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Holster JJ, El Hassnaoui M, Franssen S, IJzermans JNM, de Jonge J, Mostert B, Polak WG, de Wilde RF, Homs MYV, Groot Koerkamp B. Hepatic Arterial Infusion Pump Chemotherapy for Unresectable Intrahepatic Cholangiocarcinoma: A Systematic Review and Meta-Analysis. Ann Surg Oncol 2022; 29:5528-5538. [PMID: 35294656 PMCID: PMC9356931 DOI: 10.1245/s10434-022-11439-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 01/24/2022] [Indexed: 02/06/2023]
Abstract
Background Patients with unresectable intrahepatic cholangiocarcinoma (iCCA) have poor survival. This systematic review describes the survival outcomes of hepatic arterial infusion pump (HAIP) chemotherapy with floxuridine for patients with unresectable iCCA. Patients and Methods A literature search was conducted using the electronic databases PubMed, Medline (Ovid), Embase, Web of Science, Google Scholar, and Cochrane to find studies that reported data on the survival of patients with unresectable iCCA treated with HAIP chemotherapy using floxuridine. The quality of the studies was assessed using the Newcastle–Ottawa quality assessment Scale (NOS). Overall survival (OS) was the primary outcome measure, and progression-free survival (PFS), response rates, resection rates, and toxicity were defined as secondary outcome measures. Results After removing duplicates, 661 publications were assessed, of which nine studies, representing a total of 478 patients, met the inclusion criteria. Three out of nine studies were phase II clinical trials, one study was a prospective dose-escalation study, and the remaining five studies were retrospective cohort studies. After accounting for overlapping cohorts, 154 unique patients were included for pooled analysis. The weighted median OS of patients with unresectable iCCA treated with HAIP chemotherapy with floxuridine was 29.0 months (range 25.0–39 months). The pooled 1-, 2-, 3-, and 5-year OS were 86.4, 55.5, 39.5, and 9.7%, respectively. Conclusion HAIP chemotherapy with floxuridine for patients with unresectable iCCA was associated with a 3-year OS of 39.5%, which is favorable compared with systemic chemotherapy for which no 3-year survivors were reported in the Advanced Biliary Cancer (ABC) trials. Supplementary Information The online version contains supplementary material available at 10.1245/s10434-022-11439-x.
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Affiliation(s)
- Jessica J Holster
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | | | - Stijn Franssen
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Jan N M IJzermans
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Jeroen de Jonge
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Bianca Mostert
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Wojciech G Polak
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Roeland F de Wilde
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Marjolein Y V Homs
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands.
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Mondaca S, Yarmohammadi H, Kemeny NE. Regional Chemotherapy for Biliary Tract Tumors and Hepatocellular Carcinoma. Surg Oncol Clin N Am 2019; 28:717-729. [PMID: 31472915 DOI: 10.1016/j.soc.2019.06.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Locally advanced hepatocellular carcinoma and intrahepatic cholangiocarcinoma are associated with a grim prognosis. The development of highly effective systemic therapies for these tumors has been challenging; however, numerous locoregional treatment alternatives have emerged, including transarterial hepatic embolization (TAE), transarterial chemoembolization (TACE), drug-eluting bead TACE (DEB-TACE), hepatic arterial infusion chemotherapy (HAI), radioembolization, and stereotactic body radiation therapy. Although there is potential for long-term disease control for these therapies, the evidence to guide adequate patient selection and choose among different treatment alternatives is still limited. This review focuses on the rationale and data supporting TAE, TACE, DEB-TACE, and HAI in hepatobiliary cancers.
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Affiliation(s)
- Sebastian Mondaca
- Gastrointestinal Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Hooman Yarmohammadi
- Interventional Radiology Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Nancy E Kemeny
- Gastrointestinal Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
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Koay EJ, Odisio BC, Javle M, Vauthey JN, Crane CH. Management of unresectable intrahepatic cholangiocarcinoma: how do we decide among the various liver-directed treatments? Hepatobiliary Surg Nutr 2017; 6:105-116. [PMID: 28503558 DOI: 10.21037/hbsn.2017.01.16] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Intrahepatic cholangiocarcinoma often causes death due to obstruction of the biliary system or interruption of the vascular supply of the liver. This fact emphasizes the critical need for local tumor control in this disease. Successful local tumor control has traditionally been achievable through surgical resection for the small proportion of patients with operable tumors. Technological advances in radiation oncology and in interventional radiology have enabled the delivery of ablative radiation doses or other cytotoxic therapies for tumors in the liver. In some cases, this has translated into substantial prolongation of life for patients with this disease, but the indications for these different treatment options are still the subject of ongoing debate. Here, we review the technological advances and clinical studies that are changing the way intrahepatic cholangiocarcinoma is managed, and discuss ways to achieve individualized treatment of patients.
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Affiliation(s)
- Eugene J Koay
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bruno C Odisio
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Milind Javle
- Department of GI Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Christopher H Crane
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Lee IJ, Kim JW, Han KH, Kim JK, Kim KS, Choi JS, Park YN, Seong J. Concurrent chemoradiotherapy shows long-term survival after conversion from locally advanced to resectable hepatocellular carcinoma. Yonsei Med J 2014; 55:1489-97. [PMID: 25323884 PMCID: PMC4205687 DOI: 10.3349/ymj.2014.55.6.1489] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
PURPOSE For locally unresectable hepatocellular carcinoma (HCC) patients, concurrent chemoradiotherapy (CCRT) has been applied as a loco-regional treatment. After shrinkage of tumors in selected patients, surgical resection is performed. The aim of this study was to evaluate prognostic factors and long-term survivors in such patients. MATERIALS AND METHODS From January 2000 to January 2009, 264 patients with HCC were treated with CCRT (45 Gy with fractional dose of 1.8 Gy), and intra-arterial chemotherapy was administered during radiotherapy. Eighteen of these patients (6.8%) underwent hepatic resection after showing a response to CCRT. Cases were considered resectable when tumor-free margins and sufficient remnant volumes were obtained without extrahepatic metastasis. Prior to operation, there were six patients with complete remission, 11 with partial remission, and six with stable disease according to modified Response Evaluation Criteria in Solid Tumors. RESULTS In pathologic review, four patients (22.2%) showed total necrosis and seven patients (38.9%) showed 70-99% necrosis. A high level of necrosis (≥80%) was correlated with low risk for extrahepatic metastasis and long-term survival. In univariate analyses, vessel invasion and capsular infiltration were significantly correlated with disease free survival (DFS) (p=0.017 and 0.013, respectively), and vessel invasion was significantly correlated with overall survival (OS) (p=0.013). In multivariate analyses, capsule infiltration was a significant factor for DFS (p=0.016) and vessel invasion was significant for OS (p=0.015). CONCLUSION CCRT showed favorable responses and locally advanced HCC converted into resectable tumor after CCRT in selected patients. Long-term survivors showed the pathological features of near total necrosis, as well as negative capsule and vessel invasion.
