Combined modality therapy of hepatic metastasis. Northern California Oncology Group Pilot Study

Radiotherapy of Liver Malignancies. From Whole Liver Irradiation to Stereotactic Hypofractionated Radiotherapy

Aims and background

Until recently radiotherapy of hepatic malignancies has played a limited role due to the well-known limited radiotolerance of the liver. The aim of this paper is to review the available data on the risk of radiation-induced liver disease (RILD) and to define the modern role of radiotherapy in the management of patients with metastatic or primary liver malignancies.

Methods

The advent of three-dimensional conformal treatment planning with dose-volume histogram analysis has made the study of partial liver irradiation possible. Limited portions of the liver may withstand high doses of radiation with minimal risk of RILD. Patients with solitary unresectable liver tumors may be treated with high-dose radiotherapy with curative intent. Recently, the feasibility of stereotactically guided treatment techniques with a single fraction or few treatment sessions has been explored in numerous institutions.

Results

The radiation tolerance of the whole liver found by several investigations is in the order of approximately 30 Gy, which seriously restricts its clinical application. The role of whole liver irradiation therefore appears of limited benefit in the palliation of patients with multiple liver metastases. The use of three-dimensional conformal techniques has made partial liver irradiation possible to doses in the 70–80 Gy range with conventional fractionation. At least two published series have reported improved local control and survival rates with dose escalation with three-dimensional conformal radiotherapy in patients with unresectable liver metastases. Similar outcomes have been recently reported with single dose (or hypofractionated) stereotactic radiotherapy both in metastatic and primary hepatic malignancies with minimal morbidity. Accurate target delineation and treatment reproducibility are the key to the success of this novel treatment approach, and specific treatment planning techniques and patient setup procedures must be developed to implement it.

Conclusions

Stereotactic high-dose radiotherapy is technically feasible for the treatment of inoperable liver malignancies, with the potential of high local control and low morbidity. Definitive evidence on the clinical advantages of this technique over other more established treatments can only be gathered from well-designed clinical studies.

Radiotherapy for liver metastases: a review of evidence

Over the past decade, there has been an increasing use of radiotherapy (RT) for the treatment of liver metastases. Most often, ablative doses are delivered to focal liver metastases with the goal of local control and ultimately improving survival. In contrast, low-dose whole-liver RT may be used for the palliation of symptomatic diffuse metastases. This review examines the available clinical data for both approaches. The review found that RT is effective both for local ablation of focal liver metastases and for palliation of patients with symptomatic liver metastases. However, there is a lack of a high level of evidence from randomized clinical trials.

External-beam radiotherapy in the management of liver metastases

This review discusses the importance of palliation of liver metastases. Although colorectal cancer comprises the majority of patients with metastatic liver disease, a number of other malignancies can be involved. Palliation of metastatic disease to liver has generally not included the use of external-beam radiotherapy because of restricted liver tolerance to radiotherapy. However, more recently, treatment policies have evolved to more generous use of palliative radiotherapy with utilization of tumor boost doses to partial liver volumes. This has resulted in improvement in palliation and a suggestion of improved survival with higher radiotherapy doses, which have been well tolerated by small volumes of liver.

Hepatic toxicity resulting from cancer treatment

Radiation-induced liver disease (RILD), often called radiation hepatitis, is a syndrome characterized by the development of anicteric ascites approximately 2 weeks to 4 months after hepatic irradiation. There has been a renewed interest in hepatic irradiation because of two significant advances in cancer treatment: three dimensional radiation therapy treatment planning and bone marrow transplantation using total body irradiation. RILD resulting from liver radiation can usually be distinguished clinically from that resulting from the preparative regime associated with bone marrow transplantation. However, both syndromes demonstrate the same pathological lesion: veno-occlusive disease. Recent evidence suggests that elevated transforming growth factor beta levels may play a role in the development of veno-occlusive disease. Three dimensional treatment planning offers the potential to determine the radiation dose and volume dependence of RILD, permitting the safe delivery of high doses of radiation to parts of the liver. The chief therapy for RILD is diuretics, although some advocate steroids for severe cases. The characteristics of RILD permit the development of a grading system modeled after the NCI Acute Common Toxicity Criteria, which incorporates standard criteria of hepatic dysfunction.

