The quality Targeting of Cancer Chemotherapy Using Non-Invasive Focused Resonance Nano-Permeabilization

Received date: February 20,2017;Accepted date : March15,2017; Published date: March 20,2017. Citation for this Article: Saritha Garrepalli ,The quality Targeting of Cancer Chemotherapy Using Non-Invasive Focused Resonance NanoPermeabilization, J Cancer Research and Cellular Therapeutics, Doi: 10.31579/2640-1053/006 Copyright : © 2017 Saritha Garrepalli. This is an open-access article distributed under the terms of The Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


J Cancer Research and Cellular Therapeutics
Base-line chemotherapy induced adverse event evaluation, before applying FORN, and tumor response criteria based on PET-CT scans, were compared with chemotherapy cycles combined with the FORN protocol. Considering that most therapies offered in advanced stages of cancer offer little to no overall survival benefit, the use of a sophisticated yet safe, noninvasive RF and MR-mediated drug delivery technology like FORN, enhanced the therapeutic efficacy of cytotoxic chemotherapy; improved treatment outcomes; dramatically mitigated adverse systemic toxicities and improved Quality of Life (QoL) in this report of an NPC patient presenting with loco-regional recurrence and advanced, multiple metastases.
Case presentation and standard of care chemotherapy A forty-eight year old male patient of Anglo-Indian descent, under treatment for recurrent, metastatic, undifferentiated NPC at the Akika Center of the Japanese Cancer Research Foundation (JCRF), Japan, presented to the Manipal Hospital in Bangalore-India, in April 2013, with relapsed disease, following the 1st cycle of the 5thcourse of Carboplatin (CBDCA) + Paclitaxel (Total of 6 cycles were originally planned). Concurrent chemotherapy and FORN was initiated in consultation with the medical oncologists who afforded care for the patient in the study at the Akika Center of the JCRF, Japan and the Manipal Comprehensive Cancer Center (MCCC) and Hospital, in Bengaluru, India, together with the authors involved in the study. Detailed, anecdotal case history as well as Functional Assessment of Cancer Treatment-Head & Neck (FACT-H&N) questionnaires were initiated and maintained through the treatment period and follow up visits [5]. Karnofsky Performance Scale score (KPS/ K-score) [6] was used to assess QoL at specific time points in the study. Patient's clinical status was periodically recorded at baseline (before therapy) and at the completion of every chemo-cycle in the study.

Disease and prior treatment history
2005 (no details available from patient's medical record): A biopsy of a nasal polyp confirmed the diagnosis of locally confined, undifferentiated NPC. Patient was treated with CCRT in USA (6-Gy+weekly Cis-Diamminedichloride Platinum (CDDP) 33mg x 6 wks. (Cycle I) recurrence in the liver was diagnosed on follow  up PET-CT in Japan. Imaging revealed progressive liver metastases. Patient returned to Bengaluru, India for subsequent chemotherapy and FORN. He presented with massive hepatomegaly, anemia, thrombocytopenia, hepatic and renal dysfunction. Due to poor performance status, patient was initially started on weekly single agent Abraxane (nab-paclitaxel), however, as the parameters gradually improved clinically with reduced hepatomegaly, improved appetite and energy levels, and improvement in hematological parameters, liver and kidney dysfunction, weekly Cisplatin was added. He was also continued on Zoledronic acid monthly, in view of his bone metastases. 2014 Jan 31st: Follow up PET was done after 3 cycles of nabpaclitaxel (weekly dosing for 6 weeks with 1 week gap) + Cisplatin (weekly dosing for 5 weeks). Disease outcome was compared using PET CT (3rd) done in Japan in March 2013 and Nov 2013 with PET-CT (4th) at MCCC in Jan 2014. Treatment planned: 2 week treatment holiday followed by monthly nab-paclitaxel and Cisplatin as maintenance therapy, with adjuvant FORN. 2014 May 1st: Patient was hospitalized at the MCCC with liver failure / encephalopathy and succumbed after a few days of active medical management.

