Hepatic arterial floxuridine and leucovorin for unresectable liver metastases from colorectal carcinoma. New dose schedules and survival update

A pilot study of multimodality therapy for initially unresectable liver metastases from colorectal carcinoma: hepatic resection after hepatic arterial infusion chemotherapy and portal embolization

The prognosis of patients with unresectable liver metastases is poor, even if hepatic arterial infusion chemotherapy (HAI) or systemic chemotherapy is administered. A pilot study was performed to evaluate the feasibility and efficacy of multimodality therapy with hepatectomy after HAI and portal embolization for such patients. Eight patients with colorectal carcinoma and synchronous unresectable liver metastases underwent resection of the primary tumor and placement of a pump, followed by HAI with 5-fluorouracil and mitomycin C. Owing to shrinkage of the liver metastases, two patients could undergo extended right hepatic lobectomy after portal embolization, which was deemed to be essential to prevent post-operative hepatic failure. The median survival time of the eight patients was 30 months, with a response rate of 75%. Complications including sclerosing cholangitis and duodenal ulcer were observed in five patients (63%). Additional hepatectomy could be performed successfully after portal embolization without morbidity in two patients. These two patients are still alive more than 6 years after initiation of HAI and have been free of disease for more than 5 years after hepatectomy. Hepatectomy after HAI and portal embolization is feasible and may be an option to cure selected patients with initially unresectable liver metastases.

Is intra-arterial chemotherapy worthwhile in the treatment of patients with unresectable hepatic colorectal cancer metastases?

Regional chemotherapy, from a theoretical and pharmacological stand point, would seem to offer significant advantage over systemic therapy for the treatment of hepatic metastatic colorectal cancer patients. Clinical experience has shown us that the technique itself is fraught with practical problems, but over the years, specialist centres have learned to overcome many of these, making the technique safer and minimising the possibility of complications and toxicity. As a consequence, there is no doubt that high response rates can be achieved with HAI fluoropyrimidines. However, randomised data have only been obtained from small numbers of patients in suboptimally designed trials and, to date, true patient benefit in terms of either survival or quality of life has not been adequately demonstrated. In parallel with the U.S. Intergroup study, the U.K.-based MRC phase III clinical trial of regional versus systemic 5-FU/FA warrants urgent support and we would welcome collaboration with interested European and American centres. The outcome of this trial will fully define the role of HAI chemotherapy in the management of unresectable hepatic metastatic colorectal cancer, in the context of modern, modulated 5-FU.

Advanced and controlled drug delivery systems in clinical disease management

Advanced and controlled drug delivery systems are important for clinical disease management. In this review the most important new systems which have reached clinical application are highlighted. Microbiologically controlled drug delivery is important for gastrointestinal diseases like ulcerative colitis and distally localized Crohn's disease. In cardiology the more classic controlled release systems have improved patient compliance and decreased side effects. In the treatment of intractable pain the spinal and transdermal route is well documented. In neurology the flattened peak-through levels of antiepileptic drugs and anti Parkinson's drugs represents a more predictable kinetic profile. Tracheal delivery of corticosteroids and sympaticomimetics in asthma and Chronic Obstructive Pulmonary Disease is fully accepted in clinical practice: delivery by this route results in better efficacy and a better safety profile. In gynaecology the delivery of pulsatile hormones (LHRH) is used for pregnancy induction, while transdermal oestrogens are promising in the prevention of osteoporosis. In surgical practice the use of antibiotic impregnated bone cement and antibiotic impregnated biodegradable collagens is well established. To prevent infections intravascular catheters coated with heparin or antibiotics are used. In ophthalmology the Ocusert systems provide a controlled release of different drugs in the eye. Most spectacular is the clinical introduction of the first liposomal drugs; amfotericine B and daunorubicine. Liposomal formulations of these drugs have enhanced activity and decreased toxicity compared to conventional formulations.

Alternating floxuridine and 5-fluorouracil hepatic arterial chemotherapy for colorectal liver metastases minimizes biliary toxicity

BACKGROUND

The goals of this study of a hepatic arterial infusion (HAI) regimen of alternating floxuridine and 5-fluorouracil were to evaluate the treatment-related toxic effects, the antitumor response rate, and patient survival.

METHODS

Fifty-seven consecutive patients were treated with implanted HAI pumps and received a regimen of alternating floxuridine (0.1 mg/kg/day continuous HAI for 7 days) followed by a weekly HAI pump bolus of 5-fluorouracil (15 mg/kg for 3 weeks). Any changes in treatment plan because of toxicity, antitumor response, and survival were recorded.

RESULTS

Thirty-one (54.4%) patients responded to this HAI regimen; 14 (24.5% )patients had stable disease, and 12 (21.1%) progressed during treatment. Responders or patients with stable disease had a significantly (P < 0.05) improved survival rate (19 months median) compared with patients in whom disease progressed (12 months median). Two (3.5%) patients developed biliary sclerosis and 12 (21.1%) had mild transient liver function abnormalities. The liver alone or in combination with another area was the site of first progression of disease in 40 (70.2%) patients.

