Quality of life and survival with continuous hepatic-artery floxuridine infusion for colorectal liver metastases

Interventional Radiologic Treatment for Hepatic Arterial Occlusion after Repeated Hepatic Arterial Infusion Chemotherapy via Implanted Port–Catheter System

The present study evaluated the feasibility of interventional radiologic treatments for hepatic arterial occlusion after hepatic arterial infusion chemotherapy (HAIC) via an implanted port-catheter system. Treatment for hepatic arterial occlusion was attempted in seven patients with unresectable liver cancer. In six, the obstructed hepatic artery was recanalized. In three patients, the recanalized hepatic artery again became obstructed. However, by performing additional interventional radiologic procedures, secondary patency of the hepatic artery was successfully obtained in two patients. In conclusion, when hepatic arterial occlusion occurs, HAIC can be resumed in the attempt to recanalize the hepatic artery.

Liver regional continuous chemotherapy: Use of femoral or subclavian artery for percutaneous implantation of catheter-port systems

AIM: To evaluate the feasibility and safety of the intraarterial chemotherapy of the liver cancer by an interventional method, catheter-port system.

METHODS: Thirty-two catheter-port systems were implanted percutaneously via the femoral artery or subclavian artery. Chemotherapies were performed 0-5 d after the implantation of the catheter-port systems. The mean interval between two sequent chemotherapies was 4 wk. The occurrence of side effects of the implantation was examined clinically.

RESULTS: Implantation of the catheter-port was successful in all patients. Mean patency period was 210 d. One occlusion (3.1%) of the catheter was observed. Displacement of the catheter was observed in one case (3.1%). One patient rated a hematoma in the chest wall as important. Mild hematoma was reported in 8 cases (25%). In 3 of 32 cases (9.4%), mild pain was reported initially, and dysesthesia was reported in seven (21.9%). No patient rated overall discomfort as mild, severe, or important.

CONCLUSION: Percutaneous placement is feasible and safe for liver regional continuous chemotherapy. Compared with surgical placement, the overall complication rate is comparable or less.

Double modulation of 5-fluorouracil by trimetrexate and leucovorin in patients with advanced colorectal carcinoma

The purpose of this report is to evaluate the efficacy and toxicity (Tx) of a double modulation of 5-fluorouracil (5-FU) by trimetrexate (TMTX) and leucovorin (LV) in patients with advanced recurrent (inoperable) or metastatic colorectal cancer (ACC). Between December 1997 and August 2000, 36 patients were entered in this phase II study. Median age was 61 years, and 18 patients (50%) were female. Median performance status was 0 (range: 0-1), whereas primary tumor location was colon in 21 patients (58%) and rectum in 15 patients (42%). The number of metastatic sites was 1:29 patients (81%); 2:6 patients (17%) and 3:1 patient (3%). Hepatic involvement was observed in 33 patients (92%). Treatment consisted of TMTX 110 mg/m2 IV over 1 hour at hour (H) 0; LV 50 mg/m2 IV over 2 hours IV infusion starting at H 18; and 5-FU 900 mg/m2 IV bolus at H 20. LV (rescue) 15 mg/m2 orally was administered every 6 hours (total 6 doses) beginning at H 24. Cycles were repeated every 2 weeks until progressive disease (PD) or severe Tx. Thirty-four patients are assessable for response (R) (two patients refused further treatment after the first course of therapy), whereas all patients were assessable for Tx. Complete response: 1 patient (3%); partial response: 4 patients (12%), with an overall objective response rate of 15% (95% CI, 1%-25%); no change: 12 patients (35%); and progressive disease: 17 patients (50%). The median time to treatment failure was 4 months and median survival was 11 months. Tx was within acceptable limits. The dose-limiting side effect was mucositis. Eight episodes of grade II or III stomatitis were observed and were responsible for dosage modifications of TMTX and 5-FU. Leukopenia was observed in 16 patients (44%); neutropenia was registered in 19 patients (53%); anemia was seen in 18 patients (50%); emesis in 22 patients (61%); and dermatitis in 3 patients (8%). There were no therapy-related deaths. The double modulation of 5-FU by TMTX and LV showed modest antitumoral activity with mild to moderate Tx.

Quality of life and outcome of ultrasound-guided laser interstitial thermo-therapy for non-resectable liver metastases of colorectal cancer

OBJECTIVE

Patients with non-resectable liver metastases of colorectal cancer have poor prognosis and are mainly treated by palliative chemotherapy. Laser interstitial thermo-therapy is an innovative minimal invasive procedure for local tumour destruction within solid organs. The aim of the study was to investigate quality of life and outcome of ultrasound-guided laser interstitial thermo-therapy (US-LITT) in patients with liver metastases of colorectal cancer.

METHODS

In this prospective non-randomized study, 45 patients with liver metastases of colorectal cancer were palliatively treated by US-LITT. Patient survival was analysed by the Kaplan-Meier method and the quality of life by questionnaire C30 of the European Organisation for Research and Treatment of Cancer before, and 1 week, 1 month, and 6 months after initiation of US-LITT.

RESULTS

Median survival after initiation of US-LITT was 8.5 +/- 0.7 months with a range of 1.5-18 months. Body weight was constant 1 month after US-LITT. In the multivariate analyses, quality-of-life symptoms and functioning scales did not deteriorate in patients alive at 6 months after initiation of US-LITT. Univariate analyses outlined a significant increase of the pain subscale before and at 1 week after US-LITT.

CONCLUSIONS

This study first describes the quality of life in patients with liver metastases of colorectal cancer treated by US-LITT. Potential benefits of the minimal invasive procedure could be prolonged survival time by preserved quality of life, but this first impression needs to be verified in a comparative study.

Regional chemotherapeutic techniques for liver tumors: current knowledge and future directions

After a rather long period of stagnation, intra-arterial therapeutic approaches for treating liver tumors are currently progressing rapidly. These new modalities will increase the resectability of initially unresectable liver tumors after dramatic responses. At the same time, resectability rates are increasing with the assistance of local ablative physical treatments such as radiofrequency, resulting in an improvement of patients' median survival rates and quality of life.

Thymidylate synthetase mRNA levels are increased in liver metastases of colorectal cancer patients resistant to fluoropyrimidine-based chemotherapy

Background

Fluoropyrimidines such as 5-fluorouracil (5-FU) and 5-fluoro-2'deoxyuridine (FUDR) are among the most effective chemotherapeutic agents for treatment of metastatic colorectal cancer (CRC). Increased expression of thymidylate synthetase (TS) in CRC metastases has been proposed to be an important mechanism of resistance to fluoropyrimidine-based chemotherapy.

Methods

The present study investigated whether TS mRNA levels in liver metastases of 20 CRC patients before treatment with FUDR by hepatic arterial infusion (HAI) correlated with frequency of clinical response or survival duration.

Results

Median survival duration of patients with TS mRNA levels above and below the median was 15 and 18 months, respectively (p > 0.05). Clinical response was achieved in 40% of patients with low TS mRNA levels, but in only 20% of patients with high TS mRNA levels (p = 0.01). TS mRNA levels were also measured for liver metastases of 7 of the patients that did not achieve a clinical response. A statistically significant increase in expression of TS mRNA was observed for liver metastases resistant to chemotherapy (21 ± 14) in comparison to liver metastases of the same patients before chemotherapy (8 ± 4) (p = 0.03).

Conclusion

This is the first report to demonstrate increased TS expression in liver metastases from CRC patients resistant to fluoropyrimidine based chemotherapy. These findings are consistent with previous studies indicating that increased TS expression is associated with resistance to fluoropyrimidine-based chemotherapy.

Methodological issues in assessing health-related quality of life of colorectal cancer patients in randomised controlled trials

Although health-related quality of life (HRQOL) is increasingly reported as an important endpoint in cancer clinical trials, questions still remain about the quality of its reporting. The aim of this study was to evaluate the level of reporting of HRQOL in randomised controlled trials (RCTs) of colorectal cancer (CRC). A systematic literature search from 1980 to March 2003 was undertaken on a number of databases. Identified eligible studies were selected and then evaluated on a broad set of HRQOL predetermined criteria by four reviewers. Thirty-one randomised controlled trials involving 9683 colorectal cancer patients were identified. Nearly all studies dealt with metastatic patients and principally compared different chemotherapy regimens. The HRQOL tool most often used was the European Organisation for Research and Treatment of Cancer, Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30), which was used in 48% of the studies. Some methodological limitations were identified: 39% of the RCTs did not report HRQOL compliance at baseline and 52% did not give details on missing data. A rationale for using a specific HRQOL measure was given in only 10% of the studies. Whilst HRQOL assessment is a potential valuable source of information in understanding the impact of colorectal cancer, a number of methodological shortcomings have to be further addressed in future studies.

An update on hepatic arterial infusion chemotherapy for colorectal cancer

Hepatic metastases are a frequent complication of colorectal cancer (CRC), affecting over half of all CRC patients. Resection of isolated metastases can result in long-term survival, but the majority of patients relapse, and most have unresectable disease. Hepatic arterial infusion (HAI) chemotherapy delivers high concentrations of cytotoxic agents directly to liver metastases with minimal systemic toxicities. Advances in surgical techniques, development of fully implantable pumps, and modification of drug regimens have decreased complications and improved patient tolerability. Randomized trials comparing HAI with systemic chemotherapy have demonstrated superior response rates and times to hepatic progression for unresectable disease, and have shown better times to progression and overall survival rates in the adjuvant setting following hepatic resection. HAI chemotherapy has unique toxicities, including chemical hepatitis and biliary sclerosis, which can be mitigated by the addition of dexamethasone to therapy. In an attempt to prevent extrahepatic progression, combinations of HAI with systemic chemotherapy, including newer agents such as irinotecan and oxaliplatin, are currently being investigated, with promising early results.

Current Role of Hepatic Artery Infusion and Isolated Liver Perfusion for the Treatment of Colorectal Cancer Liver Metastases

There are many treatment options for patients with metastatic colorectal carcinoma confined to the liver. Surgical resection alone can result in significant prolongation of survival in patients with favorable prognostic factors. Randomized studies of hepatic artery infusion therapy after complete resection of liver metastases have demonstrated improvements in hepatic recurrence-free survival but no impact on overall survival. Randomized trials evaluating the treatment of unresectable disease with hepatic artery infusion therapy have demonstrated higher response rates (31%-50%) than those seen with systemic chemotherapy (8%-20%) but no survival benefit. Vascular isolation and perfusion of the liver with chemotherapy with or without biologic agents under hyperthermic conditions is another regional modality that has been explored for the treatment of unresectable colorectal cancer liver metastases. Large series report high partial response rates (68%-77%), with responses being achieved in patients with advanced tumor burden and in those who have disease progression through prior treatment of hepatic metastases.

Value of Transcatheter Arterial Embolization with Coils and n-Butyl Cyanoacrylate for Long-term Hepatic Arterial Infusion Chemotherapy

PURPOSE

To assess the value of transcatheter arterial embolization (TAE) of splanchnic arterial branches to allow continuous application of repeat hepatic arterial infusion chemotherapy (HAIC).

MATERIALS AND METHODS

In 128 patients with unresectable advanced liver cancer, percutaneous implantation of a port catheter system and TAE of splanchnic arteries with coils and/or n-butyl cyanoacrylate (NBCA) were performed. Parameters included (a) methods selected for catheter placement; (b) embolic materials used (coils and/or NBCA, number of coils, administration rate of NBCA-iodized oil) for TAE of splanchnic arteries, details of embolized arteries, and frequency of recanalization; (c) ability to prevent gastrointestinal symptoms by avoiding inflow of anticancer drugs into extrahepatic adjacent organs and to maintain distribution of contrast agents in liver, as well as management of difficulties encountered; (d) complications related to catheter system implantation or to long-term HAIC and management of such complications; and (e) final success in performing scheduled HAIC while maintaining distribution over liver via a single route without gastrointestinal symptoms caused by inflow of anticancer drugs. Fisher exact test was used to compare recanalization rate between coil-embolized and NBCA- or NBCA-coil-embolized arteries, and frequency of heterogeneously poor distribution was compared between patients with single and those with multiple hepatic arteries.

RESULTS

Embolization was successful during first catheterization in 326 arteries and during follow-up in 10. In 119 (93.0%) of 128 patients, repeat HAIC was effective until death or the time of this writing (observation period, 2-47 months). HAIC was continued in two patients, although anticancer drugs did not distribute to all liver tumors. Arteries once embolized with coils alone spontaneously recanalized at a significantly higher rate than those with NBCA (eight of 192 vs one of 144, P =.048). Rate of heterogeneously poor distribution was significantly higher in those with two or more hepatic arteries than in those with one (seven of 17 vs nine of 111, P =.001).

CONCLUSION

TAE for various splanchnic organs is useful for efficient performance of long-term HAIC.

Scanning electron microscopy study of the blood supply of human colorectal liver metastases

AIMS

The failure of hepatic artery directed treatment of colorectal liver metastases may reflect a major portal venous contribution to tumour blood supply. This study provides ultrastructural details of the blood supply of colorectal liver metastases and their association with the portal vein and hepatic artery.

METHODS

Resected liver specimens from six patients with colorectal liver metastases were examined by histology and scanning electron microscopy (SEM), following vascular resin casting.

RESULTS

Nine metastatic colorectal adenocarcinomas were identified. The main feature of all tumours on SEM was direct communication between hepatic sinusoids and tumour vessels. A direct portal venous connection with tumour vessels was observed in a single specimen, whilst a direct arteriole connection was not identified.

CONCLUSIONS

It appears that both the hepatic artery and portal vein contribute to the blood supply of colorectal liver metastases through sinusoidal connections with tumour specific blood vessels. SEM provides useful additional information on the morphological features of tumour vasculature.

What's old is new again: patients receiving hepatic arterial infusion chemotherapy

Hepatocellular carcinoma (HCC) ranks as the eighth most common cancer in the world. Although uncommon in North America, the incidence of HCC in the United States has increased by 70% since the 1980s (Yu, Yuan, Govindarajan, & Ross, 2000). The most frequent causes of malignant hepatic disease in the United States are metastases from melanoma and primary tumors of the gastrointestinal tract, breast, and lung. Surgical resection and systemic chemotherapy are the standard treatments for this disease. However, surgery is not an option for patients with advanced disease, and the response rate from systemic chemotherapy remains low. An alternative therapy for patients with HCC or cancers with liver metastases is hepatic arterial infusion of chemotherapy directly into the liver. This method allows a high total body clearance and hepatic extraction to generate high hepatic and low systemic exposures. Nursing care of patients receiving hepatic arterial infusion of chemotherapy includes patient education and monitoring for complications.

Continuous infusion of hepatic arterial irinotecan in pretreated patients with colorectal cancer metastatic to the liver

BACKGROUND

Irinotecan is an active drug in colorectal cancer. In patients with liver metastases, hepatic arterial infusion of irinotecan could theoretically result in higher exposure to the drug. In order to determine the efficacy of hepatic arterial irinotecan we conducted a phase II study in pretreated patients with liver metastases of colorectal cancer.

PATIENTS AND METHODS

Patients with measurable liver metastases of colorectal cancer with World Health Organization performance status (WHO PS) <2 were treated with a 5-day continuous infusion of hepatic arterial irinotecan every 3 weeks at a dose of 20 mg/m(2)/day.

RESULTS

Of the 25 patients included, 22 were evaluable for response. Three of 22 patients (13.6%) had a partial response, nine (40.9%) had stable disease and 10 (45.4%) had progressive disease. No complete responses were observed. Median time to progression was 2.8 (range 1.2-23.8) months. Major toxicities were vomiting and diarrhea. There was no major hematological toxicity.

CONCLUSIONS

Five-day continuous hepatic arterial infusion of irinotecan 20 mg/m(2)/day has low activity in patients with liver metastases of colorectal cancer previously treated by chemotherapy.