MRI /PD sequence protocol for FORN treatment planning and dosimetry
Dose-planning MRI-derived Proton Density (PD) sequence was obtained for the Region(s) of Interest (ROIs) to be targeted for chemo-drug delivery, in the whole body. The PD sequence that is an integrated component of most 1.5T equipment -is derived for lesions to be targeted by FORN. TR value used is set at 4000msec and TE value at 11msec. Three millimeter (mm) contiguous sections with zero spacing are maintained. The use of a 'navigator' was used to improve the resolution and minimize imaging artefacts. Appropriate Field of View -around 400-450mm was used, with phase encoding in the anterior-posterior direction. The skin was included in planning as it is integral to FORN dosimetry and treatment planning. The Dosimetry planning film is marked on the MRI film ( Figure 1) and transferred to a compact disc (CD) for use in the FORN device computer. Surface marking on the patient's skin were made, under Computeraided Tomography (CT) for aligning and focusing the FORN RF guns. A transparent sheet template is prepared with body surface markings delineating the axes to be targeted by the FORN protocol, and used to position the patient in the gantry prior to RF / MR exposure (Supplemental Figure 1).

Figure 1.
The MRI-derived target lesion marking done by the radiologist/radiology technician during PD sequence determination, is seen on the film transferred to a compact disc (CD) used for dose targeting. The region shown is the loco-regional recurrence in the nasopharynx.

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Note: Diffusion Weighted Imaging (DWI) sequences can also help to identify foci of restrictions, indicative of suspicious areas). Forn protocol The pathological diagnosis, tumor type and cellular morphology were used to determine the cell membrane thickness of target tumor cells. The cell membrane thickness of the loco-regional un-differentiated naso-pharyngeal carcinoma NPC cells and distant metastases is ideally obtained from biopsy slides during pathological diagnosis. In this case, given the time from original diagnosis and the onset of metastatic disease, the membrane thickness of NPC cells of squamous origin was set at 4.55 microns. The drug molecular weight (g/mol), peak plasma concentration time (in minutes), drug wash out time (in minutes) or its known active metabolites was determined from available literature [7]. This information is fed into the device computer as seen in Dosimetry is fixed using the gun paths planned to focus on each of the targeted ROIs. Individualized and precise RF gun-path files are programmed for all the ROI's targeted and 'mapped' as seen for each of the lesions to which the drug was driven and 'focused' for this patient ( Figure 3). E-planning for the dosimetry and the nanosecond pulses for the FORN protocol are determined using the dedicated machine intelligence and software for FORN on the device computer. The "Target Planning Films" derived from the PD sequences in the MRI for the ROIs, show the core of the tumor mass to be targeted. The number of guns/axes required to be fired for FORN depends on the cancer cell type and specific drug molecules to be permeated. A specially trained and certified FORN technologist enters specific inputs like drug / its metabolite, molecular weight (of the largest molecule), time to Peak Plasma Concentration (of the drug with the shortest peak plasma concentration time), Drug Washout Time of the drug and or its metabolites to be permeated, cell membrane thickness of the tumor tissue type and total tissue volume (cm3) of respective lesions. On the day of scheduled treatment, the patient is administered the required dose of the drug to be permeated X-minutes before applying FORN (X=peak time taken (in minutes) for the drug to attain maximum concentration in circulation in the patient). Before exposure, the patient is made to lie down on the treatment transport bed and the patient is moved into the FORN device; the RF-guns are now focused on the target ROIs using a laser-guided system. The exposure is for Yhours each day for Z-days, where Y is the time period required for the trans-permeabilization of maximum drug molecules infused and Z is the course or number of cycles of the drug on given days of drug infusion. When the planned FORN signals are withdrawn, the pores are closed and drug retained within the tumor.
FORN is targeted precisely to affected areas in the whole body, to transport and permeate the cancer drugs used in the treatment of the NPC patient described in this report, in a safe, non-invasive and precisely programmed and controlled manner.
Baseline / PET-CT scan was obtained prior to chemotherapy planning at the JCRF-Akika, Japan. Periodic post-chemotherapy and FORN assessments were done using ultrasound, CT/MRI or PET.

Chemotherapy infusion schedule and FORN
The first cycle of CBDCA + PAX course # 6 was given at JCRF, Japan. Significant adverse effects were reported by the patient. The patient travelled to Bengaluru, India to continue his chemotherapy schedule under the care of the oncologist at the MCCC and S-CARD for concurrent chemotherapy-enabled FORN. The route and time of administration of the Carboplatin and Paclitaxel was determined and fixed on Day 1 of chemocycle # 2 given at MCCC. After chemo was administered, patient was transferred to the FORN facility and treatment was administered as per protocol. The details of drugs administered in each of the chemo-cycles with respective pharmacokinetic details critical to the concurrent application of the FORN protocol, is summarized in and detailed in Supplemental Table 1. A PET scan was repeated after Cycle # 6 was completed. Evaluation of tumor response was done using PERCIST 1.0 criteria [8,9]. Based on the residual marginal SUV in one mediastinal lymph node, Cycle 7 was planned with the oncologist and enabled with FORN. The patient returned to Japan in September 2013 to resume work.

