7.3 Regional & Localized Therapy Administration
Key Takeaways
- Regional delivery exploits first-pass extraction to raise local drug concentration many-fold while limiting systemic exposure, and is only rational when disease is confined to that compartment.
- Only a defined set of agents may be given intrathecally — methotrexate, cytarabine including liposomal formulations, hydrocortisone, and thiotepa; vinca alkaloids given intrathecally cause fatal ascending myeloencephalopathy.
- Intraperitoneal cisplatin and paclitaxel improve survival in optimally debulked advanced ovarian cancer but cause substantially more catheter complications, abdominal pain, and nephrotoxicity than intravenous therapy.
- Hepatic arterial infusion of floxuridine exploits the hepatic artery's supply of liver metastases, with biliary sclerosis as the characteristic dose-limiting toxicity.
- Post-embolization syndrome, consisting of fever, right upper quadrant pain, nausea, and transaminase elevation, occurs in most patients after chemoembolization and is managed supportively rather than as infection.
7.3 Regional & Localized Therapy Administration
Blueprint focus: ONCC Domain II.C — Localized therapy (for example intravascular, intraperitoneal, intrathecal, intra-arterial). Regional therapy is tested heavily on safety rules and route-specific complications, not on efficacy data.
The Pharmacologic Rationale
Regional delivery is justified by two related principles.
- Compartmental advantage. Delivering a drug directly into a space that systemic circulation penetrates poorly — the cerebrospinal fluid, the peritoneal cavity, the bladder — can raise local concentration by one to three orders of magnitude.
- First-pass extraction. An organ that extracts most of a drug on first pass (the liver with floxuridine, for example) receives a very high local dose while systemic exposure stays low.
Regional therapy is only rational when disease is genuinely confined to that compartment. It does not treat systemic disease, and adding it to an inappropriate patient produces toxicity without benefit.
Intrathecal Chemotherapy
Intrathecal therapy treats or prevents leptomeningeal disease, most often in acute lymphoblastic leukemia, aggressive lymphomas, and leptomeningeal metastases from breast and lung cancer.
Routes: lumbar puncture, or an Ommaya reservoir — a subcutaneous scalp reservoir connected to a ventricular catheter that provides repeated access and better drug distribution throughout the CSF.
Agents that may be given intrathecally:
| Agent | Typical use | Notes |
|---|---|---|
| Methotrexate | CNS prophylaxis and treatment | Chemical arachnoiditis is the commonest acute reaction; leucovorin rescue is given systemically, never intrathecally |
| Cytarabine | CNS leukemia and lymphoma | Liposomal cytarabine gives sustained levels and requires concurrent dexamethasone to prevent chemical arachnoiditis |
| Hydrocortisone | Added to reduce arachnoiditis | Part of the classic triple intrathecal regimen |
| Thiotepa | Alternative agent | Crosses the blood-brain barrier well |
The single most important safety rule in oncology nursing
Vinca alkaloids are fatal if given intrathecally. Intrathecal vincristine causes a progressive ascending myeloencephalopathy that is essentially uniformly fatal. Standard safeguards:
- Vincristine must be dispensed only in a small-volume intravenous minibag, never in a syringe.
- The bag carries the label "For intravenous use only — fatal if given by other routes."
- Vinca alkaloids and intrathecal agents must never be transported, stored, or present in the treatment area at the same time; intrathecal doses are handled in a separate time and place.
- Independent double verification of drug, dose, and route immediately before administration.
Post-procedure nursing care: monitor for headache, nausea, fever, meningismus, and neurologic change; position per institutional protocol; observe the puncture site for CSF leak; and know that a post-dural-puncture headache is positional and may require a blood patch.
Intraperitoneal Therapy
Indication: optimally debulked (residual disease under 1 cm) advanced epithelial ovarian cancer, and selected peritoneal surface malignancies.
Standard agents: cisplatin and paclitaxel, delivered through an implanted intraperitoneal port and catheter, typically with 1 to 2 liters of warmed fluid.