A Phase II Study of Modified deGramont 5-Fluorouracil, Leucovorin, and Oxaliplatin in Previously Treated Patients with Metastatic Colorectal Cancer

PURPOSE

To evaluate the toxicity and efficacy of a modified deGramont regimen of 5-fluorouracil (5-FU), leucovorin, and oxaliplatin in patients with advanced colorectal cancer who have progressed on at least one but not more than two prior chemotherapy regimens.

PATIENTS AND METHODS

Patients with stage 4 colorectal cancer were treated with oxaliplatin 85 mg/m2 by a 2-hour intravenous infusion, followed by leucovorin 500 mg/m2 by a 2-hour intravenous infusion, followed by 5-FU 400 mg/m2 by bolus injection, followed by 5-FU 2.4 g/m2 administered by a 46-hour continuous infusion. Cycles were administered every 2 weeks.

RESULTS

Seventy patients were treated and 68 patients had previously received irinotecan. Eleven percent of patients had a partial response, 33% of CEA-evaluable patients had a > or = 50% drop in their CEA level. The median time to progression was 6.2 months, and the median overall survival was 8.7 months. Toxicity was mild to moderate, as 14% of patients experienced grade 3 or 4 neutropenia and 3% of patients experienced grade 3 neuropathy.

CONCLUSION

The modified deGramont regimen of 5-FU, leucovorin, and oxaliplatin is tolerable and is associated with a modest degree of antitumor activity in patients who have progressed on both 5-FU and irinotecan.

Palliative treatment of patients with colorectal cancer

BACKGROUND

Metastatic colorectal cancer has a poor prognosis, and the majority of patients are left with palliative measures. The development seen using palliative chemotherapy is reviewed.

MATERIAL AND METHODS

A systematic approach to the literature-based evidence was aimed at.

RESULTS

The continuous improvements during the past 13-15 years have been documented in several large conclusive trials. At the end of the 1980s, the evidence that chemotherapy should be used at all was very limited, whereas presently most patients can be offered two lines of chemotherapy based upon good scientific evidence. Median survival has gradually improved from below 6 months to above 18 months in some recent trials. Several important issues remain to be solved, such as the best sequence of treatments, what regimens to use in various situations, when to start and when to stop if a response is seen, and whether cure may be possible in a small subset of patients.

CONCLUSIONS

Progress has been rapid in advanced colorectal cancer. This is likely a result of well-designed trials in collaboration between academy and industry, showing a great interest in the disease. Future collaborations may hopefully introduce new treatment concepts, further improving outcome.

Health-related quality of life in colorectal cancer patients

Accurate assessment of quality of life in patients with colorectal cancer is essential in order to inform clinical decisions by providing insights into patients' experiences of the disease and treatment. This review summarizes the clinical evidence of how treatments for colorectal cancer impact on short- and long-term quality of life. Surgery for colorectal cancer has a short-term detrimental impact on most aspects of quality of life. Chemotherapy in palliative settings often preserves quality of life. Some studies do not demonstrate changes in keeping with clinical expectations. This may be due to insensitive quality of life tools, low numbers of patients, insufficient compliance or patients' adaptation to changes. An international consensus involving clinicians and methodologists is needed to describe robust standards for quality of life measurement in oncology.

Hepatic cryotherapy and regional chemotherapy with or without resection for liver metastases from colorectal carcinoma: how many are too many?

BACKGROUND

The number of hepatic metastases for which resection or ablation is appropriate remains controversial.

METHODS

A retrospective analysis was performed of prospectively collected data from patients with liver metastases from colorectal carcinoma who underwent hepatic cryotherapy and hepatic arterial chemotherapy (HAC) with or without undergoing resection. Patients routinely had preoperative bone scans, chest computed tomography (CT) scans, and abdominal angio-CT scans. Positron emission tomography scans were unavailable. All patients were followed until June 2002 or until death occurred. Kaplan-Meier and Cox regression methods were used to evaluate the impact of 17 potentially prognostic factors on survival.

RESULTS

One hundred seventy-two patients who underwent hepatic cryotherapy and HAC with or without undergoing liver resection for in situ eradication of metastases formed the basis of this report. One patient (0.6%) died postoperatively from myocardial infarction. The morbidity rate was 27.9%. The median survival was 28 months (range, 0-98 months). The factors age < or = 50 years, well-differentiated or moderately differentiated primary tumor, small cryolesions (<3.5 cm), complete eradication of extrahepatic metastases at cryotherapy, and low preoperative carcinoembryonic antigen (CEA) levels were associated independently with a favorable outcome. In addition, a univariate analysis showed that the absence of untreated extrahepatic disease at laparotomy, postoperative CEA normalization, and a large decline in CEA levels were significant statistically. The number of lesions was not prognostic. One hundred forty-six patients (84.9%) who underwent a complete operation had 1-year, 2-year, 3-year, 4-year, and 5-year survival rates of 89%, 65%, 41%, 24%, and 19%, respectively. The median survival of patients with 1 metastasis, 2 metastases, 3 metastases, 4 metastases, 5 metastases, 6 or 7 metastases, and 8-12 metastases were 32 months, 29 months, 30 months, 31 months, 27 months, 37 months, and 21 months, respectively (P=0.7859). Twenty-five patients had 6 or 7 lesions, and their 5-year survival rate was 25%.

CONCLUSIONS

When all colorectal hepatic lesions were eradicated, the numbers of hepatic metastases were not prognostic of survival in patients with liver metastases from colorectal carcinoma.

New method of catheter-port system implantation in hepatic arterial infusion chemotherapy

BACKGROUND

This report describes a novel method of implantation of the catheter-port system in hepatic arterial infusion chemotherapy, which is the inferior epigastric arterial approach.

METHODS

Using this method, the length of incision is about 3 cm in lower abdomen. The inferior epigastric artery is exposed above the inguinal ligament. The half of the artery is cut, and a vascular sheath is inserted into the external iliac artery along a guide wire. A catheter is inserted into the hepatic artery through the vascular sheath. Coil occlusion of nontarget artery is performed by the technique of interventional radiology. Then the vascular sheath is removed and the catheter is fixed to the inferior epigastric artery. A port is connected to the catheter and placed above the incision in the lower abdomen.

CONCLUSIONS

Using this method, the hip joint can be moved freely and port-related complications are few, which contributes to a good quality of life of patients during the therapy. The inferior epigastric arterial approach may give a benefit to those who are treated with hepatic arterial infusion chemotherapy.

Hepatic arterial infusion using pirarubicin combined with systemic chemotherapy: a phase II study in patients with nonresectable liver metastases from colorectal cancer

BACKGROUND

A prospective phase II study was performed to determine the feasibility, efficacy and safety of arterial hepatic infusion (HAI) using pirarubicin combined with intravenous chemotherapy.

PATIENTS AND METHODS

From December 1991 to April 1994, 75 patients with unresectable colorectal metastases confined to the liver were included in this multicenter study to receive intra-arterial hepatic pirarubicin and a systemic monthly regimen of 5-fluorouracil (5-FU) and folinic acid. Sixty-four patients were analyzed in the intention-to-treat analysis and 61 in the per-protocol analysis.

RESULTS

Tolerance of this regimen was rather good; however, functional catheter problems were observed in 29 patients (45%) resulting in failure of HAI in 21 cases (33%) after a median of three cycles; vomiting grade 3 was present in 12.5% of patients, neutropenia grade 4 in 23% and alopecia grade 3 in 19%. The overall response rate was 31.9% in intention-to-treat analysis, and 39.3% in per-protocol analysis. Extrahepatic progression was reported in only 21.7% of patients. Time to hepatic progression and extra-hepatic progression was 8.3 and 15 months, respectively, in intention-to-treat analysis, and 11 and 18 months, respectively, in per-protocol analysis. Median survival was 19 and 20 months in intention-to-treat analysis and per-protocol, respectively.

