Hepatocellular carcinoma (HCC) is the third most common cause of cancer-related deaths worldwide, accounting for over 600,000 deaths per year. The most common treatment strategy for intermediate and advanced stage unresectable HCC is transarterial chemoembolization (TACE), which involves the local administration of a chemotherapeutic drug combined with arterial occlusion resulting in ischemic tumor necrosis. However, TACE suffers from inadvertent exposure of noncancerous liver parenchyma to embolic agents resulting in liver injury. In some cases, over-embolization has lead to infection, necrosis of unaffected liver tissue, and even liver failure which suggests the need for a biocompatible, multifunctional embolic material which can deliver anticancer drugs with high target specificity. Our laboratory has recently developed a method to fabricate porous silicon (pSi) microparticles with defined physicochemical properties based on photolithography and anodic etching. These microparticles function as multistage drug delivery systems that can circumvent the biobarriers present in the systemic circulation enabling site-specific localization and release of chemotherapy and imaging agents. The versatility of the fabrication process enables the realization of microparticles ranging in size from 600nm to 116[mu]m in diameter with varying shapes, including discoidal, cylindrical and hemispherical, and varying porosity with pore sizes ranging from 6nm to greater than 50nm in diameter. Nanoparticles, such as quantum dots, siRNA-loaded nanoliposomes, gadolinium-based contrast agents, gold and iron oxide nanoparticles, are loaded in pSi microparticles by tailoring their pore sizes and surface chemistries. This thesis presents preliminary results on the applicability of biocompatible, engineered pSi microparticles as an embolic agent for HCC chemoembolization therapy. Hemispherical microparticles with 116[mu]m diameter were successfully fabricated and suspended in phosphate buffered saline (PBS). A microvascular construct was rapid prototyped in polydimethylsiloxane (PDMS) as an in vitro experimental platform to study the embolization behavior of pSi microparticles. Oxidized pSi microparticles were introduced into the microfluidic device at an appropriate flow rate and time-lapse images were taken showing the formation of occlusions at the bifurcation within minutes of administration. Furthermore, penetration through the bifurcation was completely hindered suggesting that pSi microparticles can potentially be used as a biocompatible, multifunctional chemoembolization agent. Although these results are promising, further investigations are warranted.

La chimioembolisation est une thérapie loco-régionale qui consiste à injecter, au moyend’un microcathéter, un principe actif et un agent d’occlusion vasculaire de manière la plussélective possible dans les artères nourricières du processus pathologique. Les microsphèresde chimioembolisation sont des microsphères calibrées et chargeables en principe actif,développées ces dernières années afin d’optimiser la chimioembolisation et permettre unelibération ciblée et contrôlée du principe actif au sein du territoire pathologique. L’utilisationde ces microsphères n’a encore jamais été appliquée à la chimioembolisation du poumon. Ellepourrait être intéressante dans le traitement des tumeurs pulmonaires malignes en permettantune imprégnation de la tumeur par un anticancéreux, tout en évitant une toxicité systémiquede ce dernier et dans le traitement des hémoptysies massives en évitant les récidives, dues àune recanalisation des vaisseaux après embolisation, par l’utilisation d’un inhibiteur duremodelage vasculaire.Notre travail a consisté à évaluer les performances de libération de l’irinotécan et dusirolimus à partir des microsphères de chimioembolisation au niveau systémique et au niveautissulaire, sur des modèles de chimioembolisation pulmonaire chez la brebis. Nos résultats ontmontré que les microsphères de chimioembolisation ne permettaient pas une délivrancetissulaire prolongée de l’irinotécan pour espérer obtenir une imprégnation efficace d’un lobepulmonaire. Les microsphères chargées en sirolimus semblent permettre une libérationcontrôlée du principe actif et paraissent intéressantes pour prévenir la recanalisation.Les microsphères de chimioembolisation doivent être améliorées pour permettre unelibération prolongée du principe actif. Des études complémentaires notamment en termesd’efficacité (modèle tumoral) doivent être réalisées pour montrer l’intérêt d’utiliser lachimioembolisation pulmonaire par microsphères en pratique clinique. / Chemoembolization is a loco-regional therapy, which consists of delivering selectively and directly to the pathologic area, by means of catheters through the vasculature, a drug and an embolic agent. The purpose is to achieve nutrient and oxygen starvation of the tumor, to minimize chemotherapy wash-out with prolonged contact with tumor tissue and therefore to increase the local drug concentration and reduce systemic toxicity. Drug eluting beads are a new generation of calibrated embolization beads, which behave as a drug delivery system. They have been developed in order to optimize chemoembolization and to control precisely the release and the dose of drug into the treatment site. Drug eluting beads have never been used for lung chemoembolization. It may be interesting to evaluate them in the treatment of lung tumors in order to impregnate the tumor with an anticancer drug while avoiding systemic toxicity of this drug and in the treatment of massive hemoptysis to avoid recurrences, induced by a recanalization of vessels after embolization, by using an inhibitor on vascular remodeling. Our purpose was to evaluate the release performances of irinotecan and sirolimus from drug eluting beads, in systemic circulation and in lung tissue, in sheep lung chemoembolization models. Our results showed that drug eluting beads did not allow a sufficient sustained delivery of irinotecan to expect to obtain an effective impregnation of a pulmonary lobe. Sirolimus eluting beads seem to allow a drug controlled release and appear interesting to prevent recanalization. Drug eluting beads have to be improved in order to allow sustained and controlled release of the drug. Complementary studies especially efficacy studies have to be investigated for showing the interest to use lung chemoembolization with drug eluting beads in clinical practice.

CoordenaÃÃo de AperfeiÃoamento de NÃvel Superior / OBJETIVO: Estabelecer um modelo de tumor no fÃgado de ratos para estudo do comportamento tumoral e avaliar o uso da quimiembolizaÃÃo transarterial. MÃTODOS: Utilizou-se oitenta e oito ratos Wistar, fÃmeas, adultos, pesando entre 175- 284 g . Realizado incisÃo abdominal de 3 cm e implantou-se o carcinossarcoma de Walker 256 no lÃbulo esquerdo do fÃgado. Dividiu-se em trÃs grupos que receberam respectivamente 100x 103 , 200x 103 e 300x 103 cÃlulas tumorais, avaliado a pega do tumor e a sobrevida. Em outro grupo de experimento com 39 animais inoculados com tumor de Walker foi avaliado a sobrevida dos animais apÃs infusÃo do 5-Flourouracil (5-FU) por via intra-peritoneal e intra-arterial. RESULTADOS: O implante do carcinossarcoma de Walker no fÃgado de ratos apresentou desenvolvimento de 100 %, teve um crescimento rÃpido e desenvolvimento de metÃstases tardiamente, levando os animais ao Ãbito entre o sÃtimo e dÃcimo quinto dia. A quimiembolizaÃÃo transarterial à possÃvel de ser realizada experimentalmente. O uso do 5-FU aumentou a sobrevida em comparaÃÃo ao grupo controle. CONCLUSÃO: O modelo de implante do tumor de Walker no fÃgado de ratos à eficiente, de fÃcil reprodutibilidade, e sobrevida mÃdia de 9,96Â0.3 dias. A quimioterapia transarterial hepÃtica pode ser realizada experimentalmente para avaliar diversas drogas. / PURPOSE: An animal model to study the behaviour of liver tumor in rat and its response after use of transarterial chemoembolization. METHODS: We use 88 Wistar rats, all of them were females, adult, weight 175-284 g. Abdominal incison of three cm and implanted the Walker carcinossarcoma 256 at left lobule of the liver. The animals were divided into three grups, that received 100x103 , 200x103, and 300x103 cells. Followed up the animas to avaliate life standing and tumoral development. In another experiment was used 39 animals which already had Walker 256 tumor and we study the survival of the animals after treatment with 5-FU IP or 5-FU IA. RESULTS: The orevall tumor development rate were 100%. Tumor growth was fast, and devolopment metastases on old fase. The animals dead between 7 and 15 day. Its possible to do chemoembolization experimentaly, after the use of 5-FU the rate survival increased. CONCLUSION: The model with Walker 256 tumor developed here is easy to repoduce, efficient, with high tumor development rate observed, the life standing is about 9,96  0,3 days. The chemoembolization experiment allows to assess several drugs.

