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Experimental Study on the Safety of Abdominal Cavity Circulatory Thermal Perfusion*
Experimental Study on the Safety of Abdominal Cavity Circulatory Thermal Perfusion*
Wenchao Liu , Chunbao Li , Wang Yu , Wei Li
Correspondence to : Wenchao Liu ; Email : xjcancer fmmu . edu . cn
Department of Oncology , Xijing Hospital , the Fourth Military Medical University , Xi ’ an 710032 , China
This work was supported by the National Natural Science Foundation of China ( No . 30973437 )
Abstract Objective : This work investigated the effect of cavity circulatory thermal perfusion ( CCTP ) on the vital signs and important organs of experimental animal dogs at different temperatures . The study likewise aimed to determine the optimal temperature for chemotherapy . Methods : Dogs were used as the experimental animal models for CCTP . CCTP was performed with cisplatin using a hyperthermic intraperitoneal treatment system at 41℃ , 42℃ , and 43℃ ( one course of clinical treatment ) . The hepatic and renal functions were detected in preserved blood samples before CCTP and at 24h after each course of the treatment . The respective morphological and pathological changes of the major abdominal organs were likewise studied at 24h as well as 2 weeks after the third course of CCTP . Results : The three courses of CCTP with a perfusion rate of 140mL / min at 41 or 42℃ did not have any observable negative effects on the hepatic and renal functions of experimental animals . On the other hand , the three courses of CCTP with a perfusion rate of 140mL / min at 43℃ had a significant negative effect on the hepatic and renal functions , with histopathological injuries in the liver , kidney , spleen , and intestines . Conclusion : CCTP with a perfusion rate of 140ml / min combined with cisplatin chemotherapy ( three times / 60min ) was safe and feasible at 42℃ , but could damage visceral organs of experimental animals at 43℃ .
Key words ： Cavity circulatory thermal perfusion ; Safety ; Thermal injury ; Thermo-chemotherapy damage
doi : 10 . 3969 / j . issn . 1000—8179 . 2012 . 22 . 006
The treatment of malignant pleural effusion mainly relies on dieresis , repeated drainage of ascites , the application of chemotherapy drugs and other methods . However , the therapeutic effect is limited . With the development of thermotherapy , the role of hyperthermia in cancer therapy is becoming more and more important . CCTP showed a good effect in the treatment of malignant effusion . The treatment performed under a warm condition with mild invasive was combined with cytotoxic drugs . Therefore its safety was more and more concerned . In this study , the safety of CCTP was assessed both in the whole body and the local of the animal models . Also the suitable temperature for CCTP was explored so as to provide the experimental evidence for the clinical application of CCTP in the treatment of malignant pleural effusion .
1 Material and Methods
1 . 1 Material
Experimental equipment : Extracorporeal circulation perfusion machine GDPR-2100S ( produced by Xi'an good doctor medical technology Co . , Ltd . ) ; RM6240 multi-channel physiological ( Chengdu Instrument Factory ) ; AI 560 digital thermometer ( Xiamen Yudian Automation Co . , Ltd . )
The experimental animal and grouping : 18 of adult healthy hybrid dogs ( provided by The Fourth Military Medical University ) , regardless of gender , with body weight of ( 18±0.5 ) kg were randomly divided into three groups : group A ( 41℃ saline+cisplatin , 6 dogs ) , group B ( 42℃ saline+cisplatin , 6 dogs ) , group C ( 43℃ saline+cisplatin , 6 dogs ) . Dogs were in separate cages .
1 . 2 Methods
1 . 2 . 1 CCTP treatment CCTP treatment was performed on each dogs in every treated groups , 60min for each time in every 3 days , repeated for 3 times . Intraperitoneal injection of anesthesia was used with sodium pentobarbital ( 50 mg/kg ) . Two needles were placed and fixed in both left and right sides of abdominal cavity . Two needles were respectively connected with the inlet and outlet catheter of the extracorporeal circulation perfusion machine GDPR-2100S . High precision PT100 temperature sensor was placed by the side of the catheter as well as in the left and right upper abdominal cavity . The input temperature for the lavage solution was 41℃ , 42℃ and 43℃ with the flow rate of 140ml / min . A single-path mode was firstly preferred . The input temperature for the 2500ml physiologic lavage solution containing 100mg / kg cisplatin was 41℃ , 42℃ and 43℃ . Then the cycle model was adapted . The whole course with constant temperatures continued for 60min .
