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Intraperitoneal chemotherapy for epithelial ovarian cancer
Hua-His Wu, MD
Epithelial ovarian cancer
- Standard therapy
- A maximum cytoreductive surgery followed by combination chemotherapy with paclitaxel and carboplatin
- A chemo-sensitive tumor
- However, most recur
- Intraperitoneal spreading
History of IP C/T
- Weisberger 1955
- Nitrogen mustard intraperitoneally for malignant ascites
- Jones 1978
- signicantly greater concentrations of certain chemotherapeutic drugs in the peritoneal cavity than in the blood.
- The first phase III trial
- since 1980s, presented in 1996
- In favor of IP arm
NCI announcement 2006
- Encouraging the GO community to consider IP chemotherapy as the standard treatment for optimally debulked advanced ovarian cancer patients
- Based on a meta-analysis of three US trials and other phase III studies
However, IP chemotherapy is still regarded as controversial issue.
- Clinical aspects
- Toxicities and QOL
- Future directions
Principles of IP C/T
Basic pharmacologic concept of IP C/T
What is the ideal anticancer agent for IP C/T?
- Very effective systemically against ovarian cancer
- Penetrate deep into the tumor
- Stays in the peritoneal cavity for prolonged period
- Low incidence of systemic adverse effect but providing satisfactory drug concentrations in the inner core of tumor
(有效 夠深 留得久)
Basic concept of IP C/T
- Peritoneal dwelling
- Solute transport model
- Anatomy of the peritoneum and capillary vessels
- Resistance to solute transport
Penetration of anticancer agents
- 4-6 layers (Ozols et al; Durand et al)
- By osteosarcoma spheroids and autoradiographs (West et al)
- Limited ability in avascular tumor mass & ≧ 250 μm in dia.
- Vinblastine & 5-FU
- In glioma spheroids (Nederman and Carlsson))
- Penetration : 5-FU > vinblastine
- In mouse model (Los et al)
- in peripheral: IP > IV
- In center : IP = IV
Peritoneal dwelling of anticancer drugs
- Longer stay of anticancer agents
- Higher drug concentration in the inner core
Is a contrary phenomenon
Anatomy of the peritoneum
- Primary interface between abdominal cavity & vessels
- Parietal peritoneum (10%) & visceral peritoneum (90%)
- The area is approximately to the body surface area (1.0 -2.0 cm2)
- Basement membrane
- Visceral lymphatics
- Monolayer of flattened cells about 0.5 mm thick
- Tight junction ; Gap junction
- Absence of tight junction in the subdiaphragmatic area directly absorbed into the lymphatic system
- The supporting structure
- Distance varies
- Visceral peritoneum
- Supplied by celiac and mesentary arteries with venous drainage via the portal vein
- Rapid firstpass metabolism by the liver
- Parietal peritoneum
- Supplied by circumflex iliac, lumbar, intercostal, and epigastric arteries with venous drainage via the systemic circulation.
- Effective peritoneal surface area
- The density of the number of perfused capillaries
- The number and the size of pores within the capillaies
- Extensive in the subdiaphragmatic area
- stoma exist,
- basement membrane absent
- Little resistance for the solute transport
- Also present in parietal and visceral peritoneum
- To maintain the relatively small volume of fluid (50-100 ml)
Mechanism of solute transport between peritoneal cavity and capillary lumen
Theoretical behaviors of anticancer agents
- Larger molecular weight or water-insolubleanticancer drugs stay longer in the peritoneal cavity
- Smaller molecular weight or water-soluble can go into the inner core but stay shorter in the cavity
- Small molecular weight agents that are metabolized in the liver to become active form should not be used for IP C/T.
- Small molecular weight agents with already active form are suitable for IP C/T
Pharmacologic advantage for IP C/T
(Modified from Markman M, Semin Oncol 1991)
Slide 21 Slide 22
Pharmacology of IP drugs
Slide 23 Slide 24 Slide 25 Slide 26
IP agents and risk
(Makhija et al, 2001)
Strengths of IP C/T
- Achieve dose intensification (as ‘high-dose’)
- Treats both intraperitoneal tumor bed and extraperitoneal tumor via systemic recirculation
- Reaches IP sites that may not be reached by IV route, especially when up to 2L dialysate are administered
- Onion skinning effect– IP cisplatin can penetrate as far as 4mm into surface of IP tumors(by definition, <1cm in size) and up to 6 repeated administrations
Clinical aspects of IP C/T
- Front-line chemotherapy
- 2nd-line chemotherapy
Phase III trials of IP vs IV cisplatin-based chemotherapy
- Eight randomized trials studied 1819 women receiving primary treatment for ovarian cancer.
- Women were less likely to die if they received an intraperitoneal (IP) component to the chemotherapy (hazard ratio (HR) =0.79; 95% confidence interval (CI): 0.70 to 0.90)and the disease free interval (HR =0.79; 95%CI: 0.69 to 0.90) was also significantly prolonged.
- There may be greater serious toxicity with regard to gastrointestinal effects, pain and fever but less ototoxicity with the intraperitoneal than the intravenous route.
Hazard ratio for time to recurrence (IP vs IV C/.T)
Hazard ratios for time to death (IP vs IV C/T)
GOG 104(Alberts et al, 1996)
GOG 104: conclusions
- As compared with IV cisplatin, IP cicplatin significantly improves survival and has significantly lower toxic effects in patients with stage III ovarian cancer and residual tumor mass of 2cm or less.
