1. Modified In Vivo Lung Perfusion for Local Chemotherapy: A Preclinical Study With Doxorubicin 
Pedro Reck dos Santos, MD, MS, Jin Sakamoto, MD, Manyin Chen, MD, Virginia Linacre, MD, Chantel Arce, BS, Mingyao Liu, MD, MS, Thomas K. Waddell, MD, PhD, Shaf Keshavjee, MD, MS, Marcelo Cypel, MD, MS 
The Annals of Thoracic Surgery 
Volume 101, Issue 6, Pages (June 2016)
DOI: /j.athoracsur
Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

2. Fig 1
In vivo lung perfusion (IVLP) system. Perfusate enters left lung through left pulmonary artery (1) and is drained by upper (2) and lower left pulmonary veins (3). After leaving left lung (4), perfusate is collected in hard-shell reservoir (5) and then directed to centrifugal pump (6), which drives flow to membrane gas exchanger, where combination of gas (oxygen, 6%; carbon dioxide, 8%; nitrogen, 86%) is added to deoxygenate perfusate and provides CO2 for inflow. Perfusate then passes leukocyte filter (8) and returns to left pulmonary artery (9). Temperature of perfusate is controlled by heat exchanger connected to gas exchanger. Standard intensive care unit type of ventilator provides ventilation to both lungs.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

3. Fig 2
Lung function and histologic assessment in in vivo lung perfusion (IVLP) with 75 mg/m2 of doxorubicin (n = 5). (A) Stable oxygenation, airway dynamics, and pulmonary artery pressure (PAP) were observed during IVLP and after 4 hours of reperfusion. No statistical difference was observed in histologic acute lung injury score between (B) before IVLP, (C) after IVLP, and (D) after reperfusion. (Cdyn = dynamic compliance; PAWP = peak airway pressure.)
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

4. Fig 3
Lung function and histologic assessment in in vivo lung perfusion (IVLP) with 75 mg/m2 of doxorubicin (Dox) + 6 g/m2 of ifosfamide (Ifos) (n = 3). (A) Stable oxygenation, airway dynamics, and pulmonary artery pressure (PAP) were observed during IVLP and after 4 hours of reperfusion. No statistical difference was observed in histologic acute lung injury score between (B) before IVLP, (C) after IVLP, and (D) after reperfusion. (Cdyn = dynamic compliance; PawP = peak airway pressure; P/F = Pao2/Fio2.)
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

5. Fig 4
Lung function of 2 animals submitted to in vivo lung perfusion (IVLP) with doxorubicin (Dox) 150 mg/m2 (pig 1, purple line; pig 2, green line). (A) Stable airway dynamics and pulmonary artery pressure (PAP) were observed during IVLP and after 4 hours of reperfusion. A drop in oxygenation levels characterized injury during reperfusion in both animals. In comparison with (B) before IVLP, histologic samples collected at the end of IVLP showed (C) air space hemorrhage, and samples collected at the end of reperfusion showed (D) more air space hemorrhage and white blood cell infiltration. (Cdyn = dynamic compliance; PAWP = peak airway pressure; P/F = Pao2/Fio2.)
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

6. Fig 5
Tissue and perfusate doxorubicin (Dox) levels measured in experiments with Dox 75 mg/m2 (n = 8). (A) Tissue levels of Dox were examined in 3 different areas of the lung—upper, middle, and lower—at the end of reperfusion. No statistically significant difference was found at end of reperfusion across 3 areas (n = 8; p > 0.26). (B) Perfusate levels were also assessed 10 minutes after administration of chemotherapy, followed by hourly assessments. Peak perfusate levels of Dox occurred at 1 hour of IVLP.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

7. Fig 6
Inflammatory cytokine profile in lung tissue. We measured 4 inflammatory cytokines in lung tissue before perfusion and at end of procedure (after 4 hours of in vivo lung perfusion [IVLP] + 4 hours of reperfusion), according to the dose of chemotherapy (doxorubicin [Dox] 75 mg/m2, Dox 75 mg/m2 + ifosfamide [Ifos] 6g/m2, and Dox 150 mg/m2). IVLP with Dox 150 mg/m2 resulted in significant increase in interleukin (IL)-8 levels compared with samples before perfusion as well as compared with other groups analyzed (p < ). Levels of IL-6, IL-1β, and tumor necrosis factor-alpha (TNFα) were not statistically significant.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

8. Fig 7
Cell death during reperfusion. Terminal deoxynucleotidyl transferase mediated deoxyuridine triphosphate nick end labeling (TUNEL) staining was performed to identify apoptotic cells (red spots) in samples collected after 4 hours of in vivo lung perfusion (IVLP) + 4 hours of reperfusion. Quantification of TUNEL- positive cells was evaluated and demonstrated significantly more apoptotic cells in doxorubicin (Dox) 150 mg/m2 group compared with other groups; p = 0.0014).
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions