Targeted Delivery of Chemotherapy With Ultrasound and Microbublles

Study Overview
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Brief Summary
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The oscillations of ultrasound (US) contrast agent microbubbles under their activation by US waves engender a modulation of the permeability of biological barriers amplifying hence the extravasation of drugs and/or fluorescent markers through a process known as sonoporation. In such a way, the bioavailability of the therapeutic agent is augmented only in the area where US waves are focused. The objective now is to translate this therapeutic approach to the clinic by performing a feasibility study with the development of a therapy regime optimized for hepatic metastases of colorectal cancer. In order to demonstrate the clinical feasibility of the therapeutic approach based on ultrasound and microbubbles, we will focus on patients with liver metastases of colorectal cancer treated with monoclonal antibodies in combination with chemotherapy.

Detailed Description
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Despite the increasing number of active molecules and the availability of news targeted therapies for cancer, therapeutic achievements remain modest for a number of tumor types. One of the major obstacles is inherent to the absence of specific delivery in the tumor tissue. We have demonstrated recently that the oscillations of ultrasound (US) contrast agent microbubbles under their activation by US waves engender a modulation of the permeability of biological barriers amplifying hence the extravasation of drugs and/or fluorescent markers through a process known as sonoporation. In such a way, the bioavailability of the therapeutic agent is augmented only in the area where US waves are focused. The objective now is to translate this therapeutic approach to the clinic by performing a feasibility study with the development of a therapy regime optimized for hepatic metastases of colorectal cancer. In order to demonstrate the clinical feasibility of the therapeutic approach based on ultrasound and microbubbles, we will focus on patients with liver metastases of colorectal cancer treated with monoclonal antibodies in combination with chemotherapy. The work aims into evaluating the therapeutic efficacy of the proposed approach on a number of selected patients. We will follow the usual treatment schemes and we will apply imaging protocols to visualize tumor progression. This technique of optimization of the intratumoral availability of anticancer drugs and based on sonoporation will improve the efficacy and safety of systemic chemotherapy by providing increased tumor uptake relative to normal tissue. This technique provides an ideal and easy strategy to optimize intratumoral drug delivery.

Official Title
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Targeted Delivery of Chemotherapy With Ultrasound and Microbubbles

Conditions
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Colorectal Cancer, Hepatic Metastases

Intervention / Treatment
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* Radiation: MRI
* Radiation: Perfusion CT scan
* Other: Contrast enhanced ultrasound
* Drug: Sonoporation


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: patient with liver metastases from colorectal cancer; patient with minimum two liver metastases which satisfy all the following criteria: diameter between 10 and 35 mm; arterially enhancing liver metastases detected with contrast enhanced ultrasound (CEUS); measurable liver metastases with CT-scan (Acceptability of a patient with more than 4 metastases or a patient with an odd number of metastases ≥ 2). age ≥ 18 years; ECOG/OMS 0-1; life expectancy of at least 12 weeks; adequate bone marrow, liver and kidney function; written informed consent obtained from subject; subjects covered by or having the rights to social security; bi-weekly chemotherapy regimen neo-adjuvant standard chemotherapy or palliative standard chemotherapy (first or second metastatic line) following the recommendations in force (national thesaurus of digestive oncology - colorectal cancer chapter: Phelip JM, Benhaim L, Bouché O, Christou N, Desolneux G, Dupré A, Léonard D, Michel P, Penna C, Rousseaux B, Tougeron D, Tournigand C. Cancer colorectal métastatique. Thésaurus National de Cancérologie Digestive, Janvier 2019, http://www.tncd.org). Exclusion Criteria: Previous local treatment of selected liver metastases (radiofrequency, radioembolization, …); Indication for local ablative therapy of selected liver metastasis (radiofrequency ablation or other validated hepatic-directed modality of treatment); Previous malignancy other than colorectal adenocarcinoma within 3 years prior to the inclusion with the exception for curatively treated basal cell carcinoma of the skin and/or curatively resected in situ cervical or breast cancer; Known contraindication to the injection of Sonovue®, of Gadolinium, of iodated contrast agent; contraindication to MRI or perfusion CT scan; Patient under legal protection; Pregnant or lactating woman, or woman with ability to procreate and without contraception; Inclusion in another therapeutic trial Uracilemia greater than or equal to 150ng/mL (suggestive of a complete DPD deficiency). Presence of any material with potential interaction with ultrasound beam (metal, etc.) or healing tissue, and which cannot be bypassed

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Selected liver metastases of the patient<br>Liver metastases randomized to receive sonoporation (US waves + gaseous microbubbles). The patient continue to receive the usual systemic chemotherapy | Radiation: MRI<br>* Magnetic Resonance Imaging<br>Radiation: Perfusion CT scan<br>* Perfusion Computerized tomography scan<br>Other: Contrast enhanced ultrasound<br>* Contrast enhanced ultrasound<br>Drug: Sonoporation<br>* Gaseous microbubbles (Sonovue) combinated with Ultrasounds<br>|
| Placebo Comparator: Not-selected liver metastases of the patient<br>Liver metatstases not randomized to receive sonoporation (US waves + gaseous microbubbles). The patient continue to receive the usual systemic chemotherapy like the active comparator arm | Radiation: MRI<br>* Magnetic Resonance Imaging<br>Radiation: Perfusion CT scan<br>* Perfusion Computerized tomography scan<br>Other: Contrast enhanced ultrasound<br>* Contrast enhanced ultrasound<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Objective response for liver metastases | Objective response for liver metastases with spiral CT scan and defined as decrease of at least 30% in the longer diameter of each selected liver metastases | 2 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Safety | Safety based on National Cancer Institute (NCI), Common Terminology Criteria for Adverse events (CTCAE) | Day 3, Day 17, Day 32, Day 47 | 
| Tolerance | Tolerance based on National Cancer Institute (NCI), Common Terminology Criteria for Adverse events (CTCAE) | Day 3, Day 17, Day 32, Day 47 | 
| Maximum percent reduction in tumor density on CT scan | Maximum percent reduction in tumor density (Hounsfield units) from baseline | 2 months | 
| Maximum percent reduction in tumor density on MRI | Maximum percent reduction in tumor density from baseline | 2 months | 
| Assessment of tumor vascularity by Perfusion CT scan | Assessment of tumor vascularity with Perfusion CT scan | 2 months | 
| Assessment of tumor vascularity by MRI | Assessment of tumor vascularity with MRI | 2 months | 
| Assessment of tumor vascularity by Dynamic Contrast-Enhanced US (DCE-US) | Assessment of tumor vascularity with Dynamic Contrast-Enhanced US (DCE-US) | 2 months | 
| Dosage of antibody anti-VEGF or anti-EGFR | Measures of serum concentration of antibody anti-VEGF or anti-EGFR | Day1, Day 3, Day 15, Day 17, Day 32, Day 45 | 
| Dosage of antibody anti-VEGF or anti-EGFR by ELISA test | Pharmacokinetic of antibody anti-VEGF or anti-EGFR | Day1, Day 3, Day 15, Day 17, Day 32, Day 45 | 
| Dosage of cytokines | Dosage of cytokines | Day1, Day 3, Day 15, Day 17, Day 32, Day 45 | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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microbubbles, sonoporation, hepatic metastases of colorectal cancer