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Neff R, Abdel-Misih R, Khatri J, Dignazio M, Garcia M, Petrelli N, Wilson P. The Toxicity of Liver Directed Yttrium-90 Microspheres in Primary and Metastatic Liver Tumors. Cancer Invest 2009; 26:173-7. [DOI: 10.1080/07357900701512688] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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53
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Contributions of meta-analyses based on individual patient data to therapeutic progress in colorectal cancer. Int J Clin Oncol 2009; 14:95-101. [PMID: 19390939 DOI: 10.1007/s10147-009-0879-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2009] [Indexed: 12/22/2022]
Abstract
Meta-analysis is the statistical process of combining information from several studies addressing the same question. Meta-analyses based on individual patient data are far more reliable and informative than those based on summary statistics obtained from the trialists or extracted from the published literature. Meta-analysis of randomized clinical trials may contribute to therapeutic progress through (1) establishing efficacy benefits beyond a reasonable doubt, (2) identifying sources of heterogeneity between trials, (3) studying subsets reliably, (4) confirming differences in toxicity profiles, (5) evaluating the cost-effectiveness of experimental therapies, (6) assessing surrogate endpoints, and (7) addressing ancillary questions. All of these potential contributions are illustrated with examples in early and advanced colorectal cancer.
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Abstract
Liver metastases are mainly supplied by the hepatic artery. Sustained high levels of intratumoral drug are achievable with certain drugs given via the hepatic artery. Floxuridine (FUDR) is an ideal drug for hepatic arterial infusion (HAI) due to its short half life, steep dose response curve, high total body clearance, and high hepatic extraction. HAI FUDR has consistently shown higher response rates than systemic chemotherapy alone, and some studies have shown a survival advantage. HAI FUDR in combination with systemic chemotherapy has evolved over the years and may be used in palliative, neoadjuvant, and adjuvant settings. The dramatic responses observed with HAI FUDR plus modern era systemic chemotherapy offer the possibility of resection and cure in selected patients. The high hepatic extraction of FUDR limits systemic side effects. Toxicity includes biliary and gastrointestinal ulcers.
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Affiliation(s)
- Derek G Power
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA
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55
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Bacchetti S, Pasqual E, Crozzolo E, Pellarin A, Cagol PP. Intra-arterial hepatic chemotherapy for unresectable colorectal liver metastases: a review of medical devices complications in 3172 patients. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2009; 2:31-40. [PMID: 22915912 PMCID: PMC3417858 DOI: 10.2147/mder.s4036] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background Hepatic artery infusion (HAI) is indicated to treat unresectable colorectal hepatic metastases, with recent applications as a neoadjuvant or adjuvant treatment. Traditionally performed with the infusion of fluoropyrimidine-based chemotherapy, it has been now tested with oxaliplatin or irinotecan and associated with systemic chemotherapy. Methods To evaluate the impact of medical devices complications we carried out a search of the published studies on HAI in unresectable colorectal liver metastases. Complications were pooled according to the applied medical system: 1) surgical catheter, 2) radiological catheter, and 3) fully implantable pump. The surgical catheter is inserted into the hepatic artery from the gastro-duodenal artery. The radiological catheter is inserted into the hepatic artery through a percutaneous transfemoral or transaxillar access. The fully implantable pump is a totally internal medical device connected to the arterial hepatic catheter during laparotomy. Results The selection criteria were met in 47/319 studies. The complications of surgical and radiological medical devices connected to a port were found in 16 and 14 studies respectively. Meanwhile, complications with a fully implantable pump were reported in 17 studies. The total number of complications reported in studies evaluating patients with surgical or radiological catheter were 322 (322/948, 34%) and 261 (261/722, 36.1%) respectively. In studies evaluating patients with a fully implantable pump, the total number of complications was 237 (237/1502, 15.8%). In 18/319 studies the number of cycles was reported. The median number of cycles with surgically and radiologically implanted catheters was 8 and 6 respectively. The fully implantable pump allows a median number of 12 cycles. Conclusions The fully implantable pump, maintaining a continuous infusion through the system, allows the lowest risk for thrombosis and infection and the best median number of cycles of loco-regional chemotherapy in HAI.
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Affiliation(s)
- Stefano Bacchetti
- Department of Surgical Sciences, Faculty of Medicine and Surgery, University of Udine, Italy
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Gallagher D, Kemeny N. Treatment of patients with colorectal cancer: emphasis on liver metastases. Expert Opin Pharmacother 2009; 10:109-24. [PMID: 19236185 DOI: 10.1517/14656560802631301] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The treatment of colorectal liver metastases has progressed considerably in recent years. Coordinated multidisciplinary management of patients on clinical trials has resulted in 5-year survival rates exceeding 50%, and for certain patients cure is now a realistic goal. For all patients, the approval of six new drugs has contributed to an increase in median survival from 6 months to over 20 months. Recent molecular discoveries promise an era of tailored therapy in which only patients known to benefit will be treated, an approach that will enable more efficient use of the already stretched resources. Clinical trials continue to investigate different combinations and methods of administering approved therapies, but if the progress of the past decade is to be replicated it is imperative that we embrace innovative treatment strategies and novel trial designs. In this review, we highlight the developments that have improved survival for patients with colorectal liver metastases and discuss the many issues that challenge further progress.
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Affiliation(s)
- David Gallagher
- Department of Medicine, Joan and Sanford Weill Medical College of Cornell University, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA
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Viúdez A, Rodríguez J, Gil-Bazo I. Unresectable liver metastases from colorectal cancer and hepatic arterial infusion chemotherapy: how, when and to whom? Cardiovasc Intervent Radiol 2009; 32:603-4. [PMID: 19194743 DOI: 10.1007/s00270-009-9514-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2008] [Accepted: 01/08/2009] [Indexed: 10/21/2022]
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Stuart K. Liver-Directed Therapies for Colorectal Metastases. SEMINARS IN COLON AND RECTAL SURGERY 2008. [DOI: 10.1053/j.scrs.2008.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Dizon DS, Schwartz J, Kemeny N. Regional chemotherapy: a focus on hepatic artery infusion for colorectal cancer liver metastases. Surg Oncol Clin N Am 2008; 17:759-71, viii. [PMID: 18722916 DOI: 10.1016/j.soc.2008.04.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Regional infusion strategies have been used as a treatment modality in multiple cancers, including ovarian, appendiceal, and colorectal cancers. Perhaps the most illustrative use of regional therapy is that of hepatic arterial infusion (HAI) for liver metastases from colorectal cancer. The administration of chemotherapy by HAI is logical and has theoretic advantages over systemic chemotherapy for the treatment of hepatic metastases from colorectal cancer. With the use of an appropriately chosen chemotherapy agent, HAI can generate an increase in hepatic tumor drug exposure as compared with intravenous delivery of the same agent. This article reviews the pharmacologic benefits of HAI therapy and the contemporary trials performed and underway.
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Affiliation(s)
- Don S Dizon
- Program in Women's Oncology, Department of Obstetrics and Gynecology, Women & Infants' Hospital, Warren Alpert Medical School of Brown University, 101 Dudley Street, Providence, RI 02905, USA.
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Power DG, Healey-Bird BR, Kemeny NE. Regional Chemotherapy for Liver-Limited Metastatic Colorectal Cancer. Clin Colorectal Cancer 2008; 7:247-59. [DOI: 10.3816/ccc.2008.n.032] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Mocellin S, Nitti D. In Reply. J Clin Oncol 2008. [DOI: 10.1200/jco.2008.17.2460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Simone Mocellin
- Surgery Branch, Department of Oncological and Surgical Sciences, University of Padova, Padova, Italy
| | - Donato Nitti
- Surgery Branch, Department of Oncological and Surgical Sciences, University of Padova, Padova, Italy
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Abstract
A number of cancers present with synchronous or metachronous hepatic metastases. Historically, many of these patients were considered unresectable and were treated with either systemic chemotherapy or supportive care. Today, a variety of options exist for the management of hepatic metastases. Newer agents for systemic therapy continue to be introduced and are providing improved progression-free and overall survival and increased resectability of liver metastases. However, complete surgical resection of isolated hepatic metastases remains the optimal management for these patients. Surgical interventions can be offered to patients with hepatic-only metastases. Hepatic artery chemotherapy represents an adjunct for those patients undergoing resection and can improve survival. This benefit may be even more pronounced when combined with systemic chemotherapy. Newer generation biologic agents can improve results. New therapeutic modalities to treat lesions that are unresectable include ablative techniques such as radiofrequency ablation (RFA) and cryoablation. This article will examine modalities of diagnosis of hepatic metastases and highlight the data regarding hepatic resection for metastases of several types of primary cancers, the rationale for, and efficacy of, hepatic arterial chemotherapy, in both the postoperative adjuvant setting and in unresectable liver disease, and review the current literature for ablative techniques in the treatment of liver metastases.