Bolus vs. continuous hepatic arterial infusion of cisplatin plus intravenous 5-fluorouracil chemotherapy for unresectable colorectal metastases

A multicenter, randomized Phase 2 study that compared patients, affected by colorectal liver metastases, who received intrahepatic arterial infusion with two different schedules of cisplatin, bolus vs. continuous infusion, and systemic 5-fluorouracil.

PURPOSE

The aim of this study was to validate results of a previous Phase 2 trial on bolus cisplatin intrahepatic arterial infusion, which reported a 47 percent response rate and a 32 percent 4-year survival rate for Gennari's Stage 2 patients, with a high rate of neurologic, gastrointestinal, and hematologic toxicity.

METHODS

One hundred nine patients were randomized in a Phase 2 study to receive cisplatin intrahepatic arterial infusion (24 mg/m2/day, 1-->5, bolus vs. continuous infusion) and systemic intravenous 5-fluorouracil (250, 375, or 500 mg/m2/day, 1-->5; escalating doses, respectively, at cycles I, II, III, and VI). To avoid neurotoxicity a maximum of six cycles was administered.

RESULTS

Preliminary results for the 78 evaluable patients are similar to those of the previous study: response rate 46 percent and at a median follow-up of 16.5 months, the overall survival was 16.5 months, with 45 percent of the patients who received more than 3 cycles alive at 3 years. Toxicity, evaluable in 99 patients, showed a decreased incidence of neurotoxicity and a tolerable gastrointestinal and hematologic toxicity, lower in the cisplatin continuous infusion arm.

CONCLUSION

This study clearly shows that cisplatin intrahepatic arterial infusion is able to provide a good palliative effect with a tolerable toxicity.

Accelerated hyperfractionated hepatic irradiation in the management of patients with liver metastases: results of the RTOG dose escalating protocol

PURPOSE

This study was prepared to address two objectives: (a) to determine whether progressively higher total doses of hepatic irradiation can prolong survival in a selected population of patients with liver metastases; (b) to refine existing concepts of liver tolerance for fractionated external radiation employing a fraction size which might be appropriate in clinical protocols evaluating elective or adjuvant radiation of the liver.

METHODS AND MATERIALS

One hundred seventy-three analyzable patients with computed tomography measurable liver metastases from primary cancers of the gastrointestinal tract were entered on a dose escalating protocol of twice daily hepatic irradiation employing fractions of 1.5 Gy separated by 4 hr or longer. Sequential groups of patients received 27 Gy, 30 Gy, and 33 Gy to the entire liver and were monitored for acute and late toxicities, survival, and cause of death. Dose escalation was implemented following survival of 10 patients at each dose level for a period of 6 months or longer without clinical or biochemical evidence of radiation hepatitis.

RESULTS

The use of progressively larger total doses of radiation did not prolong median survival or decrease the frequency with which liver metastases were the cause of death. None of 122 patients entered at the 27 Gy and 30 Gy dose levels revealed clinical or biochemical evidence of radiation induced liver injury. Five of 51 patients entered at the 33 Gy level revealed clinical or biochemical evidence of late liver injury with an actuarial risk of severe (Grade 3) radiation hepatitis of 10.0% (+/- 7.3% S.E.) at 6 months, resulting in closure of the study to patient entry.

CONCLUSION

The study design could not credibly establish a safe dose for hepatic irradiation, however, it did succeed in determining that 33 Gy in fractions of 1.5 Gy is unsafe, carrying a substantial risk of delayed radiation injury. The absence of apparent late liver injury at the 27 Gy and 30 Gy dose levels suggests that a prior clinical trial of adjuvant hepatic irradiation in patients with resected colon cancer may have employed an insufficient radiation dose (21 Gy) to fully test the question.