1 . 2 . 2 Observation The input and output temperatures were shown on GDRP-2100S . The temperature of the puncture point of both right and left upper abdomen were read by AI-5600 digital thermometer . The indexes needed to be monitored were flow rate , heart rate , blood pressure , means of arterial pressure , ascites floats and ascites colors . The temperature of four points were recorded every 10min . Peripheral blood sample were collected before and 24h after each course of the treatment . 24h as well as 2 weeks after the third course of CCTP , 2 dogs were killed in each group , collect heart , liver and spleen and kidney , fixed the tissue with 10%methanol , paraffin embed , routine HE stained and morphology observed by microscope .
1 . 3 statistics
All the data were shown as mean±standard deviation . Statistical analysis was performed using the SPSS 12 . 0 . ANOVA was used to investigate the different mean in each group . A p< ; 0 . 05 was considered significant .
2 . 1 The change of vital signs after CCTP
In group A , the mean body temperature of dogs rose by 0 . 2℃ after 1h-treatment of CCTP in 41℃ , with heart rate of ( 120±5 ) beats / min , respiratory rate of ( 15±5 ) breath / min and mean arterial pressure 125mmHg . In group B , the mean body temperature of dogs rose by 0 . 5℃ after 1h-treatment of CCTP in 42℃ , with heart rate of ( 135±5 ) beats / min , respiratory rate of ( 23±5 ) breath / min and mean arterial pressure 130mmHg . In group C , the mean body temperature of dogs rose by 1 . 5℃ after 1h-treatment of CCTP in 43℃ , with heart rate of ( 140±5 ) beats / min , respiratory rate of ( 30±5 ) breath / min and mean arterial pressure 120mmHg .
2 . 2 The change of hepatic and renal functions after CCTP
In group A and group B with the temperature of 41℃ and 42℃ , there were little change of hepatic and renal functions after CCTP , or mild change after perfusion ( p< ; 0 . 05 ) . These change returned to be normal after 2 weeks . However , in group C with the temperature of 43℃ , the damage of hepatic and renal functions were found , showing that the level of glutamic-pyruvic transaminase ( ALT ) , glutamic-oxalacetic transaminase ( AST ) , Creatinine ( Cr ) , Uric acid ( UA ) were significantly higher in 4d after CCTP ( P< ; 0 . 05 ) , and still abnormal of ALT and AST in 2 weeks after CCTP ( P< ; 0 . 05 , Table1 ) .
2 . 3 The morphological changes of abdominal organs after CCTP
In group A and group B , no obviously damage of liver , kidney , spleen and intestine were found in 24h after three courses of CCTP , as well as 2 weeks after treatment . However , in group C , mental adhesion was found in part of organs . Mesenteric vascular congestion significantly , and also small ecchymosis and hemorrhage can be found in liver and intestinal . No obviously change was found in kidney . After 2 weeks , still small area of ecchymosis left in intestinal , however , adhesion was in remission .
2 . 4 The pathological changes of abdominal organs
In group A , No change but mild congestion was found in liver , intestinal , kidney and spleen in 24h after 3 courses of CCTP , and return to normal after 2 weeks . The pathological changes of abdominal organs in group B and group C were shown in Table2 , Figure 2 .
Figure 1 General morphological changes in abdominal organs at 24h after three cycles of CCTP at 43℃ for 60 min . There was extravasated blood in a small portion of liver and intestines . The mesenteric vascular vessel was evidently congested , and the omentum adhered to most of abdominal tissues . Two weeks after CCTP . Some bowel regions were still bruised , but abdominal adhesion was relived .