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Affiliation(s)
- Cletus A Arciero
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA 19111, USA
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63
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Hepatic artery infusion in the treatment of colorectal cancer metastases. CURRENT COLORECTAL CANCER REPORTS 2008. [DOI: 10.1007/s11888-008-0018-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Kalva SP, Thabet A, Wicky S. Recent advances in transarterial therapy of primary and secondary liver malignancies. Radiographics 2008; 28:101-17. [PMID: 18203933 DOI: 10.1148/rg.281075115] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The management of liver malignancies presents many challenges. Few patients with primary hepatocellular carcinoma or metastatic disease of the liver are eligible for surgery, which is the only curative therapeutic option. Because the hepatic tumor burden is often a determinant of eligibility for surgery and is a primary contributor to morbidity and mortality, an increasing number of innovative techniques based on the transarterial administration of liver-directed drug-eluting or radiation-emitting microspheres are being tested for use in cytoreductive and palliative therapy. The delivery of therapy via a transarterial route takes advantage of the fact that hepatic malignancies are primarily supplied by the hepatic artery. The early results of clinical trials are promising; the clinical effectiveness and safety of drug-eluting and yttrium-90-bearing microspheres have been demonstrated; however, further clinical investigation is needed to verify a benefit in survival. Transarterially administered gene therapy holds promise but is still in the early stages of investigation. For all transarterial therapies, the outcome depends heavily on meticulous patient selection, careful preparation and administration of therapy, and early and regular follow-up evaluations by using an interdisciplinary approach.
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Affiliation(s)
- Sanjeeva P Kalva
- Division of Cardiovascular Intervention, Department of Radiology, Massachusetts General Hospital, Gray 2, 55 Fruit St, GRB-290, Boston, MA 02114, USA.
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65
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Mocellin S, Pilati P, Lise M, Nitti D. Meta-analysis of hepatic arterial infusion for unresectable liver metastases from colorectal cancer: the end of an era? J Clin Oncol 2007; 25:5649-54. [PMID: 18065736 DOI: 10.1200/jco.2007.12.1764] [Citation(s) in RCA: 141] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
PURPOSE The treatment of unresectable liver-confined metastatic disease from colorectal cancer (CRC) is a challenging issue. Although locoregional treatments such as hepatic arterial infusion (HAI) claim the advantage of delivering higher doses of anticancer agents directly into the affected organ, the benefit in terms of overall survival (OS) is unclear. We quantitatively summarized the results of randomized controlled trials (RCT) comparing HAI with systemic chemotherapy (SCT). METHODS To date, 10 RCTs have been published, for a total of 1,277 patients enrolled. For tumor response rates, relative risks (RR) and their 95% CIs were obtained from raw data; for OS, hazard ratios (HRs) and their 95% CIs were extrapolated from the Kaplan-Meier survival curves. RESULTS HAI regimens were based on floxuridine (FUDR) in nine of 10 RCTs, whereas in one RCT, fluorouracil (FU) + leucovorin was used. SCT consisted of FUDR, FU, FU + leucovorin, or a miscellany of FU and best supportive care in three, one, four, and two studies, respectively. Pooling the data, tumor response rate was 42.9% and 18.4% for HAI and SCT, respectively (RR = 2.26; 95% CI, 1.80 to 2.84; P < .0001). Mean weighted median OS times were 15.9 and 12.4 months for HAI and SCT, respectively; the meta-risk of death was not statistically different between the two study groups (HR = 0.90; 95% CI, 0.76 to 1.07; P = .24). CONCLUSION Currently available evidence does not support the clinical or investigational use of fluoropyrimidine-based HAI alone for the treatment of patients with unresectable CRC liver metastases, at least as a first-line therapy.
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Affiliation(s)
- Simone Mocellin
- Clinica Chirurgica Generale 2, Department of Oncological and Surgical Sciences, University of Padova, via Giustiniani 2, 35128 Padova, Italy.
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Lubienski A, Simon M, Lubienski K, Gellissen J, Hoffmann RT, Jakobs T, Helmberger T. Update Chemoperfusion und -embolisation. Radiologe 2007; 47:1097-106, 1108. [DOI: 10.1007/s00117-007-1587-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Isogai A, Nagaya M, Matsuoka H, Watanabe T, Tsukikawa S, Kubota S. An anticancer drug sensitivity test to determine the effectiveness of UFT as postoperative adjuvant chemotherapy for patients with stage III colorectal cancer. Surgery 2007; 142:741-8. [PMID: 17981195 DOI: 10.1016/j.surg.2007.06.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2006] [Revised: 05/30/2007] [Accepted: 06/02/2007] [Indexed: 10/22/2022]
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Sone M, Kato K, Hirose A, Nakasato T, Tomabechi M, Ehara S, Hanari T. Impact of multislice CT angiography on planning of radiological catheter placement for hepatic arterial infusion chemotherapy. Cardiovasc Intervent Radiol 2007; 31:91-7. [PMID: 17929088 DOI: 10.1007/s00270-007-9170-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2006] [Revised: 07/13/2007] [Accepted: 09/10/2007] [Indexed: 12/22/2022]
Abstract
The objective of this study was to assess prospectively the role of multislice CT angiography (MSCTA) on planning of radiological catheter placement for hepatic arterial infusion chemotherapy (HAIC). Forty-six patients with malignant liver tumors planned for HAIC were included. In each patient, both MSCTA and intra-arterial digital subtraction angiography (DSA) were performed, except one patient who did not undergo DSA. Comparison of MSCTA and DSA images was performed for the remaining 45 patients. Detectability of anatomical variants of the hepatic artery, course of the celiac trunk, visualization scores of arterial branches and interobserver agreement, presence of arterial stenosis, and technical outcome were evaluated. Anatomical variations of the hepatic artery were detected in 19 of 45 patients (42%) on both modalities. The course of the celiac trunk was different in 12 patients. The visualization scores of celiac arterial branches on MSCTA/DSA were 3.0 +/- 0/2.9 +/- 0.2 in the celiac trunk, 3.0 +/- 0/2.9 +/- 0.3 in the common hepatic artery, 2.9 +/- 0.2/2.9 +/- 0.3 in the proper hepatic artery, 2.9 +/- 0.3/2.9 +/- 0.4 in the right hepatic artery, 2.8 +/- 0.4/2.9 +/- 0.4 in the left hepatic artery, 2.9 +/- 0.2/2.9 +/- 0.3 in the gastroduodenal artery, 2.1 +/- 0.8/2.2 +/- 0.9 in the right gastric artery, and 2.7 +/- 0.8/2.6 +/- 0.8 in the left gastric artery. No statistically significant differences exist between the two modalities. Interobserver agreement for MSCTA was equivalent to that for DSA. Two patients showed stenosis of the celiac trunk on both modalities. Based on these imaging findings, technical success was accomplished in all patients. In conclusion, MSCTA is accurate in assessing arterial anatomy and abnormalities. MSCTA can provide adequate information for planning of radiological catheter placement for HAIC.
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Affiliation(s)
- Miyuki Sone
- Department of Radiology, Iwate Medical University, 19-1, Uchimaru, Morioka 0208505, Japan.
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69
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Hepatic arterial infusion chemotherapy through a port-catheter system as preoperative initial therapy in patients with advanced liver dysfunction due to synchronous and unresectable liver metastases from colorectal cancer. Cardiovasc Intervent Radiol 2007; 31:86-90. [PMID: 17926088 DOI: 10.1007/s00270-007-9189-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2007] [Accepted: 09/11/2007] [Indexed: 10/22/2022]
Abstract
PURPOSE We retrospectively evaluated the safety and efficacy of preoperative initial hepatic arterial infusion chemotherapy (HAIC) through a port-catheter system in patients with liver dysfunction due to synchronous and unresectable liver metastases. The aim of HAIC was to improve patients' clinical condition for later surgical removal of primary colorectal cancer. METHODS Port-catheter systems were placed radiologically in 21 patients (mean age 58.6 +/- 8.1 years) with liver dysfunction due to synchronous liver metastases from colorectal cancer. Initial HAIC of 1,000 mg/m(2) 5-fluorouracil was administered weekly as a 5 hr continuous infusion through this system. Surgical removal of the primary lesion was planned after HAIC improved the liver function. RESULTS Port-catheter system placement was successful in all patients without severe complications. Patients were followed up for a median of 309 days (range 51-998 days). After starting HAIC, no severe adverse events that caused drug loss and treatment postponement or suspension were observed in any of the patients. HAIC was performed a mean of 4.5 +/- 3.0 times and the liver function improved in all patients. Curative (n = 18) or palliative (n = 1) surgical removal of the primary lesion was performed. The remaining 2 patients died because extrahepatic metastases developed and their performance status worsened; thus, surgery could not be performed. The median survival times of all patients and the operated patients were 309 and 386 days, respectively. CONCLUSION Initial HAIC administration is a safe and efficacious method for improving liver function prior to operative resection of primary colorectal cancer in patients with liver dysfunction due to synchronous and unresectable liver metastases.
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70
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Boige V, Malka D, Elias D, Castaing M, De Baere T, Goere D, Dromain C, Pocard M, Ducreux M. Hepatic arterial infusion of oxaliplatin and intravenous LV5FU2 in unresectable liver metastases from colorectal cancer after systemic chemotherapy failure. Ann Surg Oncol 2007; 15:219-26. [PMID: 17896145 DOI: 10.1245/s10434-007-9581-7] [Citation(s) in RCA: 128] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2007] [Revised: 07/27/2007] [Accepted: 07/27/2007] [Indexed: 12/16/2022]
Abstract
BACKGROUND We have previously shown promising activity of hepatic arterial infusion (HAI) oxaliplatin combined with intravenous (IV) 5-fluorouracil (5-FU) and leucovorin (LV) as first-line chemotherapy in patients with colorectal liver metastases (CRLM) (intent-to-treat [ITT] objective response rate [ORR], 64%; secondary resection rate, 18%; overall survival [OS], 27 months). Whether this regimen could be beneficial after systemic chemotherapy failure is unknown. METHODS Patients with unresectable CRLM and history of systemic chemotherapy failure were treated bimonthly with HAI oxaliplatin (100 mg/m(2) 2 hours) combined with IV LV and IV bolus and infusional 5FU (modified LV5FU2 regimen). RESULTS Forty-four consecutive patients (median age 56 years; median number of prior systemic chemotherapy regimens, 2 range 1-5) were included, of whom 43 (98%) had previously received oxaliplatin (n = 34), irinotecan (n = 37), or both (n = 28). Patients received a median of nine cycles of HAI oxaliplatin and IV modified LV5FU2 (range 0-25). Toxicity included grade 3-4 neutropenia (43%), grade 2-3 neuropathy (43%), and grade 3-4 abdominal pain (14%). We observed 24 partial ORs (62%) among the 39 assessable patients (ITT ORR, 55%; 95% CI, 40-69%), including 17, 12, and 12 patients who had failed to respond to prior systemic chemotherapy with FOLFIRI, FOLFOX, or both, respectively. Tumor response allowed further R0 surgical resection (n = 7) or radiofrequency ablation (n = 1) of initially unresectable CRLM in eight patients (18%). Median progression-free survival and OS were 7 and 16 months, respectively. CONCLUSIONS HAI oxaliplatin and IV LV5FU2 is feasible, safe, and shows promising activity after systemic chemotherapy failure, allowing surgical resection of initially unresectable CRLM in 18% of patients.
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Affiliation(s)
- Valérie Boige
- Department of Medicine, Institut Gustave Roussy, Villejuif, France
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71
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Yezhelyev M, Osgood M, Egnatashvili V, Lumsden A, Staley CA, Kooby DA. Saphenous vein graft conduits for insertion of hepatic arterial infusion pumps in patients with abnormal hepatic arterial anatomy. J Surg Oncol 2007; 97:85-9. [PMID: 17786960 DOI: 10.1002/jso.20890] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND AND OBJECTIVES Hepatic arterial infusion (HAI) chemotherapy offers improved hepatic control for liver metastases from colon cancer. Optimal catheter insertion requires an adequate gastroduodenal artery (GDA). Limited data exists on using saphenous vein grafts (SVG) as conduits when native vasculature is inadequate. METHODS All HAI pump insertions from 7/99 to 7/03 requiring SVG conduits (N = 10) were analyzed for arterial anatomy, operative conduct, and outcome. RESULTS From 1988 through 2005, 124 HAI pumps were placed of which 10 received SVG conduits to optimize placement. Mean operative time was 251 +/- 50 min and mean blood loss was 230 +/- 30 cm(3). All were placed with palliative intent. Three patients (30%) had type 1 anatomy with inadequate GDA. Five (50%) had type 3 anatomy with replaced right hepatic artery, one (10%) had a small GDA originating off the right hepatic artery, and one patient (10%) had a trifurcation. Two (20%) pump-related complications were identified, and only one (10%) was related to vasculature (catheter thrombosis as a result of hepatic arterial stenosis distal to the SVG insertion site). CONCLUSIONS Complication rates related to SVG conduits for hepatic arterial infusion pump placement are low. Saphenous vein grafts are acceptable conduits for patients with abnormal hepatic arterial anatomy.
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Affiliation(s)
- Maksym Yezhelyev
- Department of Surgery, Emory University, Atlanta, Georgia 30322, USA
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Garrot C, Stuart K. Liver-directed therapies for metastatic neuroendocrine tumors. Hematol Oncol Clin North Am 2007; 21:545-60; ix-x. [PMID: 17548039 DOI: 10.1016/j.hoc.2007.04.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Neuroendocrine tumors, despite being indolent, frequently cause significant morbidity and mortality from hepatic metastatic lesions. It is possible to directly target these liver lesions with embolization/chemoembolization, radiofrequency ablation, or other therapies. The observational studies that exist seem to indicate a prolongation of survival. Liver-directed therapies are also able to decrease symptoms in most patients. The value of these therapeutic interventions therefore lies mainly in their palliative capabilities. Coupled with aggressive use of octreotide, local ablative techniques may frequently control symptoms of hormone excess and tumor bulk. Because of the possible adverse effects of these interventions, however, careful patient selection is essential to minimize the morbidity and mortality of the procedures.
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Affiliation(s)
- Crain Garrot
- Department of Hematology and Oncology, Beth Israel Deaconess Medical Center, Boston, MA 02215, MA 01805, USA
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Abstract
Colorectal cancer is the fourth most common type of cancer in the West and the second leading cause of cancer-related deaths in the United States. Approximately 35 to 55% of patients with colorectal cancer develop hepatic metastases during the course of their disease. Surgical resection of colorectal liver metastases represents the only chance at potential cure, and long-term survival can be achieved in 35 to 58% of patients after resection. The goal of hepatic resection should be to resect all metastases with negative histologic margins while preserving sufficient functional hepatic parenchyma. In patients with extensive metastatic disease who would otherwise be unresectable, ablative approaches can be used instead of or combined with hepatic resection. The use of portal vein embolization and preoperative chemotherapy may also expand the population of patients who are candidates for surgical treatment. Despite these advances, many patients still experience a recurrence after hepatic resection. More active systemic chemotherapy agents are now available and are being increasingly employed as adjuvant therapy either before or after surgery. Modern treatment of colorectal liver metastasis requires a multidisciplinary approach in an effort to increase the number of patients who may benefit from surgical treatment of colorectal cancer liver metastasis.
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Affiliation(s)
- Timothy M Pawlik
- Division of Surgical Oncology, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD 22187-6681, USA
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74
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Abstract
The liver is the most common site of metastatic disease from both gastrointestinal and extra-intestinal malignancies. Historically, only a minority of patients with colorectal liver metastases were candidates for resection. However, over the past several decades, liver resection has evolved as a safe and potentially curative treatment for hepatic colorectal metastases. The development of active chemotherapy and molecular targeted therapies, together with newer modalities like radiofrequency ablation, have expanded the indications for hepatic resection and improved survival. Selected patients with isolated liver metastases from neuroendocrine tumors, germ cell cancers, ocular melanoma, gastrointestinal stromal tumors (GIST), and breast cancer also may be considered for hepatic surgery.
