Embed Size (px)
Citation preview
In Vivo Lung Perfusion (IVLP) for Cancer Therapy and Gene Therapy
of the Lung
Marcelo Cypel MD, MSc, FRCSCCanada Research Chair in Lung Transplantation
Surgical Director ECLS Program UHNAssociate Professor of SurgeryDivision of Thoracic Surgery
University of Toronto
The ProblemThe lung is a very common site for metastatic disease
Often is the only site of spread
Recurrence after initial surgical resection is exceedingly high: - Colorectal 50%
- Sarcoma 70%- Melanoma 88%
World J Surg. 2013 Jun;37(6):1315-21Ann Surg Oncol. 2007 Oct;14(10):2847-53
Prognostic GroupsMST (mos.)
group I single and DFI > 35 mos. 61II single or DFI > 35 mos. 34III multiple, DFI < 36 mos. 24IV incomplete resection 14
J Thorac Cardiovasc Surg 1997; 113:37-49
More than 3 lesions or < 1 year DFI = no survivors at 5 years (osteosarcoma)
4
Annals of Oncology 20:1136-1141, 2009
Toronto data
Current Limitations• 5 years survival after surgery is only 15-45%(Including recent series with modern chemotherapy and targeted therapies)
• Median disease free survival is short (12-18mos)
• Reoperations are feasible, but often patients become inoperable
• Systemic therapy with variable grades of response and excessive toxicity
Micrometastases
6
J Vis Exp. 2012 Aug 21;
How about giving anti-cancer treatment only to the lung?
In Vivo Lung Perfusion (IVLP)
Thoracic Surgery Latner Labs
TORONTO EX VIVO LUNG PERFUSION (EVLP) SYSTEM
Perfusion : 40% COVentilation: 7cc/kg, 7BPM, PEEP 5, FiO2 = 21%
Cypel/Keshavjee J Heart Lung Transplant 2008; 27(12):1319-25Cypel/Keshavjee NEJM 2011; 14;364(15):1431-40
NEJM 2011
J Thorac Cardiovasc Surg. 2014 774-81
• Dose escalation study• 75mg/m2 well tolerated• 150mg/m2 moderate injury• 225mg/m2 severe injury leading to animal death
12
Annals of Thoracic Surgery 2016
Doxorubicin 75 mg/m2
200x
Pre IVLP Post Reperf
200x
IVLP clinical trial1) To determine the safety of IVLP with Dox.
2) To determine the maximal tolerated dose by using a titration design.
3) To determine the time from treatment to recurrence in the ipsilateral treated lung versus the non - IVLP treated contralateral lung.
IVLP
15
Recent Patient: DC home in 6 days
Dox concentrationPt02
Sample Doxorubicin
(ng/assay)serum T3 IVLPO2 T3S (200 µL) NDserum T4 IVLPO2 T4S (200 µL) NDPOD1 IVLPO2 POD1 (200 µL) NDPOD2 IVLPO2 POD2 (200 µL) NDPOD3 IVLPO2 POD3 (200 µL) NDPOD4 IVLPO2 POD4 (200 µL) ND
POD5 IVLPO2POD5 (200 µL) NDT0.5 IVLPO2 T0.5 perfusate (20 µL) 143.4T1 IVLPO2 T1 perfusate (20 µL) 76.4T2 IVLPO2 T2 perfusate (20 µL) 31.8
T3 IVLPO2 T3 perfusate (20 µL) 20.2
T4 IVLPO2 T4 lung (15 mg) 104.9
Evaluating Efficacy of Novel Treatments
18
Establishment of colorectal and sarcoma lung metastases model
Day 28 Evaluation
Day 0 InjectionSarcoma cells (5 x 10^6 cells) Colorectal cells (2.5 x 10^6 cells)
Micrometastases (Day 4)
Sarcoma model(Day 28)
Colorectal ca model(Day 28)Day 4
Establishment of colorectal and sarcoma lung metastases model
Day 28 Evaluation
Day 0 InjectionSarcoma cells (5 x 10^6 cells) Colorectal cells (2.5 x 10^6 cells)
Micrometastases (Day 4)
Sarcoma model(Day 28)
Colorectal ca model(Day 28)Day 4
Treatment IV or IVLP
IVLP only IV (Dox)
IVLP (Dox)
Sarcoma model
Left lung weights at day 25
mg *
Kruskal-Wallis statistic (p = 0.0002)(Non-parametric ) and
Dunn's Multiple Comparison Test
*
IVLP only IV FOLFOX
IVLP with FOLFOX
Colorectal model
Lung-specific gene delivery to treat/prevent pulmonary metastases recurrences
24
Lentivirus-Luciferase Distribution
Day 8
Day 28
IVLP (4 weeks) at sacrifice
Left lungRight lung
Heart
Liver Spleen
kidney
Left lung
Targeted gene: Interleukin 12 (Localized immunetherapy)
Control Group (Shamgroup)
Group 1: IT LV-IL12 (LD)
Group 2: IT LV-IL12 (HD)
Group 3: IV Oxaliplatin
Group 4: IV Oxaliplatin+ IT LV-IL12 (LD)
Group 5: IV Oxaliplatin+ IT LV-IL12 (HD)
DAY 28
Sacrifice:Histological
analysis
+ Analysis of the number of
nodules (Weksler
Technique)
+ Measurement of
IL12INF-γTNF-α
DAY 0N=5 for each
group
Injection 2.5 × 106
Cells
RCN9 colorectal cancer cell
line
Left Jugularvein
Fischer F344 250g
DAY 7
Assessment of LV-IL12 efficiency
• India ink staining + Fekete’s Solution
Slides with H&E
staining
IL-12 Lung expression
At Day 28
Efficiency of LV-IL12
Number of lung nodules/Slides
One way Anova p<0.0001
* Mann-Whitney test p<0.05
IT IL-12 group Control
Combination treatment increased lung NK cell content
Combination treatment increased IFNγ+
and polyfunctional CD4+ T cells
Conclusions
• IVLP is a new platform for treatment of pulmonarymetastases
• Phase I clinical trial IVLP Dox for sarcoma is underway(starting oxaloplatin for colorectal ca in 2018)
• Preliminary studies in small animals have shownlocalized IL-12 gene therapy to be effective
• Future directions:Complete the small animals studiescombining IVLP and IL-12. Localized IL-12 delivery in large animals (safety studies).