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Affiliation(s)
- Ik Jae Lee
- Department of Radiation Oncology, Yonsei Liver Cancer Special Clinic, Yonsei University College of Medicine, Seoul, Korea
| | - Jun Won Kim
- Department of Radiation Oncology, Yonsei Liver Cancer Special Clinic, Yonsei University College of Medicine, Seoul, Korea
| | - Kwang Hyub Han
- Department of Internal Medicine, Yonsei Liver Cancer Special Clinic, Yonsei University College of Medicine, Seoul, Korea
| | - Ja Kyung Kim
- Department of Internal Medicine, Yonsei Liver Cancer Special Clinic, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung Sik Kim
- Department of Surgery, Yonsei Liver Cancer Special Clinic, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Sub Choi
- Department of Surgery, Yonsei Liver Cancer Special Clinic, Yonsei University College of Medicine, Seoul, Korea
| | - Young Nyun Park
- Department of Pathology, Yonsei Liver Cancer Special Clinic, Yonsei University College of Medicine, Seoul, Korea
| | - Jinsil Seong
- Department of Radiation Oncology, Yonsei Liver Cancer Special Clinic, Yonsei University College of Medicine, Seoul, Korea.
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Spada F, Fazio N, Bonomo G, Monfardini L, Vigna PD, Radice D, Boselli S, Orsi F. Hepatic intra-arterial chemotherapy in patients with advanced primary liver tumours. Ecancermedicalscience 2012; 6:280. [PMID: 23226162 PMCID: PMC3512295 DOI: 10.3332/ecancer.2012.280] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2012] [Indexed: 01/07/2023] Open
Abstract
Background: Primary liver tumours (PLTs) are currently a major health problem worldwide. The study’s aim was to investigate the feasibility, toxicity, and activity of hepatic intra-arterial chemotherapy (HIAC) in patients with advanced PLTs. Methods: We retrospectively analysed 43 patients with advanced unresectable PLT, who were consecutively treated. HIAC with 5-fluorouracil, cisplatin, and mitomycin-C was administered through a radiologically positioned temporary percutaneous catheter every six weeks until tumour progression or unacceptable toxicity was reached. Results: Partial response was observed in 26% and stable disease in 41% of patients. The median overall survival was 12.3 months. Manageable catheter-related complications occurred in 23% of patients. The grade 3–4 toxicities included neutropenia, thrombocytopenia, and transaminitis. There were no toxic deaths. Conclusion: The results of this retrospective study show that HIAC is feasible, active, and manageable in patients with PLTs. The treatment could be studied in selected patients with advanced progressive HCC/BTC being treated with or ineligible for sorafenib/cisplatin plus gemcitabine.
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Affiliation(s)
- Francesca Spada
- Upper GI and NET Unit, Department of Medicine, European Institute of Oncology (IEO), Via Ripamonti 435, 20141 Milan, Italy
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Jeong SW, Jang JY, Lee JE, Lee SH, Kim SG, Cha SW, Kim YS, Cho YD, Kim HS, Kim BS, Kim KH, Kim YJ. The efficacy of hepatic arterial infusion chemotherapy as an alternative to sorafenib in advanced hepatocellular carcinoma. Asia Pac J Clin Oncol 2012; 8:164-71. [PMID: 22524575 DOI: 10.1111/j.1743-7563.2012.01543.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
AIMS Sorafenib is the only systemic treatment shown to be effective against advanced hepatocellular carcinoma (HCC). Hepatic arterial infusion chemotherapy (HAIC) has been selected as an alternative therapeutic option for advanced HCC. We investigated the efficacy and safety of HAIC as an alternative treatment for sorafenib in advanced HCC. METHODS Between May 2008 and March 2011, 20 consecutive patients were treated with sorafenib monotherapy as a first-line treatment and 21 consecutive patients who could not take sorafenib because of cost were treated with HAIC monotherapy as an alternative. Sorafenib was administered in 400 mg b.i.d. doses. For HAIC, daily cisplatin (7 mg/m(2) on days 1-5) and 5-FU (170 mg/m(2) on days 1-5) were infused every 4 weeks. We assessed overall survival (OS), progression-free survival (PFS), objective response rate (ORR) and toxicity. RESULTS Median OS was 4.9 months (95% CI, 3.4-6.4) for sorafenib and 7.3 months (95% CI, 4.5-10.2) for HAIC (P = 0.599). Median PFS was 2.0 months (95% CI, 1.96-2.05) versus 3.0 months (95% CI, 1.98-4.02) for sorafenib and HAIC, respectively (P = 0.303). ORR and disease control rate (DCR) for sorafenib were 10.0 and 35.0% versus 19.0 and 38.1% for HAIC (ORR, P = 0.413; DCR, P = 0.837). Patients treated with HAIC more frequently exhibited grade 3/4 neutropenia (23.8 vs 0% for sorafenib), whereas sorafenib therapy showed grade 3/4 hand-foot skin reaction in 10% of patients. CONCLUSION HAIC is a useful alternative treatment for advanced HCC and further prospective investigations are required.
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Affiliation(s)
- Soung Won Jeong
- Institution for Digestive Research, Digestive Disease Center, Department of Internal Medicine, Seoul, Korea
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Kim HY, Kim JD, Bae SH, Park JY, Han KH, Woo HY, Choi JY, Yoon SK, Jang BK, Hwang JS, Kim SG, Kim YS, Seo YS, Yim HJ, Um SH. A comparative study of high-dose hepatic arterial infusion chemotherapy and transarterial chemoembolization using doxorubicin for intractable, advanced hepatocellular carcinoma. THE KOREAN JOURNAL OF HEPATOLOGY 2011; 16:355-61. [PMID: 21415578 PMCID: PMC3304604 DOI: 10.3350/kjhep.2010.16.4.355] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background/Aims Transarterial chemoembolization (TACE) has long been used as a palliative therapy for unresectable hepatocellular carcinoma (HCC). High-dose hepatic arterial infusion chemotherapy (HAIC) has showed favorable outcomes in patients with intractable, advanced HCC. The aim of this study was to compare the effectiveness and safety of high-dose HAIC and conventional TACE using doxorubicin for advanced HCC. Methods The high-dose HAIC group comprised 36 patients who were enrolled prospectively from six institutions. The enrollment criteria were good liver function, main portal vein invasion (including vascular shunt), infiltrative type, bilobar involvement, and/or refractory to prior conventional treatment (TACE, radiofrequency ablation, or percutaneous ethanol injection), and documented progressive disease. Patients received 5-fluorouracil (500 mg/m2 on days 1~3) and cisplatin (60 mg/m2 on day 2 every 4 weeks) via an implantable port system. In the TACE group, 31 patients with characteristics similar to those in the high-dose HAIC group were recruited retrospectively from a single center. Patients underwent a transarterial infusion of doxorubicin every 4~8 weeks. Results Overall, 6 patients (8.9%) achieved a partial response and 20 patients (29.8%) had stable disease. The objective response rate (complete response+partial response) was significantly better in the high-dose HAIC group than in the TACE group (16.7% vs. 0%, P=0.030). Overall survival was longer in the high-dose HAIC group than in the TACE group (median survival, 193 vs. 119 days; P=0.026). There were no serious adverse effects in the high-dose HAIC group, while hepatic complications occurred more often in the TACE group. Conclusions High-dose HAIC appears to improve the tumor response and survival outcome compared to conventional TACE using doxorubicin in patients with intractable, advanced HCC.
