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BRIEF COMMUNICATION
Year : 2015  |  Volume : 11  |  Issue : 2  |  Page : 475-478

Combination of retrograde superselective intra-arterial chemotherapy and Seldinger method in locally advanced oral cancer


1 Department of Science of Physical Functions, Division of Maxillofacial Surgery, Kyushu Dental University, Kitakyushu, Fukuoka, Japan
2 Department of Dentistry and Oral Surgery, University Hospital of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan
3 Department Regenerative Oral Surgery, Unit of Translational Medicine, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan

Date of Web Publication7-Jul-2015

Correspondence Address:
Masataka Uehara
Department of Science of Physical Functions, Division of Maxillofacial Surgery, Kyushu Dental University, 2-6-1, Manazuru, Kokurakita-ku, Kitakyushu 803 8580, Fukuoka
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.140833

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 > Abstract 

The nonsurgical strategies for locally advanced oral cancer are desirable. Superselective intra-arterial infusion with radiotherapy was utilized for this purpose, and there are two types of superselective intra-arterial infusion methods: The Seldinger method and the retrograde superselective intra-arterial chemotherapy (HFT method). In one case, the HFT method was applied to locally advanced tongue cancer, and the Seldinger method was used for additional administration of cisplatin (CDDP) to compensate for a lack of drug flow in the HFT method. In another case, the HFT method was applied to locally advanced lower gingival cancer. The Seldinger method was applied to metastatic lymph nodes. In both cases, additional administration of CDDP using the Seldinger method resulted in a complete response. The combination of the HFT and Seldinger methods was useful to eradicate locally advanced oral cancer because each method compensated for the defects of the other.

Keywords: Combination, retrograde superselective intra-arterial chemotherapy, Seldinger method, oral cancer


How to cite this article:
Uehara M, Ohya R, Kodama M, Shiraishi T, Asahina I, Tominaga K. Combination of retrograde superselective intra-arterial chemotherapy and Seldinger method in locally advanced oral cancer. J Can Res Ther 2015;11:475-8

How to cite this URL:
Uehara M, Ohya R, Kodama M, Shiraishi T, Asahina I, Tominaga K. Combination of retrograde superselective intra-arterial chemotherapy and Seldinger method in locally advanced oral cancer. J Can Res Ther [serial online] 2015 [cited 2017 Nov 22];11:475-8. Available from: http://www.cancerjournal.net/text.asp?2015/11/2/475/140833


 > Introduction Top


Although the current strategy for locally advanced oral cancer is mainly surgery, nonsurgical treatments are desirable because postoperative disfigurement and loss of oral functions including speech, and swallowing, are serious problems. Although radiotherapy with systemic chemotherapy was tried for advanced oral cancer, it has been almost impossible to achieve complete response. [1],[2] Recently, superselective intra-arterial infusion with radiotherapy instead of surgery was introduced for local advanced oral cancer. There were two types of superselective intra-arterial intubation; anterograde and retrograde intubations. Anterograde intubation to the target artery is usually achieved by the Seldinger method. [3] In this method, the catheter was intubated into the target artery from the femoral artery and a high dose of cisplatin (CDDP) was administered weekly with conventional radiotherapy. The catheter was removed immediately after every infusion of CDDP. On the other hand, retrograde superselective intubation was introduced by Tohnai et al. as an HFT method. [4],[5] In this method, catheters were intubated in the target arteries via superficial temporal artery (STA) and/or occipital artery (OA) retrogradely, and the catheters were retained until treatment was finished. Therefore, the HFT method enables daily concurrent chemoradiotherapy.

We propose here that the combination of the HFT and Seldinger methods could compensate for the defects of each.


 > Patients and methods Top


Case 1

A 60-year-old woman was diagnosed with squamous cell carcinoma (SCC) of the tongue, left side (T4N2cM0) [Figure 1]. This was a primary tumor and there had been no previous treatment. Preoperative transvenous computerized tomographic angiography (CTA) was performed to identify the STA, OA, and target arteries. The catheters were intubated in the left linguo-facial trunk [Figure 2], in the right lingual artery via each STA according to Tohnai's (HFT) method. [4] Briefly, a guidewire (GT wire, 0.016 inch diameter; Terumo Corp., Tokyo, Japan) was inserted into the common carotid artery via STA. A vinyl hook-shaped catheter (Neck, 4 Fr outer diameter; Medikit Corp., Tokyo, Japan) was inserted into the STA along with the guidewire, and the guidewire was removed. Then the catheter was drawn back under fluoroscopic guidance using contrast medium (Omnipaque 300; Daiichi-Sankyo Corp., Tokyo, Japan) to insert the tip of the catheter into the target arteries. Then, blue dye (Indigocarmine; Daiichi-Sankyo Corp., Tokyo, Japan) was injected slowly from the catheter to confirm the flow to the tumor and tumor in left oral floor was not entirely stained [Figure 3]. After concurrent chemoradiotherpay (daily infusion of cisplatin [CDDP]; totaling 100 mg/m 2 and weekly infusion of docetaxel [DOC]; totaling 50 mg/m 2 , radiotherapy; Linear accelerator [2.0 Gy/day without fractionation] totaling 60.0 and 40.0 Gy in the oral and bilateral neck regions, respectively), it was manifested that a branch of the right facial artery fed the left oral floor by Seldinger method [Figure 4]. Fifty mg/m 2 of CDDP was additionally administered by Seldinger method in this region once a week for 2 weeks (total 100 mg/m 2 ). After the stomatitis subsided, a biopsy of the tongue and left oral floor was performed under local anesthesia, with the result showing complete response [Figure 5]. The patient was alive and free of disease 5 years after treatment.
Figure 1: Clinical findings before treatment in case 1

