Ovarian cancer is the second most common, and first most lethal gynecological cancer. It will affect one in seventy-eight women, and is commonly diagnosed in the later stages of the disease. The majority of the cancer’s lifespan is spent within the peritoneal cavity. Hyperthermic intraperitoneal chemotherapy (HIPEC) is an innovative new treatment that has been proven as an effective treatment in other peritoneal cancers. There is strong scientific evidence to support HIPEC as an ideal treatment for advanced ovarian cancer. Over the past two decades, there has been an increase in the number of studies focused on the efficacy of HIPEC with regards to advanced ovarian cancer. These studies have shown great promise, with two very recent phase III studies showing resounding results. It is also clear that there is a need for standardization throughout these scientific studies in order to reasonably introduce HIPEC as a standard of treatment.

京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第21997号 / 医博第4511号 / 新制||医||1037(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 武藤 学, 教授 妹尾 浩, 教授 伊達 洋至 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

La Chimiothérapie IntraPéritonnéale (CIP) est utilisée couramment pour traiter le cancer colorectal métastatique. Cependant il n'existe pas de protocole standardisé.Le but de ce projet a été de modéliser cette chimiothérapie in vitro et de comprendre le rôle de l'hypotonie dans ce modèle et son impact sur la mort des cellules cancéreuses.Nous avons déterminé les conditions optimales de traitement sur les cellules cancéreuses coliques humaines HCT116 à savoir une exposition des cellules pendant 30 minutes à 400µM d'oxaliplatine en conditions hypotoniques (G2.5%) à 37°C. Ces résultats ont été validés sur différentes lignées cancéreuses coliques humaines et murine. Nous avons également montré que ces conditions de traitements étaient également capables d’augmenter la cytotoxixité d’autres dérivés du platine comme le cisplatine et le carboplatine.La mort cellulaire induite par ce traitement en hypotonie est de type apoptotique, Et peut s’expliquer par une augmentation de l’incorporation intracellulaire d'oxaliplatine, en partie due à l'activation et à la trimérisation du transporteur du cuivre CTR1.Le traitement par l'oxaliplatine et le cisplatine (mais pas par le carboplatine) en hypotonie entraine également les stigmates de la mort immunogène, à savoir l'exposition de la calréticuline à la membrane, la libération d'ATP et le relargage d'HMGB1, suggérant que l'hypotonie permettrait d'entrainer la mort immunogène et une réponse du système immunitaire lors de cette modélisation de CIP.Enfin, in vivo nous avons pu mettre en évidence que le traitement de métastases intrapéritonéales de souris Balb/c par une injection intrapéritonéale d'oxaliplatine en hypotonie permettait un ralentissement de l’apparition de nodules tumoraux et une augmentation de la survie des souris.Ainsi, nous avons pu mettre en évidence dans ce travail que l'hypotonie est un des paramètres fondamentaux de la CIP et suggère que son utilisation pourrait permettre d'augmenter l’efficacité de la CIP et de prolonger la survie des patients. / IntraPeritoneal Chemotherapy (IPEC) is commonly used to treat colorectal cancer metastases. However there is no standardized protocol.The aim of this work was to model this chemotherapy in vitro and to understand the role of hypotonic conditions in this model and its impact on cell death.We determined that the optimal treatment parameters on HCT116 human colon cancer cells, were an exposure of the cells for 30 minutes to 400μM of oxaliplatin under hypotonic conditions (G2.5%) at 37 °C. These results have been validated on various human and murine colic cancer cell lines. We have also shown that these treatment conditions are also able to increase the cytotoxicity of other platinum derivatives such as cisplatin and carboplatin.The cell death induced by this treatment in hypotonia is apoptosis, and can be explained by an increase in the intracellular incorporation of oxaliplatin, partly due to the activation and trimerization of the CTR1 copper transporter.Treatment with oxaliplatin and cisplatin (but not carboplatin) in hypotonia also leads to the stigmata of immunogenic death, e.i. exposure of calreticulin at the membrane, release of ATP and HMGB1 in the supernatant, suggesting that hypotonia would entail immunogenic death and an immune system response during this IPEC modeling.Finally, we have been able to demonstrate in vivo that the treatment of intraperitoneal metastases of Balb/c mice by an intraperitoneal injection of oxaliplatin in hypotonia slowed down tumor nodules appearance and increased survival of the mice.Thus, in this work we highlighted that hypotonia is one of the fundamental parameters of IPEC which suggests that its use could make it possible to increase the efficacy of IPEC and maybe to prolong the survival of patients.