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Affiliation(s)
- Hee Yeon Kim
- Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Korea
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Kemeny NE, Schwartz L, Gönen M, Yopp A, Gultekin D, D'Angelica MI, Fong Y, Haviland D, Gewirtz AN, Allen P, Jarnagin WR. Treating primary liver cancer with hepatic arterial infusion of floxuridine and dexamethasone: does the addition of systemic bevacizumab improve results? Oncology 2011; 80:153-9. [PMID: 21677464 DOI: 10.1159/000324704] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2011] [Accepted: 01/17/2011] [Indexed: 01/03/2023]
Abstract
OBJECTIVES This study investigated the efficacy and safety of adding systemic (IV) bevacizumab (Bev) to hepatic arterial infusion (HAI) with floxuridine (FUDR)/dexamethasone (Dex) in unresectable primary liver cancer. METHODS Patients with unresectable intrahepatic cholangiocarcinoma (ICC) or hepatocellular carcinoma (HCC) were treated with HAI FUDR/Dex plus IV Bev. Results were compared to a recent study of HAI without Bev in a similar patient population. RESULTS Twenty-two patients (18 ICC, 4 HCC) were treated with HAI FUDR/Dex plus Bev; 7 (31.8%) had partial response and 15 (68.2%) had stable disease. Median survival was 31.1 months (CI 14.14-33.59), progression-free survival (PFS) 8.45 months (CI 5.53-11.05), and hepatic PFS 11.3 months (CI 7.93-15.69). In the previous trial with HAI alone (no Bev), the response was 50%; median survival, PFS, and hepatic PFS were 29.5, 7.3, and 10.1 months. In the present trial, bilirubin elevation (>2 mg/dl) was seen in 24% of patients and biliary stents were placed in 13.6%, versus 5.8 and 0%, respectively, in the HAI trial without Bev. Due to increased biliary toxicity, the trial was prematurely terminated. CONCLUSION Adding Bev to HAI FUDR/Dex appeared to increase biliary toxicity without clear improvement in outcome (median PFS 8.45 vs. 7.3 months, and median survival 31.1 vs. 29.5 months, for HAI + Bev vs. HAI alone groups, respectively).
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Affiliation(s)
- Nancy E Kemeny
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA. kemenyn @ mskcc.org
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Affiliation(s)
- Charles H Cha
- Surgical Oncology, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
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Woo HY, Bae SH, Park JY, Han KH, Chun HJ, Choi BG, Im HU, Choi JY, Yoon SK, Cheong JY, Cho SW, Jang BK, Hwang JS, Kim SG, Kim YS, Seo YS, Yim HJ, Um SH. A randomized comparative study of high-dose and low-dose hepatic arterial infusion chemotherapy for intractable, advanced hepatocellular carcinoma. Cancer Chemother Pharmacol 2009; 65:373-82. [PMID: 19763572 DOI: 10.1007/s00280-009-1126-2] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2009] [Accepted: 09/02/2009] [Indexed: 12/17/2022]
Abstract
PURPOSE Hepatic arterial infusion chemotherapy (HAIC) has been reported to be effective in patients with advanced hepatocellular carcinoma (HCC). METHODS In this multicenter, prospective, open-labeled, clinical trial, we randomly assigned 68 patients with advanced HCC to receive either low-dose [n = 32, 5-fluorouracil (FU), 170 mg/m(2) and cisplatin, 7 mg/m(2) on days 1-5] or high-dose HAIC (n = 36, 5-FU, 500 mg/m(2) on days 1-3 and cisplatin, 60 mg/m(2) on day 2) every 4 weeks via an implantable port system. RESULTS A total of 207 cycles of HAIC was given to the 68 patients. Overall, 6 patients (8.8%) achieved a partial response and 21 patients (30.9%) had stable disease. The objective response rate (CR + PR) was significantly improved in the high-dose group compared to the low-dose group (16.7% vs. 0%, P = 0.024). The median time to disease progression and overall survival were slightly prolonged in the high-dose group compared to the low-dose group (median survival, 193 vs. 153 days; P = 0.108; median time to disease progression, 145 vs. 90 days; P = 0.095). Multivariate analysis showed that tumor response to treatment [P = 0.007, RR 2.27 (95% CI, 1.248-4.132)] was the only factor associated with overall survival. All adverse events were tolerable and successfully managed in both treatment groups. CONCLUSIONS Both HAIC regimens are safe and effective in patients with advanced HCC. High-dose HAIC achieves a better tumor response compared to low-dose HAIC.
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Affiliation(s)
- Hyun Young Woo
- Department of Internal Medicine, College of Medicine, Pusan National University, Busan, Korea
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Carpizo DR, D'Angelica M. Management and extent of resection for intrahepatic cholangiocarcinoma. Surg Oncol Clin N Am 2009; 18:289-305, viii-ix. [PMID: 19306813 DOI: 10.1016/j.soc.2008.12.010] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Intrahepatic cholangiocarcinoma is the second most common primary liver cancer behind hepatocellular cancer. Although it is an uncommon malignancy, several reports have documented a significant rise in incidence, not only in the United States, but worldwide over the last several decades. As a result, interest in understanding the presentation, diagnosis, natural history, and efficacy of various treatment modalities has increased. This article reviews the clinical presentation, preoperative work-up, surgical management, and outcomes of patients undergoing resection for intrahepatic cholangiocarcinoma. Treatment options in unresectable patients are also reviewed.
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Affiliation(s)
- Darren R Carpizo
- Division of Surgery, UMDNJ-Robert Wood Johnson Medical School, The Cancer Institute of New Jersey, 195 Little Albany Street, Room 3040, New Brunswick, NJ 08901, USA
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Jarnagin WR, Schwartz LH, Gultekin DH, Gönen M, Haviland D, Shia J, D'Angelica M, Fong Y, DeMatteo R, Tse A, Blumgart LH, Kemeny N. Regional chemotherapy for unresectable primary liver cancer: results of a phase II clinical trial and assessment of DCE-MRI as a biomarker of survival. Ann Oncol 2009; 20:1589-1595. [PMID: 19491285 DOI: 10.1093/annonc/mdp029] [Citation(s) in RCA: 131] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND This study reports the results of hepatic arterial infusion (HAI) with floxuridine (FUDR) and dexamethasone (dex) in patients with unresectable intrahepatic cholangiocarcinoma (ICC) or hepatocellular carcinoma (HCC) and investigates dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) assessment of tumor vascularity as a biomarker of outcome. PATIENTS AND METHODS Thirty-four unresectable patients (26 ICC and eight HCC) were treated with HAI FUDR/dex. Radiologic dynamic and pharmacokinetic parameters related to tumor perfusion were analyzed and correlated with response and survival. RESULTS Partial responses were seen in 16 patients (47.1%); time to progression and response duration were 7.4 and 11.9 months, respectively. Median follow-up and median survival were 35 and 29.5 months, respectively; 2-year survival was 67%. DCE-MRI data showed that patients with pretreatment integrated area under the concentration curve of gadolinium contrast over 180 s (AUC 180) >34.2 mM.s had a longer median survival than those with AUC 180 <34 mM.s (35.1 versus 19.1 months, P = 0.002). Decreased volume transfer exchange between the vascular space and extracellular extravascular space (-DeltaK(trans)) and the corresponding rate constant (-Deltak(ep)) on the first post-treatment scan both predicted survival. CONCLUSIONS In patients with unresectable primary liver cancer, HAI therapy can be effective and safe. Pretreatment and early post-treatment changes in tumor perfusion characteristics may predict treatment outcome.