Radiation therapy in patients with unresectable hepatocellular carcinoma

From April 1978 through December 1989, a total of 17 patients with unresectable hepatocellular carcinoma (HCC) were treated with radiation therapy alone or radiation therapy in conjunction with percutaneous ethanol injection (PEI), transarterial infusion chemotherapy (TAI), or transarterial embolization (TAE) at the National Medical Center Hospital. The median survival of all patients was 13.8 months. The survival values determined at 1, 2, and 3 years were 58.8%, 26.1%, and 9.8%, respectively. Only the pretreatment liver function affected the survival value. Between patients who did not have liver cirrhosis (LC) as well as those who had LC of Child's class A and patients who had LC of Child's class B or C, the differences observed in the 1-year survival value and the median duration of survival were statistically significant (P < 0.05). The serum cholinesterase (ChE) level seemed to be a good indicator of liver function during the radiation therapy. A field size of 150 cm2 and a total dose of 5000 cGy (TDF 82) seemed to be well tolerated by patients who did not have LC and those who had LC of Child's class A. The field size determined whether patients with poor liver function such as LC of Child's class B or C would develop severe hepatic deterioration after undergoing radiation therapy.

The effect of fluorodeoxyuridine on sublethal damage repair in human colon cancer cells

Although 5-fluoro-2'-deoxyuridine (FdUrd) has been combined with hyperfractionated radiation therapy in clinical trials, the optimal method of delivering radiation therapy is not yet known. To determine the importance of the time interval between fractions on the survival of tumor cells exposed to FdUrd, we studied the effect of FdUrd on sublethal damage repair in HT29 human colon cancer cells in culture. Cells were exposed to clinically achievable concentrations of FdUrd (10-100 nM) for 14 hr followed by either single dose (8-12 Gy) or split dose (4-6 Gy x 2) external cobalt irradiation. The interval between radiation fractions was varied from 0.5 to 6 hr. FdUrd impaired sublethal damage repair in a dose dependent fashion. FdUrd had no effect on the induction of DNA double strand breaks (DSB's), but significantly reduced the rate of the repair of DNA DSB's. Exposure to 100 nM FdUrd decreased intracellular TTP pools but elevated dATP pools. These findings suggest that FdUrd may decrease sublethal damage repair by perturbing nucleotide triphosphate pools, which leads to a decrease in the ability of the cell to repair DNA DSB's. Furthermore, they suggest that hyperfractionated irradiation will be superior to once daily treatment when combined with regional delivery of FdUrd.

Treatment of cancers involving the liver and porta hepatis with external beam irradiation and intraarterial hepatic fluorodeoxyuridine

A Phase I/II clinical trial was designed for patients with malignancies of the liver and porta hepatis. This protocol employed three concepts: a) boost treatment to gross tumor within the liver for selected patients, determined by the dose-volume histogram (DVH) of the normal liver that would be irradiated by boost treatment; b) concurrent use of intraarterial hepatic 5-fluorodeoxyuridine (FdUrd) as a radiosensitizer; and c) hyperfractionation (1.5 Gy fractions given bid greater than 4 hr apart). This report describes the results of treatment of the first 33 patients entered onto this study, with a minimum follow-up of 1 year. Twenty patients received only whole liver irradiation (33 Gy). Thirteen patients were treated with whole liver irradiation (30 Gy) plus a 15 Gy (6 patients) or 30 Gy (7 patients) boost (total 45 Gy and 60 Gy to the tumor, respectively). Forty-eight percent of the evaluable patients (14/29) had an objective response, based on CT scan. The median duration of response was 8 months. The chief toxicities were fatigue, nausea, gastritis, and diarrhea, which were less than or equal to grade 2 in severity. Two patients developed mild radiation hepatitis which was treated successfully with diuretics. These data suggest that the treatment of intrahepatic malignancies can be guided by the concept of DVH analysis of the normal liver to allow the safe administration of doses of radiation that are potentially tumoricidal and are well above those that would be predicted to be tolerable for the whole liver.