Hepatocellular carcinoma (HCC) is the second most common cancer in Taiwan and transcatheter arterial chemoembolization (TACE) is now the mainstay of treatment for noncurative HCC. Due to increasing medical costs yearly and financial problem of the Bureau of National Health Insurance, it is important to reduce medical resource utilization including hospital stay and medical costs. The aim is to figure out the risk factors of extended hospital stay, and increased in-hospital medical costs in hepatocellular carcinoma patients receiving transcatheter arterial chemoembolization. The result of this study should be available for further improvement of medical care quality in the limited medical resource. From January 2008 to January 2010, 162 patients (121 male and 41 female) with histologically proven hepatocellular carcinoma underwent TACE only (131 pts) or TACE followed by catheter placement for hepatic artery infusion chemotherapy (HAIC) (31pts) at district teaching hospital. The extended hospital stay (EHS) and extended post-procedure stay (EPS) are defined as stay larger than their median values (11 & 7 days respectively). Clinical demographic, disease factors, tumor factors, procedure (TACE)-related factors and complications are used to identify the univariate factors related to EHS and EPS statistically. To find out predictors of EHS, EPS and increased in-hospital medical costs, multiple linear regression analyses are used. The risk factors for EPS are procedure-related, including complications and procedure methods ( TACE + HAIC related to TACE only) (R2=.367, p<.001), while those for EHS are complications, encephalopathy, procedure methods, Child-Pugh classification C (related to classification A) and age (R2=.490, p<.001). The predictors for increased in-hospital medical costs include procedure methods, AJCC stage IV, T4 stage, hepatoencephalopathy and complications (R2=0.615, p<.001). Taking total hospital stay into consideration, the most important risk factor related to increased medical cost is total hosptial stay itself. The most powerful risk factor for EPS, EHS is procedure-related complication. The different procedure methods also affect hospital stay and medical costs. In order to reduce medical resource utilization, we should avoid post-procedure complication and pay attention to cirrhotic degree as well as American Joint Committee of Cancer (AJCC) tumor stage system. The result of this study can provide some ideas to adjust medical expense polices for the Bureau of National Health Insurance and to control medical cost for the hospitals.

There are currently two types of intra-arterial drug-delivery system (DDS) in clinical use in the palliative treatment of primary liver cancer. The chemotherapeutic drug doxorubicin (DOX) can be formulated into a drug-in-lipiodol emulsion (LIPDOX) or a microparticulate drug-eluting bead system (DEBDOX). To facilitate development of future DDSs, we need to understand the release and local distribution of drug from these DDSs into the complex, in vivo, pathological environment. The overall aim of this project was to assess and improve understanding of the in vivo release of DOX from LIPDOX and DEBDOX and its local disposition in the liver. These processes were investigated in detail in a multisampling-site, healthy pig model and in human patients with liver cancer. The mechanisms involved in DOX disposition were studied by examining potential interactions between DOX and lipiodol and/or cyclosporine A (CsA) in pigs.   In this project, the main elimination pathway for DOX and its primary metabolite doxorubicinol (DOXol) was via bile; their extensive canalicular carrier-mediated transport (e.g. ATP-binding cassette transporters ABCB1, ABCC1, ABCC2 and ABCG2) was inhibited by CsA. CsA had no effect on the carbonyl and aldo-keto reductases responsible for the metabolism of DOX into DOXol. LIPDOX released DOX more rapidly and to a greater extent into the circulation than DEBDOX, which had only released 15% of the dose in patients after 24 hrs. The systemic exposure to DOX was lower for DEBDOX than for LIPDOX. Greater fractions of DOXol were formed in blood and bile with LIPDOX than with DEBDOX. This may have been because DOX was more widely distributed into regions with increased metabolic capacity or because of increased intracellular uptake when DOX was delivered in LIPDOX. The excipient lipiodol in the LIPDOX formulation did not interact with transporters, enzymes or membranes that would explain the increased cellular uptake of DOX. In conclusion, the release of DOX from DEBDOX is more controlled in vivo than that from LIPDOX, indicating that DEBDOX is a more robust pharmaceutical product. The formulations for future optimized DDSs should therefore be more similar to DEBDOX than to LIPDOX.