Results
Improvements in symptoms of nausea, fatigue, weight loss, and other related events, determined with the use of patient interviews and FACT-H&N, QoL and KPS-S questionnaires, reflected very good responses. Patient consistently reported that the intensity of side effects commonly experienced in Japan during the course of treatment, was minimal when chemotherapy cycles were administered concurrently with FORN. No episodes of vomiting, diarrhoea or other major gastrointestinal (GI) symptoms were experienced. Patient had Grade 2-increase of 4-6 stools/day over the baseline -after routine chemotherapy without FORN, when assessed based on criteria laid down by the National Cancer Institute Common Terminology Criteria for Adverse Events (NCI-CTCAE) [10]. More significantly, the patient's overall recovery from any side-effects, were faster. The blood work and adverse events/toxicity profile after the 1st course of the CBDCA/ PAX # 6 cycles done at the JCRF, Japan, after the chemotherapy infusion without FORN, is shown in Supplemental Table 2 as an XL spread sheet on pages 2 and 3.

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All subsequent hematological work-ups and toxicity related parameters evaluated after each Chemotherapy + FORN cycle (# 2, #3, #4, #5, #6 and #7) is also seen in Supplemental Table 2. Tumor response criteria were evaluated comparing previously refractory lesions using PERCIST 1.0 for metabolic and metastatic disease as seen in PET-CT scans, after completion of planned therapy sessions. The images of pre-treatment PET-CT evaluation and the post chemotherapy + FORN treatment is seen in sequence in . The radiology interpretation of PET-CT is abridged in Table 1.

