PHASE II STUDIES

Feasibility and effectiveness of inhaled carboplatinin NSCLC patients

Paul Zarogoulidis & Ellada Eleftheriadou & Iordanis Sapardanis &

Vasiliki Zarogoulidou & Helliel Lithoxopoulou & Theodoros Kontakiotis &

Nikolaos Karamanos & George Zachariadis & Maria Mabroudi &Athanasios Zisimopoulos & Kostantinos Zarogoulidis

Received: 22 May 2011 /Accepted: 27 June 2011 /Published online: 8 July 2011# Springer Science+Business Media, LLC 2011

Summary Background Inhaled chemotherapy is underinvestigation as an alternative therapeutic modality forNon-Small Cell Lung Cancer. Methods 60 NSCLC patientswere randomized into 3 groups in this study. 20/60 patients(group A—control group) received I.V. chemotherapy(carboplatin AUC ≈ 5.5 D1); 20/60 (group B) received 2/3 of I.V. predicted carboplatin dose by I.V. infusion and therest 1/3 as aerosol (jet nebulised D1); and 20/60 (group C)received all the predicted I.V. dose of carboplatin as aerosolin 3 equally divided fractions D1-3. In all patients I.V.docetaxel 100/m2 was as well administered (D1). Lungfunctional tests were performed in all groups beforechemotherapy in the 3rd and 6th cycles. Results Group B

had a statistically significant increase in survival comparedto control group A [275 days (95% CI 249–300) vs. 211(95% CI 185–236)]. In regard to lung functional tests, astatistically significant decline was observed only in FEV1of group C in 6 months compared to the initial measure-ment. Conclusions Inhaled carboplatin could be given as analternative root of pulmonary drug delivery in selectedpatients, but further randomized studies remain to provewhether the inhaled chemotherapy is an efficient and safetreatment modality.

Keywords NSCLC . Inhaled chemotherapy . Experimentalchemotherapy regimens . Carboplatin

Invest New Drugs (2012) 30:1628–1640DOI 10.1007/s10637-011-9714-5

P. Zarogoulidis (*) : E. Eleftheriadou : I. Sapardanis :V. Zarogoulidou :H. Lithoxopoulou :M. Mabroudi :K. ZarogoulidisAristotle University Pulmonary Department,“G. Papanikolaou” Hospital,Thessaloniki, Greecee-mail: pzarog@hotmail.com

E. Eleftheriadoue-mail: eleftheriadou_ellada@yahoo.gr

I. Sapardanise-mail: danty_s@otenet.gr

V. Zarogoulidoue-mail: zarog.v@hotmail.com

H. Lithoxopouloue-mail: helliel@hotmail.com

M. Mabroudie-mail: mmabroud@gmail.com

K. Zarogoulidise-mail: zarog@med.auth.gr

T. KontakiotisBronchoscopic Unit,“G. Papanikolaou” Hospital,Thessaloniki, Greecee-mail: kontakiotis@gmail.com

N. KaramanosLaboratory of Biochemistry, University of Patras,Patras, Greecee-mail: krmns@upatras.gr

G. ZachariadisLaboratory of Analytical Chemistry, Department of Chemistry,Aristotle University of Thessaloniki,Thessaloniki, Greecee-mail: zacharia@chem.auth.gr

A. ZisimopoulosNuclear Medicine Department, Democritus University of Thrace,Alexandroupolis, Greecee-mail: azisimop@med.duth.gr

Introduction

Lung cancer is the leading cancer site in males, comprising17% of the total new cancer cases and 23% of the totalcancer deaths. Cancer survival tends to be poorer indeveloping countries, most likely because of a combinationof a late stage at diagnosis and limited access to timely andstandard treatment [1]. Only minorities of patients withprimary lung cancer are eligible for curative surgicalresection. Similarly, surgical treatment of lung metastasisis often contraindicated due to the number or the site of thelesions and the patient’s respiratory and/or general status.Practically, early diagnosis of lung cancer has not beenpossible, and unfortunately, most patients with lung cancerbelong to advanced stages at the time of diagnosis.

In patients with advanced non-small cell lung cancer(NSCLC), factors essential to decision making are theextent of disease, weight loss and performance status, asthese are the most predictive indicators of median patientsurvival time after undergoing systemic chemotherapy [2].For patients without substantial systemic manifestations ofillness, chemotherapy is known to improve median survivaltime, when compared with the best supportive care alone[3, 4]. Good performance status, female sex, age ≤70 years,and platinum-based analogues chemotherapy have beenknown to be predictive of favorable survival rates overall[5]. Chemotherapy is widely used in both primary andsecondary lung carcinomas, but despite the use of newchemotherapeutic agents during the last decade, the ceilingof their clinical efficacy remains low. It has been observedthat gender, age, gross type, pathological type, clinical Tstage, N stage, numbers of metastatic organ, smokinghistory, VO2 peak measurement and treatment of advancednon-small cell lung cancer were independent prognosticfactors [6–9]. Studies have demonstrated that drug concen-trations in lung tumors are low after systemic administra-tion and different platinum doublets failed to provide asuperior chemotherapy regimen [10–12]. Drug concentra-tion in the tumor appears to be a key parameter to achievedrug efficacy in humans. These data support the potentialvalue of targeted chemotherapy to lung tumors, as alreadysuccessfully applied in several cancer settings such as livermetastasis, ovarian tumors, laryngeal cancer, neoplasticmeningitis/pericardial effusion or brain tumors [13–27].

Regional drug delivery has been an approach usedclinically in oncology for a few decades. In this way, it isassumed to improve the therapeutic efficacy of theantineoplastic agent by delivering relatively high concen-trations on site allowing the agents to exert their maximumcytocidal effects locally at the tumor site while minimizingsystemic toxicity. Intra-arterial, intra-cavitary, and intra-tumoral administration [Wolfgang Hohenforst-Schmidt:WCB 2010, ECBIP and WCC 2011] are examples of such

loco-regional treatment strategies [19–26, 28, 29]. Directdrug administration to the lungs via inhalation offersseveral theoretical advantages over systemic delivery,including the possibility of regional drug delivery to thelungs and airways with lower doses and fewer systemicside effects, avoiding first-pass metabolism of the drug inthe liver and the use of a noninvasive delivery system [30–40]. The alveolar surface provides a large surface area forrapid systemic absorption of soluble drugs. The mostcommon application of aerosol therapy is regional drugdelivery to the airways and parenchyma lung diseases, butthere is also an expanding role of aerosols in systemic drugdelivery such insulin for diabetes or gene therapy [41, 42].The use of aerolised chemotherapy was first reported in1968, but the development of inhalational agents foroncologic use has been limited [11, 43]. It has beenreported in studies that aerolised chemotherapy reaches apeak concentration in shorter period of time in comparisonto i.v. administration, but the amount of concentrationremains the same in the plasma for both ways ofadministration at the end of treatment [38]. Furthermore,it was observed that inhaled chemotherapy has the ability todeposit to the lymphatic tissue through lymphatic circula-tion and the pleura, constituting it a more efficient way ofadministration [31].

The reason is the fear of pulmonary toxicity. Severalchemotherapeutic agents, including novel compounds suchas irinotecan, gemcitabine, paclitaxel and docetaxel, cancause severe pulmonary reactions that develop during orshortly after treatment [44, 45]. Local administration ofhigh doses of chemotherapy via inhalation may increase therisk of drug-induced lung disease. Furthermore, a highproportion of patients with lung cancer have impairedpulmonary function due to tobacco-related illness that couldworsen the prognosis in the case of chemotherapy-inducedlung disease [46]. The risk of direct toxicity to the lungsmust therefore be evaluated for each new drug consideredfor aerosol administration. A new chemotherapeutic methodcalled nebulisation chemotherapy (NC therapy) was devel-oped and applied for loco-regional drug delivery inexperimental studies. This experimental therapeutic ap-proach involves the inhalation of ultrasonically nebulisedaerosol particles of anticancer agents through the oral cavityand bronchial tree. Various chemotherapeutic agents havebeen investigated as a free compound or as an aerosolizedliposomal encapsulated formulation. The first reportsstarted in 1983 with 5-fluorouracil, first in dogs, later inhumans [30, 31]. Paclitaxel and doxorubicin have onlybeen studied in animals; nevertheless, a phase I/II trial withaerosolized doxorubicin in humans is currently completed[32–36]. Cisplatin was firstly applied as an aerosolcompound by inhalation for laryngeal cancer in anexperimental study [27].