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Affiliation(s)
- Boris Kuvshinoff
- Department of Surgery, Roswell Park Cancer Institute, Buffalo, NY, USA
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Mandalà M, Mosconi S, Quadri A, Milesi L, Labianca R. Neoadjuvant chemotherapy for patients with liver metastases from colorectal cancer. Expert Rev Anticancer Ther 2007; 7:887-97. [PMID: 17555399 DOI: 10.1586/14737140.7.6.887] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Colorectal cancer is the second most common type of cancer in industrialized countries. Despite improved resection procedures and optimized adjuvant chemotherapy, local or distant recurrences occur in 22-25% of patients with stage II/III colon cancer. Approximately 30% of patients have advanced disease at presentation. The liver is the most common site of colorectal metastases and, interestingly, 20-30% of patients with colorectal cancer have liver-only metastases. The combined modality of chemotherapy and surgery increases overall survival and the chance of cure for metastatic patients, even if there is no agreement in terms of the best schedule and how long the treatment must last. In this paper, we review the role and the rationale of neoadjuvant chemotherapy within a multimodal approach, and discuss remaining questions and future directions.
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Affiliation(s)
- Mario Mandalà
- Unit of Medical Oncology, Ospedali Riuniti, Bergamo, Italy
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Aurora V, Mulcahy MF. Adjuvant therapy for resectable liver metastases: Can metastatic colorectal cancer be cured? CURRENT COLORECTAL CANCER REPORTS 2007. [DOI: 10.1007/s11888-007-0021-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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77
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Liersch T, Meller J, Bittrich M, Kulle B, Becker H, Goldenberg DM. Update of carcinoembryonic antigen radioimmunotherapy with (131)I-labetuzumab after salvage resection of colorectal liver metastases: comparison of outcome to a contemporaneous control group. Ann Surg Oncol 2007; 14:2577-90. [PMID: 17570017 DOI: 10.1245/s10434-006-9328-x] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2006] [Revised: 12/03/2006] [Accepted: 12/07/2006] [Indexed: 12/24/2022]
Abstract
BACKGROUND We tested whether adjuvant radioimmunotherapy (RAIT) given after R0 resection of liver metastases (LM) of colorectal cancer is safe and can improve survival. Resection of LM from colorectal cancer is the standard of care in this setting, yet two thirds will eventually relapse, and adjuvant systemic chemotherapy has failed to improve survival. METHODS Twenty-three patients who underwent R0 resection for LM of colorectal cancer received a dose of 40 to 60 mCi/m(2) (131)I-labetuzumab, a humanized monoclonal antibody against carcinoembryonic antigen. Safety (n = 23), disease-free survival, and overall survival (n = 19) were analyzed, and efficacy was then compared retrospectively with a similar contemporaneous group of control patients (n = 19) treated at the same institution during the same time period but without RAIT. RESULTS At a median follow-up of 91 months (95% confidence interval [CI], 68.0 months to infinity), the median overall survival for RAIT patients was 58.0 months (95% CI, 55.0 months to infinity), versus 31.0 months (95% CI, 26.0 months to infinity) at a 51-month median follow-up for the controls (P = .032). The median disease-free survival for RAIT patients was 18.0 months (95% CI, 11.0-31.0 months), versus 12.0 months (95% CI, 6.5-27.0 months) for the controls (P = .565). Corresponding survival rates (Kaplan-Meier analyses) were estimated to be 94.7% at 1 year, 78.9% at 2 years, 68.4% at 3 years, and 42.1% at 5 years with RAIT and 94.7%, 68.4%, 36.8%, and 15.8%, respectively, for the controls. RAIT was beneficial independently of bilobar involvement, size and number of LM, or resection margins. Transient myelosuppression was the principal adverse effect. CONCLUSIONS This first evidence of a promising survival advantage of adjuvant RAIT after long-term follow-up of colorectal cancer patients given salvage resection of LM warrants confirmation in a prospective randomized trial.
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Affiliation(s)
- Torsten Liersch
- Department of General Surgery, University of Göttingen, Göttingen, Germany
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78
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Xu J, Zhong Y, Weixin N, Xinyu Q, Yanhan L, Li R, Jianhua W, Zhiping Y, Jiemin C. Preoperative hepatic and regional arterial chemotherapy in the prevention of liver metastasis after colorectal cancer surgery. Ann Surg 2007; 245:583-90. [PMID: 17414607 PMCID: PMC1877047 DOI: 10.1097/01.sla.0000250453.34507.d3] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To investigate whether preoperative hepatic and regional arterial chemotherapy is able to prevent liver metastasis and improve overall survival in patients receiving curative colorectal cancer resection. METHODS Patients with stage II or stage III colorectal cancer (CRC) were randomly assigned to receive preoperative hepatic and regional arterial chemotherapy (PHRAC group, n = 110) or surgery alone (control group, n = 112). The primary endpoint was disease-free survival, whereas the secondary endpoints included liver metastasis-free survival and overall survival. RESULTS There were no significant differences in overall morbidity between PHRAC and Control groups. During the follow-up period (median, 36 months), the median liver metastasis time for patients with stage III CRC was significantly longer in the PHRAC group (16 +/- 3 months vs. 8 +/- 1 months, P = 0.01). In stage III patients, there was also significant difference between the 2 groups with regard to the incidence of liver metastasis (20.6% vs. 28.3%, P = 0.03), 3-year disease-free survival (74.6% vs. 58.1%, P = 0.0096), 3-year overall survival (87.7% vs. 75.7%, P = 0.020), and the median survival time (40.1 +/- 4.6 months vs. 36.3 +/- 3.2 months, P = 0.03). In the PHRAC arm, the risk ratio of recurrence was 0.61 (95% CI, 0.51-0.79, P = 0.0002), of death was 0.51 (95% CI, 0.32-0.67; P = 0.009), and of liver metastasis was 0.73 (95% CI, 0.52-0.86; P = 0.02). In contrast, PHRAC seemed to be no benefit for stage II patients. Toxicities, such as hepatic toxicity and leukocyte decreasing, were mild and could be cured with medicine. CONCLUSIONS Preoperative hepatic and regional arterial chemotherapy, in combination with surgical resection, could be able to reduce and delay the occurrence of liver metastasis and therefore improve survival rate in patients with stage III colorectal cancer.
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Affiliation(s)
- Jianmin Xu
- Department of General Surgery, Zhongshan Hospital, Fudan University; Colorectal Cancer Research Center, Fudan University, Shanghai, P. R. China.
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79
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Hildebrandt B, Pech M, Nicolaou A, Langrehr JM, Kurcz J, Bartels B, Miersch A, Felix R, Neuhaus P, Riess H, Dörken B, Ricke J. Interventionally implanted port catheter systems for hepatic arterial infusion of chemotherapy in patients with colorectal liver metastases: a Phase II-study and historical comparison with the surgical approach. BMC Cancer 2007; 7:69. [PMID: 17456240 PMCID: PMC1871598 DOI: 10.1186/1471-2407-7-69] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2006] [Accepted: 04/24/2007] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND The high complication rates of surgically implanted port catheter systems (SIPCS) represents a major drawback in the treatment of isolated liver neoplasms by hepatic arterial infusion (HAI) of chemotherapy. Interventionally implanted port catheter systems (IIPCS) have evolved into a promising alternative that enable initiation of HAI without laparatomy, but prospective data on this approach are still sparse. Aim of this study was to evaluate the most important technical endpoints associated with the use of IIPCS for the delivery of 5-fluorouracil-based HAI in patients with colorectal liver metastases in a phase 2-study, and to perform a non-randomised comparison with a historical group of patients in which HAI was administered via SIPCS. METHODS 41 patients with isolated liver metastases of colorectal cancer were enrolled into a phase II-study and provided with IIPCS between 2001 and 2004 (group A). The primary objective of the trial was defined as evaluation of device-related complications and port duration. Results were compared with those observed in a pre-defined historical collective of 40 patients treated with HAI via SIPCS at our institution between 1996 and 2000 (group B). RESULTS Baseline characteristics were balanced between both groups, except for higher proportions of previous palliative pre-treatment and elevated serum alkaline phosphatase in patients of group A. Implantation of port catheters was successful in all patients of group A, whereas two primary failures were observed in group B. The frequency of device-related complications was similar between both groups, but the secondary failure rate was significantly higher with the use of surgical approach (17% vs. 50%, p < 0.01). Mean port duration was significantly longer in the interventional group (19 vs. 14 months, p = 0.01), with 77 vs. 50% of devices functioning at 12 months (p < 0.01). No unexpected complications were observed in both groups. CONCLUSION HAI via interventionally implanted port catheters can be safely provided to a collective of patients with colorectal liver metastases, including a relevant proportion of preatreated individuals. It appears to offer technical advantages over the surgical approach.