CONCLUSIONS

In our study, the combination of intra-arterial pirarubicin and intravenous chemotherapy demonstrated some efficacy and good tolerance in the treatment of isolated colorectal liver metastases. This treatment seems to prevent extra-hepatic spread and prolong survival time. The results of this study have to be confirmed by new trials using more active systemic chemotherapy.

Adjuvant hepatic arterial chemotherapy following metastasectomy in patients with isolated liver metastases

OBJECTIVE

To examine survival and toxicity by querying a single-institutional experience with adjuvant hepatic arterial infusional (HAI) chemotherapy.

SUMMARY BACKGROUND DATA

Three randomized series in the literature have examined adjuvant HAI after complete resection of liver metastases. Only one of these trials showed an overall survival benefit at 2 years but not over the entire time period of the study. Previous studies in patients with unresectable disease were plagued by high rates of biliary toxicity.

METHODS

A retrospective review of a prospectively maintained database was performed. Hepatic arterial pumps were placed in the standard fashion. Patients received floxuridine at doses previously demonstrated as safe in the literature. Standard statistical methods were used.

RESULTS

Twenty-one of 92 patients underwent placement of hepatic arterial pumps at the time of liver resection. The HAI group was similar in all demographic measures to the non-HAI group, with the exception that the HAI patients were significantly younger. No differences were seen between the groups in either disease-free or overall survival, although a trend toward improved hepatic progression-free survival was noted. Significant biliary sclerosis developed in six patients in the HAI group, requiring chronic indwelling stents in four patients. One patient died of progressive liver failure associated with this toxicity.

CONCLUSIONS

Biliary toxicity is an important potential side effect of hepatic arterial chemotherapy. Although larger randomized studies and this one suggest significant improvements in hepatic recurrences, these have not reliably translated into overall survival benefit. This fact, in light of the potential toxicity, would argue for a larger confirmatory trial of HAI in the adjuvant setting, incorporating recent advances in systemic therapy and careful attention to hepatotoxicity.

A comparison between hepatic artery ligation and portal 5-Fu infusion versus 5-Fu intra arterial infusion for colorectal liver metastases

AIM

A prospective randomized study was executed comparing two regimens of regional therapy for liver metastases from colorectal cancer.

METHODS

Eighteen patients were allocated to hepatic artery occlusion for 16 h followed by intraportal 5-fluorouracil (5-Fu) infusion (1000 mg/m(2)) for 5 days every sixth week (HAO). Twenty-one patients received intra-arterial 5-Fu infusion+Leucovorin (100 mg) i.v. for 2 days every second week (HAI). The follow up every third month included CT and CEA. Thirteen patients had limited extrahepatic cancer. At tumor progression regional therapy was stopped and systemic chemotherapy or the best supportive care was administered.

RESULTS

The study was discontinued after randomization of 39 patients. No significant difference in survival within patients with and without extrahepatic cancer was present. The mean survival was longer in the HAI group than for the HAO group (19 months versus 13 months, p=0.0147) (median 18 (8-37) versus 12 (2-26). PR and SD were registered in 8/18 in the HAO group and 17/21 patients in HAI group. The median time to progress was 4 (1-22) months versus 7 (1-23) months for the HAO and HAI group, respectively.

CONCLUSION

Regional intraarterial infusion with 5-Fu gives significantly better survival than hepatic artery occlusion followed by portal infusion. A limited amount of extrahepatic cancer does not influence survival time. A trial comparing hepatic artery 5-FU infusion and Leucovorin versus the most effective systemic therapy is warranted.

Locoregional strategies for colorectal hepatic metastases

Hepatic colorectal metastases present a challenging problem in patients with recurrent colorectal cancer. Twenty percent of patients with recurrence will have liver metastases as a component of their disease, and only 10% of these patients will have isolated liver metastases that are resectable. Although systemic chemotherapy alone has not proven efficacious in the treatment of liver metastases, a number of options exist in managing these lesions. For those that are resectable, surgery remains the optimal treatment, with an expected 5-year survival rate of 33%-39% based on several large series. Hepatic artery chemotherapy is another adjunct treatment in patients undergoing resection and may further improve survival. This benefit may be even more pronounced when combined with systemic chemotherapy. Newer-generation agents are likely to further improve results. More recently, new therapeutic modalities have been used to treat unresectable lesions. These include hepatic artery chemotherapy and ablative techniques such as radiofrequency ablation and cryoablation. This article will highlight the data regarding hepatic resection for colorectal metastases, describe the rationale for and efficacy of hepatic arterial chemotherapy in the postoperative adjuvant setting and in unresectable liver disease, and review the current literature describing ablative techniques in the treatment of liver metastases.

Withdrawal of implanted port-catheter for hepatic arterial infusion chemotherapy with fixed catheter tip technique

The purpose of the present study is to evaluate the feasibility of a method developed to withdraw a port-catheter system that had been implanted with use of the fixed catheter tip technique. Withdrawal of an implanted catheter was required in four patients with advanced liver cancer in whom port-catheter systems had been implanted for performance of repeated hepatic arterial infusion. In all patients, port-catheter systems were successfully removed without complications. In conclusion, an implanted port-catheter system can be removed even when implanted with the fixed catheter tip technique.

Cost-effectiveness of hepatic metastasectomy in patients with metastatic colorectal carcinoma: a state-transition Monte Carlo decision analysis

OBJECTIVE

To evaluate the cost-effectiveness of hepatic resection ("metastasectomy") in patients with metachronous liver metastases from colorectal carcinoma (CRC), and to investigate the impact of operative and follow-up strategies on outcomes, cost, and cost-effectiveness.

SUMMARY BACKGROUND DATA

There is substantial evidence that resection of CRC liver metastases can result in long-term survival in some patients. However, several unresolved issues are difficult to address using currently available clinical data. These include the appropriate threshold for resection, whether to perform repeat resection, and the relative cost-effectiveness of the procedure(s).

METHODS

The authors developed a state-transition Monte Carlo decision model to evaluate the (societal) cost-effectiveness of hepatic metastasectomy in patients with metachronous CRC liver metastases. The model tracks the presence, number, size, location, growth, detection, and removal of up to 15 individual metastases in each patient. Survival, quality of life, and cost are predicted on the basis of disease extent. Imaging and surgery affect outcomes via detection and removal of individual metastases. Several patient management strategies were developed and compared with respect to cost, effectiveness, and incremental cost-effectiveness ($/quality-adjusted life year [QALY]). A reference strategy in which metastasectomy is not offered and imaging is not performed for the purpose of assessing resectability or operative planning ("no-surgery" strategy) was included for comparison. Extensive sensitivity analysis was performed to evaluate the impact of alternative model assumptions on results.

RESULTS

A strategy permitting resection of up to six metastases and one repeat resection, with CT follow-up every 6 months, resulted in a gain of 2.63 QALYs relative to the no-test/no-treat strategy, at an incremental cost of 18,100 US dollars/QALY. When additional surgical strategies were considered, the incremental cost-effectiveness ratio (ICER; relative to the next least effective strategy) of the six metastases, one repeat, 6-month strategy was 31,700 US dollars/QALY. Across a range of model assumptions, more aggressive treatment strategies (i.e., resection of more metastases, resection of recurrent metastases) were superior to less aggressive strategies and had ICERs below 35,000 US dollars/QALY. Findings were insensitive to changes in most model parameters but somewhat sensitive to changes in surgery and treatment costs.

CONCLUSIONS

Hepatic metastasectomy is a cost-effective option for selected patients with metachronous CRC metastases limited to the liver. When considering metastasectomy, more aggressive approaches are generally preferred to less aggressive approaches. Overall, surgeons should be encouraged to consider resection for all patients whose metastases can technically be removed.