There are currently two types of drug formulation in clinical use in the locoregional treatment of intermediate hepatocellular carcinoma (HCC). In the emulsion LIPDOX, the cytostatic agent doxorubicin (DOX) is dissolved in the aqueous phase, which is emulsified with the oily contrast agent Lipiodol® (LIP). In the microparticular system DEBDOX, DOX is loaded into the drug-eluting entity DC Bead™. The overall aim of the thesis was to improve pharmaceutical understanding of the LIPDOX and DEBDOX formulations, in order to facilitate the future development of novel drug delivery systems. In vivo release of DOX from the formulations and the disposition of DOX and its active metabolite doxorubicinol (DOXol) were assessed in an advanced multisampling-site acute healthy pig model and in patients with HCC. The release of DOX and disposition of DOX and DOXol where further analysed using physiologically based pharmacokinetic (PBPK) and biopharmaceutical (PBBP) modelling. The combination of in vivo investigations and in silico modelling could provide unique insight into the mechanisms behind drug release and disposition. The in vivo release of DOX from LIPDOX is not extended and controlled, as it is from DEBDOX. With both formulations, DOX is released as a burst during the early phase of administration. The in vivo release of DOX from LIPDOX was faster than from DEBDOX in both pigs and patients. The release from DEBDOX was slow and possibly incomplete. The in vivo release of DOX from LIPDOX and DEBDOX could be described by using the PBBP model in combination with in vitro release profiles. The disposition of DOX and DOXol was modelled using a semi-PBPK model containing intracellular binding sites. The contrast agent Lipiodol® did not affect the hepatobiliary disposition of DOX in the pig model. The control substance used in this study, cyclosporine A, inhibited the biliary excretion of DOX and DOXol but did not alter metabolism in healthy pigs. The disposition of DOX is similar in healthy pigs and humans, which was shown by the ease of translation of the semi-PBPK pig model to the human PBBP model.

Avec environ 700 000 décès en 2008, le carcinome hépatocellulaire se situe au 3ème rang de la mortalité par cancers dans le monde. La chimioembolisation est le traitement recommandé chez les patients atteints d’un carcinome hépatocellulaire de stade intermédiaire B de la classification Barcelona Clinic Liver Cancer. Cette technique de radiologie interventionnelle consiste en l’injection intraartérielle d’un agent anticancéreux à l’aide d’un vecteur (lipiodol ou microsphères d’embolisation) complétée par une occlusion artérielle lorsque le lipiodol est utilisé. La médiane de survie des patients traités par chimioembolisation pour un carcinome hépatocellulaire n’excède pas 2 ans et il n’existe aucun consensus sur la procédure optimale.L’objectif de notre travail est d’essayer d’améliorer la procédure de chimioembolisation en optimisant d’une part l’agent anticancéreux et d’autre part, son vecteur.Il a été démontré au cours d’un travail de sélection in vitro, que l’idarubicine est l’agent anticancéreux le plus cytotoxique sur 3 lignées humaines de carcinome hépatocellulaire. Cette anthracycline présente une cytotoxicité supérieure à 10 autres agents anticancéreux dont ceux utilisés en pratique clinique pour la chimioembolisation des carcinomes hépatocellulaires.L’essai de chimioembolisation de phase II randomisé LIPIOAMIO a montré que l’addition d’amiodarone utilisé pour stabiliser une émulsion à base de lipiodol et d’anthracycline n’augmente pas signicativement la survie des patients atteints d’un carcinome hépatocellulaire non