Invest New Drugs (2012) 30:1628–1640 1629

Cisplatin (cis-diaminedichloroplatinum) is one of themost frequently used antineoplastic agents. It is adminis-tered i.v. usually in combination with other antineoplasticagents. Most first-line chemotherapeutic regimens inadvanced stages of non–small cell lung cancer containcisplatin. However, a major dose-limiting toxicity (DLT)associated with i.v. cisplatin therapy is nephrotoxicity.Other commonly observed toxicities that may lead todose reduction are peripheral neuropathy, ototoxicity,myelosuppression, and hypersensitivity reactions or evennausea and vomiting. For this reason, research in the pastwas aimed at the development of new platinum com-pounds with less systemic side effects, such carboplatin(CP) [47]. The technique used in the present studypresents data of prolonged action of CP on the tumortissue of lung cancer. In the present clinical researchefficacy and safety of aerolised carboplatin was evaluatedwith pulmonary function tests, CT imaging, documenta-tion of the adverse effects and measurement of thecarboplatin levels.

Patient and methods

Study population-induction criteria

Patients eligible for the study were between 18 and 70 yearsof age. They had previously untreated primary non-smallcell lung cancer with a Karnofsky performance status ≥80,stage IV. The staging was decided according to the sixthedition of TNM classification of NSCLC. An adequatepulmonary reserve not <50% of the age/height predictedvalue was mandatory as defined by a measured forcedexpiratory volume in one second (FEV1), forced vitalcapacity (FVC) and diffusing capacity for carbon monoxide(DLCO) determined according to a joint statement based onthe previous statements from the American ThoracicSociety and European Respiratory Society [48]. Restingoxygen saturation should be ≥90% and exercise oxygensaturation ≥85%. All patients should have adequate renalfunction (defined by a level of serum creatinine ofV1.5 mg mL−1), hepatic enzymes (bilirubin of V1.5 mg/dL−1) and hematologic function (absolute neutrophil countof 1.5×103 mm−3 and platelet count of 1.0×105 mm−3).The mass median diameter of the tumor should be between3–5 cm, and the patients should not have upon inductionpleural effusion or atelectasis. Criteria for exclusion were:pregnancy or child-bearing potential without using contra-ceptive methods, concurrent serious infections (i.e. requir-ing an i.v. antibiotic therapy), an unstable or seriousconcurrent medical condition (e.g. recent myocardialinfarction and superior vena cava syndrome), recent majorsurgery, or large-field radiation therapy or chemotherapy in

the month before entry. Patients were not allowed to receiveany concurrent radiotherapy to the lungs, immunotherapyor investigational agents while on study. These criteriawhere chosen based on previous publications with aerolisedchemotherapeutic treatments which were applied on humansubjects [36, 37]. This study was conducted in accordancewith the ICH Harmonized Tripartite Good Clinical PracticeGuidelines issued by the International Conference onHarmonization (ICH) and the principles of the Declarationof Helsinki [49, 50]. Furthermore, the study protocol wasapproved by our Institutional Review Board (IRB). Writteninformed consent was obtained from each patient beforestudy enrollment. Patient`s characteristics upon admissionare presented in Tables 1 and 2.

Study design-objective

Patients were randomized into three subgroups (A, B, C).Group A was defined as the control group. All patients inthis group received carboplatin AUC 5.5 and docetaxel100 mg/m2 only by i.v. infusion on Day 1. In group B the 1/3 of the predicted dosage of carboplatin was administeredvia inhalation with the use of a jet nebulizer and the rest 2/3of the dosage via i.v. administration on Day 1. In group Ccarboplatin was administered only via inhalation as aerosol,with the use of jet nebulizer in a three day equally divideddose. All patients of groups B and C also receiveddocetaxel 100 mg/m2 i.v. Day 1. Patients upon admissionhad their respiratory capacity evaluated (FEV1, FVC,DLCO, and 6 MWT). Forced expiratory volume in 1 s

Table 1 Patients characteristics upon admission (M/F = Male/Female)

Subtype Group An=20 M/F

Group Bn=20 M/F

Group Cn=20 M/F

Squamus 7/2 6/2 5/3

Adenocarcinoma 6/3 4/4 6/4

Non-Differantiated

2/− 2/− 1/−

Neuroendocrinal −/− 2/− 1/−Karnosfky performance status

90–100 7/1 8/3 6/6

80 8/4 7/2 5/3

Metastatic site

Bone 4/2 6/3 3/1

Adrenal 4/1 1/1 2/1

Liver 6/3 3/2 4/3

CNS 2/− 2/− 2/1

Contralateralnodes

1/4 2/3 0/2

N3 lymphnodules

3/3 3/1 2/2

1630 Invest New Drugs (2012) 30:1628–1640

(FEV1) and forced vital capacity (FVC)was evaluated in everychemotherapy session before and after aerosol treatment.Carbon monoxide diffusing capacity (DLCO) and 6 minwalking test (6MWT) evaluation was performed every3 months, 3 times in total. Besides chest x-ray, the lungparenchymawas also evaluated with high-resolution computedtomography (HRCT) upon admission and re-evaluated every3 months, 3 times in total. The primary end point in this studywas to evaluate the efficacy and safety of the chemotherapeuticagent carboplatin (CP) administered as aerosol.

Safety-dose administration

Due to the cytotoxic properties of carboplatin, minimizingexposure to the drug is mandatory. For this reason, thehealthcare workers and patients were dressed in full barrierprotection clothing [safety glasses, respirator face mask (3 M1873 V Health Care Respirator), gown, gloves, cap, andsleeves]. Treatment was done in a negative pressure room, andthe drug was administered to the patients inside a demistifiertent (Demistifier Canopy model 2000, Peace Medical, Inc.,Orange, NJ). The tent, industry standard for healthcare workerprotection, meets all requirements for high-risk proceduresaccording to Centers for Disease Control (CDC), Prevention,and Occupational Safety and Health Administration regula-tion. It isolates the patient in a vinyl enclosure similar to anoxygen tent. Air is drawn upward from the area inside thecanopy and flows through a High- Efficiency Particulate Airsystem (HEPA) at a rate of 240 to 360 air changes per hour.Previous studies with aerosolized toxic agents, such asribavirin and pentamidine, as well as a study with cisplatinshowed the effectiveness of the system in limiting occupa-tional exposure [37, 51–53]. The aerosol compound wasproduced with the use of an up mist (Medic Aid) jetnebulizer using 10 Lt of O2. For the administration of theaerosol, a two way throttle nozzle with filter was selected

(respiromed precision nebulizer special medication, Manu-facturer: Int’Air Medical, F-01002 BOURG EN BRESSE).This nozzle has two valves; the first was activated byinhalation and the second by exhalation. The exhalationvalve has a filter pad that collects the exhaled aerosol. Thepressure generated by the compressor enables nebulizationof 0.4 to 0.5 mL of drug per minute. To determine whetherpatients continue to exhale platinum following dosing, onepatient was asked to breathe through a nebulizer for 20 min,1 h, and 18 h after the last inhalation. The exhalation filtersof these nebulizers and the one used during the last 20-mininhalation session were washed with 100 mL buffer and thisfluid was assayed for platinum. The concentration of totalplatinum amounted to 80.5 Amol/L in the filter takendirectly after an inhalation session. However, in the assayedfilters, 1 and 18 h after treatment, no platinum wasmeasurable at all. This suggests that exhaled air of thepatient after 1 h seems to contain very low up until noconcentrations of total platinum, and so the environmentseems to be safe for other persons. The filter stopped anyaerosol to leak in the environment.