Chemo Cycle With Forn Discussion
The majority of patients with squamous cell carcinomas of the head and neck present with locally advanced tumors. The first-line treatment for NPC consists of combined modality management [11,12]. Despite these aggressive protocols, many patients develop loco-regional recurrences with or without metastasis. New technology, more effective and less toxic chemotherapy regimens, and targeted therapy offer new opportunities for treating NPC patients who require multiple chemo-cycles during the course of the disease. Considering that most therapies offered in advanced stages of the disease offer little to no overall survival benefit in NPC [13], the use of an effective drug delivery method to enhance therapeutic efficacy and circumvent systemic side effects was considered. Using FORN concurrently with systemic chemotherapy, in an advanced case of NPC with metastatic lymph nodes, skeletal and liver metastases; dramatically improved survival, tumor response and very good QoL [14,15]. This case is being presented with the intent to disseminate the potential application of a concurrent, non-invasive drug delivery technology to trans-permeate drugs intra-tumorally, in routine clinical practice, along with planned cancer chemotherapy. Electric field pulses reported as inducing transient permeabilization of drugs, have long been known, and extensively reported [16]. Probably the most important feature of a biomembrane is that it is a selectively permeable structure. This means that the size, charge, and other chemical properties of the atoms and molecules attempting to cross it will determine whether they succeed in doing so. Selective permeability is essential for effective separation of a cell or organelle from its surroundings [17]. While electro-permeabilization is a technique using short pulses of electrical fields to cause temporary holes in the cell membrane in vitro, nano-permeabilization is a technique by which temporary pathways are precisely created for a specific molecule based on its molecular weight and size, in vivo. In nanopermeabilization, as described in the FORN protocol used in this patient study, specific cells in the ROI were resonated in a high, instantaneous magnetic field, followed by the delivery of nanosecond radio-pulses that penetrate only such resonating cells. This process is achieved non-invasively, within the cells natural environment. Like electro-permeabilization, nanopermeabilization can be widely used for the introduction of molecules such as DNA, antibodies, enzymes, and drugs into cells [1]. Research and development for use of the FORN protocol with concurrent chemotherapy, has facilitated the delivery of a variety of small and very large molecule drugs into target tissue, noninvasively, despite all normally restrictive size and permeability constraints.
Controlled drug delivery technology has advanced significantly in the last few decades, leading to the development of various clinical formulations improving patient compliance and convenience [18,19].
The critical intracellular target for cytotoxic drugs is dependent on intracellular concentrations of the drug moiety, and/or its metabolites, which in turn is dependent on membrane permeability [20]. Anti-tumoral drugs therefore need direct access to the cytosol to fully exert their cytotoxic potential. Lower doses than the ones required in classical protocols of chemotherapy regimens could also technically be used to achieve better therapeutic indices even with highly cytotoxic drugs [21]. Potentiating cytotoxicity of various chemotherapy agents and other targeted molecules can also be increased several fold by this 'focused' internalization process enabled by the FORN protocol, just as how the cytotoxicity of Cisplatin is potentiated up to 70 times more in suspended cell cultures using electric pulses in vitro [16]. Such 'potentiation' can be highly controlled using FORN, by in-putting delivery parameters like molecular mass of the drug / active metabolite, peak plasma concentration, total tissue volume and cell membrane characteristics. FORN used concurrently with conventional chemotherapy in this patient with recurrent, metastatic NPC, very clearly potentiated the anti-tumor effectiveness of Carboplatin and Paclitaxel, based on reviewing the disease response and clinical outcome. Drug delivery could be timed and precisely localized in vivo, to achieve the desired therapeutic impact without concomitant cytotoxic adverse effects. The Institute for Safe Medication Practices (ISMP) using FDA data estimates the 2011 licensed drug death figure at 128,000. This excludes chemo drug deaths, which are classified as cancer deaths. Licensed drugs are the number 4 killer of human beings, according to the FDA's own figures. It is an epidemic. They refer to 2 million "Adverse Drug Reactions" which they call ADRs, and 100,000 deaths a year, with approved drugs.
A startling study by Public Health England and Cancer Research UK has found that cancer treatment itself may be killing up to 50 percent of patients [22]. In a first of its kind study, the researchers on this study dug deeper into cancer patients who died within 30 days of beginning their treatment, indicating that the treatment caused the death, not the cancer. Across the nation, they found that 8.4 percent of those undergoing treatment for lung cancer, and 2.4 percent of those being treated for breast cancer, died within a month of beginning treatment. Results varied greatly based on the hospital however, as an alarming 50.9 percent of those in Milton Keynes Hospital -UK, beginning chemotherapy treatment for lung cancer died within 30 days. Researchers noted that the total number of patients treated at the hospital was much smaller than the norm, but the numbers remain eye-opening, and the list is endless. Efficient and effective drug delivery processes are being increasingly reported in the literature to circumvent issues related to traversing the blood brain barrier (BBB) and improving bioavailability to enhance therapeutic effect. Ideal delivery systems should allow targeting of the drug to tumors. Improving therapeutic efficacy while simultaneously mitigating toxic side effects of commonly used cancer drugs; as well as reducing the iteration of new drugs in the pipeline, due to failed drug trials, is the hope. Although many advances in treatment have been made, they have yielded only modest survival benefits for cancer patients [2].