Peritoneal carcinomatosis (PC) is traditionally regarded as a terminal stage of disease with a poor prognosis and systemic chemotherapy is regarded as palliative treatment. In order to improve survival and even to achieve cure for selected patients with PC, cytoreductive surgery and intraperitoneal che-motherapy have been advocated. Despite complete macroscopic removal of tumour, residual microscopic malignant cells might result in recurrence. Intraperitoneal chemotherapy aims to kill residual malignant cells and thereby needs to be distributed in the entire peritoneal cavity. This aggres-sive combined loco-regional treatment has a high risk of morbidity and mor-tality. Whether the increased risks are acceptable to improve survival re-quires investigation and the impact of loco-regional treatment of PC on health-related quality of life (HRQL) needs to bee explored The overall aim of this thesis was to analyse the impact of cytoreductive surgery and intraperitoneal chemotherapy on patients with peritoneal carci-nomatosis. A significant survival improvement (median 32 months) was seen in 18 patients with PC of colorectal origin subjected to loco-regional treatment, in comparison to matched controls treated with systemic chemotherapy (me-dian survival 14 months, Paper I). The results of single-photon emission computer-tomography (SPECT) in 51 patients were correlated to the number of intraperitoneal chemotherapy courses that could be performed without further surgery (Paper II). Postoperative 30-days morbidity and 90-days mortality was investigated in 123 PC-patients after loco-regional treatment. Severe adverse events occurred in 51 (41%) patients. Five patients (4%) had treatment-related mortality. Stoma formation, duration of surgery, periopera-tive blood loss, and extent of PC was associated with morbidity (Paper III). HRQL was investigated in 64 patients. HRQL was negatively affected at 3 months but a partial recovery was seen at 8 months. 30-day morbidity did not have any impact on HRQL at 8 months (Paper IV). This treatment there fore appears justified despite considerable toxicity in view of possible life prolongation.

Peritoneal carcinomatosis (PC) is a common manifestation of both gastrointestinal and gynecologic malignancies. Until recently, this condition was considered beyond curative intent treatment. Since the 1980s, new treatment strategies combining cytoreductive surgery (CRS) with perioperative intraperitoneal and intravenous chemotherapy have emerged. The underlying hypothesis considers CRS responsible for the removal of the macroscopic disease and that perioperative chemotherapy should address the residual microscopic disease. These new treatment regimens have presented encouraging clinical results that contrast with prior failure. The parameters for perioperative chemotherapy are mainly extrapolated from literature on peritoneal dialysis and data from systemic chemotherapy. The overall aim of this thesis was to provide a pharmacokinetic and pharmacodynamic rationale for perioperative intraperitoneal (IP) and intravenous (IV) chemotherapy in PC patients and, to assess its toxicity. After intraoperative IV administration of 5-fluorouracil or ifosfamide, substantial levels of these drugs were found inside the peritoneal fluid and tumor nodules (Papers I and II). This created a pharmacologically advantageous situation whereby a normothermic administered IV drug was subject to the effect of the local hyperthermia in the peritoneal fluid and tumor nodule. High levels of 5-fluouracil, ifosfamide and doxorubicin were observed inside the tumor nodules (Papers I, II and III) and, the identical pharmacokinetic advantage (expressed as Area Under the Curve (AUC) IP/IV ratios)) resulted in different drug levels of doxorubicin according to the density of the tumor nodules (Paper III). These data stressed the importance of pharmacodynamic variables such as tumor nodule density, size, and, vascularity. Therefore, the tumor nodule is proposed as a more appropriate pharmacological endpoint than AUC ratios. After IP Mitomycin C administration in PC patients with a contracted abdomen, mitomycin clearance from the abdomen decreased (Paper IV), which indicated  these patients at risk of under-treatment. Consequently, these pharmacologic data indicate a change in dosimetry for these treatment protocols might be warranted according to the diffusion area. Although diffusional vectors are viewed the main driving force for these treatment protocols, only pharmacokinetic variables such as dose, volume and duration are considered. As pharmacodynamic variables are equally important in the pharmacological assessment of cytotoxic effect, the tumor nodule was proposed as the center of a new conceptual model (Paper I). Mitomycin C data on non-metabolizers ( Paper IV) indicated the cytotoxicity of these cancer chemotherapy protocols is at the level of the individual tumor nodules. The morbidity and mortality of a new bidirectional intraoperative chemotherapy regimen in PC patients was analyzed (Paper V) which provided a means for identifying subsets of patients at risk for increased toxicity. This thesis provides pharmacokinetic and pharmacodynamic guidance for improving perioperative chemotherapy treatment strategies in PC patients and reports its toxicity.

