title: Correlation between melphalan pharmacokinetics and hepatic toxicity following hyperthermic isolated liver perfusion for unresectable metastatic disease.
abstract: BACKGROUND
  In the present work, we report on the results of our pilot study of hyperthermic isolated hepatic perfusion (IHP) with melphalan alone for patients with unresectable metastatic liver tumors refractory to conventional treatments, with particular regard to the correlation between pharmacokinetic findings and hepatic toxicity.
  
  
  METHODS
  Inclusion criteria were unresectable liver metastases, hepatic parenchyma replacement <or=50%, normal liver function, and previous failure of at least one conventional treatment. IHP was performed under hyperthermic conditions with melphalan (1.5 mg/kg body weight). Completeness of vascular isolation of the liver and drug distribution volumes of the perfusion circuit were assessed by a radiolabeled albumin-based method. Drug concentrations in perfusate and plasma were measured by means of high-performance liquid chromatography (HPLC).
  
  
  RESULTS
  Twenty patients with unresectable liver metastases underwent IHP. No intraoperative mortality occurred. Treatment-related systemic toxicity was minimal and reversible. Three patients (15%) experienced grade 4 hepatic toxicity and died due to liver failure and subsequent multiorgan failure. Other six patients had significant (grade 3-4) but transitory hepatic toxicity. Complete and partial responses were observed in three and nine out of 17 evaluable patients, respectively (overall response rate = 70%). The pharmacokinetics study showed a 3% mean perfusate-to-plasma drug leakage (range 1-6%). Logistic regression analysis showed that drug concentration in the perfusate circuit, but not preoperative tests, significantly and independently correlated with hepatic toxicity (P = 0.028).
  
  
  CONCLUSIONS
  Following melphalan-based IHP, objective tumor regression could be observed in a remarkable percentage of patients refractory to standard treatments. However, hepatic toxicity and related mortality were significant. Our findings suggest that drug dosage personalization based on the measurement of drug distribution volumes might minimize hepatic toxicity.
authors.affiliation: Surgery Branch, Department of Oncological and Surgical Sciences, University of Padova, via Giustiniani 2, 35128, Padova, Italy.
authors.forename: Simone
authors.initials: S
authors.lastname: Mocellin
authors.forename: Pierluigi
authors.initials: P
authors.lastname: Pilati
authors.forename: Pierpaolo
authors.initials: P
authors.lastname: Da Pian
authors.forename: Marco
authors.initials: M
authors.lastname: Forlin
authors.forename: Susanna
authors.initials: S
authors.lastname: Corazzina
authors.forename: Carlo Riccardo
authors.initials: CR
authors.lastname: Rossi
authors.forename: Federico
authors.initials: F
authors.lastname: Innocente
authors.forename: Carlo
authors.initials: C
authors.lastname: Ori
authors.forename: Dario
authors.initials: D
authors.lastname: Casara
authors.forename: Francesca
authors.initials: F
authors.lastname: Ujka
authors.forename: Donato
authors.initials: D
authors.lastname: Nitti
authors.forename: Mario
authors.initials: M
authors.lastname: Lise
mesh_terms: D000328:Adult; D000368:Aged; D018906:Antineoplastic Agents, Alkylating / Q000009:adverse effects / Q000493:pharmacokinetics*; D056486:Chemical and Drug Induced Liver Injury / Q000209:etiology*; D010478:Chemotherapy, Cancer, Regional Perfusion; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D006979:Hyperthermia, Induced; D008113:Liver Neoplasms / Q000188:drug therapy* / Q000556:secondary / Q000601:surgery; D008297:Male; D008558:Melphalan / Q000009:adverse effects / Q000493:pharmacokinetics*; D008875:Middle Aged; D010865:Pilot Projects
chemical_list: D018906:Antineoplastic Agents, Alkylating; D008558:Melphalan