EORTC Early Clinical Studies Group early phase II trial of S-1 in patients with advanced or metastatic colorectal cancer

Cancer of the colon and rectum is one of the most frequent malignancies both in the US and Europe. Standard palliative therapy is based on 5-fluorouracil/folinic acid combinations, with or without oxaliplatin or irinotecan, given intravenously. Oral medication has the advantage of greater patient convenience and acceptance and potential cost savings. S-1 is a new oral fluorinated pyrimidine derivative. In a nonrandomized phase II study, patients with advanced/metastatic colorectal cancer were treated with S-1 at 40 mg m-2 b.i.d. for 28 consecutive days, repeated every 5 weeks, but by amendment the dose was reduced to 35 mg m-2 during the study because of a higher than expected number of severe adverse drug reactions. In total 47 patients with colorectal cancer were included. In the 37 evaluable patients there were nine partial responses (24%), 17 stable diseases (46%) and 11 patients had progressive disease (30%). Diarrhoea occurred frequently and was often severe: in the 40 and 35 mg m-2 group, respectively, 38 and 35% of the patients experienced grade 3-4 diarrhoea. The other toxicities were limited and manageable. S-1 is active in advanced colorectal cancer, but in order to establish a safer dose the drug should be subject to further investigations.

Improvement of carcinoembryonic antigen-specific prodrug gene therapy for experimental colon cancer

BACKGROUND

Improvement of tumor-specific gene expression is very important for achieving successful effects in prodrug gene therapy for advanced cancer with metastatic lesions. We used the Cre/loxP system for enhancing carcinoembryonic antigen (CEA)-specific prodrug gene therapy of cytosine (CD)/5-fluorocytosine (5-FC) for the treatment of a colon cancer model accompanied with liver metastases.

METHODS

Orthotopic colon cancer models were developed. Seven days later, adenovirus vector (3 x 10(9) pfu)was injected into the abdominal cavity, and 5-FC was administered for the next 10 days.

RESULTS

In these models, the double administration of AxCEANCre expressing Cre recombinase under the control of the CEA promoter, and AxCALNLCD expressing the CD gene under the control of the CAG promoter by the Cre-mediated switching system, completely inhibited liver metastases, and significantly reduced primary tumor volume compared to the administration of Mock or AxCEACD (P <.001). The survival periods of the mice treated with AxCEANCre and AxCALNLCD were longer than mice treated with Mock or AxCEACD, and longer than the mice treated with AxCACD (P <.05).

CONCLUSIONS

The enhanced CEA-specific prodrug gene therapy using the Cre/loxP system was useful for the treatment of advanced colon cancer with liver metastases, implicating clinical application.

Interstitial ablative techniques for hepatic tumours

BACKGROUND

Most patients with liver tumours are not suitable for surgery but interstitial ablative techniques may control disease progression and improve survival rates.

METHODS

A review was undertaken using Medline of all reported studies of cryoablation, radiofrequency ablation, microwave ablation, interstitial laser photocoagulation, high-intensity focused ultrasound and ethanol ablation of primary liver tumours and hepatic metastases.

RESULTS

Although there are no randomized clinical trials, cryoablation, thermal ablation and ethanol ablation have all been shown to be associated with improved palliation in patients with primary and secondary liver cancer. The techniques can be undertaken safely with minimal morbidity and mortality.

CONCLUSION

Although surgical resection remains the first line of treatment for selected patients with primary and secondary liver malignancies, interstitial ablative techniques are promising therapies for patients not suitable for hepatic resection or as an adjunct to liver surgery.

Quality of life in patients with colorectal metastasis and intrahepatic chemotherapy

BACKGROUND

Liver metastasis from colorectal cancer remains an oncological challenge. Hepatic chemotherapy has been used; however, rigorous quality of life (QOL) measurements are lacking. The aim of this study was to describe unique QOL issues to formulate a specific tool for this population.

METHODS

A purposive sample was identified of patients treated with intrahepatic chemotherapy. Consenting patients completed a demographic tool and the City of Hope QOL Scale/Cancer Patient survey. An in-depth interview on QOL concerns was conducted, taped, and transcribed verbatim. The data from the interviews were coded to identify recurrent themes.

RESULTS

Sixteen patients participated. Physical well-being was maintained. Significantly lower subscale scores were noted for psychological, social, and spiritual domains compared with nonpatient norms (City of Hope volunteers; n = 169). Patients found intrahepatic chemotherapy convenient but were unable to pursue vigorous activity, and their sleep habits changed. Psychologically, patients felt reassured to receive specific therapy to their liver.

CONCLUSIONS

Pilot evaluation of QOL in this population revealed changes in physical, psychological, social, and spiritual dimensions. Both disease- and treatment-specific concerns were identified, and the results provide evidence for items to include in a QOL questionnaire specific to this population.

Current treatment for liver metastases from colorectal cancer

The liver is the commonest site of distant metastasis of colorectal cancer and nearly half of the patients with colorectal cancer ultimately develop liver involved during the course of their diseases. Surgery is the only therapy that offers the possibility of cure for patients with hepatic metastatic diseases. Five-year survival rates after resection of all detectable liver metastases can be up to 40%. Unfortunately, only 25% of patients with colorectal liver metastases are candidates for liver resection, while the others are not amenable to surgical resection. Regional therapies such as radiofrequency ablation and cryotherapy may be offered to patients with isolated unresectable metastases but no extrahepatic diseases. Hepatic artery catheter chemotherapy and chemoembolization and portal vein embolization are often used for the patients with extensive liver metastases but without extrahepatic diseases, which are not suitable for regional ablation. For the patients with metastatic colorectal cancer beyond the liver, systemic chemotherapy is a more appropriate choice. Immunotherapy is also a good option when other therapies are used in combination to enhance the efficacy. Selective internal radiation therapy is a new radiation method which can be used in patients given other routine therapies without effects.

Colorectal cancer in 2003: old principles, new strategies

In the last two decades the prognosis of colorectal cancer has improved for two reasons: (i) the proportion of patients with localized disease has increased and treatment has been standardized, and (ii) new chemotherapeutic agents have led to a longer life expectancy for patients with advanced disease. In this review the current insights in disease etiology and treatment of localized and disseminated colorectal cancer are discussed.

Intrahepatic arterial versus intravenous fluorouracil and folinic acid for colorectal cancer liver metastases: a multicentre randomised trial

BACKGROUND

The liver is the most frequent site for metastases of colorectal cancer, which is the second largest contributor to cancer deaths in Europe. We did a randomised trial to compare an intrahepatic arterial (IHA) fluorouracil and folinic acid regimen with the standard intravenous de Gramont fluorouracil and folinic acid regimen for patients with adenocarcinoma of the colon or rectum, with metastases confined to the liver.

METHODS

We randomly allocated 290 patients from 16 centres to receive either intravenous chemotherapy (folinic acid 200 mg/m2, fluorouracil bolus 400 mg2 and 22-h infusion 600 mg/m2, day 1 and 2, repeated every 14 days), or IHA chemotherapy designed to be equitoxic (folinic acid 200 mg/m2, fluorouracil 400 mg/m2 over 15 mins and 22-h infusion 1600 mg/m2, day 1 and 2, repeated every 14 days). The primary endpoint was overall survival, and analysis was by intention to treat.

FINDINGS

50 (37%) patients allocated to IHA did not start their treatment, and another 39 (29%) had to stop before receiving six cycles of treatment because of catheter failure. The IHA group received a median of two cycles (0-6), compared with 8.5 (6-12) for the intravenous group. 45 (51%) IHA patients who did not start or did not receive six cycles switched to intravenous treatment. In both groups, grade 3 or 4 toxicity was uncommon. Median overall survival was 14.7 months for the IHA group and 14.8 months for the intravenous group (hazard ratio 1.04 [95% CI 0.80-1.33], log-rank test p=0.79). Similarly, there was no significant difference in progression-free survival.

INTERPRETATION

Our results showed no evidence of an advantage in progression-free survival or overall survival for the IHA group; thus continued use of this regimen cannot be recommended outside of a clinical trial.

Quality of life in patients with advanced colorectal cancer: what has been learnt?