The patients were instructed to maintain a slow breathingpattern through the inhalation therapy. The time of the inhaleddrug administration differ between 40min (15 ml) and 50 min(25 ml) and depended on the amount of the drug in theresidual cap. Upon completion of the inhalation, the patientsrinsed their mouth with water and washed their face. Eachpatient was observed for 30 min after completion of theprocedure. Patients in groups B and C were given aerosolbronchodilator (Ipratropium Bromide, Salbutamol) and aero-sol corticosteroid (Beclomethasone) before the inhaled carbo-platin. A chemotherapy cycle took place every 28 days.

Study drug inhalation solution

CP, an antitumoral drug characterized by a relatively highsolubility in water, has been already used successfully incancer chemotherapy. It is an analog of cisplatin, with a similarspectrum of activity. CP presents a less toxic profile, incomparison to cisplatin [47]. Cisplatin has been tested inanimals and humans as aerosol [37, 38, 54, 55]. Thephysicochemical properties of aerolised drugs (for example:molecular weight, shape, charge, PH, mass median diameterof aerosol particles and aqueous solubility) determine the rateof diffusion through the respiratory tract. Water soluble drugsdistribute most readily in the extracellular membrane (ECM),and therefore efficiently diffuse around and between cells[12]. Soluble drugs remaining for a prolonged time in theECM have an increased penetration [12]. Polydisperseaerosols are more extensively dispersed within the intra-pulmonary airways, in contrast to monodisperse aerosols(GSD <1.22) with a similar mass median aerodynamicdiameter (MMAD) [56]. The narrower size distribution of

Table 2 Patients respiratory capacity upon admission and HRCTfindings (M/F = Male/Female)

Group An=20 M/F

Group Bn=20 M/F

Group Cn=20 M/F

50–75%pred

≥75%pred

50–75%pred

≥75%pred

50–75%pred

≥75%pred

FVC 7/5 5/3 12/4 3/1 10/3 3/4

FEV1 7/5 5/3 12/4 3/1 10/3 3/4

DLCO 10/3 4/3 10/6 4/0 9/4 5/2

6MWT 7/5 5/3 12/4 3/1 10/3 3/4

Emphysema 2/− 2/1 2/1 3/1

Ground-glass

1/− 2/− 1/−

Grazy-pavingpattern

– 1/− –

Invest New Drugs (2012) 30:1628–1640 1631

monodisperse aerosols allows more selective regional airwaytargeting and deposition within the intrapulmonary tree. CPwas selected to be experimentally administered by nebulisa-tion based on previous experimental aerosol studies with thesimilar compound cisplatin [38, 54, 55, 57]. The carboplatinsterile, aqueous pyrogen-free solution was supplied by ourmolecular biology laboratory. NaCl, solution (0.9%) waspresent to render the product iso-osmotic as well as toenhance the stability of the carboplatin. The concentrationof carboplatin in the product was 150 mg/15 ml asdetermined by high-performance liquid chromatography.

Characteristics of the inhaled compound

The up mist jet nebulizer with the addition of 10 Lt O2

produced droplet size of, mass median aerodynamicdiameter was ≈3.7 microns with geometric SD of ≈1.9microns. It was observed in previous studies that larger sizedroplets remain in the upper respiratory tract and do notdiffuse to the lower parenchyma [22, 30–38, 58].

An eight-stage Andersen cascade impactor, Mark II, wasused to assess the aerodynamic size distribution of thecarboplatin formulation. The formulation was primed byfiring five shots into waste. Then five shots (at 5 s intervals)were fired into the cascade impactor under a flow rate of28.3 L/min. The samples were analyzed on a spectropho-tometer at a wavelength of 320 nm. The mass medianaerodynamic diameter (MMAD) and geometric standarddeviation (GSD) were obtained, based on impaction data,using established software in our laboratory. Other param-eters, such as percentage throat deposition, respirable massand respirable fraction, were calculated based on the knownamount of drug deposited on the various components.Impaction experiments were conducted at least three times.To evaluate whether there was an actual deposition of thedrug to the lung parenchyma in one of our patients weadministered radiolabelled inhaled carboplatin and withscintiscan we verified the deposition of the drug. Thescintiscan demonstrated that the deposition was to thewhole lung parenchyma not just the large airways. Thesame technique was applied in previous published studiesfor evaluation of the different drug depositions [22, 59, 60].

Dose delays/adjustments

Dose delays and adjustments were made according toCancer Common Toxicity Criteria, Version 2.0 [61].

Pharmacokinetics

The application of pharmacokinetic techniques allowsaccurate and reproducible quantification of drug deliveryby measuring plasma levels to reflect lung absorption,

although this is dependent on sufficiently sensitive assays[57]. Pharmacokinetic parameters were determined byplotting the CP plasma concentrations versus time data[62]. The complete plasma pharmacokinetic profile wasgenerated by collecting blood samples within 30, 120, 240,360, 480, 600, 720, 840 and 960 min for all subgroups. Thedosage given in group C per Day (3 day regimen) byinhalation varied between 160 and 230 mg. In group B thedosage given on Day 1 by inhalation varied also between160 and 230 mg, but i.v. carboplatin was administered atthe same time with a dosage range between 320 and460 mg. In Group A the dosage range on Day 1 wasbetween 550 and 700 mg administered i.v. Blood sampleswere collected in heparinized tubes and were centrifuged.The obtained plasma was frozen and shipped in dry ice foranalysis of carboplatin. Platinum in biological fluids iscurrently determined by atomic or mass spectrometrictechniques usually based on plasma or flame atomization.In this study a validated method for platinum determinationwhich was based on the Inductively Coupled PlasmaAtomic Emission Spectrometry (ICP-AES) technique aftersuitable optimization was used [59, 63–65]. For thispurpose a Perkin Elmer Optima 3100 XL axial viewingspectrometer was employed for all platinum measurements.The operating conditions were optimized in order to obtainmaximum sensitivity and to eliminate possible matrixinterference from the injection of non-digested plasmasamples. The analytical wavelength for Pt was set at265.945 nm and a 2-point background estimation procedurewas applied in order to minimize any possible spectralinterference between analytes. The incident power foratomization was examined and the level of 1,500 W wasfound as optimum. A medium level nebulizer flow rate forargon was applied. A platinum single-element standardcontaining 1,000 mg l-1 Pt was provided by Merckand usedfor the preparation of working standards. Using a series ofseven working standards, an external calibration curve wasprepared. Plasma samples were diluted using Milli-Q wateras diluents and homogenized in ultrasonic. For plasmadilutions ultra pure water of Milli-Q quality (18.2 MΩ,Millipore, Bedford USA) was used. The results are medianvalues from triplicate analysis of each sample (Fig. 1).

Pulmonary function test-evaluation

Spirometry, Carbon monoxide diffusion capacity and6 MWT were used to assess the effect of drug inhalationto the airways and gas exchange, every 3 months

CT imaging

A CT scan of the thorax with high-resolution slices wasperformed at baseline to evaluate the lung parenchyma

1632 Invest New Drugs (2012) 30:1628–1640

since most of the patients were smokers. CTs of the thoraxwith high-resolution slices were performed instead of theusual CT scans for the patient’s restaging to check forpossible damage to the lung parenchyma by the inhaledagent. The evaluation of the CT images was made with theNational Cancer Institute Common Criteria version 2,radiographic evidence of interstitial disease with symptoms(grade 2—Radiation Therapy Oncology Group/ EuropeanOrganization for Research and Treatment of Cancer LungLate Radiation Morbidity Scoring Scheme) [66].