The treatment of hepatic metastases from colorectal cancer with radiation therapy alone or combined with chemotherapy or misonidazole

In summary, whole liver RT alone is generally well tolerated and, in most cases, offers some palliative benefit. It is difficult to determine its ultimate impact on survival since many patients treated with this single modality have extra-hepatic disease. In addition, the dose of radiation which the liver can tolerate is not adequate to control gross disease. The addition of chemotherapy (systemic and/or intra-hepatic) appears promising. However, further follow-up and randomized trials need to be performed before this is known with certainty. The use of misonidazole in the dosages and techniques employed by the RTOG did not appear to enhance overall survival. More innovative techniques of delivering RT, including intraoperative brachytherapy, radiolabeled antibodies, and hyperfractionated external beam RT require further investigation in order to determine their efficacy.

Regional treatment of hepatic metastases and hepatocellular carcinoma

Hepatic metastases represent a common site of dissemination for a number of primary malignancies related in part to the dual blood supply, large blood flow, and receptive environment of the hepatic parenchyma. Although this review focuses on regional therapy, we have included sections on systemic therapy to better interpret the results with intrahepatic therapy. We will also discuss the efficiency of hepatic arterial ligation, embolization, and radiotherapy of hepatic metastases. Primary gastrointestinal neoplasms are particularly prone to produce hepatic metastases. Because colorectal carcinoma metastasizes to the liver in up to 70% of patients with advanced disease, the treatment of hepatic metastases is a relevant topic. We will discuss the systemic and regional therapy of colorectal, gastric, and gallbladder cancers. Breast carcinoma and malignant melanoma frequently metastasize to the liver, and we have described systemic and regional treatments of these diseases. Because sarcomas are often treated by regional therapy, we have included a section on the treatment of hepatic sarcomas. Neuroendocrine tumors (carcinoid and islet cell), although often slow growing, frequently metastasize to the liver and then cause symptomatic problems. Much of the work done with embolization and hepatic ligation in the treatment of hepatic metastases has been performed in neuroendocrine tumors, and these studies, as well as the systemic and regional chemotherapy of hepatic metastases, will be described. The last section concerns the treatment of hepatocellular carcinoma. We have outlined the staging systems used. We then detail the results of systemic and intrahepatic therapy, embolization, and hepatic ligation in the treatment of hepatocellular carcinoma. Because hepatic metastases are a frequent problem, many patients are available for clinical investigation. It is hoped that newer strategies for the treatment of liver metastases will lead to higher response rates and perhaps control of local disease. These therapeutic approaches may also give us leads to the treatment of systemic disease.

Hepatic irradiation in primary and metastatic liver cancer

Between December 1973 and September 1987, 21 patients with primary liver cancer and 41 patients with metastatic liver cancer were treated with external irradiation, intra-arterial infusion chemotherapy and/or transarterial embolization (TAE) at the National Medical Center Hospital, the National South Kyushu Central Hospital and the National Kure Hospital. Of the patients with primary liver cancer, 13 cases were treated with intra-arterial infusion chemotherapy (30-40 mg adriamycin or 10 mg mitomycin C) and hepatic irradiation. Eight cases were treated by TAE and hepatic irradiation. In the Child A group, the survival period of the chemotherapy + hepatic irradiation cases (mean: 608 days) was longer than that of the TAE + hepatic irradiation cases (mean: 216 days). The median survival period of all the cases was 7.0 months (mean: 10.9 months). For 16 of the 21 patients (who had absorbed over 40 Gy), the median survival period was 11.9 months (mean: 11.7 months). For 5 of the 21 patients (who had absorbed below 40 Gy), the median survival period was 4.3 months (mean: 7.9 months). Of the patients with metastatic liver cancer, the median survival period was 7.2 months (mean: 8.0 months). For 22 of the 41 patients (who had absorbed over 40 Gy), the median survival was 7.9 months (mean: 12.6 months). For 19 of the 41 patients (who had absorbed below 40 Gy), the median survival period was 1.7 months (mean: 2.6 months). The pretreatment serum GOT (glutamate oxaloacetate transaminase) levels and the pretreatment Karnofsky performance status index were the factors governing the prognosis of the cases with metastatic liver cancer, while toxicity was generally mild.