résécable non métastatique. Nous avons par ailleurs montré que l’idarubicine était chargeable et donnait une solution stable plusieurs mois avec les microsphères d’embolisation DC Bead™. Un essai de phase I est en cours pour déterminer la dose limitante de l’idarubicine administrée dans une solution de microsphères DC Bead™ au cours d’une séance de chimioembolisation chez des patients atteints d’un carcinome hépatocellulaire non résécable, non métastatique. Quelques résultats préliminaires de cet essai sont présentés dans le manuscrit. / With 700,000 deaths in 2008, hepatocellular carcinoma is the 3rd most common cause of cancer-related death worldwide. Transarterial chemoembolization is the standard treatment for intermediate-stage hepatocellular carcinoma. This intraarterial treatment is performed by injecting an anticancer drug carried by ethiodized oil or by drug-eluting beads and followed by the occlusion of the artery when ethiodized oil is used. Median survival of patients remains < 2 years, and there is no consensus about the optimal treatment regimen. The aim of our work was to improve the efficacy of transarterial chemoembolization in optimizing the anticancer drug and its carrier.We have demonstrated that idarubicin was the most cytotoxic anticancer drug in an in vitro screening study of 11 anticancer drugs on 3 human hepatocellular carcinoma cell lines. Idarubicin was more cytotoxic in our experiment than the anticancer drugs which are currently used for transarterial chemoembolization of hepatocellular carcinoma.The randomized LIPIOAMIO phase II trial has shown that the addition of amiodarone to stabilize an emulsion composed of an anthracycline and of ethiodized oil injected for transarterial chemoembolization does not improve significantly survival of patients with a non resectable, non metastatic hepatocellular carcinoma. We have also demonstrated that idarubicin could be loaded in drug-eluting DC Bead™ and that the resulting solution was stable during several months.We designed the dose-escalation IDASPHERE phase I trial to determine the limiting dose of idarubicin administred in a solution of drug-eluting DC Bead™ during a transarterial chemoembolization session in patients with non resectable, non metastatic hepatocellular carcinoma. First results of the trial are presented in the manuscript.

121 9. Summárý Purpose: This study was designed to evaluate the role of interventional radiology in liver transplantation programme. The aim is to present our experience, technical outcomes and long-term clinical results with chemoembolization of hepatocellular carcinoma in patients before liver transplantation and with percutaneous treatment of vascular and biliary complication after orthotopic liver transplantation. Methods: Twenty five patients (17 men, 8 women, mean age 57.76 years) with HCC were scheduled for TACE prior to liver transplantation from 2008 to 2012. Twenty three procedures were performed, 7 c-TACE in 2008 and 16 DEB TACE in next years. Thirty patients (13 men, 17 women, mean age 46.4 years) with biliary strictures after liver transplantation without endoscopic access possibility were treated with balloon dilatation and biliary duct drainage from 1996 and 2010. Twenty patients (13 men, 7 women, mean age 45.25 years) were treated with PTA/stent due to hepatic artery stenosis after liver transplantation between 1996 and 2011. Stents were placed to the hepatic/celiac artery in 16 PTAs, balloon dilatation alone was performed in 7 stenosis due to tortuosity of the vessel. Results: Liver transplantation was performed to 20 patients after TACE. Only one patient (4.5 %) was excluded from waiting...