Statistical analysis

Continuous variables were summarized as means (±SD) ormedians (with interquartile ranges). For categorical varia-bles, the percentages of patients in each category werecalculated. Three month evaluations of FEV1, FVC, DLCOand 6MWT were compared between groups of patients byunpaired Student’s t-test, chi-square test, or Fisher’s exacttest, as appropriate. A p value of less than 0.05 wasconsidered to indicate statistical significance. All analyseswere carried out with the use of Statistical Package forSocial Sciences 17.01 December 2008, Chicago, U.S.A.).Overall survival was defined as the interval between thedate of pathologic diagnosis and death or last follow-upwith any death defined as an event.

Results

Toxicity-adverse effects

Neutropenia was observed in 15/20 (75%) patients (grade 3in 2/20) patients in group A, 12/20 (60%) patients (grade 3

in 2/20) in group B and 7/20 (35%) patients (grade 3 in 1/20) in group C. The difference observed between the threegroups was significant (0.01) in favor of group C. Therewas no difference observed for anemia among the threegroups. Anemia grade 3 was observed only in 1/20 patientsof group A and 1/20 patients in group B. In group B feverin 5/20 patients and irritative cough was observed in 13/20patients, but remission was observed in two to three days.In group C 7/20 patients had fever and 14/20 irritativecough after the three day inhaled chemotherapy, butremission was observed after two to three days from lastinhalation. All adverse effects were recorded and arepresented in Table 3. Similar temporary side effects suchcryptogenic organizing pneumonia pattern and fever werepresented by Wolfgang Hohenforst-Schmidt in WCB 2010due to ITC treatment, but all symptoms were relievedwithin a week of drug administration. We presented theseadverse effects analytically, since these were the majorproblems for the patients to handle. Toxicity and adverseeffects were evaluated according to Cancer CommonToxicity Criteria, Version 2.0 [61].

Lung function tests (LFTs)

The FEV1, FVC, DLCO and 6MWT of the patients in eachgroup at baseline are demonstrated in Table 2. There was anevaluation of FEV1 and FVC before and after chemother-apy for group B and C in order to examine whether or notthe inhaled agent induced bronchoconstriction. The medianvalues before and after inhaled chemotherapy are presentedin Fig. 2 and there was no difference in the sixth month datathat are presented. In Fig. 3(a, b, c, d) FEV1, FVC, DLCOand 6MWT evaluations are presented upon inclusion andevery three months. In a six month evaluation, FEV1 was

Fig. 1 Pt concentrations (mg/L)were assessed in plasma as de-scribed in the experimental part atthe indicated time intervals

Invest New Drugs (2012) 30:1628–1640 1633

significantly lower in group C, but there was no differencefor the FVC and DLCO, in comparison to groups A and B(Fig. 3b,c).

Survival

Longer survival was observed in Group B in comparison togroup A with a significant survival benefit of sixty-fourdays (p<0.001). Group C had also longer survival thangroup A with a survival benefit of twenty-five days, but itwas of no significance (Fig. 4). Wolfgang Hohenforst-

Schmidt presented similar preliminary survival findings forITC combined with iv treatment at the WCB and otherinternational meetings.

Pharmacokinetics

Pharmacokinetic profile demonstrated that group C withtotally inhaled carboplatin on Day 1 (Fig. 1) had a delayedpeak of the drug in comparison to groups B and A. It wasdecided that the comparison of the platinum concentrationshould be done only in Day 1.

Table 3 Adverse events

Adverse Events GROUP AN=20 CTCGRADE

Overall Incidence,n (%)

Group B N=20CTC GRADE

Overall Incidence,n(%)

GROUP CN=20 CTCGRADE

Overall Incidence,n(%)

1 2 3 4 1 2 3 4 1 2 3 4

Cardiovascular

Thrombosis/embolism

– 1 1(5) 1 1(5)

Constitutional

Fatigue 6 4 2 12(60) 8 2 1 11(55) 4 3 1 8(40)

Fever 2 2(10) 3 2 5(25) 5 2 7(35)

Rigors – 3 1 1 5(25) 5 1 6(30)

Dermatologic

Alopecia 9 7 1 17(85) 9 4 1 14(70) 7 4 2 13(65)

Rash 6 2 1 9(45) 4 5 9(45) 5 3 8(40)

Gastrointestinal

Anorexia 6 4 2 12(60) 8 4 1 9(45) 4 5 3 12(60)

Dysgeusia 3 1 4(20) 15 2 17(85) 6 7 2 1 16(80)

Flatulence 1 1(5) 4 4(20) –

Heartburn 3 2 5(25) 6 1 7(35) 5 3 8(40)

Mucositisc 4 1 5(25) 6 3 9(45) 5 6 1 12(60)

Nausea 9 3 12(60) 12 3 15(75) 7 5 2 14(70)

Odynophagia – 4 4(20) 4 2 6(30)

Pyrosis

Pharygitis 1 1(5) 9 3 12(60) 8 3 2 13(65)

Vomiting 9 3 12(60) 8 1 9(45) 6 2 1 9(45)

Neurologic

Headache 1 1(5) 5 5(25) 3 2 5(25)

Myalgia 1 1(5) 3 3(15) 4 1 5(25)

Pulmonary

Bronchitis 1 1(5) 6 2 8(40) 8 1 9(45)

Dyspnea 4 4(20) 8 1 9(45) 5 4 2 11(55)

Hoarseness//Voicechange

5 5(25) 9 5 14(70) 7 5 3 15(75)

Irritative cough 2 1 3(15) 9 4 13(65) 7 5 2 14(70)

Productive 5 5(25) 7 2 1 10(50) 9 5 2 16(80)

Hematologic

Anemia 3 2 1 6(30) 3 2 1 6(30) 3 3(15)

Neutrapenia 9 4 2 15(75) 8 2 2 12(60) 4 3 1 8(40)

1634 Invest New Drugs (2012) 30:1628–1640

CT evaluations

Evaluation of the thorax with HRCT slices performed atbaseline demonstrated that the pulmonary parenchyma of asmall number of patients presented emphysema, groundglass and a grazy paving pattern (Table 2). These patientswere included, since these findings are common amongsmokers or former smokers and were not due an underlyingsystematic disease. During the follow up, none of thepatients presented acute lung injury or acute respiratorydistress syndrome or any kind of damage to the lungparenchyma immediately after inhaled chemotherapy orduring the 6 month evaluation.

Efficacy assessment

From January the first 2005 until December 2009 sixtypatients were enrolled in our study. In group A five patientshad partial response, eight had stable disease and sevenprogressive disease. In group B two patients had completeresponse, six partial, three stable disease and nine patientsprogressive disease. In group C one patient had completeresponse, four partial, five patients stable disease and 10patients progressive disease. Evaluation of the disease on

tumor site was according to the RECIST criteria version 1.1[67].

Discussion

In the present study we evaluated the efficacy and the safetyof inhaled carboplatin, a well known and efficient anti-cancer agent. Carboplatin is known to have a less toxicprofile in comparison to other platinum analogues [47].Previous studies have administered the anticancer agentcisplatin at maximum inhaled dose of 80 mg m−2 per weekpresenting promising results of safety and efficiency. Otherchemotherapeutic agents also administered aerolised werepaclitaxel, docetaxel, cisplatin, 5-fu, and doxorubicin. Inthese studies less systematic side-effects were observed [31,33, 36, 38, 54, 58, 68]. All patients were decided to bechemo naïve, since patients undergoing 2nd line treatmentwould be under the influence of the first line systemictoxicities and fatigue. In our study less systematic sideeffects were observed (Group C) especially regarding theuse of G-CSF agents as observed in previous publishedstudies. This effect was probably due to the larger localabsorption of one of the two chemotherapy agents (CP in

Fig. 2 a Indicates FEV1 capac-ity before inhalation of the che-motherapy regimen, and cIndicates FEV1 capacity afterinhalation of the chemotherapyregimen. b Indicates FVC ca-pacity before inhalation of thechemotherapy regimen, and dIndicates FVC capacity afterinhalation of the chemotherapyregimen. All graphs includeboth Group B and Group Cwhere inhaled chemotherapywas administered

Invest New Drugs (2012) 30:1628–1640 1635

this case), in this way the smaller drug quantity of CP in thesystematic circulation prevented the myelosupression. Inaddition, regional therapies provide a protection for thepatient against the cancer burden by reducing myelosu-pression, by providing adequate immune status.