Phase II evaluation of sequential hepatic artery infusion of 5-fluorouracil and hepatic irradiation in metastatic colorectal carcinoma

Twenty-seven patients with measurable liver metastases from colorectal carcinoma were entered on a protocol of intermittent hepatic artery infusion (HAI) of 5-fluorouracil (5-FU) followed by consolidation with hepatic irradiation. Five partial responses were observed in 23 evaluable patients. Median duration of response was 3.5 months. A response was evident after chemotherapy alone in four of five responders. Hepatic irradiation converted one patient with stable disease after chemotherapy to a partial responder. Median survival for all patients was 9.0 months (range 1.5-34.0). Combined modality treatment with HAI of 5-FU followed hepatic irradiation was well tolerated but did not appear to be synergistic.

Chemoimmunotherapy of experimental hepatic metastases

Previous studies from our laboratory have demonstrated that particulate glucan is efficacious in the therapy of a syngeneic murine reticulum cell sarcoma (M5706), which specifically metastasizes from its primary site to the liver. The present study was undertaken to examine the therapeutic efficacy of a newly developed soluble glucan, in combination with cyclophosphamide in the treatment of hepatic metastatic disease. Male C57Bl/6J mice were injected subcutaneously on Day 0 with 1 x 10(4) sarcoma cells. Glucan (200 mg per kg i.v.), cyclophosphamide (45 mg per kg i.p.) or glucan and cyclophosphamide were administered beginning on Day 20, when hepatic metastases were evident, and continued at 3-day intervals up to Day 50. Combined therapy with glucan and cyclophosphamide resulted in reduction of hepatic metastatic lesions on Day 36, compared to control. Survival data revealed that the combination of glucan and cyclophosphamide significantly (p less than 0.001) extended median survival time and the time to 100% mortality in an additive fashion, when compared to either therapy alone. Glucan-cyclophosphamide therapy was also effective in decreasing primary tumor weight to a level that was significantly (p less than 0.05) less than when therapy was initiated. In vitro studies revealed that Kupffer cell tumoricidal activity against sarcoma was increased (p less than 0.05) following glucan and cyclophosphamide. Glucan and cyclophosphamide also enhanced bone marrow proliferation and splenocyte response to mitogens in vitro. Additionally, glucan was observed to exert a direct cytostatic effect on sarcoma in vitro.(ABSTRACT TRUNCATED AT 250 WORDS)

A comparison of misonidazole sensitized radiation therapy to radiation therapy alone for the palliation of hepatic metastases: results of a Radiation Therapy Oncology Group randomized prospective trial