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Affiliation(s)
| | | | | | - M Gönen
- Department of Epidemiology and Biostatistics
| | | | - J Shia
- Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | | | | | | | - A Tse
- Department of Medical Oncology
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Seo YS, Kim JN, Keum B, Park S, Kwon YD, Kim YS, Jeen YT, Chun HJ, Kim CY, Kim CD, Ryu HS, Um SH. Radiotherapy for 65 patients with advanced unresectable hepatocellular carcinoma. World J Gastroenterol 2008; 14:2394-400. [PMID: 18416468 PMCID: PMC2705096 DOI: 10.3748/wjg.14.2394] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the efficacy of radiotherapy (RT) in patients with advanced unresectable hepatocellular carcinoma (HCC).
METHODS: A total of 65 patients were treated with RT in the Korea University Medical Center. The median age of the patients was 60 years, and 86.2% were men. 18.5% and 81.5% of the patients were diagnosed as TNM stage III and IV-A, respectively. Treatment response was assessed 4 mo after initiation of RT. Tumor regression rate 1 mo after initiation of RT (TRR1m) was also assessed. Duration of survival was calculated from the initiation of RT.
RESULTS: The objective treatment response was 56.9%. The 12 mo survival rate was 34.7%. Predictive factors for survival were Child-Pugh grade, α-fetoprotein level and treatment response. An objective response was achieved more frequently in patients with TRR1m≥ 20% than in those with TRR1m < 20% (P < 0.001).
CONCLUSION: RT is effective in treating advanced HCC with a tumor response rate of 56.9%.
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Hepatic arterial infusion of mitomycin C with degradable starch microspheres for unresectable intrahepatic cholangiocarcinoma. Clin Oncol (R Coll Radiol) 2008; 20:241-6. [PMID: 18222071 DOI: 10.1016/j.clon.2007.12.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2007] [Revised: 11/08/2007] [Accepted: 12/10/2007] [Indexed: 01/27/2023]
Abstract
AIMS With no effective chemotherapy, the prognosis of unresectable intrahepatic cholangiocarcinoma is extremely poor. Hepatic arterial infusion of mitomycin C with degradable starch microspheres has been reported to be an effective treatment for unresectable liver metastasis. We retrospectively evaluated the efficacy and safety of this chemotherapy for treating unresectable intrahepatic cholangiocarcinoma. MATERIALS AND METHODS Hepatic arterial infusion chemotherapy through an implanted port system was carried out in 20 patients with unresectable intrahepatic cholangiocarcinoma. Degradable starch microspheres mixed with mitomycin C and contrast media were injected until either embolisation of the hepatic artery or influx to the gastroduodenal system was confirmed. This treatment was repeated weekly. RESULTS Hepatic arterial infusion chemotherapy was carried out 204 times. The response rate was 50.0%. Twelve patients experienced transient epigastralgia and four experienced gastroduodenal ulcer. The time to progression was 8.3 months and the median survival time was 14.1 months. CONCLUSIONS This chemotherapy was effective and feasible for patients with unresectable intrahepatic cholangiocarcinoma. Further study with a larger number of patients is warranted.
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Ko HK, Ko GY, Yoon HK, Sung KB. Tumor response to transcatheter arterial chemoembolization in recurrent hepatocellular carcinoma after living donor liver transplantation. Korean J Radiol 2007; 8:320-7. [PMID: 17673843 PMCID: PMC2627154 DOI: 10.3348/kjr.2007.8.4.320] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Objective To evaluate the tumor response and patient survival rate following transcatheter arterial chemoembolization (TACE) in recurrent hepatocellular carcinoma (r-HCC) after living donor liver transplantation (LDLT). Materials and Methods Twenty-eight patients with r-HCC underwent one or more cycles of TACE after LDLT (mean, 2.5 cycles). After a mixture of iodized oil and anti-cancer drugs was injected via the arteries feeding the tumors, these vessels were embolized with a gelatin sponge. Tumor response was determined by follow-up CT imaging on all patients four weeks after each TACE procedure. Patient survival was calculated using the Kaplan-Meier survival curve. Results After TACE, targeted tumor reduced in size by 25% or more in 19 of the 28 study patients (67.9%). However, intrahepatic recurrence or extrahepatic metastasis occurred in 21 of the 28 patients (75.0%) during the 3-month follow-up period and in 26 of the 28 patients (92.9%) during the 6-month period following TACE. Extrahepatic metastasis was noted in 18 of the 28 patients (64.3%). The 1-, 3- and 5-year survival rates following TACE were 47.9, 6.0 and 0%, respectively, with a mean survival of nine months in all patients. There were no significant complications related to TACE. Conclusion TACE produces an effective tumor response for targeted r-HCC after LDLT. However, the survival rate of patients with r-HCC after LDLT is poor due to extrahepatic metastasis and intrahepatic recurrence.
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Affiliation(s)
- Heung Kyu Ko
- Department of Radiology, Severance Hospital, University of Yonsei College of Medicine, Seoul 120-752, Korea.
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Shim SJ, Seong J, Lee IJ, Han KH, Chon CY, Ahn SH. Radiation-induced hepatic toxicity after radiotherapy combined with chemotherapy for hepatocellular carcinoma. Hepatol Res 2007; 37:906-13. [PMID: 17610506 DOI: 10.1111/j.1872-034x.2007.00149.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
AIM The purpose of the present study was to analyze hepatic toxicity following radiotherapy combined with regional chemotherapy for hepatocellular carcinoma (HCC). METHODS From 2001 to 2003, a total of 132 patients with HCC received 3-D conformal radiation therapy (3D-CRT) combined with chemotherapy. Patients were divided into two groups based on drug localization: the transcatheter arterial chemoembolization (TACE) group, where the chemotherapeutic drug (adriamycin) was localized within the tumor, and the non-TACE group, where the drugs (adriamycin, cisplatin, 5-fluorouracil) were diffusely spread over the entire liver. RESULTS Patients were evaluated by biochemical parameters for any hepatic toxicity prior to, during, and until 12 months after 3D-CRT. Hepatic toxicity was defined as radiation-induced liver disease (RILD) or combined modality-induced liver disease (CMILD), which is defined as RILD with abnormal elevation of total bilirubin levels. In the TACE group, three patients developed RILD (5.6%) and none developed CMILD. In the non-TACE group, three patients (3.7%) and seven patients (8.8%) developed RILD and CMILD, respectively. CONCLUSION Hepatic toxicity following radiotherapy combined with regional chemotherapy for HCC might be influenced by the distribution of the chemotherapeutic drugs. A more precise understanding of hepatic toxicity from chemoradiotherapy will help design optimal treatments for HCC.
