Hepatic artery catheterization for chemotherapy

Ambulatory hepatic artery infusion chemotherapy for cancer of the liver

We have used continuous hepatic arterial infusion chemotherapy to treat 105 patients with cancer of the liver originating from colorectal, other gastrointestinal, and nongastrointestinal sites. The response rate seen in colorectal metastases was two to three times that expected for systemic chemotherapy. The median survival of responders of 16 months was significantly better then for nonresponders (6 months). The median duration of response was 9 months. The results for patients with other tumor types were less encouraging. Although minor problems developed in about 30 percent of the patients, major complications requiring removal of the catheter were not common. Expertise derived from managing many patients and a team approach, with a defined protocol for catheter care and follow-up, contributed to the success of the ambulatory program. However, the role of hepatic arterial infusion chemotherapy remains under debate. At the root of the controversy is the lack of randomized, controlled trials supporting the superiority of hepatic arterial infusion over systemic chemotherapy in the treatment of colorectal liver metastases. This and other issues, including the current liberal use of implanted infusion pumps, should be studied.

Pseudoaneurysm of abdominal aorta: a complication of intrahepatic arterial infusion therapy

Arterial perforation by an indwelling intrahepatic catheter for infusion chemotherapy occurred in a 69-year-old man with liver metastases from rectal cancer. Computed tomography demonstrated a pseudoaneurysm formation and was diagnostic of the complication.

Regional management of liver metastases. I

This is the first of a two part series. In this issue, Part I presents the natural history of liver metastasis and various proposed staging systems. Indications for surgical resection, which remains the treatment of choice are reviewed. For the majority of patients with unresectable metastases of the liver, various regional treatment approaches seem to give higher response rates than systemic chemotherapy. Technical aspects and therapeutic results of infusion chemotherapy via the hepatic artery and ligation of hepatic artery alone are considered. The totally implantable pump represents and advance in long-term infusion chemotherapy.

Hepatic artery infusion with 5-fluorouracil and mitomycin-C in metastatic colorectal carcinoma phase II study

Thirty-two patients with hepatic metastases colorectal carcinoma were treated with hepatic artery infusion (HAI) employing 5-fluorouracil (5-FU) and mitomycin-C (mito-C). Catheters were placed percutaneously via the femoral artery. Two schedules were employed: (I) 5-FU 1,200 mg/m2 IA (D1-4) and mito-C 8 mg/m2 IA (D1 + D4); (2) 5-FU 1,200 mg/m2 IA (D1-6) and mito-C 8 mg/m2 IA (D1 + D4). Courses were repeated every 4 weeks. Thirty patients with measurable disease were evaluable, 22 received schedule I and 8 patients schedule II. Complete response occurred in two patients (6.7%) and partial response in 13 patients (43.3%). Five patients (16.7%) had minimal regression. The overall response rate as 66.7%. Median survival of all patients from start of treatment was 11.2 months. Median survival of responders and nonresponders was 12.4 months and 4.6 months, respectively (P less than 0.05). No differences in response rates, duration of response, or survival was seen between the two schedules. Drug toxicity was moderate to severe, but morbidity of HAI per se was minimal. Intermittent HAI of 5-FU and mito-C is a well-tolerated treatment modality associated with few serious complications. The response rate, duration of response, and the survival is comparable to continuous HAI infusion of 5-FU or floxuridine (FUDR). As given in this study, mito-C did not appear to provide added benefit.

The practicality of chronic hepatic artery infusion therapy of primary and metastatic hepatic malignancies: ten-year results of 124 patients in a prospective protocol

Ten-year results are presented of 124 patients with malignancy apparently limited to the distribution of the hepatic artery, treated to prospective protocol with continuous infusion of 5-FUdR through an hepatic artery catheter. Nearly all patients had moderate to massive hepatic replacement. Of 88 patients with colorectal carcinoma, 64 (73%) had clinically objective and subjective remission. Median survival for responders was 13 months; for the entire group, ten months. Of 13 patients with hepatoma, nine had clinically significant regression with a median survival of 11 months. Ten patients had carcinoma of the gall bladder or bile duct with seven obtaining clinically significant regression. Complications encountered are discussed and are similar to other series. Of the patients experiencing clinically significant remission, all but one reached the complete independence performance status, and 84% reached normal activity levels. Thus, for hepatic localized tumor, this therapy is worthwhile and practical.

Colorectal cancer: the modern treatment of disseminated disease - a review

Most patients who develop cancer of the large bowel will eventually develop recurrence and will therefore be considered for treatment of that recurrence. There exists very great confusion as to the efficacy of the various treatment options available. This review has attempted to evaluate critically the claim for therapeutic efficacy of the various treatment options, with particular regard to patients with liver metastases from primary tumours of the large bowel. A case can be made out for surgical removal of recurrent or disseminated colorectal cancer, but there is no evidence that any form of treatment other than total surgical excision will result in prolonged patient survival. All forms of treatment can be effective in palliating symptomatic patients. Therefore, with the exception of total surgical excision of recurrent tumour, treatment should be reserved for those patients with symptoms, and the choice of treatment offered should be weighed against possible side-effects.