Ovarian cancer has the highest mortality rate of all gynecological malignancies, due to inadequate treatment strategies and poor early diagnosis. Intraperitoneal (IP) chemotherapy administered on an intermittent schedule has been pursued for ovarian cancer treatment. However, local toxicities and complications associated with indwelling IP catheters required to deliver the chemotherapeutics have been documented. Furthermore, shortening or completely removing treatment-free periods between each chemotherapy cycle has shown improved efficacy compared to intermittent chemotherapy. The focus of this thesis was to develop and characterize a biocompatible and biodegradable IP injectable depot sustained drug delivery system as a new treatment strategy for ovarian cancer. A polymer-lipid injectable formulation (PoLigel) was developed and used for sustained docetaxel (DTX) delivery. The PoLigel resulted in homogeneous DTX peritoneal distribution and sustained plasma levels in healthy mice, which was in contrast to Taxotere®, the clinically used formulation of DTX. Sustained plasma, tissue, tumor and ascites DTX concentrations were observed in mice bearing IP SKOV3 tumors or ID8 ascites over a 3 week period following IP administration of the PoLigel. The intratumoral distribution and tumor penetration of DTX in subcutaneous (SC) and IP SKOV3 tumors were characterized. DTX distributed more towards the tumor core and diffused 1.5 fold further from blood vessels of the IP tumors compared to the SC tumors. The high efficacy observed in the IP SKOV3 and ID8 models and the SC SKOV3 model was attributed to favorable drug distribution at the whole-body, peritoneal and intratumoral levels in combination with local and systemic sustained drug exposure. Sustained chemotherapy with DTX alone and in combination with a drug efflux transporter inhibitor was investigated in multidrug resistant (MDR) ovarian cancer. In vitro, combination delivery via the PoLigel resulted in more apoptosis, greater intracellular accumulation of DTX, and lower DTX efflux in MDR ovarian cancer cells. Sustained combination chemotherapy was more than twice as efficacious as intermittent Taxotere® treatment in MDR ovarian cancer. Significant anti-tumor efficacy was also observed in the MDR model following sustained DTX chemotherapy compared to intermittent Taxotere®. Overall, results presented here encourage the clinical investigation of IP sustained chemotherapy for ovarian cancer treatment.