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Affiliation(s)
- Su J Shim
- Departments of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
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Hamada A, Yamakado K, Nakatsuka A, Takaki H, Takeda K. Clinical Utility of Coaxial Reservoir System for Hepatic Arterial Infusion Chemotherapy. J Vasc Interv Radiol 2007; 18:1258-63. [PMID: 17911516 DOI: 10.1016/j.jvir.2007.05.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
PURPOSE To test the feasibility and clinical utility of a reservoir with coaxial catheters (a 2.9-F microcatheter and a 5-F catheter) and a port (ie, coaxial reservoir) that was developed to perform repeated hepatic arterial infusion chemotherapy (HAIC) in patients with unresectable liver neoplasms. MATERIALS AND METHODS The coaxial reservoir was implanted in 64 patients with unresectable liver neoplasms as a result of difficulty in implanting a conventional reservoir with a 5-F catheter. The 2.9-F microcatheter tip was inserted into the gastroduodenal artery (n = 22), pancreaticoduodenal arcade (n = 20), or peripheral hepatic artery (n = 22) through the 5-F catheter, and a side hole created in the leading end of the microcatheter was oriented toward the proper hepatic artery. Technical success was defined by implantation of the coaxial reservoir and initiation of HAIC. The study endpoint was interruption of HAIC or death. Technical success and early and delayed complications were recorded. RESULTS The technical success rate was 100%. HAIC was repeated every 1-4 weeks during the mean follow-up period of 14.1 months. Arterial infusion chemotherapy was interrupted in 17 patients (27%) as a result of hepatic arterial occlusion (16%, n = 10), catheter dislocation (3%, n = 2), catheter occlusion (3%, n = 2), wound infection (3%, n = 2), or breakage of the port (2%, n = 1). Patency rates of the hepatic artery were 96%, 82%, and 50% at 6 months, 1 year, and 2 years after reservoir implantation, respectively. CONCLUSION Implantation of the coaxial reservoir is feasible, safe, and useful in expanding the indication of HAIC to patients with unresectable liver neoplasms.
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Affiliation(s)
- Ayumi Hamada
- Department of Radiology, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan.
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Park JY, Ahn SH, Yoon YJ, Kim JK, Lee HW, Lee DY, Chon CY, Moon YM, Han KH. Repetitive short-course hepatic arterial infusion chemotherapy with high-dose 5-fluorouracil and cisplatin in patients with advanced hepatocellular carcinoma. Cancer 2007; 110:129-37. [PMID: 17508408 DOI: 10.1002/cncr.22759] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Hepatic arterial infusion chemotherapy (HAIC) has often been selected as a therapeutic option for patients with advanced hepatocellular carcinoma (HCC). The objective of the current study was to evaluate the efficacy and safety of repetitive HAIC with high-dose 5-fluorouracil (5-FU) and cisplatin given for 3 days in patients with advanced HCC. METHODS Between January 2001 and December 2004, a total of 41 patients with unresectable advanced HCC were enrolled. The patients underwent HAIC via the implantable port system with 5-FU (at a dose of 500 mg/m(2) on Days 1-3) and cisplatin (at a dose of 60 mg/m(2) on Day 2) every 4 weeks. Tumor response was assessed at the end of every 3 cycles. RESULTS The median age of the patients was 53 years and 34 patients (82.9%) had evidence of portal vein thrombosis. In total, 230 cycles of HAIC were administered to the 41 patients, with a median of 6 cycles given (range, 1-14 cycles). Nine patients (22.0%) achieved a partial response and 14 patients (34.1%) had stable disease. The median time to disease progression and overall survival were 7.0 months and 12.0 months, respectively. The overall survival was found to be significantly longer in the successful disease control group (patients with a complete response, partial response, and stable disease) than in the disease progression group (median of 14.0 months vs 6.0 months; P < .001). Adverse reactions were tolerable and successfully managed with conservative treatment. CONCLUSIONS HAIC with high-dose 5-FU and cisplatin given for 3 days achieved effective and safe results in patients with advanced HCC. Therefore, repetitive short-course HAIC with high-dose 5-FU and cisplatin may be useful as an alternative therapeutic option for patients with advanced HCC.
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Affiliation(s)
- Jun Yong Park
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
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21
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Cormier JN, Thomas KT, Chari RS, Pinson CW. Management of hepatocellular carcinoma. J Gastrointest Surg 2006; 10:761-80. [PMID: 16713550 DOI: 10.1016/j.gassur.2005.10.006] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2005] [Accepted: 10/03/2005] [Indexed: 01/31/2023]
Abstract
Hepatocellular carcinoma (HCC) is one of the most common tumors globally, with varying prevalence based on endemic risk factors. In high-risk populations, including those with hepatitis B or C or with cirrhosis, serum alpha-fetoprotein (AFP) and screening ultrasound have improved detection of resectable HCC. Treatment options, including surgical resection, for patients with HCC must be selected based on the number and size of hepatic tumors, underlying hepatic function, patient condition, and available resources. An approach, which has been summarized shows the corresponding treatment choices under given clinical circumstances. For cirrhotic patients with less than three tumor nodules of a size less than 3 cm or a solitary HCC less than 5 cm, liver transplantation offers long-term survival similar to that observed in patients transplanted for nonmalignant disease. Ablative treatment using either chemical or thermal techniques provides locally effective tumor destruction. Transcatheter arterial chemoembolization (TACE) is commonly used for palliation of unresectable tumors as well as an adjunct to surgical resection, treatment of tumors before transplant, and in conjunction with other ablative therapies in a multimodality approach. Regional approaches to chemotherapy have produced more encouraging results than systemic chemotherapy, although both remain ineffective for long-term tumor control. Several newer treatment modalities are under investigation, including gene therapy, tagged antibodies, isolated perfusion, and novel radiotherapy techniques.
