatments of BC patients with LM in progression after systemic chemotherapy, especially with TNBC. The present data allow interesting considerations about tolerability and responses, but do not allow robust conclusions about survival.

Polymeric films loaded with cisplatin for malignant pleural mesothelioma: a pharmacokinetic study in an ovine model

BACKGROUND

Malignant pleural mesothelioma (MPM) continues to be a distressing tumor due to its aggressive biologic behavior and scanty prognosis. Several therapeutic approaches have been tested both in clinical and preclinical settings, being intrapleural chemotherapy one of the most promising. Some years ago, our interest focused on polymeric films loaded with cisplatin for the adjuvant intrapleural treatment of surgical patients. After in vitro and in vivo studies in a rat recurrence model of MPM, the aim of this study was to evaluate the pharmacokinetics of the polymeric films in a sheep model in view of further studies in a clinical setting.

METHODS

An ovine model was used. Animals were divided into four groups according to pharmacologic treatment: control group (three animals undergoing left pneumonectomy and saline-NaCl solution); intrapleural hyaluronate cisplatin films (HYALCIS) group (six animals undergoing left pneumonectomy and intrapleural application of polymeric films loaded with cisplatin); intrapleural cisplatin solution (six animals undergoing left pneumonectomy and intrapleural application of cisplatin solution); intravenous cisplatin (five animals undergoing left pneumonectomy and intravenous administration of cisplatin solution). The primary objective was the plasmatic and pleural concentration of cisplatin in the treatment groups. The secondary objective was the treatment-related toxicity evaluated by plasmatic analysis performed at prearranged time intervals and histological examinations of tissue samples collected during animal autopsy. Analysis of variance (ANOVA) was used for statistical analysis. Bonferroni correction was applied for comparison between all groups.

RESULTS

Twenty female Sardinian sheep with a mean weight of 45.1 kg were studied. All animals survived the surgical procedures. The whole surgical procedure had a mean duration of 113 minutes. Cisplatin blood levels obtained from polymeric films application were low during the first 24 hours after the application; then, the cisplatin blood level increased gradually and progressively until it reached significantly higher plasmatic concentrations after 120 hours compared to intrapleural cisplatin solution (P=0.004) and intravenous administration (P=0.001), respectively. Considering cisplatin concentration at 168 hours after the application, animals treated with polymeric films had higher plasmatic values than animals treated with intrapleural cisplatin solution and intravenous cisplatin (P=0.001). Despite the high cisplatin plasmatic concentrations, treatment related-toxicity towards kidneys and liver was comparatively lower compared to the intravenous and intrapleural cisplatin administration and closer to the control levels.

CONCLUSIONS

Polymeric films loaded with cisplatin allowed to reach significantly higher intrapleural and plasmatic cisplatin concentrations compared to intrapleural and intravenous cisplatin solution, providing at the same time, a significant reduction of treatment related toxicity.