In our study the pharmacokinetic profile obtaineddemonstrated a maximum peak of carboplatin in Group A(23.04 mg/L) and Group B (18.88 mg/L) in 30 min. InGroup C only 1.88 mg/L were measured in 30 min, butreached a delayed maximum peak concentration of7.98 mg/L in 360 min. The possible explanation for thegraphs in Group B and C is that there was a sustainedrelease of the drug from the site of deposition to thesystemic circulation. In Group B there was simultaneouslyinhaled 1/3 of predicted dose and i.v. 2/3 of predicted dosecarboplatin administration, for this reason although therewas maximum peak concentration at 30 min, there waspossibly also a sustained release of the drug. The curves ingraph A in Fig. 1 represent the concentrations of carbopla-tin for the three groups in Day 1 of the chemotherapyadministration. It should be taken under account thatpatients in group C received a three day carboplatin

administration (Day 2 and Day 3), since their predicteddose according to AUC 5.5 was divided in three equaldoses.

A major limitation of the study was the addition of the i.v.docetaxel agent, since systemic toxicity observed could bedue to this i.v. regimen, as docetaxel is known for systemictoxicity, for this reason a control group (A) was established toclear out this point. In addition tumor site efficiency of theinhaled agent could not be evaluated properly, since anotherchemotherapeutic agent was administered in combination astherapy. It was decided to administer a doublet chemotherapyregimen as first line treatment, since this is the gold standardfor NSCLC. Proper evaluation of the inhaled carboplatinshould be made administered as a single agent to evaluatesystemic toxicity and efficacy of the drug alone.

Furthermore, a small number of patients included in thestudy had ground glass and/or grazy paving pattern. Thesefindings were attributed to the cancer lesions, atelectasis oremphysema (Table 1). We included these patients, eventhough they had this radiological pattern, to further evaluatewhether pre-existing lesions would become aggravated.Moreover the loss of CP that was observed from the filter is

Fig. 3 a Forced Expiratory Volume in 1 s evaluation. There was nodifference between the three groups during the first three monthobservation, but during the six month observation a decrease of 7% (p=0.012) was observed between group A (control group) and group C(three day inhaled carboplatin administration in favor of group A) bForced Vital Capacity evaluation. There was no difference between thethree groups during the first three month observation, but during the sixmonth observation a decrease of 7%(p=0.012) was observed between

group A (control group) and Group C (three day inhaled carboplatinadministration) in favor of Group A c Carbon Monoxide DiffusingCapacity evaluation. There was no difference between the three groupsduring the six month observation period d Minute Walking Testevaluation. There was significant difference during the three monthobservation between group A and Group C 43 meters (p=0,019) infavor of group C. There was no difference at baseline and during the sixmonth observation

1636 Invest New Drugs (2012) 30:1628–1640

one of the study limitations, but the loss was not largeenough by itself to influence the overall survival differencesamong the groups. The breathing pattern and lung functionplays a crucial role. However, none of our patients hadCOPD stage III or IV as these patients were excluded fromthe beginning. Co-morbidities such diastolic dysfunctionand coronary heart disease were not evaluated as inprevious studies [69, 70], since all patients included didnot have severe COPD and had stable heart disease, to beeligible to receive a doublet chemotherapy regimen.Administration of CO2 5–7% could play a role in thebreathing pattern to obtain larger tidal volume and slowerrespiratory frequency for better aerosol absorption.

The respiratory system is known to have a vast variety ofprotection mechanisms such cough, sputum and alveolisurfactant against foreign micro bodies. There are a numberof factors that affect the efficacy and bioavailability ofaerolised drug formulation [22, 57, 58, 71, 72]. Thesefactors are summarized: 1) Aerosol particle size. 2) Airwaygeometry and humidity. 3) Lung clearance mechanisms. 4)Deposition in lung disease. 5) Bronchial circulation. 6)Breathing frequency (F), tidal volume (TV) and duration ofinhalation. Previous studies have used a new technology oftransferring a chemotherapeutic agent by liposome encap-sulation (e.g. PEG) [53, 60, 69, 73–79]. This method isvery promising since the inhaled substance has the ability

to remain for a prolonged time on the alveoli surface andlung parenchyma, and also cannot be deactivated fromlymphocytes.

Further improvement of the drug administration could bedone with the addition of 5% CO2 which increases tidalvolume (TV) by 170–180% and decreases respiratoryfrequency (RF), making the patient to breath slower anddeeper, making in turn the aerolised chemotherapy todiffuse deeper in the lung parenchyma [70, 80–82]. In thisstudy, this method was not applied due to technical reasonsand the patients were given instructions to breath slowlyand deep with a steady rhythm. Other newer techniquessuch as multibreath nitrogen-washout (MBNW), fractionalexhaled nitric oxide (FeNO), and forced oscillation tech-nique (FOT) may allow differential regional lung assess-ment (small vs. large airways) as evidenced by recentstudies using inhaled drug formulations with specific abilityto penetrate into the distal lung [83].

This study also monitored the respiratory capacity in amore complete way than other similar studies [31, 33, 38, 48,54]. Previous studies have not used HRCT or 6MWT forpatient evaluation. Furthermore, it should be noted that allpatients in groups B and C received nebulised bronchodilatorand corticosteroid to increase the absorption of the aerolisedchemotherapy, these drugs have shown to affect thetherapeutic effectiveness of aerosolized medications [22].

Is there a place for local administration of therapy forpatients with lung cancer? Three potential strategies can beenvisioned: incorporation of inhalational therapy for patientswith advanced disease, incorporation of inhalational therapyinto adjuvant strategies, and use of inhalational compoundsfor chemoprevention. The strategy of inhaled “adjuvant”carboplatin also may ultimately apply to surgically treateddiseases with frequent recurrence/ metastasis to the lungs,such as sarcomas and thyroid cancer. A final potentialapplication of inhalational approaches is that of chemo-prevention. Two required preconditions for effective chemo-prevention are, an effective agent and minimal or no toxicity.Inhalational approaches present an attractive option forminimizing toxicity. Limitations to this approach are evidentin the inclusion and exclusion criteria for this initial study.Specifically, patients must have no more than moderatepulmonary dysfunction, cannot be oxygen dependent, andcannot have received prior radiation therapy to the chest. Inaddition, patients who have had a prior pneumonectomy wereexcluded from this study. These qualifications limit theapplicability of this strategy to patients with lung cancer untiladditional studies show the safety of treating patients withthese characteristics. In addition, although the administrationof this treatment modality at this point seems complex andexigent, it is absolutely necessary, firstly to perfect thetechnique but also the compound of administration beforediminishing the precaution measures.

Fig. 4 Survival. The three groups had significant difference (p=0.016). Group B (275±12.9, 95%CI 249–300) presented significantprolonged survival in comparison to group A (211±12.8, 95%CI 185–236) (p=0.01) with a survival benefit of 64 days. Group C (250±6.8,95%CI 238–263) in comparison to group A had a survival benefit of3 days but it was not significant. Also group B in comparison to groupC had a survival benefit twenty-five days, but it was also notsignificant. All values are median

Invest New Drugs (2012) 30:1628–1640 1637

Finally, the quality of life is a parameter that should hadbe taken under strong consideration, since a less invasiveand toxic root of administration would be more attractiveby most clinical physicians and patients. We were not ableto evaluate this parameter, since docetaxel was administeredintraveniously. A large number of patients request that thedrug administration is less invasive, since peripheral veinthrombosis and skin ulcers usually occur as a local sideeffect of the i.v. treatment. Moreover, the time required fornebulisation chemotherapy is less than the usual timerequired for i.v. administration.