Between May 1980 and July 1983, the RTOG conducted a randomized prospective study comparing external radiation therapy and misonidazole to radiation therapy alone for patients with hepatic metastases. Two hundred fourteen patients were accessioned to this study of whom 187 were evaluable. Radiation therapy was delivered to the whole liver to a dose of 21.0 Gy in 7 fractions. Misonidazole was administered orally, 1.5 gm/m2 daily 4-6 hr before each treatment. Patients in the two treatment groups were evenly distributed with respect to stratification variables including primary site, extent of metastatic disease, and Karnofsky Performance Score (KPS). End points examined included amelioration of hepatic pain, improvement of KPS and alkaline phosphatase, decrease in liver and tumor size, and survival. The addition of misonidazole did not significantly improve the therapeutic response to radiation therapy in any of the parameters studied. Hepatic irradiation was effective in relieving abdominal pain with 80% of the symptomatic patients achieving improvement following therapy. Pain was completely relieved in 54% of these patients. Patients with liver metastases from colon carcinoma improved more frequently than those with metastases from other primary tumor sites (p = 0.02). Relief of pain occurred more frequently in patients treated with radiation therapy and misonidazole (87%) compared with radiation therapy alone (74%) (p = 0.08). Palliation of pain was prompt, occurring within a median of 1.7 weeks from the initiation of treatment, and 94% of patients who improved did so within 6 weeks of treatment. The median duration of response was 13.0 weeks in the symptomatic patients; 52% of those surviving 3 months remained improved. KPS improved in 28% of patients. Serial CT scans revealed a partial response in 7% and a marginal response in 13% of patients. One patient had a complete response to treatment. The median survival of patients treated in this series was 4.2 months with no difference between the two treatment groups. Patients with metastases from colon carcinoma and an initial KPS of 80 or more (48% of the patient population) had a median survival of 5.8 months with radiation therapy alone compared with 6.6 months with radiation therapy and misonidazole (p = 0.36). There was no significant treatment related morbidity. Radiation therapy remains an excellent palliative tool for the management of patients with symptomatic hepatic metastases. Further research must continue to identify new methods of selectivity enhancing the tumor response to radiation therapy.

Response of colo-rectal hepatic metastases to concomitant radiotherapy and intravenous infusion 5 fluorouracil

Twenty-three patients with colo-rectal hepatic metastases were retrospectively reviewed after completing treatment with split course liver irradiation and continually infused concomitant intravenous 5-fluorouracil. Although no patient attained a complete response, an objective partial response was documented in 15 (Responders). The Responders had a median survival of 45 weeks whereas Non-responders had a median survival of 17 weeks. Patients with metastatic disease solely in the liver or those with a Karnofsky performance score (k.p.s) of over sixty, had a median survival of 49 weeks. Patients with multiple organ metastatic involvement had a median survival of 25 weeks and those with a Karnofsky with less than 60 had a median survival of 27 weeks. (p values of 0.006 and 0.03, respectively.) The overall survival of the group completing treatment was 30 weeks, and 19 patients (83%) achieved subjective palliation. The patients tolerated therapy well. There was minimal hematological toxicity; 3 patients developed a leucocyte count of less than 2000 and 1 developed a platelet count of 30,000. The palliation and prolongation of survival attained with minimal complications suggest that adjuvant liver irradiation with concomitant infusion 5-fluorouracil radiosensitization may be an option to offer patients identified to be at high risk of developing subclinical liver disease.

Therapeutic efficacy of glucan in a murine model of hepatic metastatic disease

Glucan, a particulate beta-1,3-polyglucose immunomodulator, was evaluated for its ability to modify hepatic metastases and survival in mice with reticulum cell sarcoma. Sarcoma M5076 cells were injected subcutaneously (1 X 10(5) cells) into syngeneic C57BL/6J male mice. On Day 20, histopathological studies indicated the presence of hepatic micrometastases. At this time, glucan (0.45 mg per mouse) or dextrose was administered intravenously. Therapy was continued at 3-day intervals up to Day 50. By Day 36 postchallenge, the glucan-treated group, when compared to the control group, showed a marked decrease in hepatic metastases, both grossly and histopathologically. A significant inhibition in the growth of the primary tumor also occurred. Plasma clearance of bromosulfophthalein measured on Day 36, denoted that glucan therapy maintained hepatic parenchymal cell functional integrity, while a 4-fold impairment in bromosulfopthalein removal was observed in control mice. Glucan-treated mice showed a 28% (p less than 0.05) long-term survival. In contrast, control mice showed a 100% mortality by Day 42 postchallenge. Studies to evaluate the mechanism of the anti-metastatic action of glucan indicated that 8 days after glucan administration, isolated hepatic macrophages were significantly more cytotoxic to sarcoma cells in vitro than were normal Kupffer cells. At this time, the cytotoxic activity of peritoneal and splenic macrophages from glucan-treated mice were unaltered. Additionally, co-incubation of particulate glucan with diverse populations of normal or tumor cells in vitro indicated that glucan exerted a direct cytostatic effect on sarcoma and melanoma cells and, in contrast, had a proliferative effect on normal spleen and bone marrow cells.(ABSTRACT TRUNCATED AT 250 WORDS)