Ovarian cancer has the highest mortality rate of all gynecological malignancies, due to inadequate treatment strategies and poor early diagnosis. Intraperitoneal (IP) chemotherapy administered on an intermittent schedule has been pursued for ovarian cancer treatment. However, local toxicities and complications associated with indwelling IP catheters required to deliver the chemotherapeutics have been documented. Furthermore, shortening or completely removing treatment-free periods between each chemotherapy cycle has shown improved efficacy compared to intermittent chemotherapy. The focus of this thesis was to develop and characterize a biocompatible and biodegradable IP injectable depot sustained drug delivery system as a new treatment strategy for ovarian cancer. A polymer-lipid injectable formulation (PoLigel) was developed and used for sustained docetaxel (DTX) delivery. The PoLigel resulted in homogeneous DTX peritoneal distribution and sustained plasma levels in healthy mice, which was in contrast to Taxotere®, the clinically used formulation of DTX. Sustained plasma, tissue, tumor and ascites DTX concentrations were observed in mice bearing IP SKOV3 tumors or ID8 ascites over a 3 week period following IP administration of the PoLigel. The intratumoral distribution and tumor penetration of DTX in subcutaneous (SC) and IP SKOV3 tumors were characterized. DTX distributed more towards the tumor core and diffused 1.5 fold further from blood vessels of the IP tumors compared to the SC tumors. The high efficacy observed in the IP SKOV3 and ID8 models and the SC SKOV3 model was attributed to favorable drug distribution at the whole-body, peritoneal and intratumoral levels in combination with local and systemic sustained drug exposure. Sustained chemotherapy with DTX alone and in combination with a drug efflux transporter inhibitor was investigated in multidrug resistant (MDR) ovarian cancer. In vitro, combination delivery via the PoLigel resulted in more apoptosis, greater intracellular accumulation of DTX, and lower DTX efflux in MDR ovarian cancer cells. Sustained combination chemotherapy was more than twice as efficacious as intermittent Taxotere® treatment in MDR ovarian cancer. Significant anti-tumor efficacy was also observed in the MDR model following sustained DTX chemotherapy compared to intermittent Taxotere®. Overall, results presented here encourage the clinical investigation of IP sustained chemotherapy for ovarian cancer treatment.

Skrandžio vėžys yra ketvirta pagal dažnį ir antra pagal mirtingumą onkologinė liga pasaulyje. Sergančių šia liga 5 metų išgyvenamumas siekia tik 25 proc. Esant didelei ligos atkryčio rizikai dažniausiai skiriama adjuvantinė chemoterapija, nors daugumoje atsitiktinių imčių studijų statistiškai reikšmingo išgyvenamumo pagerėjimo nenustatyta. Dažniausia skrandžio vėžio gydymo nesėkmės priežastis yra lokoregioninis recidyvas (40-65 proc. ligonių, kuriems atliktos radikalios operacijos) ir pilvaplėvės metastazės. Siekiant sumažinti lokoregioninių recidyvų dažnį, pradėtas taikyti suderintas chemospindulinis gydymas. Šio tyrimo tikslas- nustatyti adjuvantinio gydymo efektyvumą po radikalių skrandžio vėžio operacijų su D2 limfadenektomija ir pagrįsti šio gydymo metodo tikslingumą. Darbo tikslui įgyvendinti buvo suformuluoti šie uždaviniai. 1. Įvertinti radikaliai dėl skrandžio vėžio operuotų su D2 limfadenektomija pacientų išgyvenamumą taikant adjuvantinį chemospindulinį gydymą arba adjuvantinę chemoterapiją. 2. Įvertinti adjuvantinio chemospindulinio gydymo toksiškumą po radikalių operacijų su D2 limfadenektomija, palyginti jį adjuvantinės chemoterapijos 5-fluoruracilu ir leukovorinu sukeliamu toksiškumu. 3. Įvertinti ankstyvos pooperacinės intraperitoninės chemoterapijos toksiškumą ir palyginti jos efektyvumą taikant su adjuvantiniu chemospinduliniu gydymu. 4. Palyginti gyvenimo kokybę po radikalių operacijų dėl skrandžio vėžio atliekant gastrektomiją ir subtotalinę skrandžio... [toliau žr. visą tekstą] / Gastric cancer is the fifth most common cancer and the second leading cause of cancer-related death worldwide. The 5-year survival rate of these patients is approx. 25. Adjuvant chemotherapy is frequently used for treatment, despite the fact that many randomized studies failed to demonstrate a better patient survival. The high rate of recurrence, even in patients undergoing state-of-the art curative resection, suggests that effective adjuvant chemoradiation and chemotherapy might indeed be an attractive concept to improve the overall outcomes of patients with gastric cancer. The aim of this study was to evaluate the effectiveness of the adjuvant therapy after curative resection with D2 lymphadenectomy for gastric cancer and determine its role in the treatment of cancer patients. The goals of this study were: 1. To compare the survival of patients receiving adjuvant chemoradiation or adjuvant chemotherapy after the curative resection with D2 lymphadenectomy for gastric cancer. 