Conclusion

Inhaled carboplatin could be given as an alternative root ofdrug administration, without significant pulmonary sideeffects. In this study, it is likely that patients in partialinhaled chemotherapy (group B) had a statistically signif-icant survival in comparison to control group (A). Apossible explanation for the survival benefit in group B isthe simultaneously high concentration of the chemotherapyregimen to the tumor site, lymph nodes and systematiccirculation. Inhaled chemotherapy is an attractive treatmentmodality, since high loco-regional concentrations of anti-neoplastic agents are more efficient. Further randomizedstudies with a single agent remain to prove whether theinhaled chemotherapy is an efficient and safe treatmentmodality.

Competing interests The authors declare that they have no competinginterests.

References

1. Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D (2011)Global cancer statistics. CA Cancer J Clin 61:69–90. doi:10.3322/caac.20107

2. Brundage MD, Davies D, Mackillop WJ (2002) Prognostic factorsin non-small cell lung cancer: a decade of progress. Chest 122(3):1037–1057. doi:10.1378/chest.122.3.1037

3. Stewart LA, Pignon JP (1995) Chemotherapy in non-small celllung cancer: a meta-analysis using updated data on individualpatients from 52 randomised clinical trials. Non-small Cell LungCancer Collaborative Group. BMJ 311:899–909

4. Spiro SG, Rudd RM, Souhami RL, Brown J, Fairlamb DJ, GowerNH,Maslove L,Milroy R, Napp V, ParmarMK, PeakeMD, StephensRJ, Thorpe H, Waller DA, West P, Big Lung Trial Participants (2004)Chemotherapy versus supportive care in advanced non-small cell lungcancer: improved survival without detriment to quality of life. Thorax59(10):828–836. doi:10.1136/thx.2003.020164

5. Albain KS, Crowley JJ, LeBlanc M, Livingston RB (1991)Survival determinants in extensive-stage non-small-cell lungcancer: the Southwest Oncology Group experience. J Clin Oncol9(9):1618–1626

6. Ando M, Ando Y, Sugiura S, Minami H, Saka H, Sakai S,Shimokata K, Hasegawa Y (1999) Prognostic factors for short-term survival in patients with stage IV non-small cell lung cancer.Jpn J Cancer Res 90(2):249–253

7. Peng H, Ma M, Han B (2011) Survival analysis of 1,742 patientswith stage IV non-small cell lung cancer. Zhongguo Fei Ai Za Zhi14(4):362–366. doi:10.3779/j.issn.1009-3419.2011.04.11

8. Richter Larsen K, Svendsen UG, Milman N, Brenøe J, PetersenBN (1997) Exercise testing in the preoperative evaluation ofpatients with bronchogenic carcinoma. Eur Respir J 10(7):1559–1565. doi:10.1183/09031936.97.10071559

9. Jones LW, Eves ND, Kraus WE, Potti A, Crawford J, BlumenthalJA, Peterson BL, Douglas PS (2010) The lung cancer exercisetraining study: a randomized trial of aerobic training, resistancetraining, or both in postsurgical lung cancer patients: rationale anddesign. BMC Cancer 10:155. doi:10.1186/1471-2407-10-155

10. Schiller JH, Harrington D, Belani CP, Langer C, Sandler A, KrookJ, Zhu J, Johnson DH (2002) Comparison of four chemotherapyregimens for advanced non small-cell lung cancer. N Engl J Med346:92–98

11. Sharma S, White D, Imondi AR, Placke ME, Vail DM, Kris MG(2001) Development of inhalational agents for oncologic use. JClin Oncol 19:1839–1847

12. Minchinton AI, Tannock IF (2006) Drug penetration in solidtumours. Nat Rev Cancer 6:583–592. doi:10.1038/nrc1893

13. Kemeny NE, Niedzwiecki D, Hollis DR, Lenz HJ, Warren RS,Naughton MJ, Weeks JC, Sigurdson ER, Herndon JE 2nd, ZhangC, Mayer RJ (2006) Hepatic arterial infusion versus systemictherapy for hepatic metastases from colorectal cancer: a random-ized trial of efficacy, quality of life, and molecular markers(CALGB 9481). J Clin Oncol 24:1395–1403. doi:10.1200/JCO.2005.03.8166

14. Armstrong DK, Bundy B, Wenzel L, Huang HQ, Baergen R, Lele S,Copeland LJ, Walker JL, Burger RA (2006) Intraperitoneal cisplatinand paclitaxel in ovarian cancer. N Engl J Med 354:34–43

15. Guerin C, Olivi A, Weingart JD, Lawson HC, Brem H (2004)Recent advances in brain tumor therapy: local intracerebral drugdelivery by polymers. Invest New Drugs 22:27–37. doi:10.1007/s11060-005-7411-y

16. Glantz MJ, Jaeckle KA, Chamberlain MC, Phuphanich S, RechtL, Swinnen LJ, Maria B, LaFollette S, Schumann GB, Cole BF,Howell SB (1999) A randomized controlled trial comparingintrathecal sustained-release cytarabine (DepoCyt) to intrathecalmethotrexate in patients with neoplastic meningitis from solidtumors. Clin Cancer Res 5:3394–3402

17. Robinson WR, Coberly C, Beyer J, Lewis A, Ballard C (2008)Office-based intraperitoneal chemotherapy for ovarian cancer. JOncol Pract 4(5):225–228. doi:10.1200/JOP.0858503

18. Hofstra LS, Bos AM, de Vries EG, van der Zee AG, Beijnen JH,Rosing H, Mulder NH, Aalders JG, Willemse PH (2001) A phaseI and pharmacokinetic study of intraperitoneal topotecan. Br JCancer 85(11):1627–1633. doi:10.1054/bjoc.2001.2161

19. Foote RL, Kasperbauer JL, Okuno SH, Nichols DA, Olsen KD,Brown PD, Garces YI, Sargent DJ, Strome SE (2005) A pilotstudy of high-dose intra-arterial cisplatin chemotherapy withconcomitant accelerated radiotherapy for patients with previouslyuntreated T4 and selected patients with T3N0-3M0 squamous cellcarcinoma of the upper aerodigestive tract. Cancer 103(3):559–568. doi:10.1002/cncr.20803

20. Osaki T, Hanagiri T, Nakanishi R, Yoshino I, Taga S, Yasumoto K(1999) Bronchial arterial infusion is an effective therapeuticmodality for centrally located early-stage lung cancer: results ofa pilot study. Chest 115:1424–1428. doi:10.1378/chest.115.5.1424

21. Alberts DS, Liu PY, Hannigan EV, O’Toole R, Williams SD, YoungJA, Franklin EW, Clarke-Pearson DL, Malviya VK, DuBeshter B(1996) Intraperitoneal cisplatin plus intravenous cyclophospha-

1638 Invest New Drugs (2012) 30:1628–1640

mide versus intravenous cisplatin plus intravenous cyclophospha-mide for stage III ovarian cancer. N Engl JMed 335(26):1950–1955

22. Labiris NR, Dolovich MB (2003) Pulmonary drug delivery. Part I:physiological factors affecting therapeutic effectiveness of aero-solized medications. Br J Clin Pharmacol 56:588–599.doi:10.1046/j.1365-2125.2003.01892.x

23. Maisch B, Ristic AD, Pankuweit S, Neubauer A, Moll R (2002)Neoplastic pericardial effusion. Efficacy and safety of intra-pericardial treatment with cisplatin. Eur Heart J 23:1625–1631.doi:10.1053/euhj.2002.3328

24. Markman M, Cleary S, Pfeifle C, Howell SB (1986) Cisplatinadministered by the intracavitary route as treatment for malignantmesothelioma. Cancer 58:18–21. doi:10.1002/1097-0142(19860701)58:1<18::AID-CNCR2820580105>3.0.CO;2-C