Septic endarteritis due to intra-arterial catheters for cancer chemotherapy. I. Evaluation of an outbreak. II. Risk factors, clinical features and management, III. Guidelines for prevention

A cluster of three cases of staphylococcal septic endarteritis originating from percutaneously inserted brachial artery catheters for regional cancer chemotherapy prompted an epidemiologic and clinical study of bacteremic infections associated with this therapeutic modality. Nine cases were identified over a 3 1/2-year period (1.6% of all catheterizations), all caused by Staphylococcus aureus. The cluster followed discontinuation of hexachlorophene for scrub of the extremity prior to cannulation; phage-typing suggested the three cases were caused by the patients' own strains of Staphylococcus. These infections produced a distinctive clinical syndrome which facilitates implicating the catheter in the genesis of fever occurring in a patient receiving intra-arterial chemotherapy: early localized pain (89%) and hemorrhage (78%), and Osler's nodes distally (44%), later followed by local inflammation (78%), purulence (56%) and signs of systemic sepsis (100%) (each factor, p less than or equal to .005). Duration of cannulation did not influence susceptibility to infection. However, difficult cannulations or need for repositioning the catheter (p = .0096), prior radiation therapy (p = .033), leukopenia (p less than .05) and hypoalbuminemia (p less than .05) were all associated with septicemia. In the 25 months since implementation of specific control measures, there have been no further catheter-related septicemia in 310 catheterization (p less than .001). Guide-lines for prevention and management of these infections are provided.

Prolonged and continuous percutaneous intra-arterial hepatic infusion chemotherapy in advanced metastatic liver adenocarcinoma from colorectal primary

Sixty patients with advanced metastatic adenocarcinoma of the liver from a colorectal primary were treated by prolonged and continuous intra-arterial hepatic arterial infusion chemotherapy over a period of time from December 1969 through July 1976. A 10-day course of 5-FU was administered in the hospital, and patients were discharged receiving 5-FUDR by continuous arterial infusion through a chronometric infusion pump. Objective responses of 100% were obtained in 15% of patients, 50% response in 39% of patients, and 25% response in 21% of patients. The median survival from onset of treatment was 8.5 months, 6.9 months, and 7 months, respectively, for 100%, 50%, and 25% responders versus 3.6 months for nonresponders. Survivals from onset of treatment were generally less in those with no disease-free interval. No relationship of response to sex and age was found. Patients previously treated with 5-FU intravenously responded to intra-arterial chemotherapy; 13% had a 100% response, and 54% had a 50% response. No relationship of drug dose to response was observed. Drug toxicity was frequently systemic and mild to moderate. Numerous complications occurred due to the catheter, complete or partial thrombosis occurring in 18.6% and 20.8%, respectively, and 30% of patients had displacement of the catheter. The role of partial arterial occlusion in terms of response and survival may be significant. Future studies should involve comparison of direct surgical placement versus percutaneous placement of catheters.

Nonsystemic treatment of metastatic tumors of the liver--a review

Hepatic metastasis is usually quite resistant to conventional systemic chemotherapy. Nonsystemic treatment of metastatic tumors of the liver include surgical resection; infusion of chemotherapeutic agent(s), either via hepatic artery or portal vein; ligation of hepatic artery; radiotherapy; and other more investigative approaches (isolation perfusion, cryosurgery, liver transplantation, etc). The relative applicability, results, and limitations of each of these therapeutic modalities are reviewed.

Current status of regional arterial infusion chemotherapy

The rationale for this method is that a prolonged, continuous exposure of tumor cells to an antimetabolite is required for effective antimetabolic activity to develop in the tumor cell population. Overall experience in selected sites such as head and neck, liver, and extremities is reviewed.

Results of 27 cases with hepatic metastases treated by combination chemotherapy

The results of using a standard combination of cytotoxic agents in 27 cases of secondary liver cancer are reported. A brief review of the methods available for treating hepatic metastases from solid tumours, as opposed to lymphomata, is included. The response rate depends on the site of the primary lesion. It is suggested that in patients with mammary or colorectal primary tumours, combination chemotherapy represents an advance in treatment with an objective response rate of 73% and 66% respectively in the 2 groups. The method requires no specialized equipment as neither grossly deranged liver enzymes nor jaundice are contra-indications to treatment, and toxicity is easily monitored and readily controlled.

Hepatic artery occlusion following hepatic artery catheterization

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