Accurate assessment of health-related quality of life (HRQoL) in patients with advanced colorectal cancer is essential to improve our understanding of how cancer and chemotherapy influence patients' life and to adapt treatment strategies. Specific questionnaires have descriptive and predictive value and can be used to evaluate new therapies. Results from HRQoL assessments in randomised trials help patients and physicians to choose between treatment options. More than half of the patients treated with palliative chemotherapy have an improvement or at least a preservation of their HRQoL. However, several trials have found small differences in HRQoL between treatment groups. This may be due to the insufficient sensitivity of tools, low numbers of patients or missing data. An international consensus on the methods of measurement of HRQoL in oncology is warranted to enhance compliance, to better interpret results and to optimise the publication of precise HRQoL data.

Technical complications of continuous intra-arterial chemotherapy with 5-fluorodeoxyuridine and 5-fluorouracil for colorectal liver metastases

BACKGROUND

Intra-arterial chemotherapy is an effective modality to treat unresectable hepatic metastases from colorectal primaries if systemic chemotherapy has failed. Response rates of more than 40% and a median survival of 15 to 25 months have been reported from randomized trials. In this retrospective study, we analyzed specific technical complications associated with continuous intra-arterial chemotherapy for colorectal liver metastases.

METHODS

From 1982 to 1995, single-center clinical data from 180 patients with colorectal liver metastases were evaluated. Continuous intra-arterial chemotherapy was administered using either an implanted infusion pump or an intra-arterial port with an external infusion pump. The intra-arterial catheter was implanted according to the Watkins' technique. The treatment protocols consisted of 5-fluorouracil- or 5-fluorodeoxyuridine-based regimens.

RESULTS

A total of 70 patients (39%) received an intra-arterial infusion pump and 110 patients (61%) an intra-arterial port. Sixty-eight technical complications affected port systems (62%), whereas 29 patients with pumps (41%) were affected by technical complications. Therapy-relevant complications were observed in 47% of the ports and 30% of the infusion pumps. The median complication-free survival was 12.2 months for infusion pumps and 7.3 months for ports (P =.0016).

CONCLUSIONS

Our data demonstrate that pumps are superior to ports in terms of complication rate and complication-free survival. On the basis of our results, pumps have a potential for a longer treatment, which may result in a prolonged median survival.

Arterial chemotherapy as adjuvant and palliative treatment of hepatic colorectal metastases: an update

Regional hepatic chemotherapy with FUDR significantly improves local recurrence rates and may impact overall survival in patients with hepatic colorectal metastases. The results of prospective randomized trials confirm that careful patient selection, a thorough knowledge of intricate hepatic arterial anatomy, and an understanding of the pharmacokinetics and delivery of FUDR optimize treatment efficacy. A multimodality approach that includes adjuvant therapy in addition to cytoreductive surgery offers promise for the treatment of unresectable hepatic metastases. Because many tumors recur in extrahepatic sites, the addition of novel systemic agents such as CPT-11 may further reduce recurrences. Molecular analysis of the tumor may ultimately help select patients who are good candidates for regional chemotherapy.

Radiologic placement of side-hole catheter with tip fixation for hepatic arterial infusion chemotherapy

PURPOSE

To investigate the technical outcome of radiologic catheter placement with use of a side-hole catheter with distal fixation for hepatic arterial infusion chemotherapy.

MATERIALS AND METHODS

Between January 1993 and September 1999, 426 patients were referred to our department to undergo intraarterial infusion chemotherapy for unresectable malignant liver tumors. A subclavian artery was exposed under local anesthesia and a catheter was inserted. After inserting the tip of the side-hole catheter into the gastroduodenal artery, splenic artery, or peripheral branch of the hepatic artery, the catheter tip was fixed to the vessel with use of coils and a mixture of n-butyl cyanoacrylate (NBCA) and iodized oil. The proximal end of the catheter was connected to an implanted port, and the port system was embedded subcutaneously.

RESULTS

Placement was successful in 425 of 426 patients (99.8%) in a mean time of 76 minutes. Catheter dislodgement was noted in 12 patients (2.8%). Cumulative patency rates of the hepatic artery calculated according to the Kaplan-Meier method for the entire group were 91.0%, 81.4%, and 58.1% at 6 months and 1 and 2 years, respectively. Complications related to catheter placement were observed in nine cases and included dysfunction of the implanted system (n = 3), significant bleeding around the implanted port (n = 2), improper infusion of NBCA and iodized oil (n = 2), and cerebral infarction (n = 2).

CONCLUSION

Radiologic catheter placement via a subclavian artery with side-hole catheter placement with distal fixation for hepatic arterial infusion chemotherapy is a highly successful procedure with a reduced risk of catheter dislodgment and arterial occlusion.

Management of colorectal liver metastases

Hepatic metastases occur in 60% of patients following resection for colorectal cancer. Liver resection is the only curative option, with one third of resected patients alive at five years. In those developing recurrence in the liver following resection, further liver surgery may be curative, with similar 5 years survival rates of about 30%. Until recently surgery was feasible in only 15-25% of patients with colorectal liver metastases. New strategies, such as downstaging chemotherapy, portal vein embolization and two-stage hepatectomy, may increase the resectability rate by 15%. Earlier detection of liver metastases would increase resectability, although good follow-up trials are lacking. Once suspected, colorectal liver metastases are staged by spiral CT, CT portography and MRI, which have similar overall accuracies. Mortality following liver resection is less than 5% in major centres, with a morbidity rate of 20% to 50%. Prognostic scoring systems can be used to predict the likely cure rate with resection. Pulmonary metastases occur in 10-25% of patients with resected colorectal cancer, but are limited to the lung in only 2% of cases. In these selected cases surgery provides long-term survival in 20-40%, and repeat lung resection has shown similar rates. For patients with unresectable disease, chemotherapy and ablation techniques have been demonstrated to prolong survival, although chemotherapy alone has been shown to improve quality of life.

Chemotherapy options for metastatic colorectal carcinoma: First, second, third line

For almost 40 years, the only option for patients with unresectable metastases was treatment with 5-fluorouracil. In the last decade, new drugs became available that changed attitude toward treatment of metastatic CRC as well as the prognosis for some patients although the "story" of 5-FU is not finished yet. Irinotecan, oxaliplatin and oral fluoropyrimidines produces higher response rates, longer symptom control and longer survival for the majority of the patients with unresectable metastases. Neoadjuvant chemotherapy is particularly interesting, because according to the results of some studies, it actually allows curative resections of previously unresectable liver metastases. This paper deals with the current status of chemotherapy of metastatic CRC, and some dilemmas about that issue. Also, we report results of third line chemotherapy of metastatic CRC patients treated at the Institute for Oncology and radiology of Serbia (IORS).

Using n-butyl cyanoacrylate and the fixed-catheter-tip technique in percutaneous implantation of a port-catheter system in patients undergoing repeated hepatic arterial chemotherapy

OBJECTIVE

The purpose of our study was to evaluate the usefulness of adding n-butyl cyanoacrylate to microcoils to fix the catheter tip in percutaneous implantation of a port-catheter system for hepatic arterial-infusion chemotherapy.

SUBJECTS AND METHODS

Ninety-three patients (64 men and 29 women; age range, 38-83 years; mean age, 62.2 years) with unresectable advanced liver cancer underwent percutaneous implantation of a port-catheter system with the catheter tip fixed at the gastroduodenal artery with microcoils and a mixture of n-butyl cyanoacrylate and iodized oil. The rates of successful implantation and complications closely associated with this technique and management of the complications were reviewed.

RESULTS

Percutaneous port-catheter placement was successfully performed in all patients. However, in eight patients, complications occurred: hepatic arterial obstruction (n = 5, 5.4%); catheter dislocation (n = 2, 2.2%); recanalization of the gastroduodenal artery (n = 1, 1.1%); or movement of n-butyl cyanoacrylate (n = 1, 1.1%). In five of the eight patients with complications, hepatic arterial-infusion chemotherapy was continued either after observation of the patient to ensure that stability had been established or after treatment using comparatively easy interventional techniques. In three (3.2%) of the 93 patients, planned hepatic arterial-infusion chemotherapy could not be performed because of complications associated with the technique.