25. Markman M (1996) Intraperitoneal therapy of ovarian cancer.Oncologist 1:18–21

26. Rusch VW, Figlin R, Godwin D, Piantadosi S (1991) Intrapleuralcisplatin and cytarabine in the management of malignant pleuraleffusions: a Lung Cancer Study Group trial. J Clin Oncol 9:313–319

27. Okuyama S, Matsumotos K, Saijo H, Suetake M, Yuasa R,Mishina H (1993) Reinforcing aerosol cisplatin for radiotherapyof laryngeal cancer. Tohoku J Exp Med 169(3):253–255

28. Duvillard C, Romanet P, Cosmidis A, Beaudouin N, Chauffert B(2004) Phase 2 study of intratumoral cisplatin and epinephrinetreatment for locally recurrent head and neck tumors. Ann OtolRhinol Laryngol 113:229–333

29. Goldberg EP, Hadba AR, Almond BA, Marotta JS (2002)Intratumoral cancer chemotherapy and immunotherapy: opportu-nities for nonsystemic preoperative drug delivery. J PharmPharmacol 54:159–180. doi:10.1211/0022357021778268

30. Tatsumura T, Yamamoto K, Murakami A, Tsuda M, Sugiyama S(1983) New chemotherapeutic method for the treatment oftracheal and bronchial cancers G nebulization chemotherapy.Gan No Rinsho 29:765–770

31. Tatsumura T, Koyama S, Tsujimoto M, Kitagawa M, KagamimoriS (1993) Further study of nebulisation chemotherapy, a newchemotherapeutic method in the treatment of lung carcinomas:fundamental and clinical. Br J Cancer 68:1146–1149

32. Gautam A, Koshkina N (2003) Paclitaxel (Taxol) and taxoidderivates for lung cancer treatment: potential for aerosol delivery.Curr Cancer Drug Targets 3:287–296

33. Hershey AE, Kurzman ID, Forrest LJ, Bohling CA, Stonerook M,Placke ME, Imondi AR, Vail DM (1999) Inhalation chemotherapyfor macroscopic primary or metastatic lung tumors: proof ofprinciple using dogs with spontaneously occurring tumors as amodel. Clin Cancer Res 5(9):2653–2659

34. Koshkina NV, Golunski E, Roberts LE, Gilbert BE, Knight V(2004) Cyclosporin A aerosol improves the anticancer effect ofpaclitaxel aerosol in mice. J Aerosol Med 17(1):7–14.doi:10.1089/089426804322994415

35. Minchin RF, Johnston MR, Aiken MA, Boyd MR (1984) Pharma-cokinetics of doxorubicin in isolated lung of dogs and humansperfused in vivo. J Pharmacol Experim Therap 229(1):193–198

36. Otterson GA, Villalona-Calero MA, Hicks W, Pan X, Ellerton JA,Gettinger SN, Murren JR (2010) Phase I/II study of inhaleddoxorubicin combined with platinum-based therapy for advancednon-small cell lung cancer. Clin Cancer Res 16(8):2466–2473.doi:10.1158/1078-0432.CCR-09-3015

37. Wittgen BPH, Kunst PWA, van der Born K, van Wijk AW, PerkinsW, Pilkiewicz FG, Perez-Soler R, Nicholson S, Peters GJ, PostmusPE (2007) Phase I Study of aerosolized SLIT cisplatin in thetreatment of patients with carcinoma of the lung. Clin Cancer Res13(8):2414–2421. doi:10.1158/1078-0432.CCR-06-1480

38. Selting K, Waldrep JC, Reinero C, Branson K, Gustafson D, KimDY, Henry C, Owen N, Madsen R, Dhand R (2008) Feasibility

and safety of targeted cisplatin delivery to a select lung lobe indogs via the AeroProbe® intracorporeal nebulization catheter. JAerosol Med Pulm Drug Deliv 21(3):255–268. doi:10.1089/jamp.2008.0684

39. Khanna C, Vail DM (2003) Targeting the lung: preclinical andcomparative evaluation of anticancer aerosols in dogs with naturallyoccurring cancers. Curr Cancer Drug Targets 3(4):265–273

40. Kleinstreuer C, Zhang Z, Donohue JF (2008) Targeted drug-aerosoldelivery in the human respiratory system. Annu Rev Biomed Eng10:195–220. doi:10.1146/annurev.bioeng.10.061807.160544

41. Laube BL (2005) The expanding role of aerosols in systemic drugdelivery, gene therapy, and vaccination. Respir Care 50:1161–1176

42. Zarogoulidis P, Papanas N, Kouliatsis G, Spyratos D, ZarogoulidisK, Maltezos E (2011) Inhaled insulin: too soon to be forgotten? JAerosol Med Pulm Drug Deliv. doi:10.1089/jamp.2011.0876[Epub ahead of print]

43. Shevchenko IT, Resnik GE (1968) Inhalation of chemicalsubstances and oxygen in radiotherapy of bronchial cancer.Neoplasma 15:419–426

44. Camus P, Fanton A, Bonniaud P, Camus C, Foucher P (2004)Interstitial lung disease induced by drugs and radiation. Respira-tion 71:301–326. doi:10.1159/000079633

45. Camus P (2004) Interstitial lung disease in patients with non-small-cell lung cancer: causes, mechanisms and management. Br JCancer 91(Suppl 2):S1–S2. doi:10.1038/sj.bjc.6602060

46. Sarna L, Padilla G, Holmes C, Tashkin D, Brecht ML, Evangelista L(2002) Quality of life of long-term survivors of non-small-cell lungcancer. J Clin Oncol 20:2920–2929. doi:10.1200/JCO.2002.09.045

47. Moore MJ, Erlichman C (1998) Pharmacology of anticancer drugs.In: Tannock IF, Hill RP (eds) The basic science of oncology, 3rd edn.McGraw-Hill Health Professions Division, New York, pp 370–391

48. Miller MR, Hankinson J, Brusasco V, Burgos F, Casaburi R,Coates A, Crapo R, Enright P, van der Grinten CP, Gustafsson P,Jensen R, Johnson DC, MacIntyre N, McKay R, Navajas D,Pedersen OF, Pellegrino R, Viegi G, Wanger J (2005) ATS/ERSTask Force: standardisation of spirometry. Eur Respir J 26(2):319–338. doi:10.1183/09031936.00130010

49. ICH HARMONISED TRIPARTITE GUIDELINE (1995) Pub-lished in the Federal Register, Vol. 60, No. 40, p. 11264–11268, 1http://www.ich.org/fileadmin/Public_Web_Site/ICH_Products/Guidelines/Safety/S3A/Step4/S3A_Guideline.pdf

50. WORLD MEDICAL ASSOCIATION DECLARATION OF HEL-SINKI. Ethical Principles for Medical Research Involving HumanSubjects http://www.wma.net/en/30publications/10policies/b3/17c.pdf

51. Krilov LR (2002) Safety issues related to the administration ofribavirin. Pediatr Infect Dis J 21:479–481

52. Ros JJ, Langen MC, Stallen PC, Lenderink AW (1996) Pentam-idine aerosols and environmental contamination: health-careworkers at risk. Pharm World Sci 18:148–152

53. Wahlin B,MalmstromB, SoopM,Hellstrom LG (1996) A paediatriccanopy system for aerosol administration and minimized environ-mental pollution. Acta Anaesthesiol Scand 40:932–939

54. Chou AJ, Bell MD, Mackinson C, Gupta R, Meyers PA, Gorlick R(2007) Phase Ib/IIa study of sustained release lipid inhalationtargeting cisplatin by inhalation in the treatment of patients withrelapsed/progressive osteosarcoma metastatic to the lung. JClinical Oncology. ASCO Annual Meeting Proceedings Part I,25(18Suppl):9525

55. Geller DS, Gorlick R (2010) Osteosarcoma: a review of diagnosis,management, and treatment strategies. Clin Adv Hematol Oncol 8(10):705–718