Toxicity profile: intraperitoneal therapy produces substantially more abdominal pain and distention, nausea, catheter infection, catheter obstruction and leakage, bowel injury, nephrotoxicity, and neuropathy than intravenous therapy. Completion rates are correspondingly lower, and the decision requires an explicit conversation about the survival benefit weighed against the burden.
Nursing management: verify catheter patency and absence of infection before each instillation; warm the infusate to body temperature; instill by gravity; reposition the patient side to side to distribute drug across peritoneal surfaces; monitor abdominal girth, pain, and respiratory effort; aggressive hydration and electrolyte replacement with cisplatin.
HIPEC (hyperthermic intraperitoneal chemotherapy) delivers heated chemotherapy intraoperatively immediately after cytoreductive surgery — most often for appendiceal and colorectal peritoneal metastases and pseudomyxoma peritonei. Postoperative care focuses on fluid shifts, hypothermia or hyperthermia, electrolyte derangement, prolonged ileus, and neutropenia.
Intra-Arterial and Intravascular Therapy
Hepatic arterial infusion (HAI). An implanted pump delivers floxuridine into the hepatic artery. Liver metastases derive their blood supply almost entirely from the hepatic artery while normal hepatocytes are supplied mainly by the portal vein, so tumor is exposed selectively. Floxuridine is nearly completely extracted on first pass, which keeps systemic toxicity low. The characteristic dose-limiting toxicity is biliary sclerosis — a rising alkaline phosphatase and bilirubin that mandates dose reduction or discontinuation. Dexamethasone is often added to the pump to mitigate it. Nursing care centers on pump refill scheduling, site assessment, and monitoring liver enzymes at every refill.
Transarterial chemoembolization (TACE) delivers chemotherapy plus embolic particles into the tumor-feeding artery, most often for hepatocellular carcinoma. Transarterial radioembolization (TARE, Y-90) delivers yttrium-90 microspheres instead.
Post-embolization syndrome occurs in most patients within 24 to 72 hours: fever, right upper quadrant pain, nausea, fatigue, and transaminase elevation. It is a predictable inflammatory response to tumor necrosis, not infection, and is managed with analgesia, antiemetics, antipyretics, and hydration. Distinguish it from hepatic abscess or cholecystitis when fever is prolonged or rigors appear.
Isolated limb perfusion or infusion delivers high-dose melphalan to an extremity isolated from systemic circulation for in-transit melanoma or extremity sarcoma; compartment syndrome and regional toxicity are the concerns.
Intravesical and Intrapleural Therapy
Intravesical therapy for non-muscle-invasive bladder cancer uses BCG (an immunotherapy) or intravesical chemotherapy such as mitomycin or gemcitabine, instilled through a urinary catheter and retained for about 2 hours with periodic repositioning.
- BCG is a live attenuated organism. It is contraindicated with gross hematuria, traumatic catheterization, active urinary tract infection, or significant immunosuppression, because of the risk of disseminated BCG infection presenting as persistent high fever and systemic illness — an emergency requiring antituberculous therapy.
- Teach patients to sit to void for 6 hours after instillation and to disinfect the toilet with bleach.
- Expect transient dysuria, frequency, and hematuria; escalate for fever above 38.5 °C persisting beyond 24 to 48 hours.
Intrapleural therapy is primarily pleurodesis with talc or doxycycline through a chest tube or at thoracoscopy for recurrent malignant pleural effusion, or drainage through an indwelling tunneled pleural catheter. Pain and fever are expected; monitor for re-expansion pulmonary edema after large-volume drainage, and drain no more than about 1.5 liters at one sitting or until chest discomfort or cough develops.
A nurse practitioner is reviewing orders for a patient with acute lymphoblastic leukemia scheduled to receive both intrathecal methotrexate and intravenous vincristine on the same day. Which safety practice is mandatory?
A patient with hepatocellular carcinoma undergoes transarterial chemoembolization. Thirty-six hours later he has a temperature of 38.4 °C, right upper quadrant pain, nausea, and an AST that has risen from 42 to 180 U/L. He is hemodynamically stable. What is the most appropriate interpretation and action?
A patient with optimally debulked stage III ovarian cancer is receiving intraperitoneal cisplatin and paclitaxel through an implanted peritoneal port. Which nursing action is specific to this route?