CONCLUSION

Fixation of the catheter tip in the gastroduodenal artery using a combination of microcoils and a mixture of n-butyl cyanoacrylate and iodized oil is a useful and safe technique in percutaneous port-catheter placement for repeated hepatic arterial infusion chemotherapy.

Embolization of the right gastric artery before hepatic arterial infusion chemotherapy to prevent gastric mucosal lesions: approach through the hepatic artery versus the left gastric artery

OBJECTIVE

The purpose of our study was to evaluate whether the hepatic artery or the left gastric artery is the better route of approach for selective embolization of the right gastric artery before hepatic arterial infusion chemotherapy using a port-catheter system.

SUBJECTS AND METHODS

Eighty-six patients (56 men, 30 women; mean age, 62.1 years) with unresectable advanced liver cancer underwent percutaneous implantation of a port-catheter system. In the 75 patients who had not undergone gastrectomy, right gastric artery embolization was performed before port-catheter system placement to prevent gastric mucosal lesions. In 43 patients, the approach for embolization was through a microcatheter inserted from the hepatic artery site, and in the remaining 32 patients, the approach was from the left gastric artery. The success rates of these two groups were compared.

RESULTS

Embolization was successfully accomplished at the first attempt in 72.1% of the 43 patients in whom the microcatheter was inserted from the hepatic artery site. In contrast, in 93.8% of 32 patients, embolization was successfully performed through the left gastric artery. The success rate of embolization was significantly higher in the latter group (p = 0.0173, chi-square test). A second attempt in which the catheter was redirected to another approach, performed on the same day in a majority of patients, resulted in successful embolization in an additional eight patients, with a final success rate of 92.0%.

CONCLUSION

Embolization of the right gastric artery using microcoils through a microcatheter advanced through the left gastric artery may be the preferred method for the preparation of repeated hepatic artery infusion.

Laparoscopic placement of hepatic artery catheter for regional chemotherapy infusion: technique, benefits, and complications

Approximately 15% to 18% of patients diagnosed with colorectal cancers present with metastases confined to the liver. Although many may undergo a liver resection procedure, some will not be candidates for surgery or will have recurrence of liver disease within the first 2 years after liver metastasis resection. For this subset of patients, regional hepatic chemotherapy, including intra-arterial chemotherapy, has been shown to improve control of the disease and, in some cases, prolong survival. With the advent of laparoscopic surgery and its application to more and more advanced procedures, the possibility of laparoscopic placement of a chemotherapy infusion catheter in the hepatic artery with all the advantages of a minimally invasive approach appears to be a viable alternative in our hands. From November 1993 through February 2002, 20 patients (12 male, 8 female) successfully underwent laparoscopic placement of a hepatic artery infusion catheter at the Texas Endosurgery Institute. Correct placement of the catheter was confirmed by methylene blue injections via the hepatic artery catheter at the time of surgery. Chemotherapy was generally initiated in the immediate postoperative period. Mean age was 68.3 years (range, 46-82). Twelve of the patients (60%) had previously undergone abdominal surgery. There were 27 major laparoscopic procedures performed at the time of hepatic artery catheter placement. There were no conversions to an open procedure. Mean operative time was 186 minutes (range, 125-280), and mean blood loss was 132 mL (range, 20-300). These values include the 27 major concurrent laparoscopic procedures performed at the time of catheter placement, including 18 cholecystectomies, 7 colectomies, and 2 liver resections. Median hospital stay was 3 days (range, 3-25), with a median return to regular diet of 3 days. There were no intraoperative complications and no deaths secondary to catheter placement. There were 2 late complications, for an overall rate of 10%. For all 17 patients with residual hepatic disease whose chemotherapy was successfully instituted, regression of the metastases was evident by abdominal computed tomographic criteria and CEA levels. Laparoscopic hepatic artery catheterization is both feasible and safe. It incurs all the benefits of a minimally invasive procedure and can be performed at the time of laparoscopic colectomy to avoid the necessity of a second procedure.

Hepatic artery chemotherapy for colorectal liver metastases: technical considerations and review of clinical trials

Hepatic artery infusion (HAI) of chemotherapeutic agents for colorectal hepatic metastases is associated with significantly higher response rates compared to systemic chemotherapy. However, response rates have not consistently translated into improved survival. Several randomized trials have evaluated the implantable pump for treating unresectable colorectal hepatic metastases. Meta-analysis of these studies have demonstrated an improved survival advantage with pump therapy as well as improved quality of life. Recent studies of HAI of chemotherapy as adjuvant therapy following liver metastases resection have also demonstrated a potential survival advantage. Toxicities of HAI can be treatment limiting, but measures have emerged for overcoming these side effects. These randomized clinical trials have established HAI as a reasonable therapeutic option in patients with unresectable disease, and as adjuvant therapy in patients with resectable disease.

Evaluation of aggressively treated patients with unresectable multiple liver metastases from colorectal cancer

PURPOSE

The aim of this study was to assess the value of aggressively treating patients with unresectable liver metastases from colorectal cancer and a poor prognosis.

METHODS

From 1988 to 1999, 64 patients with unresectable multiple liver metastases from colorectal cancer who had received hepatic arterial infusion chemotherapy were investigated. All patients did not have synchronous extrahepatic metastases at the time of initiating our treatment. When liver metastases were suitable for resection after hepatic arterial infusion chemotherapy, we excised them and repeated prophylactic hepatic arterial infusion chemotherapy as long as possible. We evaluated the efficacy of hepatic arterial infusion chemotherapy by computed tomography and divided these patients into responders and nonresponders. We performed univariate analysis using the log-rank test to calculate predictive factors. In addition, the Cox proportional hazards model was used to perform multivariate analysis of factors related to survival.

RESULTS

The survival rate of all patients was 67.8 percent after 1 year and 10 percent after 5 years. However, the survival rate for 16 patients who received hepatectomy after hepatic arterial infusion chemotherapy was 35.1 percent after five years. Multivariate analysis demonstrated that the response after hepatic arterial infusion chemotherapy was the most indicative prognostic factor.

CONCLUSIONS

The prognosis of selected patients who responded to hepatic arterial infusion chemotherapy and received hepatectomy was improved. Applying aggressive treatment as outlined in our strategy may improve the chances of long-term survival.

Brain infarction after percutaneous implantation of port-catheter system via the left subclavian artery

The aim of this study was to evaluate the incidence of brain infarction after percutaneous implantation of a port-catheter system via the left subclavian artery for hepatic arterial infusion chemotherapy. In 90 patients with inoperable liver cancer, a port-catheter system was implanted via the left subclavian artery. In 5 patients (5.6%) brain infarction occurred after port-catheter implantation. In one patient (1.1%) thrombi formed around the catheter, as confirmed by autopsy. The risk of brain infarction should be taken into consideration when a trans-left subclavian arterial access route is used for the percutaneous implantation of a port-catheter system for hepatic arterial infusion chemotherapy.

Temporary unilateral microembolization of the lung-a new approach to regional chemotherapy for pulmonary metastases

BACKGROUND

Except in patients with resectable disease, treatment of pulmonary metastases is still disappointing. Regional chemotherapy may be a suitable method for delivering more effective doses to regionally confined tumors while minimizing systemic toxicity. We propose an unilateral chemoembolization of the lung applicable by endovascular method.

MATERIALS AND METHODS

An unilateral microembolization of the lung with degradable starch microspheres (DSM) alone (group 1) and combined with carboplatin (group 2) was performed on Sprague-Dawley rats (n = 12). Microcirculatory parameters were studied by in vivo videomicroscopy and radiological pattern on pulmonary angiogram.

