Curative and palliative aspects of regional chemotherapy in combination with surgery.
Many attempts have been made in the last two decades to improve the outcome of patients with advanced or metastasised solid tumours. In particular, combined-modality treatment strategies combining surgery with more localised therapies, e.g. radiotherapy, or systemic therapies such as chemotherapy have yielded promising data. The aim of regional chemotherapy is to improve locoregional cytostatic drug concentrations by achieving greater local efficacy and to diminish systemic side effects by reducing plasma drug levels. Highly qualified and experienced exponents of regional chemotherapy can complement surgical measures by applying multimodal strategies, because of their high efficacy in terms of tumour mass reduction without permanent tissue injuries, such as fibrosis or the damage to the vascular bed familiar from radiotherapeutic interventions. During the last 15 years, several new and very effective methods of administration, such as isolated pelvic perfusion or isolated thoracic perfusion, have extended the therapeutic arsenal of regional chemotherapy. The techniques needed for such transcutaneous and minimally invasive approaches as angiographically administered intra-arterial chemotherapy have been improved and side effects and the complication rate, dramatically reduced. Pharmacokinetic evaluations have demonstrated the high efficacy of one of the new regional modes of administration, isolated abdominal perfusion. With this technique, it is possible to attain cytostatic drug concentrations twice as high as those attained with systemic high-dose therapy with the same drug (treosulfan), but with only a quarter of the dosage and without bone marrow transplantation. Such techniques are now also available for the pelvic area, the thoracic region, the chest wall, the liver and the limbs. Regional chemotherapy is a very effective tool for induction therapy when tumours are apparently inoperable, as it can lead to sufficient shrinkage to make such tumours resectable. of all cases In an unselected series of 131 patients with colorectal liver metastases liver surgery with curative intent was possible after two cycles of therapy in 21.4% when immuno-chemoembolisation plus intra-arterial infusion was used as an inductive treatment. In 57.4% of these patients systemic chemotherapy had preceded surgery. After a median follow-up of more than 3 years, median survival has not been reached in the resected group and was 30 months for the group treated by regional chemotherapy alone. The aforementioned abdominal perfusion technique gave response rates in the range of 60-70% in patients with peritoneally metastasised and recurrent ovarian cancer. In about 55% of these cases, a second debulking procedure was possible, leading to a reduction in pain and symptoms and prolongation in survival, with a 1-year survival rate of 67%. Regional chemotherapy also seems to be very effective as an induction treatment in advanced non-small-cell lung cancer (NSCLC) patients in stages III A (bulky disease) and III B. After two cycles of isolated thoracic perfusion, the rate of remission was 86.3%. Removal of the remaining tumour structures was possible in 72.6% of all cases. Despite the high efficacy, the rate of side effects was low and acceptable. A steep increase in lung function parameters was observed in responding patients. This technique paves the way for a more effective induction therapy in advanced NSCLC, followed by resection and adjuvant radiotherapy of the mediastinum.
Müller
Herwart
H
Department of Surgical Oncology, Carl von Hess Hospital, Hammelburg, Germany. h.mueller@klinik-hammelburg.de
Hilger
Ralf
R
D000970:Antineoplastic Agents / Q000008:administration & dosage* / Q000627:therapeutic use; D002289:Carcinoma, Non-Small-Cell Lung / Q000188:drug therapy / Q000601:surgery; D010478:Chemotherapy, Cancer, Regional Perfusion / Q000379:methods*; D015179:Colorectal Neoplasms / Q000473:pathology; D003131:Combined Modality Therapy; D006801:Humans; D008113:Liver Neoplasms / Q000188:drug therapy / Q000556:secondary; D008175:Lung Neoplasms / Q000188:drug therapy / Q000601:surgery; D009369:Neoplasms / Q000188:drug therapy* / Q000601:surgery*; D010166:Palliative Care; D011379:Prognosis
D000970:Antineoplastic Agents