Regional management of liver metastases. II

Metastatic cancer of the liver has a dominant influence upon survival despite the presence of metastasis in other sites. For patients with untreated liver metastases, the median survival after diagnosis is 75 days, and only 7% survived 1 year. Prognosis of hepatic metastasis is related to the extent of liver involvement, and various staging systems have been proposed (Table I.1). Hepatic metastases are quite resistant to conventional systemic chemotherapy. Surgical resection is the treatment of choice whenever possible, but the resectability rate is rather low and the surgical mortality relatively high. Patients with solitary metastasis and those with primary in the colon, especially females, have had the best results. Regional chemotherapy to the liver has the advantages of achieving higher local concentrations of drug, prolonging the contact of drug and tumor cells, and reducing systemic toxicity. Infusion catheter can be placed either percutaneously or directly at the time of celiotomy. Many reports show that hepatic IA infusion of chemotherapeutic agents (5FU or FUDR) can give favorable response in 55%-80% of the cases and can prolong survival in comparison with untreated patients or patients receiving systemic chemotherapy (Tables I.2 and I.3). Some investigators have added one or more other agents to improve the therapeutic results. For instance, patients who were refractory to 5FU or MMC given as a single IV drug responded to the combination infusion therapy. Evidence from animal and human studies have demonstrated that both primary and metastatic tumors in the liver receive their blood supply almost exclusively from the hepatic arterial system, whereas normal liver tissue has a double supply: the hepatic artery and the portal vein. Thus, deliberate ligation of the hepatic artery has been used as a treatment of metastatic tumors of the liver. From 1966 to 1981, some 518 patients were reported to have undergone this operation as compared to 2327 patients treated with hepatic IA infusion chemotherapy (Table I.4). Although selective necrosis of tumor nodules has been demonstrated after HAL, there is always a shell of viable malignant cells left at the periphery. Thus, several series have administered chemotherapeutic agents either to the distal hepatic artery or to branches of the portal vein to prevent tumor regrowth. Currently there is no definite evidence that HAL with added infusion chemotherapy to the liver gives better response and/or survival results than infusion chemotherapy via the hepatic artery only and/or via the portal vein branches. The availability of a totally implantable infusion pump represents a remarkable advance in long-term i

Primary carcinoma of the liver: clinical course and therapeutic results

A Finnish series of 53 patients with primary carcinoma of the liver has been examined with a view to establishing the clinical course, the therapeutic results, and the factors which might influence the prognosis. Four tumors were resected, with one 6-year survival. All patients with no effective treatment were dead within 1 year from diagnosis. Thirty-seven nonresected patients with primary liver carcinoma were treated with chemotherapy and/or hepatic irradiation with mean survival time of 9.1 months after diagnosis. The best palliation in these patients was achieved by the combination treatment of chemotherapy and hepatic irradiation; the mean survival time was 13.8 months and, considering only the responders, 18.3 months. The laparotomy finding of 46 cases revealed that 67% of patients were without extrahepatic metastases of primary liver carcinoma at the time of diagnosis. At autopsy that figure was 44%. These data demonstrate that primary liver carcinoma is surprisingly often localized in the liver, but yet survival in these patients seems to be only occasionally favorably influenced by recent therapies, except hepatic resection, which remains the treatment of choice when feasible. Perhaps for primary carcinoma of the liver, the combination treatment of chemotherapy and hepatic irradiation gives better palliation than either one of these therapies alone.