RESULTS

After injection of DSM, mean embolization time in subpleural capillaries was 7.1 +/- 2.3 min, followed by a mean flow retardation of 14.3 +/- 4.6 min; 21.4 +/- 4.7 min after embolization, original flow of erythrocytes was observed demonstrating reperfusion and reversibility of microembolization. After reperfusion relative fluorescence measured in subpleural alveoli was 0.13 +/- 0.049 in group 1, 0.105 +/- 0.016 in group 2, and 0.11 +/- 0.036 in control group (NS). Alveolar septal diameter was 17.3 +/- 1.13 microm in group 1, 16.8 +/- 1.25 microm in group 2, and 16.6 +/- 1.08 microm in control group (NS), demonstrating neither altered permeability nor pulmonary edema. Pulmonary angiogram confirmed patency of the central pulmonary artery.

CONCLUSION

For the first time unilateral microembolization of the lung could be established in an experimental model. By injection of DSM, reversible embolization on arteriolar and capillary level could be demonstrated without occlusion of the main branches of the pulmonary arteries. Alveolar-capillary membrane disorder as symptom of early toxicity could not be detected even with additional application of carboplatin.

Arterial chemotherapy of 5-fluorouracil and mitomycin C in the treatment of liver metastases of colorectal cancer

AIM: Regional chemotherapy using hepatic artery catheters is a good method of treating patients with colorectal cancer liver metastases. We investigated the survival of patients with liver metastases from colorectal cancer using 5-fluorouracil (5-FU) and mitomycin C Cthrough implantable hepatic arterial infusion port.

METHODS: Seventy-five patients with inoperable liver metastases from colorectal cancer were included between March, 1992 and November, 2001. We placed implantable hepatic arterial catheter (HAC) port by laparotomy.5-FU, 1000 mg/m²/d continuous infusion for five days every four weeks, was delivered in the hepatic arterial catheter through the port. Mitomycin C, 30 mg/m²/d infusion in the first day every cycle through the port. Response to the treatment was evaluated by serial determinations of plasma CEA and imaging techniques consisting of computerized tomography and sonography of liver.

RESULTS: Sixty-eight were performed hepatic artery chemotherapy and fifty-six were followed up among seventy-five HAC patients. Twenty-six patients (46.4%) have responded and 4 complete remission were achieved. Eight patients (14.3%) had stable liver metastases. Twenty-two patients (39.3%) were progressed with increased tumor size and number. Twenty-nine patients (51.8%) had a decreased serum CEA level, while 10 patients (17.9%) were stable and 17 patients (30.4%) had an increased serum CEA level. There were no operative death in this series. Complications, which occurred in 18 patients (32.1%), were as followed: hepatic artery thrombosis in 11, Upper gastric and intestinal bleeding in 3, liver abscess in 1, pocket infection in 1, cholangitis in 1, and hepatic artery pseudo-aneurysm in one patient.

CONCLUSION: Combined infusion of 5-FU and mitomycin C by hepatic artery catheter port is an effective treatment for liver metastases from colorectal cancer. The high response and lower complication rates prove the adjuvant treatment of colorectal cancer with this treatment.

[Measure of quality of life in patients with metastatic colorectal cancer: techniques and main results]

PURPOSE

Until the 1990s, the patient's duration of life was the main measure for determining the value of palliative chemotherapy for colorectal cancer. Quality of life recently appeared as a main end point. The aim of this article is to provide an overview of the instruments used to measure quality of life in patients with metastatic colorectal cancer, to review the published data and to analyse the bias and methodological problems.

CURRENT KNOWLEDGE AND KEY POINTS

QoL is a multidimensional subjective concept, which can be measured using psychometric instruments. Quality of life measurement has a descriptive and prognostic value. Results from quality of life assessment in randomized trials have given useful information and help patients and physicians to choose between treatment options. More than half of the patients with palliative chemotherapy had at least stabilization of quality of life. Response to chemotherapy and side-effects influence quality of life. Quality of life assessment clearly requires methodological improvement. Missing data are a particularly difficult problem, which should be improved by a better organization.

FUTURE PROSPECTS AND PROJECTS

Psychometric properties of EORTC QLQ-CR38 et FACT-C should be checked in French language. An international consensus on methods of measurement of quality of life in oncology is warranted to enhance compliance, to better interpret quality of life results et to optimize publications of precise quality of life data.

Regional therapy of hepatic metastases

In conclusion, there are a variety of treatment approaches used by surgeons, interventional radiologists, and medical oncologists to treat metastatic cancer distributed throughout the liver. One conclusion is that the number of different techniques suggests that no single treatment has been uniformly successful to date. A second conclusion is that the number of techniques applied argues for the importance of this as a clinical problem in oncology today. The number of patients with metastatic disease to the liver and the potential for long-term survival if that disease can be controlled will lead to further combinations and refinements of these techniques in future clinical trials.

Genetic detection of liver micrometastases that are undetectable histologically

BACKGROUND

Predicting liver metastasis from colon cancer is essential for improving its prognosis. We studied to what extent genetic detection of cancer cells in the resected liver tissue can predict the incidence of macroscopic liver metastasis with a similar mouse model to clinical colorectal cancer that causes a several decade percentage of metachronous hepatic metastases after resection of the primary lesions.

MATERIALS AND METHODS

A LS174T human colorectal cancer cell suspension was injected into the spleens of nude mice. One to 10 days after splenic injection, 3 x 3 mm of liver tissue was removed, and a splenectomy was performed. Liver tissue was used for genetic detection and histological examination. Five weeks after splenic injection, the number of macroscopic metastases on the surface of the liver was counted.

RESULTS

Eight of the 45 cases were positive for tumor cells in liver tissue genetically, while only 1 was positive for tumor cells histologically. Macroscopic liver metastases were seen 5 weeks after splenic injection in 11 of 37 (29.7%) cases negative for tumor cells genetically and in 8 of 8 (100%) cases positive for tumor cells genetically. Five or more metastases were seen in 3 of 37 (8.1%) cases negative for tumor cells genetically and in 7 of 8 (87.5%) cases positive for tumor cells genetically.

CONCLUSIONS

The cases which were positive for tumor cells in liver tissue genetically at the time of splenectomy had more significantly macroscopic liver metastases some weeks later than the cases negative for tumor cells. This study suggests that if micrometastasis was detected genetically, the development of metachronous macroscopic liver metastasis could be predicted.

Raltitrexed in the treatment of elderly patients with advanced colorectal cancer: an active and low toxicity regimen

In spite of the high prevalence of advanced colorectal cancer in the elderly, we have little data on the efficacy and toxicity of chemotherapy in this age group. Raltitrexed is a thymidylate synthetase inhibitor with known activity in the treatment of advanced colorectal cancer. The objective of this study was to analyse the efficacy and tolerance of raltitrexed in elderly patients with advanced colorectal cancer. 92 patients diagnosed with advanced colorectal cancer aged >or=70 years were entered into the study. Raltitrexed was given at a dose of 3 mg/m(2) once every 3 weeks for a minimum of three cycles. A total of 511 cycles were given with a median of five cycles per patient. 20 out of the 90 patients evaluable for response achieved a partial response (PR) (22%, 95% Confidence Interval (CI): 17-36%), 43 (48%) remained stable and 27 showed progression (30%). The mean duration of response was 24 weeks and the progression-free interval was 15 weeks. The overall median survival was 41 weeks. 31 patients (39%, 95% CI: 28-50%) experienced a clinical benefit (improvement of the performance status without a worsening of symptoms or relief of symptoms without a worsening of the performance status). The main toxicities were gastrointestinal and haematological. 12 patients (13%) developed grade 3-4 side-effects: 7 had nausea/vomiting (8%), 6 a transaminase increase (7%), 4 asthenia (4%), 3 diarrhoea (3%), 2 neutropenia (2%), 2 anaemia (2%) and 1 thrombocytopenia (1%). Three toxic deaths occurred (3%). The group of patients with a creatinine clearance <or=1.08 ml/s was found to have a higher risk of developing grade 3-4 toxicity compared with those with adequate renal function (8/18 versus 4/72; P<0.001). In conclusion, raltitrexed is an active, convenient and low toxicity treatment for the elderly with advanced colorectal cancer. However, it must be used cautiously in elderly patients with a creatinine clearance <or=1.08 ml/s since they are at a higher risk of suffering grade 3-4 toxicity.