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Affiliation(s)
- Bert Hildebrandt
- CharitéCentrum für Tumormedizin, Medizinische Klinik mit Schwerpunkt Hämatologie und Onkologie, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, D-13344 Berlin, Germany
| | - Maciej Pech
- CharitéCentrum für Tumormedizin, Klinik für Strahlenheilkunde, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, D-13344 Berlin, Germany
- Klinik für Radiologie und Nuklearmedizin, Otto-von-Guericke-Universität Magdeburg, Leipziger Str. 44, D-30120 Magdeburg, Germany
| | - Annett Nicolaou
- CharitéCentrum für Tumormedizin, Medizinische Klinik mit Schwerpunkt Hämatologie und Onkologie, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, D-13344 Berlin, Germany
| | - Jan M Langrehr
- CharitéCentrum für Chirurgische Medizin, Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, D-13344 Berlin, Germany
| | - Jacek Kurcz
- Akademia Medyczna Katedra i Zakład Radiologii, Szpital Kliniczny Nr 1, M. Skłodowskiej-Curie St. 68, PL-50369 Wrozlaw, Poland
| | - Birgit Bartels
- CharitéCentrum für Tumormedizin, Medizinische Klinik mit Schwerpunkt Hämatologie und Onkologie, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, D-13344 Berlin, Germany
| | - Alexandra Miersch
- CharitéCentrum für Tumormedizin, Klinik für Strahlenheilkunde, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, D-13344 Berlin, Germany
| | - Roland Felix
- CharitéCentrum für Tumormedizin, Klinik für Strahlenheilkunde, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, D-13344 Berlin, Germany
| | - Peter Neuhaus
- CharitéCentrum für Chirurgische Medizin, Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, D-13344 Berlin, Germany
| | - Hanno Riess
- CharitéCentrum für Tumormedizin, Medizinische Klinik mit Schwerpunkt Hämatologie und Onkologie, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, D-13344 Berlin, Germany
| | - Bernd Dörken
- CharitéCentrum für Tumormedizin, Medizinische Klinik mit Schwerpunkt Hämatologie und Onkologie, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, D-13344 Berlin, Germany
| | - Jens Ricke
- CharitéCentrum für Tumormedizin, Klinik für Strahlenheilkunde, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, D-13344 Berlin, Germany
- Klinik für Radiologie und Nuklearmedizin, Otto-von-Guericke-Universität Magdeburg, Leipziger Str. 44, D-30120 Magdeburg, Germany
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80
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Sameshima S, Horikoshi H, Motegi K, Tomozawa S, Hirayama I, Saito T, Sawada T. Outcomes of hepatic artery infusion therapy for hepatic metastases from colorectal carcinoma after radiological placement of infusion catheters. Eur J Surg Oncol 2007; 33:741-5. [PMID: 17399936 DOI: 10.1016/j.ejso.2007.02.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2006] [Accepted: 02/12/2007] [Indexed: 10/23/2022] Open
Abstract
AIM The aim of this study is to evaluate the safety and efficacy of hepatic artery infusion (HAI) of 5-fluorouracil (5FU) for patients with liver metastases from colorectal carcinoma after radiological placement of infusion catheters. METHODS Forty-two patients with liver metastases from colorectal carcinoma received radiological placement of infusion catheters using the distal fixation method. They received continuous HAI of 5FU 1,000-1,500mg for 5h weekly or biweekly. Tumor status was assessed by chest-abdominal computed tomography (CT) scan after every 10 infusions. Hepatic perfusion was checked by CT arteriography via the infusion port after every 10 infusions. RESULTS Radiological placements of catheters were performed successfully in all cases. Each patient received an average of 36 treatments (range: 10-98). Catheter failure was found in 3 patients (7.1%). Nine incidents of grade 1 toxicity were observed in 8 patients (19.0%). There was a complete response in 6 patients, partial remission in 18, stable disease in 9, and progression of disease in 9 (response rate: 57.1%). Overall median survival time was 29.1 months. Using Cox's proportional hazard model, lymph node metastases in primary colorectal carcinoma and pre-treatment serum CEA affected overall survival (P=0.011, P=0.005). CONCLUSIONS HAI after radiological placement of infusion catheters is a safe and effective treatment particularly for patients with no lymph node metastasis in primary carcinoma or with a low pre-treatment serum CEA level.
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MESH Headings
- Aged
- Angiography
- Antimetabolites, Antineoplastic/administration & dosage
- Antimetabolites, Antineoplastic/adverse effects
- Antimetabolites, Antineoplastic/therapeutic use
- Biomarkers, Tumor/blood
- Carcinoembryonic Antigen/blood
- Carcinoma/drug therapy
- Carcinoma/secondary
- Catheterization, Peripheral/adverse effects
- Catheterization, Peripheral/instrumentation
- Catheters, Indwelling/adverse effects
- Chemotherapy, Cancer, Regional Perfusion/instrumentation
- Colonic Neoplasms/pathology
- Disease Progression
- Female
- Fluorouracil/administration & dosage
- Fluorouracil/adverse effects
- Fluorouracil/therapeutic use
- Hepatic Artery
- Humans
- Infusion Pumps
- Liver Neoplasms/drug therapy
- Liver Neoplasms/secondary
- Male
- Radiography, Interventional
- Rectal Neoplasms/pathology
- Remission Induction
- Survival Rate
- Tomography, X-Ray Computed
- Treatment Outcome
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Affiliation(s)
- S Sameshima
- Department of Surgery, Gunma Prefectural Cancer Center, 617-1 Takabayashi-nishi, Ota, Gunma 373-8550, Japan.
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81
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Pereira PL. Actual role of radiofrequency ablation of liver metastases. Eur Radiol 2007; 17:2062-70. [PMID: 17429644 DOI: 10.1007/s00330-007-0587-0] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2006] [Revised: 12/18/2006] [Accepted: 01/09/2007] [Indexed: 01/12/2023]
Abstract
The liver is, second only to lymph nodes, the most common site for metastatic disease irrespective of the primary tumour. More than 50% of all patients with malignant diseases will develop liver metastases with a significant morbidity and mortality. Although the surgical resection leads to an improved survival in patients with colorectal metastases, only approximately 20% of patients are eligible for surgery. Thermal ablation and especially radiofrequency ablation emerge as an important additional therapy modality for the treatment of liver metastases. RF ablation shows a benefit in life expectancy and may lead in a selected patient group to cure. Percutaneous RF ablation appears safer (versus cryotherapy), easier (versus laser), and more effective (versus ethanol instillation and transarterial chemoembolisation) compared with other minimally invasive procedures. RF ablation can be performed by a percutaneous, laparoscopical or laparotomic approach, and may be potentially combined with chemotherapy and surgery. At present ideal candidates have tumours with a maximum diameter less than 3.5 cm. An untreatable primary tumour or a systemic disease represents contraindications for performing local therapies. Permanent technical improvements of thermal ablation devices and a better integration of thermal ablation in the overall patient care may lead to prognosis improvement in patients with liver metastases.
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Affiliation(s)
- Philippe L Pereira
- Department of Diagnostic Radiology, Eberhard-Karls-University of Tübingen, Hoppe-Seyler-Str.3, 72076 Tuebingen, Germany.
