Romano Scalerta

Hyperthermic intraoperative intraperitoneal chemotherapy with cisplatin and doxorubicin in patients who undergo cytoreductive surgery for peritoneal carcinomatosis and sarcomatosis - Phase I study

Hyperthermic intraperitoneal intraoperative chemotherapy (HIIC) combined with cytoreductive surgery (CS) has been proposed as a new multimodal treatment mainly for carcinomatosis of gastrointestinal origin. To evaluate whether this regimen could be used for other tumor types, the authors conducted a Phase I study on HIIC with doxorubicin and cisplatin in patients with peritoneal carcinomatosis or sarcomatosis.

Molecular detection of circulating tumor cells is an independent prognostic factor in patients with high‐risk cutaneous melanoma

Detection of circulating tumor cells (CTCs) might improve current staging procedures by identifying a subgroup of patients with minimal residual disease and thus a higher risk of disease recurrence. Forty patients with ≥2‐mm‐thick cutaneous melanoma with or without lymph node metastasis were enrolled. After standard radical surgery and adjuvant therapy in case of lymph node metastasis, patients were followed up with routine physical and radiologic assessments as well as serial PCR‐based analysis of CTCs using 2 melanoma markers (tyrosinase and Melan‐A/Mart‐1). After a median follow‐up of 30 months, 18 patients had disease recurrence and 28 were PCR‐positive before the disease became clinically evident. The sensitivity of the molecular test was 83%. Median time to PCR positivity and median PCR‐to‐relapse time were 12 and 8 months, respectively. At multivariate analysis, PCR positivity was an independent predictor of disease recurrence (hazard ratio = 2.06, 95% CI 1.07–3.35; p = 0.03). Among high‐risk melanoma patients, serial PCR‐based analysis of CTCs can identify a subgroup at higher risk of disease recurrence, with clinically significant advance. Therefore, CTC detection might be employed for the selection of patients for adjuvant treatment and during follow‐up for early indication of therapeutic failure.

Induction of Endothelial Nitric Oxide Synthase Expression by Melanoma Sensitizes Endothelial Cells to Tumor Necrosis Factor-Driven Cytotoxicity

Purpose: The cascade of molecular events leading to tumor necrosis factor (TNF)-mediated tumor regression is still incompletely elucidated. We investigated the role of endothelial nitric oxide synthase in determining the tumor-selective activity of TNF. Experimental Design: Using quantitative real-time PCR, endothelial nitric oxide synthase gene levels were measured in melanoma metastases of the skin and normal skin biopsies obtained from 12 patients before undergoing TNF-based therapy. In vitro, the ability of melanoma cells supernatant to affect endothelial nitric oxide synthase transcription by endothelial cells and the influence of nitric oxide synthase inhibition on TNF cytotoxicity toward endothelial cells was evaluated. Results: Endothelial nitric oxide synthase transcript abundance resulted significantly greater in tumor samples rather than in normal skin samples and in patients showing complete response to TNF-based treatment rather than in those showing partial/minimal response. In vitro, melanoma cells’ supernatant induced endothelial nitric oxide synthase gene expression by endothelial cells. Nitric oxide synthase inhibition slowed endothelial cells proliferation and, if induced before TNF administration, decreased the cytokine-mediated cytotoxicity on endothelial cells. Conclusions: Taken together, these findings support the hypothesis that high expression of endothelial nitric oxide synthase in the tumor microenvironment might increase or be a marker for endothelial cells sensitivity to TNF. These observations may have important prognostic and/or therapeutic implications in the clinical setting.

A simplified procedure for continuous intraoperative external monitoring of systemic leakage during isolated limb perfusion.