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Affiliation(s)
- Janice N Cormier
- Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University School of Medicine, Nashville, Tennessee 37232-4753, USA
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Uraki J, Yamakado K, Nakatsuka A, Takeda K. Transcatheter hepatic arterial chemoembolization for hepatocellular carcinoma invading the portal veins: therapeutic effects and prognostic factors. Eur J Radiol 2005; 51:12-8. [PMID: 15186879 DOI: 10.1016/s0720-048x(03)00219-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2003] [Revised: 07/11/2003] [Accepted: 07/15/2003] [Indexed: 12/30/2022]
Abstract
PURPOSE This retrospective study was undertaken to evaluate the therapeutic effects of transcatheter hepatic arterial chemoembolization on hepatocellular carcinoma (HCC) invading the portal veins and to identify prognostic factors. MATERIALS AND METHODS Sixty-one patients underwent chemoembolization. The HCC had invaded the main portal vein in 23 patients, a first-order branch in 25 patients and a second-order branch in 13 patients. The hepatic arteries feeding the tumors were embolized with gelatin sponge after a mixture of iodized oil and anticancer drugs was injected via these vessels. Tumor response was evaluated by measuring tumor sizes on CT images. A reduction in maximum diameter of 25% or more was considered to indicate response to chemoembolization. Significant prognostic factors were identified by univariate and multivariate analyses. RESULTS Tumor size was reduced by 25% or more in 26 patients (43%). The 1-, 3- and 5-year survival rates were 42, 11 and 3%, respectively, with mean survival of 15 months in all patients. In the univariate analysis, the following six variables were significantly associated with prognosis: (i) tumor response; (ii) ascites; (iii) accumulation of iodized oil in tumor thrombi; (iv) in main tumors; (v) Okuda classification; and (vi) tumor size. In the multivariate analysis, the first three of these factors showed significantly independent values for patient prognosis. CONCLUSION Chemoembolization appears to be an effective treatment for HCCs invading the portal venous system. The prognostic factors identified here are expected to be helpful in classifying patients with HCCs invading the portal veins and should serve as useful guidelines for chemoembolization in clinical practice.
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Affiliation(s)
- Junji Uraki
- Department of Radiology, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8057, Japan
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Cha C, Fong Y, Jarnagin WR, Blumgart LH, DeMatteo RP. Predictors and patterns of recurrence after resection of hepatocellular carcinoma. J Am Coll Surg 2003; 197:753-8. [PMID: 14585409 DOI: 10.1016/j.jamcollsurg.2003.07.003] [Citation(s) in RCA: 216] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The majority of patients with hepatocellular carcinoma (HCC) who undergo complete tumor resection subsequently develop tumor recurrence. The objectives of this study were to determine the risk factors for recurrence of HCC after hepatectomy and to examine the outcomes once tumor recurrence occurs. STUDY DESIGN From February 1990 to May 2001 a total of 164 patients underwent liver resection for HCC at our institution and were prospectively followed. Time to recurrence and survival after recurrence were determined by Kaplan-Meier analysis. Patient, tumor, and treatment characteristics were tested for their prognostic significance by univariate and multivariate analysis using the logrank test and the Cox proportional hazards model, respectively. RESULTS The median patient age was 64 years (range 21 to 87 years) and 106 patients (65%) were male. After a median followup of 26 months, 90 patients (55%) have developed recurrent cancer. Among them, 75 patients (83%) had tumor detectable in the liver, which was the only site of disease in 67 (74%). In all, 15 patients (20%) had extrahepatic disease (7 lung, 4 peritoneum, 2 pancreas, 1 bone, and 1 brain). The median time to recurrence was 24 months (range 1 to 274 months). Predictors of recurrence on univariate analysis were tumor size greater than 5 cm, more than one tumor, cirrhosis, vascular invasion (microscopic or macroscopic), and tumor satellites. On multivariate analysis only tumor size greater than 5 cm (p = 0.04) and vascular invasion (p = 0.01) predicted recurrence. The median survival after recurrence was 11 months (range 0 to 60 months). Of the 90 patients who developed tumor recurrence 49 (67%) were able to undergo additional ablative or surgical therapy (33 embolization, 9 ethanol injection, and 14 re-resection). On multivariate analysis vascular invasion in the original tumor predicted poor survival after recurrence (p = 0.009). CONCLUSIONS The liver is the predominant site of first recurrence after resection of hepatocellular carcinoma, and once recurrence occurs survival is limited. The current study underscores the need for effective adjuvant therapy for patients with HCC treated with partial hepatectomy.
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Affiliation(s)
- Charles Cha
- Hepatobiliary Service, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
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Seong J, Park HC, Han KH, Chon CY. Clinical results and prognostic factors in radiotherapy for unresectable hepatocellular carcinoma: a retrospective study of 158 patients. Int J Radiat Oncol Biol Phys 2003; 55:329-36. [PMID: 12527045 DOI: 10.1016/s0360-3016(02)03929-9] [Citation(s) in RCA: 146] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE To analyze the treatment results and prognostic factors affecting survival in patients with unresectable hepatocellular carcinoma treated with local radiotherapy (RT). METHODS AND MATERIALS Between 1992 and 2000, 158 patients with unresectable hepatocellular carcinoma received local RT. Sixty-seven patients had an advanced UICC Stage III lesion and 91 patients had Stage IVA. The mean tumor size was 9.0 +/- 3.0 cm, and liver cirrhosis was present in 142 patients. Local RT was combined with transarterial chemoembolization as primary treatment (107 patients) or as salvage after failure of repeated transarterial chemoembolization (51 patients). The mean radiation dose was 48.2 +/- 7.9 Gy in daily 1.8-Gy fractions. RESULTS The mean follow-up was 21.6 months after diagnosis and 14.6 months after RT. The response rate was 67.1%. The overall survival rate at 2 and 5 years was 30.5% and 9%, respectively, from the time of diagnosis (median survival time 16 months) and 19.9% and 4.7%, respectively, after RT (median survival time 10 months). On univariate analysis, tumor size (p = 0.047), the presence of portal vein thrombosis (p = 0.007), and RT dose (p = 0.001) were significant factors for survival. However, on multivariate analysis, RT dose was the only significant factor (p = 0.01). CONCLUSION Local RT achieved substantial tumor regression and survival. The radiation dose was found to be a significant prognostic factor in the RT of hepatocellular carcinoma. Additional efforts for dose escalation are warranted to improve the treatment results in parallel with better protecting the nontumorous liver.
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Affiliation(s)
- Jinsil Seong
- Department of Radiation Oncology, Brain Korea 21 Project for Medical Science, Yonsei University Medical College, Seoul, South Korea.
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Abstract
Hepatocellular carcinoma (HCC) is one of the most common malignancies worldwide, responsible for an estimated one million deaths annually. The incidence in the United States has steadily increased over the past two decades. Although HCC has historically had a dismal prognosis, it is now being detected earlier as a result of improved radiologic imaging and surveillance. This affords the opportunity to treat patients with curative intent, and may improve survival. Partial hepatectomy and transplantation each provide potentially curative therapy for selected patients with HCC. Transplantation is indicated when there is severe underlying liver dysfunction. Local ablative therapy, such as ethanol injection, hepatic artery embolization, and radiofrequency ablation, offer palliation for patients when surgery is not feasible. The rational application of the myriad of therapies to a patient with HCC is designed to maximize both quality of life and survival.