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82
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Stubbs RS, O'Brien I, Correia MM. Selective internal radiation therapy with 90Y microspheres for colorectal liver metastases: single-centre experience with 100 patients. ANZ J Surg 2007; 76:696-703. [PMID: 16916386 DOI: 10.1111/j.1445-2197.2006.03834.x] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Many patients with colorectal liver metastases die from liver-only disease. Selective internal radiation therapy (SIRT) is an evolving method suitable for treating patients with non-resectable metastatic liver disease. METHODS One hundred patients with advanced colorectal liver metastases were treated with SIRT. A single dose of between 2.0 and 3.0 GBq of (90)Y microspheres was given into the hepatic artery either by a surgically implanted portacath or a percutaneous femoral catheter. When a port was used (n = 87), SIRT was followed by hepatic arterial chemotherapy with 5-fluorouracil. RESULTS Treatment-related morbidity occurred in 11 patients. Responses to SIRT were assessed by serial computed tomography scans and carcinoembryonic antigen (CEA) measurement. Median CEA level 3 months after SIRT (expressed as percentage of initial CEA) was 18%. Only 5 of 80 patients (6.25%) scanned at 3 months showed disease progression. Survival was significantly more in those who experienced a good tumour marker response and in those who were slow to develop extrahepatic disease. Survival was independently influenced by the use of ongoing hepatic arterial chemotherapy, the extent of liver involvement and the lymph node status of the original primary tumour. CONCLUSION Selective internal radiation therapy is a very effective and well-tolerated regional treatment for colorectal liver metastases, which should be considered for those with liver-only metastatic disease.
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Affiliation(s)
- Richard S Stubbs
- Wakefield Gastroenterology Centre, Wakefield Hospital, Wellington, New Zealand.
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83
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Arciero CA, Sigurdson ER. Liver-directed therapies for patients with primary liver cancer and hepatic metastases. Curr Treat Options Oncol 2006; 7:399-409. [PMID: 16904057 DOI: 10.1007/s11864-006-0008-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Liver cancer, whether primary or metastatic, is a major cause of death throughout the world. The surgical management of these diseases varies according to the extent of disease and the overall health of the patient. Surgical resection of hepatic disease remains the only chance for cure. However, a large proportion of patients with liver cancer are unable to undergo a complete surgical resection. These patients are often treated with liver-directed therapies. Although not as effective as surgical resection, these approaches can help to improve the survival of patients. In patients with primary liver cancer, underlying liver disease often prohibits surgical intervention. However, survival advantages have been gained with the application of percutaneous alcohol injection and radiofrequency ablation (RFA). In patients with hepatic metastases, the number of metastases is often what prevents surgical resection. In these patients, RFA, cryoablation, and hepatic artery infusional therapy have all aided in prolonging survival. As chemotherapeutic agents improve and targeted therapies are developed, more patients will be able to undergo surgical management of their liver cancer, primary or metastatic.
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Affiliation(s)
- Cletus A Arciero
- Department of Surgical Oncology, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA 19111, USA
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84
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Abstract
For the past several decades, the therapy for metastatic colorectal cancer had modest benefits because of the limited therapeutic options. Bolus 5-fluorouracil (5FU) and leucovorin (LV) were the standard of care in the United States until 2002, with a response rate of 25% and a median survival of 10 to 12 months. However, with the advent of new agents, namely oxaliplatin and irinotecan, there has been a dramatic change in the way we treat metastatic colorectal cancer. Based on many well-conducted large randomized trials, we have evidence that combination chemotherapy incorporating oxaliplatin or irinotecan with infusional 5FU/LV is superior to 5FU/LV, with doubling of overall survival (OS) to approximately 20 months. There remains some uncertainty as to the best first-line regimen. This might be irrelevant because studies have shown that OS is dependent on exposure to all the active agents, regardless of the time period of exposure. Bevacizumab, which uses anti-angiogenic strategies, has improved disease-free survival (DFS) and OS when combined with standard chemotherapy and is a vital component of metastatic colorectal cancer therapy. However, there are no data supporting its use past progression. Cetuximab, an epithelial growth factor receptor inhibitor, is mainly used in irinotecan-refractory patients. In spite of all these advances, 5-year OS rates continue to be limited. Patients with curative resection of metastatic disease seem to have longer DFS and better 5-year OS rates. This should be a potential goal for responding patients with upfront unresectable, organ-limited disease.
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Affiliation(s)
- Smitha Patiyil
- Division of Medical Oncology, Mayo Clinic, Rochester, MN 55905, USA
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85
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Bartlett DL, Berlin J, Lauwers GY, Messersmith WA, Petrelli NJ, Venook AP. Chemotherapy and regional therapy of hepatic colorectal metastases: expert consensus statement. Ann Surg Oncol 2006; 13:1284-92. [PMID: 16955384 DOI: 10.1245/s10434-006-9018-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2006] [Accepted: 06/02/2006] [Indexed: 01/08/2023]
Affiliation(s)
- David L Bartlett
- Division of Surgical Oncology, University of Pittsburgh, Pennsylvania, USA
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86
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Inoue Y, Miki C, Kusunoki M. Current directions in chemotherapy for colorectal cancer. J Gastroenterol 2006; 41:821-31. [PMID: 17048045 DOI: 10.1007/s00535-006-1873-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2006] [Accepted: 07/04/2006] [Indexed: 02/04/2023]
Affiliation(s)
- Yasuhiro Inoue
- Department of Gastrointestinal and Pediatric Surgery, Division of Reparative Medicine, Institute of Life Sciences, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu 514-8507, Japan
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88
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Matsuoka H, Nagaya M, Tsukikawa S, Yanagi Y, Isogai A, Kubota S. Repeated hepatic intra-arterial chemotherapy based on results of anticancer drug sensitivity test in patients with synchronous hepatic metastases from colorectal cancer. Surgery 2006; 140:387-95. [PMID: 16934600 DOI: 10.1016/j.surg.2006.03.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2005] [Revised: 12/22/2005] [Accepted: 03/03/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVE We determined whether hepatic intra-arterial infusion of 5-fluorouracil (5-FU) in patients with synchronous hepatic metastases from colorectal cancer, in whom the primary lesion was resectable but hepatic metastatic lesions were non-resectable helped improve survival time when administered on the basis of the results of the anticancer drug sensitivity test. PATIENTS AND METHODS The study population consisted of 29 patients with synchronous hepatic metastases from colorectal cancer who underwent surgical resection of the primary lesion alone. Of these 29 patients, 21 received hepatic intra-arterial infusion of 5-FU postoperatively after the 5-FU sensitivity test. The remaining 8 patients underwent surgical resection of the primary lesion but neither sensitivity testing nor hepatic intra-arterial chemotherapy. Tissue fragments were cultured, with each concentration of 5-FU in the thermoreversible gelation polymer forming a three-dimensional structure at 37 degrees C. The viability of tumor cells was evaluated according to WST methods; inhibitory concentration of 50% (IC50) values were calculated. We considered cancer tissue to be sensitive to IC50 values that were below twice the peak plasma concentration (120 microg/ml). RESULTS Of the 21 patients, 10 had sensitivity to 5-FU and 11 had no sensitivity. The response rates were 90.0% and 9.1%, respectively. The median survival times were 38 months and 10 months in these groups, respectively, and 7 months in patients who received no chemotherapy. This finding indicates a significantly longer survival time in the sensitive group, compared with either the insensitive group or the no chemotherapy group (P = .0014 P = .0023). The cumulative survival rate was significantly higher in the sensitive group compared with the insensitive group (P = .0001) CONCLUSIONS Ultimately, the group with sensitivity to 5-FU showed a significantly longer median survival time than the insensitive group.
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Affiliation(s)
- Hiromitsu Matsuoka
- Department of General Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
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89
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Homsi J, Garrett CR. Hepatic arterial infusion of chemotherapy for hepatic metastases from colorectal cancer. Cancer Control 2006; 13:42-7. [PMID: 16508625 DOI: 10.1177/107327480601300106] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Sixty percent of colon cancer patients develop liver metastasis. Only 25% of those have potentially resectable hepatic metastases, and approximately 58% of those patients relapse. METHODS We review the indications and the technical aspects of hepatic artery infusion (HAI) of chemotherapy, as well as the efficacy, morbidity, and outcomes. RESULTS HAI of chemotherapy has been used following hepatic metastasectomy, in patients with unresectable metastases, or in combination with other agents. Floxuridine, the chemotherapeutic agent most studied, is administered through an implantable subcutaneous infusion pump connected to a surgically placed hepatic artery catheter, which delivers the chemotherapeutic agents at a slow fixed rate. Treatment-related toxicities include chemical hepatitis, biliary sclerosis, and peptic ulceration. Some trials report a survival benefit for HAI over systemic chemotherapy with acceptable toxicity. CONCLUSIONS Regional perfusion chemotherapy can be logistically and technically complicated to deliver. The development of newer systemic agents with superior efficacy in the treatment of metastatic colorectal cancer will likely diminish the role of regional perfusion therapy in the future.