Peritoneal metastasis is an important metastasis route of digestive system tumor , especially in gastrointestinal tumor , and it is also the main causes of death . Thermo chemotherapy is considered to be one of an important therapy ways for digestive system tumor .
Cavity thermal perfusion can be divided into abdominal irradiation heating in vitro and intraperitoneal circulation heating . The perfusion solution did not flow in former while it is continuous flowing in later . There was study found that , the relative safe temperature for non-cycle perfusion is 43℃ for 30 min . It is also supported by a in vitro study shown that 43℃ for 40min is a safety tipping point to organs and tissues [ 1 ] . However , the safe temperature for cycle perfusion was unclear . Therefore , the study aimed to determine the optimal temperature for cavity circulatory thermal perfusion combined with chemotherapy .
Dogs were selected as experimental animal to explore the optimal temperature for CCTP . According to the experimental animal and clinical application , 1 dog was perfused by pure physiology saline at the perfusion flow rate of140mL / min for 45℃ . Finally , the dog is dead at 3d after CCTP . Therefore , 43℃ and 60 min were suspected to be the tolerated limiting for dog perfused by saline combined with cisplatin . Based on this study , 42℃ is a safety temperature among 41℃ , 42℃ and 43℃ .
According to the pathological changes of organs in this study , no obviously effect were found after three courses of CCTP with ( physiological saline+cisplatin ) condition of 41℃ , 140mL / min and 60min . It can be used as the temperature for prophylactic treatment . Under the CCTP ( physiological saline+cisplatin ) with condition of 42℃ , 140ml / min flow rate for 60min , mile damage were found in liver , spleen , kidney and intestines of dogs . And it can recover at 2 weeks , as a reversible injury . So it can also be used for CCTP treatment . An irreversible injury of liver , spleen and intestines can be found after CCTP treatment under the condition of 43℃ , 140mL / min of flow rate for 60min , and it cannot recover at 2 weeks after treatment . So 43℃ cannot be used as CCTP treatment .
42℃~43℃ was considered to be the ideal temperature [ 2-4 ] , under which tissues and cells can obtain best effect . The effect is not obvious when the temperature is below 40℃ . While the tissues may be injured when the temperature is above 43~45℃ and no effect of reversal of drug resistance was found [ 5-6 ] . CCTP treatment with the temperature of 43℃ for 60min induced irreversible injury on cells . The study found that the damage mechanism of heating of 41~42℃ includes the change of tumor cell membrane permeability [ 7 ] , degrade the extracellular matrix [ 8 ] , up-regulation of cell adhesion ability [ 9 . 13 ] . Additionally , heat can promote D N A and platinum binding , and increase the intracellular concentration of platinum drugs , and inhibit cisplatin-induced cell damage repair mechanism [ 10 , 14 ] . So synergistic effect can be found when cisplatin was combined with hyperthermia [ 11 ] . The organ injured temperature obtained from this study was lower than the temperature reported previously . It possibly because of different technology of temperature monitor ; secondly , tissue fluid erosion damage caused by perfusion flow ( flow rate 140mL / min ) . The faster of flow rate the more damage might be made . Thirdly , chemotherapy drugs had the directly effect on tissues . All the above suggested that the tissue injured during perfusion were not only caused by high temperature ( 43℃ ) , but also by fluid power and drug .
Recently , different kinds of circulating perfusion machine with distinct temperature control method and heating methods were used . So the different model of thermal damage may happen . The GDRP-2100 we used in this study can precisely control and measure temperature and maintain a constant peritoneal temperature after heating rapidly , and guarantee the heat and drug dispersed in body and organ evenly . There were three main conclusions in this study , CCTP with the condition of 41℃ , at flow rate of 140mL / min for 60min had no obviously injure effect ; with 42℃ , reversible injury happened ; and with 43℃ , serious and irreversible injury happened . In conclusion , for dogs , the safety condition of CCTP is 42℃ , with the flow rate or 140mL / min , 3 times , and 60min per course .
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Observation of the clinical treatment effect of body cavity circulative hyperthermic perfusion chemotherapy to treat malignant pleural effusion