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Intra‐arterial chemotherapy for head and neck cancer

trial. For most oncologists who have limited experience with the IA method of drug delivery, and generally consider it to be more complex and invasive than IV chemotherapy, the results as published will be accepted without further question. For those of us who have experience with the IA approach, there remain some concerns that may have influenced the results of this trial. The most prominent concern relates to the technique used to deliver the IA infusions. The contemporary method for IA infusions employs the transfemoral approach for the placement of microcatheters through which the chemotherapy agent can be rapidly and selectively infused to the tumor bed. The determination of which artery or arteries to infuse and whether to target the external carotid artery and its branches on the ipsilateral side versus additional infusions through the contralateral carotid artery system is a judgment typically made by the interventional radiologist based on observed blood flow and anatomical location of the primary disease. 4 For the vast majority of patients, we have observed that the primary tumor can be effectively treated simply by using the carotid artery system on the side ipsilateral to the side of the tumor, even when the lesion has crossed the midline. We have noted that most tumors extending across the midline will continue to receive arterial flow through the ipsilateral vessels. In our experience, the decision to perform an additional infusion through the contralateral carotid artery is reserved only for a small number of patients whose primary disease substantially encompasses the opposite side of the upper aerodigestive tract or who have angiographic evidence of a bilateral arterial supply. Furthermore, the proportion of the infusate delivered through the contralateral arterial system is virtually always smaller. However, in the current study Rasch et al chose to employ bilateral infusions in the majority of patients (58 %) receiving IA chemotherapy using the criteria of ‘‘more than 1 cm extension across the midline’’ and delivering 50% if the infusate through the opposite vessels. Inherent to the technique of bilateral IA infusions is the necessity to divide the total dose and, hence, diminish the effect of the drug delivered. In the case of cisplatin infusion with sodium thiosulfate neutralization, an infusate that has been divided may represent an amount that is disproportionate to the targeted tumor volume. As a consequence, not only is the cisplatin more likely to be neutralized by the sodium thiosulfate, but also a suboptimal dose is delivered to the tumor