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Affiliation(s)
- Charles Cha
- Hepatobiliary Service, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA
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Seidenfeld J, Korn A, Aronson N. Radiofrequency ablation of unresectable primary liver cancer. J Am Coll Surg 2002; 194:813-28; discussion 828. [PMID: 12081073 DOI: 10.1016/s1072-7515(02)01180-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Jerome Seidenfeld
- Technology Evaluation Center, Blue Cross and Blue Shield Association, Chicago, IL 60601-7680, USA
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Tanaka N, Yamakado K, Nakatsuka A, Fujii A, Matsumura K, Takeda K. Arterial chemoinfusion therapy through an implanted port system for patients with unresectable intrahepatic cholangiocarcinoma--initial experience. Eur J Radiol 2002; 41:42-8. [PMID: 11750151 DOI: 10.1016/s0720-048x(01)00414-4] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Arterial chemoinfusion therapy through an implanted port system was performed for patients with unresectable intrahepatic cholangiocarcinoma (ICC). Eleven patients with unresectable ICC were studied. Seven patients had stage-IV disease, two had stage-III disease, and two had stage-II disease. The mean tumor size was 7.0+/-2.6 cm (range 3.8-13.5 cm). A catheter and port system was percutaneously implanted, and anticancer drugs featuring fluorouracil were administered via the infusion system every 1-2 weeks on the outpatient basis in all patients except 2. Arterial chemoinfusion therapy was repeated 12-84 times per patient (mean 51 times). Partial and minor responses were achieved in sevenents (64%). Disease was stable in two patients (18%), and progressed in the other two patients (18%). Tumor growth was controlled during a mean period of 14.5 months in seven responders and two patients with stable disease. The survival rates were 91% at 1 year, 51% at 2 years, 20% at 3 years, and 10% at 4 years, respectively. The mean survival period was 26 months. Toxicity such as cholangitis and pancytopenia was found in three patients (27%). This treatment seems to improve the prognosis of patients with unresectable ICC and deserves further studies.
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Affiliation(s)
- Naoshi Tanaka
- Department of Radiology, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan.
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Abstract
The liver is a common site of metastases from cancers from most sites, but particularly from the gastrointestinal tract, since the portal vein drains into the liver. About half of all patients with colorectal cancer develop liver metastases. The response of liver metastases to systemic combination chemotherapy has improved, but the 2-year survival is only 25-30%. Hepatic-arterial infusion of chemotherapy produces higher response rates, with a 2-year survival of 50-60%. In patients who can undergo liver resection followed by hepatic-arterial infusion, the 2-year survival is 85%. This review summarises the anatomical basis, pharmacokinetic background, and cost-effectiveness of this procedure. We discuss the phase II and phase III studies of hepatic-arterial infusion therapy, with a focus on liver metastases from colorectal cancer.
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Affiliation(s)
- N Kemeny
- Memorial Sloan-Kettering Cancer Center, Gastrointestinal Oncology Service, New York, NY 10021, USA.
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Abstract
Given the poor prognosis of HCC and the therapeutic challenge posed by underlying liver cirrhosis, efforts and resources must be directed towards preventive strategies. Return on the investment in such research is likely to be greater than can be expected from treatment of advanced disease.
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Affiliation(s)
- A Aguayo
- Department of Medical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas, USA
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Pohlen U, Berger G, Binnenhei M, Reszka R, Buhr HJ. Increased carboplatin concentration in liver tumors through temporary flow retardation with starch microspheres (Spherex) and gelatin powder (Gelfoam): an experimental study in liver tumor-bearing rabbits. J Surg Res 2000; 92:165-70. [PMID: 10896817 DOI: 10.1006/jsre.2000.5856] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Regional chemotherapy of primary and secondary malignant liver tumors is superior to systemic therapy. The regional advantage can be further increased by flow retardation. Absorbable gelatin powder (Gelfoam) and starch microspheres (Spherex) may serve as embolizing agents because of their particle size and embolization time. Carboplatin was for the first time applied as a cytostatic agent in regional chemotherapy. Embolization and flow retardation times were measured. The embolization time of Gelfoam was 27 min, and that of starch microspheres (Spherex), 7 min, on average. Mean flow retardation of Gelfoam was 153 min, and that of starch microspheres (Spherex) 38 min. The concentration differences in systemic and regional chemotherapy were determined in VX-2 liver tumor-bearing rabbits. In regional chemotherapy, the tumor concentration was increased by a factor of 3.6 compared with systemic therapy. Coapplication with an embolizing agent increased the tumor concentration of carboplatin by a factor of 44 to 47. Concentrations of absorbable gelatin powder (Gelfoam) and starch microspheres (Spherex) did not differ significantly.
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Affiliation(s)
- U Pohlen
- Department of Surgery, University Hospital Benjamin Franklin, Free University of Berlin, Hindenburgdamm 33, Berlin, D-12200, Germany
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Abstract
The battle against malignancies of the liver is far from over, although tremendous strides have been made in the past decade, such as improved diagnostic capabilities, safe surgical resection, availability of safe nonsurgical ablative modalities, multimodality therapy, and aggressive approach to recurrent disease. Even after the best attempts at curative treatment, recurrence of primary and secondary malignancies of the liver continues to be the cause of demise for more than 70% of treated patients. The battle continues in the laboratories, where investigations are focused on delineating the pathophysiology of cancer on the molecular and genetic levels and mapping the patterns of cancer emergence and spread. The new millennium holds promise for formulating therapies that may improve disease-free survival for patients with malignancies of the liver.
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Affiliation(s)
- J I Tsao
- Department of Surgery, Tufts University School of Medicine, Burlington, Massachusetts, USA
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Seong J, Keum KC, Han KH, Lee DY, Lee JT, Chon CY, Moon YM, Suh CO, Kim GE. Combined transcatheter arterial chemoembolization and local radiotherapy of unresectable hepatocellular carcinoma. Int J Radiat Oncol Biol Phys 1999; 43:393-7. [PMID: 10030267 DOI: 10.1016/s0360-3016(98)00415-5] [Citation(s) in RCA: 127] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE The best prognosis in hepatocellular carcinoma (HCC) can be achieved with surgical resection; however, the number of resected cases are limited due to advanced lesions or associated liver disease. The purpose of this study was to investigate the efficacy and toxicity of a prospective trial of combined transcatheter arterial chemoembolization (TACE) and local radiotherapy (RT) in unresectable HCC. METHODS AND MATERIALS Patients with histologically proven unresectable HCC due to either advanced lesions or associated cirrhosis were eligible. From March 1992 to August 1994, 30 patients were entered into this study. TACE was performed with Lipiodol (5 ml) and doxorubicin (Adriamycin ; 50 mg), followed by gelatin sponge particle (Gelfoam) embolization. Local RT was started within 7-10 days following TACE. Mean tumor dose was 44.0+/-9.3 Gy in daily 1.8 Gy fractions. Response was assessed by computerized tomography (CT) scan 4-6 weeks following completion of the treatment and then at 1-3-month intervals. Survival was calculated from the start of TACE using the Kaplan-Meier method. RESULTS An objective response was observed in 19 patients, giving a response rate of 63.3%. Distant metastasis occurred in 10 patients, with 8 in the lung only and 2 in both lung and bone. Survival rates at 1, 2, and 3 years were 67%, 33.3%, and 22.2%, respectively. Median survival was 17 months. There were 6 patients surviving more than 3 years. Toxicity included transient elevation of liver function tests in all patients, fever in 20, thrombocytopenia in 4, and nausea and vomiting in 1. There was no treatment-related death. CONCLUSION Combined TACE and local RT is feasible and tolerable. It gives a 63.3% response rate with median survival of 17 months. We feel that this regimen would be a new promising modality in unresectable HCC. Further study is required to compare the therapeutic efficacy of this regimen to TACE alone.