56. Morrow PE. Conference on the scientific basis of respiratorytherapy. Aerosol therapy. Aerosol characterization and deposition.Am Rev Respir Dis 110:88–99

57. ICH HARMONISED TRIPARTITE GUIDELINE SAFETYPHARMACOLOGY STUDIES FOR HUMAN PHARMACEUT-

Invest New Drugs (2012) 30:1628–1640 1639

ICALS S7A (2000) http://www.ich.org/fileadmin/Public_Web_Site/ICH_Products/Guidelines/Safety/S7A/Step4/S7A_Guideline.pdf

58. Gagnadoux F, Hureaux J, Vecellio L, Urban T, Le Pape A, Valo I,Montharu J, Leblond V, Boisdron-Celle M, Lerondel S, Majoral C,Diot P, Racineux JL, Lemarie E (2008) Aerosolized chemotherapy.J Aerosol Med Pulm Drug Delivery 21(1):61–70. doi:10.1089/jamp.2007.0656

59. Lipworth BJ (1996) Pharmacokinetics of inhaled drugs. Br J ClinPharmacol 42(6):697–705. doi:10.1046/j.1365-2125.1996.00493.x

60. Laube BL (2005) The expanding role of aerosols in systemic drugdelivery, gene therapy, and vaccination. Respir Care 50(9):1161–1176

61. Cancer Therapy Evaluation Program. Common Toxicity Criteria,Version 2.0.June 1, 1999. http://ncictephelp@ctep.nci.nih.gov

62. Gavini E, Manunta L, Giua S, Achenza G, Giunchedi P (2005)Spray-dried poly(D,L-lactide) microspheres containing carbopla-tin for veterinary use: in vitro and in vivo studies. AAPSPharmSciTech 20;6(1):E108-E114. doi: 10.1208/pt060117

63. Morrison JG,White P,McDougall S, Firth JW,Woolfrey SG,GrahamMA, Greenslade D (2000) Validation of a highly sensitive ICP-MSmethod for the determination of platinum in biofluids: application toclinical pharmacokinetic studies with oxaliplatin. J PharmaceutBiomed Anal (24):1–10. doi:10.1016/S0731-7085(00)00377-0

64. Tibben MM, Rademaker-Lakhai JM, Rice JR, Stewart DR,Schellens JHM, Beijnen JH (2002) Determination of totalplatinum in plasma and plasma ultrafiltrate, from subjects dosedwith the platinum-containing N-(2-hydroxypropyl)methacryla-mide copolymer AP5280, by use of graphite-furnace Zeemanatomic-absorption spectrometry. Anal Bioanal Chem 373:233–236. doi:10.1007/s00216-002-1340-9

65. Villarino N, Cox S, Yarbrough J, Martín-Jiménez T (2010)Determination of carboplatin in canine plasma by high-performance liquid chromatography. Biomed Chromatogr 24(8):908–913. doi:10.1002/bmc.1385

66. Trotti A, Byhardt R, Stetz J, Corn B, Fu K, Gunderson L,McCormick B, Morris M, Tyvin Rich, Shipley W, Curran W(2000) Common toxicity criteria: version 2.0. an improvedreference for grading the acute effects of cancer treatment: impacton radiotherapy. Int J Radiat Oncol* Biol* Phys (IJROBP) 47(1):13–47. doi:10.1016/S0360-3016(99)00559-3

67. Eisenhauer EA, Therasse P, Bogaerts J, Schwart LH, Sargent D, FordR, Dancey J, Arbuck S, Gwyther S, Mooney M, Rubinstein L,Shankar L, Dodd L, Kaplan R, Lacombe D, Verweij J (2009) Newresponse evaluation criteria in solid tumours: Revised RECISTguideline (version 1.1). Eur J Cancer 45:228–247. doi:10.1016/j.ejca.2008.10.026

68. Wang Z, Chen HT, Roa W, Finlay W (2003) Farnesol for aerosolinhalation: nebulization and activity against human lung cancercells. J Pharm Pharm Sci 6:95–100

69. Yancik R (1997) Cancer burden in the aged: an epidemiologic anddemographic overview. Cancer 80(7):1273–1283. doi:10.1002/(SICI)1097-0142(19971001)80:7<1273::AID-CNCR13>3.0.CO;2-4

70. Piepoli MF, Davos C, Francis DP, Coats AJ, ExTraMATCHCollaborative (2004) Exercise training meta-analysis of trials inpatients with chronic heart failure (ExTraMATCH). BMJ 328(7433):189. doi:10.1136/bmj.37938.645220.EE

71. International Commission on Radiological Protection (1994) Humanrespiratory tract model for radiological protection. Elsevier ScienceLtd; ICRP Publication 66; Ann. ICRP 24(1/3), Oxford

72. Clay MM, Pavia D, Newman SP, Clarke SW (1983) Factorsinfluencing the size distribution of aerosols from jet nebulisers.Thorax 38(10):755–759

73. Khalid MN, Simard P, Hoarau D, Dragomir A, Leroux JC (2006)Long circulating poly(ethylene glycol)-decorated lipid nanocap-sules deliver docetaxel to solid tumors. Pharm Res 23(4):752–758.doi:10.1007/s11095-006-9662-5

74. Hitzman CJ, Wattenberg LW, Wiedmann TS (2006) Pharmacoki-netics of 5-Fluorouracil in the hamster following inhalationdelivery of lipid-coated nanoparticles. J Pharm Sci 95:1196–1211. doi:10.1002/jps.20607

75. Hureaux J, Lagarce F, Gagnadoux F, Vecellio L, Clavreul A, RogerE, Kempf M, Racineux JL, Diot P, Benoit JP, Urban T (2009)Lipid nanocapsules: ready-to-use nanovectors for the aerosoldelivery of paclitaxel. Eur J Pharmac Biopharmac 73(2):239–246. doi:10.1016/j.ejpb.2009.06.013

76. Koshkina NV, Waldrep JC, Roberts LE, Golunski E, Melton S,Knight V (2001) Paclitaxel liposome aerosol treatment inducesinhibition of pulmonary metastases in murine renal carcinomamodel. Clin Cancer Res 7(10):3258–3262

77. Ajay G, Nadezhda K (2003) Paclitaxel (Taxol) and taxoidderivates for lung cancer treatment: potential for aerosol delivery.Curr Cancer Drug Targets 3:287–296

78. Utsuki T, BremH, Pitha J, Loftsson T, Kristmundsdottir T, Tyler BM,Olivi A (1996) Potentiation of anticancer effects of microencapsu-lated carboplatin by hydroxypropyl α-cyclodextrin. J Contr Release40(3):251–260. doi:10.1016/0168-3659(95)00192-1

79. Chen W, Lu DR (1999) Carboplatin-loaded PLGA microspheresfor intracerebral injection: formulation and characterization. JMicroencapsul 16(5):551–563. doi:10.1080/026520499288753

80. Stegen K, Neujens A, Crombez G, Hermans D, Van de WoestijneKP, Van den Bergh O (1998) Negative effect, respiratory reactivity,and somatic complaints in a CO2 enriched air inhalation paradigm.Biol Psychol 49(1–2):109–122

81. Koshkina NV, Knight V, Gilbert BE, Golunski E, Roberts L,Waldrep JC (2001) Improved respiratory delivery of the anticancerdrugs, camptothecin and Paclitaxel, with 5% CO2-enriched air:pharmacokinetic studies. Cancer Chemother Pharmacol 47(5):451–456

82. Newsom Davis J, Stagg D (1975) Interrelationships of the volumeand time components of individual breaths in resting man. JPhysiol 245:481–498

83. Usmani OS, Barnes PJ (2011) The small airways: an importanttarget in asthma and COPD treatment. Respir Dis Pract 21:1–4.doi:10.3109/07853890.2011.585656

1640 Invest New Drugs (2012) 30:1628–1640