CONCLUSIONS

This regimen had reversible or no hepatobiliary toxicity in more than 95% of patients. Tumor reduction or stabilization of disease was observed in 79% of the patients, who had a median survival of 19 months. Reduced toxicity and more effective chemotherapeutic regimens may increase the likelihood of survival after HAI chemotherapy for unresectable colorectal liver metastases.

Treatment of colorectal cancer: hepatic metastasis

Almost one-third of patients dying from colorectal cancer have tumor limited to the liver. Systemic chemotherapy is the appropriate palliative management of patients with metastases to the liver and other sites. For many patients with isolated hepatic metastases, systemic chemotherapy is also the most appropriate treatment. However, results with systemic chemotherapy indicate that one-third or less of patients will respond to such treatments, and long-term survival is rare. In this report we provide information concerning the natural history of colorectal hepatic metastases, followed by the expected benefits with systemic chemotherapy. This information provides background for the regional therapeutic strategies of surgical resection, cryosurgery, and hepatic artery chemotherapy. We discuss the selection factors appropriate for such treatments, morbidity and mortality, and the potential long-term benefits of such approaches. The last section focuses on surgical considerations in hepatic resection and hepatic artery chemotherapy.

Arterial therapy of hepatic colorectal metastases

Considerable experience of the treatment of irresectable hepatic colorectal metastases has accumulated over the past three decades. In this review, the rationale for hepatic artery treatment of colorectal metastases to the liver is presented and various access techniques and chemotherapeutic agents for infusion are discussed. Randomized trials of hepatic artery chemotherapy (HAC) are analysed, and the promising results of recent studies combining less toxic and more effective agents are summarized. Continuous infusion pumps provide the most reliable and long-lasting access for HAC. Appropriate surgical techniques and medical management can minimize complications. Although tumour progression is best controlled by HAC, a clear-cut survival advantage has yet to be demonstrated. While hepatic artery infusion chemotherapy cannot yet be recommended outside investigational protocols, the experience gained so far should stimulate further studies.

Adjuvant therapy with chemotherapy and radiation therapy in the management of carcinoma of the pancreatic head

Surgical resection remains the backbone of the curative management of carcinoma of the pancreatic head. The primary cause of recurrence appears to be residual locoregional subclinical disease. Data supporting the use and continued study of adjuvant chemotherapy and radiation therapy are summarized.

Regional chemotherapy of colorectal cancer

Hepatic metastases are a major cause of mortality in patients with colorectal carcinoma. The rationale for hepatic arterial chemotherapy has an anatomical and pharmacological basis as presented below. The randomised studies are reviewed and demonstrate a significantly higher response rate with hepatic arterial therapy versus systemic therapy. Survival information is difficult to evaluate because some of the studies are small, and some had a crossover design, but two studies demonstrate a significant improvement in 2-year survival after hepatic arterial therapy compared with systemic therapy. New combinations of 5-fluoro-2-deoxyuridine with dexamethasone and/or leucovorin have produced response rates as high as 72%, median survivals of 22-27 months, and a 2-year survival of 66%. More recent studies on patients who have failed previous systemic chemotherapy have produced response rates around 50%. Hepatic toxicity, especially biliary sclerosis, is the dose limiting toxicity, occurring in 6-25% of patients. To truly define the role of regional therapy, a more accurate randomised study will have to be conducted, to determine if hepatic arterial infusion improves the quality of life and, or survival in patients with hepatic metastases from colorectal cancer.

Toxicity study of hepatic artery infusion chemotherapy with massive dose FUDR in rats

Hepatic artery infusion (HAI) of fluoroudeoxyuridine (FUDR) has been shown to be effective in the treatment of liver metastases from colorectal cancer. However, local toxicity is the most serious limitation of this therapy. The aetiology of HAI toxicity remains unclear. To assess the HAI toxicity, forty-eight non-tumour-bearing, healthy BD-IX rats were randomized to control or treatment groups. The control group (n = 24) received heparinized saline alone (200 u heparin kg-1 day-1) and the treatment group (n = 24) received 6.7 mg FUDR kg-1 day-1 (equivalent to the human dose of 1.0 kg-1 day-1) via HAI for 28 days. Blood samples were collected for haematologic and biochemical analysis twice a week (on days 3 and 7). Toxicity was evaluated by determination of mortality, body weight, white blood cell (WBC) count, serum glutamic oxaloacetic transaminase (SGOT), alkaline phosphatase (ALP), total bilirubin and blood urea nitrogen (BUN), and creatinine. No significant differences in WBC, SGOT, BUN and creatinine levels were found between the group receiving FUDR treatment and the control group. Significantly higher total bilirubin levels, mortality and body weight loss were found in the FUDR-treated group than in the control group. A multivariate analysis revealed that total bilirubin level was the only significant predictor of mortality in the FUDR treatment group. These results suggested that biliary tract damage seems to be the principal toxicity of HAI FUDR chemotherapy.