Aims Isolated limb perfusion (ILP) with high doses of an alkylating agent alone or in combination with tumor necrosis factor (TNF) in hyperthermic conditions (HAP) has been proposed for the treatment of locoregional tumors. A critical step in ILP/HAP is accurate monitoring of systemic leakage to prevent the toxic effects of chemotherapy, and in particular of TNF. Ten percent systemic leakage from the perfusion circuit is considered the maximum acceptable leakage. In this study we report our experience of a new leakage monitoring system. Materials and methods This new simplified procedure is based on the use of 99mTc-labeled soluble human serum albumin (HSA) and a hand-held gamma probe as detector. The procedure consists of the following steps: 1) A standardized 99mTc-HSA dose of 0.5 MBq/kg body weight is injected into the perfusion circuit before chemotherapy/TNF perfusion, and a hand-held gamma probe (IGP) is placed over the precordial area in a zone that was marked on the skin during a simulation test; 2) 48-72 hours before ILP/HAP a complete simulation test is performed with a 99mTc-HSA dose corresponding to 10% of the total dose calculated for the patients body weight; 3) during the simulation test the maximum countrate zone on the precordial area is detected by IGP and marked on the patients skin; 4) a 60-min curve of effective 99mTc-HSA radioactivity decay (physical and biological) is calculated and fitted; 5) to compare external counting with the effective circulating radioactivity, patient blood samples and circuit blood samples are taken every five minutes during ILP/HAP and measured by a laboratory gamma counter and very convenient thanks to the favorable characteristics of IGP. The placed in the operating room. Results External counting with a hand-held gamma probe was easy to perform time/activity curves obtained during simulation tests showed a regular and constant effective decay with a mean decay rate of 30% at 60 minutes compared to baseline values. The external measurements obtained by IGP proved to be well correlated with blood samples measured in vitro by a laboratory gamma counter. The results of this procedure, in particular the data of the simulation test for each patient, allowed us to correct the limit of 10% maximum leakage during ILP/HAP in accordance with the time/activity curve. Conclusions Although 99mTc-HSA has some unfavorable characteristics, it offers many advantages over 131I-HSA. The procedure proposed by us, which was based on the use of an IGP and 99mTc-HAS at a standardized dose of 0.5 MBq/kg body weight and on an individual simulation test for each patient performed 48 hours before ILP/HAP, proved to be simple and accurate in monitoring systemic leakage during ILP/HAP anticancer therapy.

True versus Mild Hyperthermia during Isolated Hepatic Perfusion: Effects on Melphalan Pharmacokinetics and Liver Function

Hyperthermic antiblastic isolated hepatic perfusion (IHP) with melphalan has been recently proposed as an alternative therapeutic option for patients with unresectable liver tumors. Although melphalan–heat antiblastic synergism is at a maximum at temperatures higher than 41 °C, IHP has so far been performed in humans at lower temperatures. In this experimental work, we compared IHP under mild versus true hyperthermic conditions in terms of drug pharmacokinetics and liver function. Ten pigs were submitted to IHP with melphalan 1.5 mg/kg at a mean temperature of 40 °C (group A, n = 5) or 42 °C (group B, n = 5). After a 60-minute perfusion, a 15-minute washout was performed. Perfusate-to-plasma leakage was monitored using scintigraphy. Throughout perfusion, samples from the systemic blood, perfusate, and liver parenchyma were obtained to measure melphalan concentrations. Liver function was assessed using standard blood tests and the indocyanine green-based test. No deaths related to the IHP procedure were recorded. All animals had transient liver function impairment, with all liver function test results returning to normal within the observation period. At histologic examination, liver damage was similar under both hyperthermic conditions. Melphalan levels in the perfusate were not significantly different in the two study groups (the mean perfusate/plasma area under the curve from 0 to 60 minutes ratios were 463 and 501, respectively). These results correlated well with those obtained using the scintigraphic method. Liver drug concentrations remained unchanged after true hyperthermia IHP. Under true hyperthermic conditions, neither an increase in liver parenchyma toxicity nor changes in melphalan pharmacokinetics were observed. These findings support the use of true hyperthermia in the clinical setting to exploit fully the antitumor synergism between melphalan and heat.

Doxorubicin activity is enhanced by hyperthermia in a model of ex vivo vascular perfusion of human colon carcinoma.

There is little information on the pharmacokinetics and pharmacodynamics of doxorubicin (DXR) administered during locoregional treatments of colon carcinoma under hyperthermic conditions. The aim of this study was to evaluate distribution and activity of DXR in healthy tissue and tumor tissues under hyperthermic conditions by using an experimental model of ex vivo isolated vascular perfusion of human colon segments bearing primary carcinoma. The influence of topoisomerase-IIα (TPI2α) expression on the anti-cancer activity of DXR combined with heat was evaluated as well. Twenty seven colon segments surgically resected for primary carcinoma were perfused ex vivo under physiological conditions (group A, n = 7), with DXR (group B, n = 6), under hyperthermic conditions (group C, n = 6), and with the combination DXR–hyperthermia (group D, n = 8). Samples of perfusate and tissues (normal and pathologic) were collected during 90 minutes of perfusion. Doxorubicin concentration in perfusate and tissues was assessed with high-performance liquid chromatography. Protein expression of TPI2α, the main molecular target of DXR, was measured by image analysis in normal mucosa and tumor samples. Drug uptake was increased by heat equally in healthy and diseased tissue. Under hyperthermic conditions, DXR activity was significantly higher in pathologic mucosa than in normal mucosa. Furthermore, the activity of DXR combined with heat correlated with baseline TPI2α levels in tumor tissue. From these findings, it appears that heat sensitizes tumor cells—but not normal mucosa—to DXR activity. Furthermore, protein levels of TPI2α in pretreatment samples could predict tumor sensitivity to DXR.

Search for melanoma markers in plasma and serum samples

Fourteen blood samples from patients with melanomas and 11 blood samples from healthy subjects were analyzed by matrix-assisted laser desorption/ionization mass spectrometry. The study focussed on species of low molecular weight, in the 800–5000 Da range, present in plasma and sera. While for healthy subjects plasma samples lead to the production of a higher number of ionic species, for melanoma patients a high number of diagnostic ions, present with high frequency and with quite high relative abundance, are present, in particular, in serum samples and, to a lesser extent, also in plasma. Since plasma samples are obtained more easily in comparison to sera, it is possible to suggest that plasma can also be used for these studies.

Isolated Vascular Perfusion of Human Colon with Adenocarcinoma

2 183 (78–304) mmHg; arterial PCO2 36 (31–46) mmHg. No important signs of tissue damage were found at histology. Autonomous or stimulated peristalsis (or both) was present throughout the experiment. Mean O2 extraction was 7.9 ml/min/100 g (range 3.1–11.0). Mean glucose consumption was 229 mg/100 g (range 174–252). The model worked well and appears promising, particularly for future use in various pharmacokinetic and pharmacodynamic studies of antiblastic agents.

Hypoxic antiblastic stop-flow limb perfusion: a novel treatment for in transit melanoma metastases. Clinical outcome and pharmacokinetic findings

BackgroundHypoxic antiblastic stop-flow perfusion (SFP) has recently been proposed as a therapeutic option for patients with locally advanced tumors. The present paper reports on the clinical and pharmacological results of our prospective study of limb SFP for the treatment of in transit melanoma metastases. Patients and methodsTwenty-three patients with limb-sited melanoma metastases were treated with melphalan (10 mg/l) based pelvic (n=11, group A) or femoral (n=12, group B) SFP under hypoxic conditions. Systemic and locoregional toxicity, tumor response rate, and local progression–free survival were analyzed. Melphalan concentrations were measured in the perfusate and systemic circulation during SFP, and after 30-minute hemofiltration. Perfusate-to-plasma leakage was assessed using a scintigraphic method. ResultsNo postoperative deaths occurred. Mild locoregional toxicity was observed in 5 patients (18%), and systemic toxicity was mild to severe in 8 patients (30%), the incidence being higher in group A. Tumor response rate (complete + partial response) and time to local disease progression were significantly different in group A and B (9% vs 58% and 7 vs 13 months, respectively). The pharmacokinetic study showed that pelvic SFP was associated with a higher leakage rate and a lower area under the curve ratio than femoral SFP (44% vs 31% and 5.6 vs 9.8, respectively). ConclusionsLimb SFP is a feasible and relatively simple procedure, and is associated with an acceptable toxicity rate. Tumor response rates are encouraging and strictly depend upon drug leakage. Further efforts should be made to exploit the potential anti-tumor activity of this novel locoregional drug delivery system.