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Figure 2: Computerized tomographic angiography of case 1. Left linguo-facial trunk was recognized

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Figure 3: Findings of tumor at blue dye injection from catheter that was inserted in the left linguo-facial trunk by the retrograde superselective intra-arterial intubation. Distinct blue staining was observed in the tongue, lower gingiva, and buccal mucosa on the left side, although there was a lack of blue staining in the left oral floor (arrow)

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Figure 4: Findings in the oral cavity after blue dye injection from a catheter that was inserted into a branch of the right facial artery by the Seldinger method. Blue staining was observed in the left oral floor where the flow from the left linguo-facial trunk was insufficient (arrow)

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Figure 5: Findings at 7 weeks after treatment. The tumor was free at the left tongue and oral floor

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Case 2

A 72-year-old woman was diagnosed with SCC of the lower gingiva, left side (T4N3M0) [Figure 6] and [Figure 7]. This was a primary tumor and there had been no previous treatment. The HFT method was carried out in the right facial and lingual arteries as well as left facial artery via right STA, OA and left STA, respectively, and these arteries were confirmed as tumor feeders by blue dye staining. And concurrent chemoradiotherapy was carried out with adequate hydration (daily infusion of CDDP; totaling 200 mg/m 2 and weekly infusion of DOC; totaling 60 mg/m 2 , radiotherapy; intensity-modulated radiation therapy [twice daily hyperfractionation with 1.0 Gy per fraction] totaling 72.0 Gy in the mandible, tongue and metastatic lymph nodes). For the Seldinger method, the targets were the left lingual artery, which was not catheterized in the HFT method, and a branch of the left facial artery, which was identified as a feeder of metastatic lymph nodes [Figure 8]. The additional administration of CDDP by the Seldinger method was carried out when the dose of radiotherapy was 38 Gy (70 mg in a branch of the left facial artery, 30 mg in the left lingual artery). After the stomatitis almost subsided, enhanced CT was taken to assess the effects in both the primary and neck lesions with result of complete response [Figure 9]. However, she died from pneumonia 4 months after the treatment.
Figure 6: Clinical findings of lower gingival cancer before treatment in case 2

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Figure 7: Findings of computerized tomography in case 2 before treatment. Metastatic lymph node over 6 cm in the submental region was observed

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Figure 8: Findings of computerized tomography during treatment with the retrograde superselective intra-arterial intubation in case 2. Two metastatic submandibular lymph nodes were recognized (arrows)

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Figure 9: Four weeks after additional administration of CDDP using the Seldinger method. Metastatic lymph nodes were disappeared

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 > Discussion Top


Robbins et al. [6] reported that complete response in the primary site was obtained in 171 of 213 cases (80%), and the Kaplan Meier plot projection for cancer-related 5-year survival was 53.6% in stage III-IV head and neck cancer patients by weekly intra-arterial infusions of CDDP at a dose of 150 mg/m 2 for four times (total 600 mg/m 2 ) and radiotherapy to a total dose of 68-72 Gy. On the other hand, the HFT method for stage III-IV oral cancer patients was proposed as a daily intra-arterial infusion of CDDP and a weekly infusion of DOC, and total doses of CDDP and DOC were 150 mg/m 2 and 60 mg/m 2 , respectively, with concurrent radiotherapy to a total dose of 60 Gy. Mitsudo et al. [5] reported that complete response in the primary site was achieved in 30 of 30 cases (100%), and that a 73.0% rate of 5-year survival was achieved by the HFT method. Furthermore, we also reported that complete response in the primary site was achieved in 13 of 13 cases (100%) and the 5-year survival rate was 78.6% (11 of 13 cases) for stage III-IV oral cancer patients (data not shown). [7] The better prognosis as well as lower total doses of CDDP and radiotherapy in the HFT method than in the Seldinger method may indicate the curative superiority of the HFT method, although a strict comparison between these protocols might be difficult because of differences in the chemotherapeutic regimens. CDDP makes the tumor radio-sensitive, in addition to its direct antitumor effect, in terms of the inhibition of DNA repair processes, [8],[9] and at least 2 μg/mL of platinum appears to be required to induce the inhibition of DNA repair. [10] Accordingly, daily administration of CDDP into the tumor feeders during radiotherapy might effectively contribute to the inhibition of DNA repair in the HFT method. Additionally, the lower total doses of CDDP and radiotherapy in the HFT method compared to the Seldinger method may contribute to a decrease in complications. Indeed, six treatment-related deaths (grade V) (2.8%) were reported within 213 cases in which Seldinger method was used, [6] while no grade V toxicity was reported in the HFT method. [5],[7] On the other hand, the Seldinger method may be superior to the HFT method in terms of the variety of applicable target arteries, as the latter is applicable only to lingual, facial, and maxillary arteries. Furthermore, the Seldinger method can target small branches of arteries because anterograde catheterization appears to have a technical advantage in the reachability of the catheter into small vessels, and the detailed visualization of vasculature by angiogram would be helpful for catheterization.