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Affiliation(s)
- Jade Homsi
- Gastrointestinal Tumor Program, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
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90
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Abstract
Gastroenterologists have a primary role in the management of colorectal cancer patients in that they frequently establish the diagnosis, direct or perform tumor staging evaluations, and initiate referrals for oncologic treatment. Several important advances have been made in the adjuvant treatment of colon and rectal cancers and in therapy of metastatic disease. These advances include the development of more effective combination chemotherapy regimens and molecularly targeted antibodies. These antibodies are directed against regulators of angiogenesis (vascular endothelial growth factor) and tumor cell growth (epidermal growth factor receptor) and have been shown to enhance the efficacy of cytotoxic chemotherapy. In the treatment of localized rectal cancer, the integration of chemotherapy and radiation with surgery has resulted in neoadjuvant approaches that achieve improved tumor control, sphincter preservation, and reduce treatment-related toxicities. This review presents an update of the current approach to colon and rectal cancer treatment, highlighting recent chemotherapeutic advances in the management of these highly prevalent malignancies.
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Affiliation(s)
- Dirk M Bernold
- Division of Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota 55902, USA
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91
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Abstract
Colorectal carcinoma is the third most common cause of cancer death in the United States, with 135,000 new cases and 55,000 deaths annually. Ultimately, two-thirds (99,000) of all patients with colorectal cancer will develop metastasis to the liver and other organs in their life span, making metastatic colorectal cancer the second leading cause of cancer-related death in North America. The optimal management of these patients has become increasingly complex with the myriad of treatment options that are available. Because the timing of any therapy (surgery, chemotherapy, or others) has become integral to the success of the treatment, a collaborative approach involving multiple specialties is needed for the best patient outcome. Defined clinical and pathologic determinants of outcome have been demonstrated to effect the overall and disease-free survival of patients with metastatic colorectal cancer. Understanding of these determinants remains essential to any treating physician and has lead to significant paradigm shifts in the management of patients with metastatic colorectal cancer.
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Affiliation(s)
- Angela M. Lewis
- From the Department of Surgery, Division of Surgical Oncology, James Graham Brown Cancer Center, University of Louisville School of Medicine, Louisville, Kentucky
| | - Robert C.G. Martin
- From the Department of Surgery, Division of Surgical Oncology, James Graham Brown Cancer Center, University of Louisville School of Medicine, Louisville, Kentucky
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92
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Kim JC, Kim HC, Lee KH, Yu CS, Kim TW, Chang HM, Ryu MH, Kim JH, Ha HK, Lee MG. Hepatic arterial infusion alternating with systemic chemotherapy in patients with non-resectable hepatic metastases from colorectal cancer. J Gastroenterol Hepatol 2006; 21:1026-35. [PMID: 16724990 DOI: 10.1111/j.1440-1746.2005.04023.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Hepatic arterial infusion (HAI) chemotherapy has a number of limitations, including a low rate of complete response and frequent extrahepatic recurrence, in colorectal cancer patients with non-resectable hepatic metastases. METHODS Twenty-nine colorectal cancer patients with non-resectable hepatic metastases were consecutively enrolled for HAI alternating with systemic chemotherapy (HA + SC group). The protocol comprised six cycles of alternating HAI (5-FU + leucovorin for 14 days, and mitomycin C on the first day) and systemic chemotherapy (5-FU + leucovorin). Colorectal cancer patients with two or more hepatic metastases treated using hepatic resection and systemic chemotherapy (HR + SC group) were selected as a comparative group. RESULTS Within the HA + SC group, complete response was achieved in eight patients (28%), whereas 13 patients (45%) showed progressive disease. Six of the eight patients with complete response lived for more than 38 months. Extrahepatic recurrences were more frequent in the HR + SC group than the HA + SC group (47 vs 21%, P = 0.024). The two groups did not differ with respect to overall and hepatic progression-free survival (P = 0.947 and 0.444, respectively), displaying median +/- SE values of 38 +/- 7 and 20 +/- 3 months in the HA + SC group, and 39 +/- 9 and 33 +/- 14 months in the HR + SC group, respectively. One patient in each group experienced toxic hepatitis, and sclerosing cholangitis occurred in one patient of the HA + SC group. Other complications were mostly grade 1 or 2. CONCLUSIONS HAI alternating with systemic chemotherapy led to a promising response and hepatic progression-free survival, possibly reducing extrahepatic recurrence in colorectal cancer patients with non-resectable liver metastases.
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Affiliation(s)
- Jin C Kim
- Department of Surgery, University of Ulsan College of Medicine, 388-1 Poongnap-2-Dong, Songpa-Ku, Seoul 138-736, Korea.
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93
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Biasco G, Derenzini E, Grazi G, Ercolani G, Ravaioli M, Pantaleo MA, Brandi G. Treatment of hepatic metastases from colorectal cancer: Many doubts, some certainties. Cancer Treat Rev 2006; 32:214-28. [PMID: 16546323 DOI: 10.1016/j.ctrv.2005.12.011] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2005] [Revised: 12/11/2005] [Accepted: 12/20/2005] [Indexed: 02/06/2023]
Abstract
About 50% of patients with colorectal cancer (CCR) are destined to develop hepatic metastases during the course of the disease. Surgery is currently the only potentially curative treatment with a five year survival rate after hepatectomy from 26% to 49%. The criteria for resectability are now less rigid than in the past and the tendency to adopt a more aggressive treatment of metastatic lesions is the rule. Systemic infusion chemotherapies based on 5-fluorouracil (5-FU), oxaliplatin (OHP) and irinotecan (CPT-11) are well tolerated and have been shown to be effective in non-operable patients. These regimens allow surgery for patients who are initially not suitable for resection, giving them a probability of survival at five years similar to that of patients operated on at diagnosis. Intra-arterial infusion chemotherapy (HAI) is very effective in inducing objective responses, but is costly, difficult to manage and encumbered by major side effects, so that its application is necessarily limited to centres with specific experience. However, despite the broader criteria and recent advances of chemotherapy, surgery is not possible in most patients. The role of other local therapeutic techniques like cryosurgery (CS) and radiofrequency ablation (RF), alone or combined with surgery or chemotherapy, is not yet established in a multidisciplinary therapeutic approach. Roughly two thirds of patients relapse during the first two years after surgery suggesting appropriate post-operative chemotherapy treatment after hepatic resection may be indicated, but no randomised studies have been published to date. In case of relapse, another hepatectomy should be considered. The role of novel targeted therapies in pre-operative, post-operative and palliative management has yet to be evaluated.
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Affiliation(s)
- G Biasco
- L. and A. Seràgnoli Institute of Haematology and Medical Oncology, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.
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94
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Sofocleous CT, Schubert J, Kemeny N, Covey AM, Brody LA, Getrajdman GI, Thornton R, Winston C, Brown KT. Arterial Embolization for Salvage of Hepatic Artery Infusion Pumps. J Vasc Interv Radiol 2006; 17:801-6. [PMID: 16687745 DOI: 10.1097/01.rvi.0000217937.81939.18] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Hepatic artery infusion pumps (HAIPs) ideally provide for homogenous perfusion of the liver with chemotherapeutic agents. Perfusion of extrahepatic organs or asymmetric liver perfusion (ie, "misperfusion") is diagnosed by nuclear scintigraphy and precludes the use of HAIPs. The purpose of this study is to report experience in salvaging HAIPs with arterial embolization. MATERIALS AND METHODS A single-center HAIP database was retrospectively reviewed for cases from 1999 to 2005 to identify patients who underwent angiography to treat misperfusion documented by nuclear scintigraphy. Patient demographics, nuclear scintigraphic findings before and after embolization, angiographic findings, embolization variables, and outcomes were recorded. Technical success (defined by cessation of flow to the vessel responsible for misperfusion) and clinical success (ie, successful use of the pump) were calculated. RESULTS During the study period, 475 HAIPs were implanted. Of those, 43 (9%) had abnormal nuclear scintigraphic findings of misperfusion, but only 32 (7%) had angiographic abnormalities. In eight of 32 cases, hepatic arterial thrombosis and extravasation at the catheter tip were found, which precluded salvage by embolization. In 24 of 32 cases, a vessel presumed responsible for the misperfusion was identified and targeted for embolization. Technical success and clinical success were achieved in 21 of 24 patients (87.5%) and 19 of 24 patients (79%), respectively, who underwent 27 embolization procedures. The three technical failures (12.5%) were the result of inability to catheterize the identified vessel. CONCLUSIONS Percutaneous arterial embolization of a vessel to correct misperfusion shown by nuclear scintigraphy is safe and effective. This approach can be expected to result in HAIP salvage in the majority of patients.