Purpose: To evaluate the efficiency of a multimodality approach consisting of transcatheter arterial chemoembolization (TACE) and radiofrequency ablation (RFA) as bridging therapy for patients with hepatocellular carcinoma (HCC) awaiting orthotopic liver transplantation (OLT) and to evaluate the histopathological response in explant specimens. Materials and Methods: Between April 2001 and November 2011, 36 patients with 50 HCC nodules (1.4–5.0 cm, median 2.8 cm) on the waiting list for liver transplantation were treated by TACE and RFA. The drop-out rate during the follow-up period was recorded. The local efficacy was evaluated by histopathological examination of the explanted livers. Results: During a median follow-up time of 29 (4.0–95.3) months the cumulative drop-out rate for the patients on the waiting list was 0, 2.8, 5.5, 11.0, 13.9 and 16.7% at 3, 6, 12, 24, 36 and 48 months, respectively. 16 patients (with 26 HCC lesions) out of 36 (44.4%) were transplanted by the end of study with a median waiting list time of 13.7 (2.5–37.8) months. The histopathological examination of the explanted specimens revealed a complete necrosis in 20 of 26 HCCs (76.9%), whereas 6 (23.1%) nodules showed viable residual tumor tissue. All transplanted patients are alive at a median time of 29.9 months. Imaging correlation showed 100% specificity and 66.7% sensitivity for the depiction of residual or recurrent tumor. Conclusion: We conclude that TACE combined with RFA could provide an effective treatment to decrease the drop-out rate from the OLT waiting list for HCC patients. Furthermore, this combination therapy results in high rates of complete tumor necrosis as evaluated in the histopathological analysis of the explanted livers. Further randomized trials are needed to demonstrate if there is a benefit in comparison with a single-treatment approach. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

Les microsphères d'embolisation, apparues dans les années 2000, sont des dispositifs médicaux dirigées contre les tumeurs hépatiques non opérables. Elles sont calibrés et peuvent être chargées en anticancéreux. Ces avancées majeures permettent de contrôler le niveau d'occlusion et la concentration en principe actif à injecter dans la tumeur. Cependant, le type, la taille des microsphères ou encore la concentration en anticancéreux varient d'un centre à un autre et d'un pays à un autre. Notre travail vise à comparer, sur des modèles de tumeurs hépatiques, les propriétés d'élution et l'efficacité antitumorale de différentes préparations de microsphères. La microspectroscopie infrarouge est utilisée pour mesurer la quantité de doxorubicine présente dans les microsphères à différents délais alors que la microspectrofluorimétrie permet d'évaluer la concentration et la distribution de la doxorubicine autour des billes. L'évaluation de l'activité antitumorale du traitement est mesurée sur les images spectrales infrarouge grâce à un modèle de prédiction et confirmée par un examen histopathologique. Les résultats ont montré que la vitesse d'élution dépend des propriétés physicochimiques de la microsphère, de sa taille et de la concentration de chargement. Les concentrations tissulaires de doxorubicine mesurées induisent une réduction significative de la viabilité tumorale. Le model de prédiction est un outil robuste et précis pour évaluer les modifications tissulaires. Ces résultats permettent de formuler des hypothèses mécanistiques sur l'activité antitumorale de différentes préparations de microsphères afin d'optimiser leur utilisation dans une stratégie thérapeutique clinique. / Transarterial chemoembolization is the most common treatment for patients with unresectable liver tumors. Calibrated drug eluting beads offer the advantages of controlling the level of occlusion, the amount of drug delivered, and the duration of drug delivery to the tumor. However, optimal procedure still remains unanswered and treatments differ through the use of various beads sizes or dose of loading. Our work is to compare, on experimental liver tumor model, the release properties and antitumor effects for different preparations of doxorubicin eluting beads. The amount of drug retained inside the beads, at different time point, is assessed by infrared microspectroscopy. Doxorubicin concentration and distribution in the tissue are determined by microspectrofluorimetry. Tissue modifications are quantified by a prediction model on infrared images and compared with the conventional pathological examination of stained tissue sections. Results show that elution rate of doxorubicin depend on the beads composition, the size and the loaded concentration. The doxorubicin tissue concentration induces a significant decrease of tumor viability. The prediction model established by infrared microspectroscopy is an accurate and robust tool to quantify tissue modifications. These results allow the formulation of mechanistic hypotheses on antitumor activity of different preparations of beads to optimize their use in a clinical therapeutic strategy.