2. To evaluate the toxicity of the adjuvant chemoradiation after the curative resection with D2 lymphadenectomy for gastric cancer and to compare it with the toxicity caused by adjuvant chemotherapy with 5- Fluorouracil and Leucovorin. 3. To assess the toxicity of the early postoperative intraperitoneal chemotherapy and compare its effectiveness with the combined intraperitoneal chemotherapy and adjuvant chemoradiation therapy. 4. To compare the quality of life after the total and subtotal... [to full text]

Le cancer de l'ovaire est la première cause de décès par cancer gynécologique. Cette thèse avait pour objectif la prospection de nouvelles solutions thérapeutiques fondées sur la délivrance prolongée d'agents anti tumoraux à l'aide de systèmes macromoléculaires de synthèse. L'un des obstacles majeurs était la disposition d'un modèle de tumeur pertinent chez l'animal. Après un examen bibliographique des connaissances acquises, le deuxième chapitre examine le potentiel d'un panel de xénogreffes dérivées de tumeurs ovariennes humaines directement greffées chez la souris immunodéprimée. Il est montré que les principales caractéristiques phénotypiques et moléculaires des tumeurs originales sont maintenues au niveau des greffes. Les résultats traduisent la présence d'une hétérogénéité intra-tumorale et d'une oligoclonalité au niveau des tumeurs primaires. L'ensemble confirme l'importance du choix du modèle tumoral pour l'évaluation de nouveaux traitements et l'étude des mécanismes aboutissant aux rechutes de la maladie et au développement d'une chimiorésistance. Un troisième chapitre traite l'exemple d'un système de délivrance prolongée fondé sur le couplage d'un agent antitumoral modèle, la doxorubicine, associé de diverses manières à un vecteur macromoléculaire biorésorbable, le poly(L-lysine citramide). Le premier conjugué obtenu par couplage direct sur le vecteur étant trop stable, divers systèmes ont été conçus pour obtenir la libération souhaitée. L'utilisation d'un bras espaceur clivable de type ester-hydrazone a fourni le meilleur résultat. Pour pallier la complexité de ces conjugués, une stratégie innovante fondée sur le piégeage de la doxorubicine dans une gélatine artificielle à base de poly(N-acryloyl glycinamide) est prospectée qui devrait permettre l'utilisation simultanée de plusieurs principes actifs piégés temporairement par voie physique dans un gel adhésif et fournir des solutions mieux adaptées aux contraintes cliniques des traitements intrapéritonéaux. / Ovarian carcinoma is the most lethal gynecologic malignancy. The aim of this PhD thesis was to develop new therapeutic approaches based on novel synthetic macromolecular drug delivery systems for intraperitoneal chemotherapy. These objectives were limited by the requirement of reliable tumor models for experimental studies. After a concise review of knowledge published in the literature, the potential interest of the establishment of a collection of tumor grafts derived from samples of human tumors is examined in a second chapter. Data show that the major phenotypic and genotypic features of the original tumors are maintained in the xenografts. They also confirm the importance of this tumor model to test new drugs and to analyze intratumoral heterogeneity and oligoclonality in primary ovarian carcinoma. The collection will be also helpful to study the mechanisms leading to disease recurrences and resistance to chemotherapies. An example of drug delivery system based on the different associations of a model chemotherapeutic drug (doxorubicin) with a bioresorbable macromolecular vector, namely poly(L-lysine citramide), is addressed in a third chapter. Direct amid linkage in the first conjugate was too stable with respect to antitumoral cytotoxicity desired after in vivo administration and different systems were generated subsequently to increase drug release in tumor deposits. The best results were obtained with a hydrazone cleavable spacer containing an ester group. To overcome the complexity of these conjugates, a novel strategy based on doxorubicin entrapment in a synthetic gelatin made of (poly(N-acryloyl glycinamide) is developed. This strategy should allow physical temporary entrapment of different drug molecules in a adhesive gel and could provide new solutions to the therapeutic challenges of intraperitoneal administration.