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Affiliation(s)
- Constantinos T Sofocleous
- Division of Interventional Radiology and Image-Guided Therapies, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, New York 10021, USA.
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95
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Velasco JM, Hieken TJ, Yamin N, Doolas A. Colorectal Hepatic Metastasis. Surg Oncol 2006. [DOI: 10.1007/0-387-21701-0_36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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96
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Hao CY, Ji JF. Surgical treatment of liver metastases of colorectal cancer: Strategies and controversies in 2006. Eur J Surg Oncol 2006; 32:473-83. [PMID: 16580172 DOI: 10.1016/j.ejso.2006.02.016] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2005] [Accepted: 02/20/2006] [Indexed: 12/14/2022] Open
Abstract
AIMS To review the latest strategies and controversies in the surgical treatment of liver metastases of colorectal cancer systemically and comprehensively. METHODS A medline based literature search on relevant topics was performed in PubMed for key articles concerning the novel strategies and controversies in the management of liver metastases of colorectal cancer. Some information was obtained from 'Proc Am Soc Clin Oncol' published recently. The findings and discussions were related to our own experiences. RESULTS Although for well-indicated patients, a consensus has been reached that hepatic resection is the only management that could provide the patients curability, there still exist many controversies, such as the prognostic evaluation, contraindications to hepatic resection, treatment for synchronous liver metastases, the place of laparoscopic surgery, etc. Meanwhile, various strategies to improve the respectabilities are available, including neoadjuvant chemotherapy, portal vein embolization, two stage hepatectomy, and some locally ablative approaches. The current condition is difficult and sometimes confusing for a relevant surgeon when designing treatment protocols for more complex diseases. CONCLUSION As the advancing of the management of liver metastases of colorectal cancer, more patients will become candidates for and benefit from potentially curative surgical resections. Optimal effect could only be achieved when used in a manner tailored to the individual patient.
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Affiliation(s)
- C Y Hao
- Peking Unversity School of Oncology, Beijing Cancer Hospital, People's Republic of China
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97
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Neoadjuvant and adjuvant therapy combined with resection of hepatic colorectal cancer metastases. CURRENT COLORECTAL CANCER REPORTS 2006. [DOI: 10.1007/s11888-006-0006-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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98
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Ben-Josef E, Normolle D, Ensminger WD, Walker S, Tatro D, Ten Haken RK, Knol J, Dawson LA, Pan C, Lawrence TS. Phase II trial of high-dose conformal radiation therapy with concurrent hepatic artery floxuridine for unresectable intrahepatic malignancies. J Clin Oncol 2006; 23:8739-47. [PMID: 16314634 DOI: 10.1200/jco.2005.01.5354] [Citation(s) in RCA: 234] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
PURPOSE A phase II trial was conducted to determine if high-dose radiation with concurrent hepatic arterial floxuridine would improve survival in patients with unresectable intrahepatic malignancies. PATIENTS AND METHODS Three-dimensional conformal high-dose radiation therapy was delivered concurrently with hepatic arterial floxuridine in 128 patients. The radiation dose was based on a normal-tissue complication probability model and subjected the patient to an estimated maximum risk of radiation-induced liver disease of 10% to 15%. The study design provided more than 80% power to detect a two-fold increase in median survival compared with historical controls at a 5% significance level. RESULTS The median radiation dose delivered was 60.75 Gy (1.5-Gy fractions bid). At a median follow-up time of 16 months (26 months in patients who were alive) the median survival was 15.8 months (95% CI, 12.6 to 18.3 months), significantly longer than in the historical control. The actuarial 3-year survival was 17%. The total dose was the only significant predictor of survival. Primary hepatobiliary tumors had a significantly greater tendency to remain confined to the liver than did colorectal cancer metastases. Overall toxicity was acceptable, with 27 patients (21%) and 11 patients (9%) developing grade 3 and 4 toxicity, respectively, and one treatment-related death. CONCLUSION The results suggest that, compared with historical controls, high-dose focal liver irradiation with hepatic artery floxuridine prolongs survival in patients with unresectable chemotherapy-refractory metastatic colorectal cancer and primary hepatobiliary tumors. This provides a rationale for intensification of local therapy for unresectable hepatobiliary cancers and integration of this regimen with newer systemic therapy for patients with colorectal cancer.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Antimetabolites, Antineoplastic/adverse effects
- Antimetabolites, Antineoplastic/therapeutic use
- Bile Duct Neoplasms/secondary
- Bile Duct Neoplasms/therapy
- Bile Ducts, Intrahepatic/drug effects
- Bile Ducts, Intrahepatic/pathology
- Bile Ducts, Intrahepatic/radiation effects
- Carcinoma, Hepatocellular/secondary
- Carcinoma, Hepatocellular/therapy
- Cholangiocarcinoma/secondary
- Cholangiocarcinoma/therapy
- Colorectal Neoplasms/pathology
- Colorectal Neoplasms/therapy
- Combined Modality Therapy
- Digestive System Surgical Procedures
- Dose-Response Relationship, Radiation
- Female
- Floxuridine/adverse effects
- Floxuridine/therapeutic use
- Follow-Up Studies
- Hepatic Artery
- Humans
- Infusions, Intra-Arterial
- Liver Neoplasms/secondary
- Liver Neoplasms/therapy
- Male
- Middle Aged
- Prospective Studies
- Radiotherapy Dosage
- Radiotherapy, Conformal/adverse effects
- Radiotherapy, Conformal/methods
- Survival Analysis
- Treatment Outcome
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Affiliation(s)
- Edgar Ben-Josef
- Department of Radiation Oncology, Division of Hematology Oncology, University of Michigan, UH-B2C490, 1500 E Medical Center Dr, Ann Arbor, MI 48109-0010, USA.
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99
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Vigna-Taglianti F, Vineis P, Liberati A, Faggiano F. Quality of systematic reviews used in guidelines for oncology practice. Ann Oncol 2006; 17:691-701. [PMID: 16461333 DOI: 10.1093/annonc/mdl003] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Systematic reviews are an important tool for developing clinical recommendations. Those of high quality assure a good level of confidence on the strength of the recommendations. METHODS A QUOROM-based checklist was applied to the reviews cited in a sample of guidelines on breast and colon cancer prevention and therapy. The checklist provided a weight for each criterion and a total quality score. Each review was independently evaluated by two reviewers; disagreements were solved by consensus. RESULTS Eighty reviews (96%) were retrieved and evaluated; 36 focused on breast, and 44 on colorectal cancer. Twenty-three reviews (29%) did not match the definition of systematic review. In 17 (21%) the searching methods were unclear or described elsewhere. Forty (50%) were systematic. Not systematic, low and very low quality reviews accounted for 70% of the total. No review obtained the A+ class score; only 5 (6%) the A- and 7 (9%) the B+. CONCLUSIONS The results of this assessment provide a sober picture of the quality of the sources used to build guidelines. Oncologists should be aware that they could be relying on poor underlying documents. Writing groups should be aware of methodological problems, and should consult the existing manuals for the preparation of guidelines.
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Affiliation(s)
- F Vigna-Taglianti
- Department of Biomedical Sciences and Human Oncology, University of Torino, Torino, Italy.
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100
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Stratmann SL. Hepatic artery chemotherapy in the management of colorectal metastases. Proc (Bayl Univ Med Cent) 2006; 15:376-9. [PMID: 16333468 PMCID: PMC1276641 DOI: 10.1080/08998280.2002.11927869] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Stacy L Stratmann
- Department of Surgery, Baylor University Medical Center, Dallas, Texas, USA
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