- The only same “dose-intensity” in both arms phase 3 RCT
Shorts of GOG 104
- GOG 111
- Median survival from 24 months (P+C) to 38 months ( P+T)
GOG 114(Markman et al, 2001)
GOG 114: conclusions
- The 2nd phase 3 RCT to show IP cisplatin is superior to IV cisplatin in small volume residual advanced ovarian cancer
- The 1st phase 3 trial in ovarian cancer to a median survival of >5 years
- Trial demonstrated that IP cisplatin favorably impacts survival, even through IV paclitaxel is a component of regimen
Shorts of GOG 114
- More complications in IP arm
- Neutropenia, thrombocytopenia
- G-I & metabolic toxicities
- Carbopltin x 2 cycles ( AUC 9)
GOG 172(Armstrong et al, 2006)
GOG 172residual tumor size & survival
GOG 172: conclusions
- Significantly survival benefit in IP arm
- The 65.6 months median survival is the longest survival reported to date from a randomized trial in advanced ovarian cancer
Shorts of GOG 172
- The IP regimen uses higher and more frequent dosing than the IV regimen
- Toxicities were greater on the IP arm
- Fewer patients on the IP arm were able to complete 6 cycles of therapy
- Intravenous and intraperitoneal chemotherapy are associated with equivalent survival in patients with minimal residual stage III epithelial ovarian cancer after optimal cytoreductive surgery (<1m).
- PEC or PAC regimens
NCI Clinical Announcement, 1/5/06Pooled survival benefit of IP regimens
- Progression-free survival
- HR=0.79 (95%CI: 0.70-0.90)
- Overall survival
- HR=0.79 (95%CI: 0.70-0.89)
- The role of carboplatin
- GOG 158 (non-inferiority test)
- GOG 114 (moderately high dose IV Carboplatin before IP C/T)
- Cross-trial GOG172 vs GOG 158
- How many coursesof IP C/T is adequate?
- Effect of Dose intensity?
- IP regimen uses higher and more frequent dosing schedule than the IV regimen
Cross-trial comparison of GOG 172 and GOG 158
GOG 172: eligible patients in IP arm
- Although fewer than half the patients assignedto the IP group received six cycles of IP treatment, the group as a whole had a significant improvement in survival as compared with the intravenous group. It is possible that most of the benefit of IP therapy occurs early, during the initial cycles, or that the benefit of IP therapy may be greater if more patients can successfully complete six cycles of treatment.
IP C/T as Consolidation
Potential IP consolidation regimens
- Cisplatin alone (50 mg/m2)
- Cisplatin + topotecan
- Cisplatin + FUDR
IP C/T as 2nd-line C/T
- Phase I or II studies
- IP C/T is safe, feasible, and pharmacokinetically advantageous, but responses varied widely.
- Critical factors for response
- Tumor burden at initial treatment
- Paltinum sensitivity
- Few candidates for 2nd-line IP C/T
- Those with stage IV, macroscopic, platinum-resistant, or extraperitoneal dz are less likely to be benefit
- Extensive adhesion
- 2nd-look op become rare recurrence is detected by palpable or imageable lesions and symptoms.
- Catheter issues
- Patient selection
- Toxicity and QOL
Complications of Catheter
- Bowel perforation
- Fistula formation
Catheter issuesTiming of placement
- 34% discontinued IP C/T for catheter-specific complications (Walker et al, GO,2006)
- Not associated with complication rate
- Pre-operative counseling, if possible
- Laparotomy, laparoscopy
- Close the vaginal cuff
Catheter issuesTypes of Catheter
- Tenckhoff peritoneal dialysis catheter
- Subcutaneous port implantation
- BardPort peritoneal catheter system
- JP, CWV catheters
- Veress needles
Bardport catheter system
Catheter issuesSite of port placement
- To minimize patient discomfort, and
- Facilitate ease of access
- Port site
- Superior and medial to the iliac crest, or
- On the inferior thorax, at the midclavicular line, overlying the ribs.
Slide 65 Slide 66
Patient selection issues
- Patient characteristics
- eg.: renal function ; neuropathy (DM –associated)
- Significant peritoneal adhesion
- Ongoing abdominal infection, or indwelling IP catheter becomes infected or malfunction, will be unable to treated by this route of drug delivery
- Size of residual tumor masses
- <0.5 cm, 1cm, or 2 cm ? Onion skinning
- Lt colon or rectosigmoid colon resection ?
Toxicity and QOL
- In GOG172, in IP more
- Bone marrow suppressions,
- neurologic symptoms,
- and infections
Who said all IP cisplatin therapy is more toxic than IV cisplatin therapy?
Quality of LifeGOG 172
How to reduce the toxicities from IP C/T?
- IP cisplatin-related toxicites
- IP Paclitaxel-related toxicities
- IV Docetaxel: less neurotoxic than Taxol
- IP Docetaxel no dose-limiting toxicities
(Morgan et al)
- IP catheter-related toxicities
- IP cisplatin-based C/T has been shown to have a survival benefit over IV cisplatin-based C/T for advance ovarian cancer patients with optimal debulking.
- However, there are a number of unanswered questions that should be resolved before IP C/T becomes truly a standard care in the ovarian cancer.
Is IP administration of carboplatin replacable to IP cisplatin as a less toxic alternative?
Is IP administration of paclitaxel necessary or IP administration of docetaxelacceptable?
What is the optimal number of IP treatment?
What is the optimal timing for the IP catheter placement and what is the optimal type and material?
Is IP C/T for ovarian cancer with bulky residual tumor as effective as those for small residual tumor?
How effective is IP C/T for retroperitoneal lymph node metastasis?