A administração intraperitoneal de 5-fluorouracil (5-FU) no pós-operatório imediato reduz a recorrência local e prolonga a sobrevida dos pacientes com câncer colônico. Contudo, esse tratamento também pode prejudicar a cicatrização das anastomoses intestinais. O objetivo deste estudo foi determinar os efeitos da quimioterapia (QT) intraperitoneal (IP) pós-operatória (PO) precoce com o 5-FU e da selagem anastomótica com o TachoSil sobre o processo de cicatrização de anastomoses colônicas. Quarenta ratos foram divididos em quatro grupos (I - IV, com dez ratos em cada) e submetidos à secção do cólon esquerdo seguida por anastomose. As anastomoses dos ratos dos grupos II e IV foram cobertas com o TachoSil. Solução salina (2 ml/dia grupos I e II) ou 5-FU (20 mg/kg/dia grupos III e IV) foi administrado por via IP uma vez ao dia, desde do procedimento cirúrgico até a morte programada dos animais no quarto dia pós-operatório. Foram realizadas medidas da pressão de ruptura e análise histopatológica das anastomoses. A perda relativa de peso foi significativamente maior nos animais do grupo III comparado a todos os demais grupos (p=0,0004). Não houve diferença significativa entre os grupos no que se refere à presença de fístulas, coleções perianastomóticas, sinais de dilatação intestinal pré-anastomótica ou aderências pós-operatórias. A pressão de ruptura foi significativamente menor no grupo III comparada a todos os demais grupos (p=0,001). A neoangiogênese foi significativamente menor no grupo III comparada aos grupos I e II (p=0,05). A infiltração fibroblástica foi significativamente maior no grupo I e em comparação ao grupo III (p=0,035). Não ocorreu diferença significativa entre os grupos no que concerne à presença de infiltração de células inflamatórias e deposição de colágeno. Os dados obtidos permitem concluir que a QT IP precoce com 5-FU afetou negativamente a fase inicial da cicatrização de anastomoses colônicas. Contudo, a selagem com o TachoSil foi capaz de reverter alguns dos efeitos adversos decorrentes da QT. / The administration of 5-fluorouracil (5-FU) during the early postoperative period can decrease local cancer recurrence but may also cause impairment of the anastomotic healing. This study examined the effects of the use of this therapy and of the anastomotic sealing with a fibrin-collagen patch (TachoSil) on the healing of colon anastomoses. Forty male rats were divided into four groups (I to IV, 10 rats each) that underwent transection and anastomosis of the left colon. The anastomoses were covered with TachoSil in groups II and IV. Saline solution (2 ml/day groups I and II) or 5-FU (20 mg/kg/day; groups III and IV) was administered intraperitoneally (IP) once daily for three days. Bursting pressure (BP) was recorded and the anastomoses were examined macroscopically and graded histologically. The relative weight loss was significantly higher in group III than in the other groups (p=0.0004). Anastomotic dehiscense, postoperative adhesion formation, perianastomotic collections, and preanastomotic dilatation did not differ significantly among groups. BP was significantly lower in group III compared to all other groups (p=0.001). Neoangiogenesis was significantly lower in group III compared to groups I and II (p=0.05). Fibroblastic activity was significantly higher in group I compared to group III (p=0.035). Inflammatory cell infiltration and collagen deposition did not differ significantly among groups. Our results shown that the early postoperative IP chemotherapy with 5-FU impaired the healing of colon anastomoses. However, anastomotic sealing with TachoSil reversed some of the negative effects of this therapy.