Therapy of liver tumors metastatic from colorectal cancer with whole-liver radiation combined with 5-FU, adriamycin, and methotrexate

Twenty-seven patients with liver metastasis from colorectal cancer were treated with intrahepatic arterial chemotherapy and external radiotherapy consisting of 5-fluorouracil (5-FU) (10 mg/kg/day for 8 days), adriamycin (5 mg/m2/day for 7 days) and methotrexate (MTX) (240 mg/m2/X1), combined with 2,100 rads of whole liver irradiation. Twenty of these patients (74%) had previously received systemic chemotherapy. Of the 21 patients who could be fully evaluated, seven (33%) had an objective partial response and another 10 (48%) had stable disease following treatment. The median duration of survival for all patients after initiation of treatment was 6.5 months. Those patients responding to therapy survived longer (12.7 months) than those who had stable disease (5.5 months) or disease progression (2.5 months). The response rate was not affected by previous chemotherapy. Additionally, of the 14 patients with symptoms related to the disease, nine (64%) experienced substantial relief of these symptoms. Toxicity with the therapy used in this study was generally moderate. The median nadiR WBC was 3,500 cells/mm3; the median nadir platelet count, 121,000 cells/mm3. There was, however, one treatment-associated fatality from sepsis in a patient whose WBC was 900 cells/mm3.

Treatment of asymptomatic metastatic cancer to the liver from primary colon and rectal cancer by the intraarterial administration of chemotherapy and radioactive isotopes

Forty patients with asymptomatic metastatic cancer to the liver discovered at the time of laparotomy were treated by combined intrahepatic arterial chemotherapy and internal irradiation in the form of 90Yttrium microspheres. One group of 25 patients were treated by a catheter inserted at the time of operation and received 100 mCi; of 90Yttrium microspheres and 5-fluorouracil on a continuing basis. They survived an average of 26 mo (varying from 9 to 60 mo). The second series of 15 patients referred after surgery were treated by the percutaneous insertion of the catheter into the hepatic artery and received a bolus of combined chemotherapy consisting of PlatinolTM, Methotrexate, and 5-fluorouracil. They survived an average of 31 mo, which varied from 12 to 60 mo. The dose of 100 mCi of 90Yttrium was well tolerated by the liver. Prospective studies are in progress, limiting the treatment to the internal irradiation to determine its precise role in the overall treatment of metastatic cancer to the liver.

Concomitant hepatic radiation and intraarterial fluorinated pyrimidine therapy: correlation of liver scan, liver function tests, and plasma CEA with tumor response

Sixteen patients with metastatic disease to the liver (12 colorectal and four unknown primary tumors) were treated in a pilot study of hepatic irradiation (2500-3000 rads in 10-12 fractions) delivered concomitantly with continuous short-term intraarterial infusion of 5-fluorouracil (1 g/d) or FUDR (0.5 mg/kg/d) via a percutaneously placed hepatic artery catheter. Abnormal liver function tests, including SGOT, LDH, and alkaline phosphatase, decreased in all patients by day 7-10 of treatment, and other metabolic factors, including serum cholesterol, calcium, albumin, phosphorous, and uric acid, also decreased, often to subnormal levels by termination of treatment (day 15-20). These chemical alterations did not correlate with tumor response in that the identical pattern was observed in responders (ten patients) as well as nonresponders (six patients). Objective determinants of response were assessed by serial monitoring of the plasma carcinoembryonic antigen (CEA) and liver scan. In 14 patients with elevated CEA levels, tumor response (nine patients), nonresponse (four patients), and relapse (five patients) was predicted and confirmed by sequential monitoring of CEA. In one patient, a paradoxical decrease in plasma CEA was associated with progressive disease. The liver scan identified all responding patients but was difficult to quantitate and was delayed for months following subjective clinical response and changes in plasma CEA levels.

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.

Short-term intra-arterial mitomycin C in hepatic metastases

Short-term intra-arterial Mitomycin C treatment of hepatic metastases from various malignancies was performed in 24 evaluable patients. An objective regression was obtained in 12 patients. The median survival of responders was 11 months compared with 3 months in nonresponders. No complication of the technical procedure occurred and the treatment was well tolerated. The only side effect of clinical importance was thrombocytopenia, which occurred at a median dose of 45 mg of Mitomycin C.