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A major factor contributing to limitations in systemic delivery is doselimiting drug toxicity. 'Safe' Chemotherapy need not be an oxymoron. For the longest time, chemotherapy has been a double-edged sword, with the balance tipping heavily against it, due to the dangers of systemic toxicities accompanying even the best of molecularly target agents in this day and age of personalized, precision medicine. Reports and studies have flooded the 'playing' field with every possible combination of drug molecules being used to achieve even minimal survival advantage in very aggressive brain tumors [23][24][25] as well as in the more long-drawn out but equally aggressive, treatment refractory NPC being discussed here [26][27][28]. The problem remains that very little consideration is applied to the QoL in these patients being subjected to random drug combinations, with no real understanding of synergies or complicated drug-drug interactions that could induce even more severe systemic toxicities! The challenge has been that the treatment does not specifically target cancerous cells, and randomly destroys normal, healthy, fast-dividing cells in its wake. "Most cancer patients die of chemotherapy. Chemotherapy does not truly eliminate breast, colon, or lung cancers despite all the years of research and trial designs applied to date. The immune system is hit particularly hard by chemotherapy and the body often does not recuperate enough to adequately protect from common illnesses, leading to death [22]." The fact that chemo only contributes on average about 2% to overall survival rate, is very alarming, and not often discussed. It is important to remember that the "2.1% average" can be deceptive. Some cancers do respond better to chemo than others. According to a 2004 report by Morgan et al. "The contribution of cytotoxic chemotherapy to 5-year survival in adult malignancies was estimated to be 2.3% in Australia and 2.1% in the USA ." Technically speaking, an ideal delivery method would be one that achieves adequate coverage of tumor volume while minimizing unwanted toxicities. Optimal delivery requires three important components: 1) the ability to target the tumor while minimizing local and systemic effects; 2) applicability over a wide range of therapies, and 3) a safe, efficacious method of continuous delivery with noninvasive methods while monitoring volumes of distribution (Vd) of agents. Although promising results are now being reported with the use of NAB-paclitaxel combined with cisplatin (NAB-TP) for advanced NPC [31]; a drug used on our patient too, the anti-tumor efficacy in patients with locally advanced NPC needs to be viewed in the light of post-treatment quality of life in patients with multiple, severe metastatic disease as reported here, and managed with concurrent FORN. The toxicities induced by NAB-TP treatment were well tolerated and manageable in this patient, when it was administered concurrently with FORN. Given the protracted course of the disease and the many cycles of CCRT and multiple chemo-drugs over the survival span of the patient, it was not surprising that he was finally diagnosed with liver failure and encephalopathy. Ironically, although the death certificate assigned the cause of death as metastatic liver disease, a very thorough radiological review of the final PET scan did not show any residual 'metabolically active' disease in the liver ( and Table 1). Minimizing systemic exposure, thereby reducing the comorbidities in patients with advanced disease, will allow for significant improvements in quality of life and supportive care for the terminally ill. This outcome should also include improvement in symptoms and patient satisfaction, with reduced caregiver burden. The American Society of Clinical Oncology (ASCO) provided a provisional clinical opinion (PCO) that recommended that end of life counselling should be an integral component of treatment planning even at the earliest presentation of a patient diagnosed with cancer . More often than not, systemic chemotherapies that are given to advanced cancer patients, although essentially hoping to achieve palliation of some kind, are excessively toxic in these patients who are already severely immune-compromised and weakened both by the disease and multiple cytotoxic chemotherapy regimens. A very significant advantage of this process of concurrent chemotherapy with FORN is that it is not restricted to any specific type of drug molecule or solid tumor type.
Drug "focusing" is achieved by MRI derived tissue proton density determinations of ROIs, and creating drug molecule and size-specific temporary nano-pores to accentuate cellular permeability. The NPC case study reported here for the first time, details the procedure in one patient in a pilot study series, who received FORN for 6 consecutive chemotherapy cycles and survived with very good QoL despite the very advanced status of the disease. The pilot study being conducted to clinically validate the technology, included several other patients with a variety of advanced solid tumors like Stage 1V Ovarian cancer on 1 cycle of systemic Carboplatin and Gemzar; advanced breast cancer with liver, lung and skeletal metastases on Ixempra + Capecitabine; Ca. Breast with liver, pelvic bone, left adrenal & brain metastasis on oral Lapatinib and Temozolamide; Herceptin-failed breast cancer, with multiple brain metastases on palliative chemotherapy; Anaplastic Astrocytoma on oral Temozolamide + natural, large molecule Physalis minima; pediatric, recurrent, medulloblastoma on systemic Cyclophosphamide & Etoposide; adult glioblastoma on Temozolamide and natural Curcuminoids; and advanced, radiation-induced secondary, relapsed metastatic osteosarcoma on oral Sorefinib. In all these cases of advanced solid tumor patients, receiving either 'curative'chemotherapy as part of 'standard of care' treatment regimens or palliative chemotherapy, showed significant reduction in drug-induced adverse effects, tolerating previously intolerable, chemotherapy and having very active, good quality of life for the duration of FORN treatment. More studies that combine the power of pharmaco-kinetic and pharmaco-dynamic toxicity criteria, alongside quantitative evaluation of blood, tissue and excretion of infused drug and it's active metabolites, over the period of a chemo-cycle, needs to be done. Parallel evaluation of criteria of myelosuppression and other adverse effects in a specific group of cancer patients with advanced solid tumors on different 'trial and error' chemotherapeutic regimens, would throw more light on the projected reduction of drug in systemic circulation during FORN. More importantly, improving and salvaging "failed" drug pipelines with novel drug moieties, vaccines, genetic materials or any other molecules of interest in vivo, can facilitate novel drug discovery and improve patient compliance using FORN-enabled concurrent chemotherapy, in routine clinical practice.