ABSTRACT
Control of pelvic cancer may improve the quality of life in such patients and result in longer survival even in the presence of cancer outside the pelvis. Systemic chemotherapy and radiation therapy has failed due to high resistance of the tumour and poor vascularisation. Regional pelvic chemotherapy, by isolated regional perfusion, has been used by several groups in an effort to control advanced bladder and rectal malignancies. In the last 10 years, however, less emphasis has been placed on perfusion and more on intra-arterial chemotherapy alone or in conjunction with chemofiltration. Although their initial technique used an open occlusion of the aorta and inferior vena cava, they subsequently adapted the use of balloon occlusion- catheter. The aim of this work is to evaluate the applicability, efficacy, and safety of Pelvic Stop-Flow Infusion [PSFI] in the management of patients with locally advanced bladder and rectal malignancies. To complete our study in this field after our successful initial experience in management of locally advanced cancer cervix and ovaries. The study included 45 patients with locally advanced or recurrent cancer bladder and 45 patients with locally advanced or recurrent cancer rectum. Patients are classified into 2 classes: Class 1: Including 45 patients with advanced or recurrent cancer bladder previously treated by surgery, radiotherapy and/or chemotherapy. They are divided into 3 groups [Group I: [Control group]: included 15 patients whom received conventional chemo/radiotherapy. Group II: [Palliative group] included 15 patients, whom are not candidates for surgical interference. They received PSFI with the aim of palliation. Group III: [Pre-operative group]: included 15 patients, whom are candidates for surgery after receiving PSFI with the aim of under-staging. The type of surgery might be definitive, cytoreductive, or palliative. Class II: Including 45 patients with advanced or recurrent colorectal cancer previously treated by surgery, radiotherapy and / or chemotherapy. They are divided into 3 groups, each of them included 15 patients: Group I: [Control group], Group II: [Palliative group], Group III [Pre-operative group]. As first described by Aigner, 1993, the technique entails exposure of the Femoral artery and vein via a longitudinal incision in the groin, then arteriotomy and venotomy were done for admitting the large bore, rigid catheters. A more simplified our technique, the percutaneous balloon infusion, is the one we used. Serial pelvic and systemic blood samples were collected during the infusion period, and pelvic- to systemic drug- exposure ratio was determined. Tumour response was evaluated 8-12 weeks after completion of aortic stop-flow infusion cycle [s] with clinical examination, tumour volume response [by abdomino-pelvic CT], pain response, histological response, tumour marker response, laparotomy finding, disease frees survival [as regard further metastasis and local recurrence], procedure related complications, chemotherapeutic toxicity, and overall survival. Our study found that: In Cancer bladder patients treated with palliative pelvic stop-flow: 10/15 cases [66.6%] shown reduction of size, and 8/15 patients [53%] shown improvement of pain. In Cancer bladder patients treated with pre-operative pelvic stop-flow: 12 out of 15 cases [80%] shown reduction of size, with a highly significant P- value = 0.005 [9/12 underwent radical cystectomy, the remainder underwent palliative resection], and 9 patients [60%] shown improvement of pain. In colorectal cancer patients treated with palliative pelvic stop-flow: 11/15 patients [73.3%] shown reduction in size, and 7/15 patients [46.7%] shown improvement of pain. In colorectal cancer patients treated with preoperative pelvic stop-flow: 13 out of 15 cases [86.6%] shown reduction of size, with a highly significant P- value 0.003, [5/13 underwent abdomino-perineal resection, 3/13 underwent low anterior resection, and 2/13 underwent abdomino-perineal resection and liver metastectomy, the remainder 3 patients underwent palliative resection] Also 8/15 patients [53.3%] shown improvement of pain. The stop-flow method is introduced to markedly reduce blood flow to target tissue, and higher drug delivery than either simple intra-arterial or intravenous infusion. [2] Retarded blood flow may improve response not only by lengthening exposure time, but also by induced tissue hypoxia and low cellular pH. [3] Our technique is a new, easy, low cost procedure that can be done as a one-day procedure in the angiography room