Intratumoral chemotherapy for lung cancer: re-challenge current targeted therapies

Abstract

Strategies to enhance the already established doublet chemotherapy regimen for lung cancer have been investigated for more than 20 years. Initially, the concept was to administer chemotherapy drugs locally to the tumor site for efficient diffusion through passive transport within the tumor. Recent advances have enhanced the diffusion of pharmaceuticals through active transport by using pharmaceuticals designed to target the genome of tumors. In the present study, five patients with non-small cell lung cancer epidermal growth factor receptor (EGFR) negative stage IIIa–IV International Union Against Cancer 7 (UICC-7), and with Eastern Cooperative Oncology Group (ECOG) 2 scores were administered platinum-based doublet chemotherapy using combined intratumoral-regional and intravenous route of administration. Cisplatin analogues were injected at 0.5%–1% concentration within the tumor lesion and proven malignant lymph nodes according to pretreatment histological/cytological results and the concentration of systemic infusion was decreased to 70% of a standard protocol. This combined intravenous plus intratumoral-regional chemotherapy is used as a first line therapy on this short series of patients. To the best of our knowledge this is the first report of direct treatment of involved lymph nodes with cisplatin by endobronchial ultrasound drug delivery with a needle without any adverse effects. The initial overall survival and local response are suggestive of a better efficacy compared to established doublet cisplatin–based systemic chemotherapy in (higher) standard concentrations alone according to the UICC 7 database expected survival. An extensive search of the literature was performed to gather information of previously published literature of intratumoral chemo-drug administration and formulation for this treatment modality. Our study shows a favorable local response, more than a 50% reduction, for a massive tumor mass after administration of five sessions of intratumoral chemotherapy plus two cycles of low-dose intravenous chemotherapy according to our protocol. These encouraging results (even in very sick ECOG 2 patients with central obstructive non-small cell lung cancer having a worse prognosis and quality of life than a non-small cell lung cancer in ECOG 0 of the same tumor node metastasis [TNM]-stage without central obstruction) for a chemotherapy-only protocol that differs from conventional cisplatin-based doublet chemotherapy by the route, target site, and dose paves the way for broader applications of this technique. Finally, future perspectives of this treatment and pharmaceutical design for intratumoral administration are presented.

Intraoperative Cryosurgical Freezing Assists with Local Drug Delivery and Targeting of Tumor Fluids in VX2 Model, which Translates in Locoregional Drug Targeting of Tumor Fluids during Cryoprobe-Assisted Surgical Resection of Breast Cancer

“…The tracer entrapment within tumor core during and after the thaw process as seen in the VX2 study suggests the use of Freezethaw assisted injection of active drug not only during the resection but also in the resection cavity margins. The local injection of cytotoxic would help priming residual tumor cells to adjuvant systemic therapies 49,50 , and/or radiotherapy 6 .…”

Endobronchial Ultrasound (EBUS) for Local Drug Application: Future Methodology

“…[4,[22][23][24] The endobronchial ultrasound system administered successfully to the target tissue the formulation. [22] The major issue that has to be discussed before any kind of application is the dosage of the formulation which should be based on the tissue volume, drug and matrix of the designated tissue.…”

“…[4,[22][23][24] The endobronchial ultrasound system administered successfully to the target tissue the formulation. [22] The major issue that has to be discussed before any kind of application is the dosage of the formulation which should be based on the tissue volume, drug and matrix of the designated tissue. [22,25] The major issue is to create a molecule that can efficiently penetrate the tumor tissue indifferent of its microenvironment, and with a smaller drug concentration to have a higher apoptosis rate.…”

“…[22] The major issue that has to be discussed before any kind of application is the dosage of the formulation which should be based on the tissue volume, drug and matrix of the designated tissue. [22,25] The major issue is to create a molecule that can efficiently penetrate the tumor tissue indifferent of its microenvironment, and with a smaller drug concentration to have a higher apoptosis rate. If these parameters are carefully combined then the drug formulation will be distributed homogenously within the tumor and the treatment will be effective.…”

“…[22,28,29] Several new drug formulations have been used and are necessary to overcome distribution issues within the tumor volume. [30] [31,32] Direct intratumoral administration has the advantage that a lower dosage is used and several other systems such the lung parenchyma is bypassed.…”