In case 1, left tongue cancer invaded to oral floor and extrinsic lingual muscles. Because the left linguo-facial trunk was confirmed by CTA [Figure 2], the catheter was retrogradely intubated in it via left STA and retained. However, insufficient flow was confirmed in the left oral floor by blue dye staining [Figure 3]. We should note by case 1 that the Seldinger method is useful for detecting anomalous arteries that feed a tumor; thus anticancer agents could be administered in the tumor where flow is insufficient by the HFT method. In case 2, metastatic lymph nodes were targeted by the Seldinger method, and additional CDDP was administered with the result of complete response. The present results could indicate the potential of the Seldinger method to eradicate metastatic lymph nodes. In our previous study, [7] it was reported that metastatic lymph nodes had completely disappeared in five out of six cases (83.3%), while Mistudo et al. [5] reported that the complete response of metastatic lymph nodes was recognized in nine out of 23 cases (39.1%) by the HFT method. Although branches of the facial artery might feed metastatic lymph nodes in level I, lymph nodes at other levels appear to be fed by other arteries. The Seldinger method may be useful for the superselective administration of anticancer agents to any metastatic lymph node.


 > Conclusion Top


The combination of the HFT and Seldinger methods would be useful for eradicating locally advanced oral cancer without surgery.


 > Acknowledgement Top


We acknowledge Dr. Tohnai for his technical teaching of the HFT method, and we also acknowledge Dr. Hajime Imada, Norihiko Furuta, and Kousuke Taniguchi for their clinical support.

 
 > References Top

1.
Driemel O, Ettl T, Kölbl O, Reichert TE, Dresp BV, Reuther J, et al. Outcome and histopathologic regression in oral squamous cell carcinoma after preoperative radiochemotherapy. Strahlenther Onkol 2009;185:296-302.  Back to cited text no. 1
    
2.
Freier K, Engel M, Lindel K, Flechtenmacher C, Mühling J, Hassfeld S, et al. Neoadjuvant concurrent radiochemotherapy followed by surgery in advanced oral squamous cell carcinoma (OSCC): A retrospective analysis of 207 patients. Oral Oncol 2008;44:116-23.  Back to cited text no. 2
    
3.
Robbins KT, Storniolo AM, Kerber C, Seagren S, Berson A, Howell SB. Rapid superselective high-dose cisplatin infusion for advanced head and neck malignancies. Head Neck 1992;14:364-71.  Back to cited text no. 3
    
4.
Tohnai I, Fuwa N, Hayashi Y, Kaneko R, Tomaru Y, Hibino Y, et al. New superselective intra-arterial infusion via superficial temporal artery for cancer of the tongue and tumour tissue platinum concentration after carboplatin (CBDCA) infusion. Oral Oncol 1998;34:387-90.  Back to cited text no. 4
    
5.
Mitsudo K, Shigetomi T, Fujimoto Y, Nishiguchi H, Yamamoto N, Furue H, et al. Organ preservation with daily concurrent chemoradiotherapy using superselective intra-arterial infusion via a superficial temporal artery for T3 and T4 head and neck cancer. Int J Radiat Oncol Biol Phys 2011;79:1428-35.  Back to cited text no. 5
    
6.
Robbins KT, Kumar P, Wong FS, Hartsell WF, Flick P, Palmer R, et al. Targeted chemoradiation for advanced head and neck cancer: Analysis of 213 patients. Head Neck 2000;22:687-93.  Back to cited text no. 6
    
7.
Uehara M, Shiraishi T, Tobita T, Nonaka M, Asahina I. Antitumor effects on primary tumor and metastatic lymph nodes by superselective intra-arterial concurrent chemoradiotherapy for oral cancer. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;110:172-7.  Back to cited text no. 7
    
8.
Fu KK, DeGregorio MW, Phillips JW. Plasma and tumor concentrations of cisplatin following intraperitoneal infusion or bolus injection with or without continuous low-dose-rate irradiation. NCI Monogr 1988;6:123-7.  Back to cited text no. 8
    
9.
Lagrange JL, Bondiau PY, Tessier E, Chauvel P, Renée N, Etienne MC, et al. Tumoral platinum concentrations in patients treated with repeated low-dose cisplatin as a radiosensitizer. Int J Cancer 1996;68:452-6.  Back to cited text no. 9
    
10.
Douple EB, Richmond RC. Platinum complexes as radiosensitizers of hypoxic mammalian cells. Br J Cancer Suppl 1978;3:98-102.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]



 

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