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Affiliation(s)
- J Seong
- Department of Radiation Oncology, Yonsei University Medical College, Seoul, Korea
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Oldhafer KJ, Frerker MK, Lang H, Fauler J, Flemming P, Schmoll E, Nadalin S, Moreno L, Pichlmayr R. High-dose mitomycin C in isolated hyperthermic liver perfusion for unresectable liver metastases. J INVEST SURG 1998; 11:393-400. [PMID: 9895113 DOI: 10.3109/08941939809032216] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
In order to reduce systemic side effects and increase intrahepatic mitomycin C (MMC) concentrations, isolated hyperthermic liver perfusion (IHLP) has been performed using MMC. This article describes the pharmacokinetics of MMC in IHLP and presents our clinical experience with its use in six patients suffering from unresectable liver metastases. Primary tumors consisted of colorectal carcinomas in three cases, breast cancer in two, and a choroidal melanoma in one. Dosages of MMC varied between 0.5 and 1.0 mg MMC/kg body weight. MMC was added as a bolus directly into the extracorporeal circuit. Intrahepatic temperature was elevated to 40.0-41.0 degrees C by hyperthermic perfusion. MMC concentrations were measured in peripheral blood (preperfusion, then at 5, 30, and 55 min during perfusion, and finally at 5 and 60 min and 6 and 24 h after perfusion) and in recirculating perfusate (5, 30, and 55 min). While markedly elevated MMC concentrations (maximum 6290 ng/mL) were found in the liver perfusate, systemic concentrations remained low (maximum 45 ng/mL), indicating no considerable leakage. MMC concentrations in the perfusate constantly decreased during perfusion. After rinsing with 1500 mL saline, a mean concentration of 52.5+/-33 ng MMC/mL was measured in the washout from 5 patients. In 1 patient with a colorectal carcinoma, MMC concentrations in the perfusion medium were 10-fold and in the plasma 2-fold higher than in the other patients. This high MMC concentration caused severe intrahepatic vascular damage and finally led to the patient's death. In conclusion, IHLP and intrahepatic perfusion with MMC resulted in a high response of hepatic tumors. Systemic exposure of MMC can be reduced effectively by isolated perfusion. However, hepatic toxicity of MMC must be considered.
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Affiliation(s)
- K J Oldhafer
- Department of Abdominal and Transplantation Surgery, Hannover Medical School, Germany
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Oldhafer KJ, Lang H, Frerker M, Moreno L, Chavan A, Flemming P, Nadalin S, Schmoll E, Pichlmayr R. First experience and technical aspects of isolated liver perfusion for extensive liver metastasis. Surgery 1998. [PMID: 9626312 DOI: 10.1016/s0039-6060(98)70200-4] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND New drugs and modalities for locoregional tumor treatment in recent years may offer new potential for isolated liver perfusion in patients with nonresectable liver tumors. The purpose of this study was to prove the feasibility of arterial isolated liver perfusion and to assess the tolerance of perfusion with high-dose tumor necrosis factor (TNF). METHODS Twelve patients with extensive liver metastases previously treated unsuccessfully with systemic chemotherapy underwent isolated hyperthermic liver perfusion using a heart-lung machine. High doses of mitomycin were administered in the first six and a combination of TNF and melphalan in the last six patients. RESULTS No operative death occurred and no direct postoperative liver failure was observed in any patient. In cases of variations of the arterial hepatic blood supply, the perfusion was done through the splenic artery or an angiography catheter. Histologic analysis of tumor biopsy specimens obtained on the first postoperative day revealed major tumor necrosis in 8 of 12 patients. CONCLUSIONS Isolated arterial perfusion of the liver is a complex surgical procedure that is feasible in patients with anatomic variations of the hepatic artery. The remarkable histologic response to perfusion in several pretreated patients, especially after application of high-dose TNF and melphalan, suggests that this modality is very effective in tumor killing.
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Affiliation(s)
- K J Oldhafer
- Department of Abdominal and Transplantation Surgery, Hannover Medical School, Germany
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35
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Ku Y, Iwasaki T, Fukumoto T, Tominaga M, Muramatsu S, Kusunoki N, Sugimoto T, Suzuki Y, Kuroda Y, Saitoh Y, Sako M, Matsumoto S, Hirota S, Obara H. Induction of long-term remission in advanced hepatocellular carcinoma with percutaneous isolated liver chemoperfusion. Ann Surg 1998; 227:519-26. [PMID: 9563540 PMCID: PMC1191307 DOI: 10.1097/00000658-199804000-00012] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The aim of this study was to report the long-term results of percutaneous isolated liver chemoperfusion with hepatic venous isolation and charcoal hemoperfusion (HVI-CHP) in patients with multiple advanced hepatocellular carcinoma (HCC). SUMMARY BACKGROUND DATA The results of conventional chemotherapy including regional and systemic chemotherapy in patients with HCC remain dismal, and long-term survivors after treatment are rare among patients with multiple advanced HCC. In an effort to improve this situation, we previously developed a novel system of percutaneous isolated liver chemoperfusion with HVI-CHP. METHODS Doxorubicin (60 to 150 mg/m2) was administered via the hepatic artery, under conditions of extracorporeal drug elimination by HVI-CHP in 28 consecutive patients with advanced HCC (39 total treatments). Hepatic venous isolation and charcoal hemoperfusion was accomplished mainly by the single catheter technique using a newly developed 4-lumen-balloon catheter, which was used to isolate and capture total hepatic venous outflow and, at the same time, to direct the filtered blood to the right atrium. RESULTS Complete remission was achieved in five patients, of which four received repeated treatments (two or three times). Although 1 of 5 patients with complete remission died of pulmonary metastases at 8 months, the other 4 remain healthy and free of disease at 20, 24, 27, and 42 months after the first treatment. Partial responses were observed in 12 patients. Duration of response in responders (complete and partial) with repeated treatments was significantly longer than that with a single treatment (p = 0.01). The overall survival rate by the Kaplan-Meier method was 39.7% at 5 years. The treatments were well-tolerated, and the primary side effects were mild to moderate chemical hepatitis and reversible myelosuppression. CONCLUSIONS The results suggest that percutaneous isolated liver chemoperfusion with HVI-CHP is an effective palliative treatment in the majority of patients and yields long-term complete remission in some patients with multiple advanced HCC.
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Affiliation(s)
- Y Ku
- Department of Surgery I, Kobe University School of Medicine, Japan
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36
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Abstract
The evolution of hepatic cryotherapy as an accepted treatment for patients with non-resectable hepatic malignancy has required concurrent evaluation and development of perioperative anesthetic management of these cases. Review of published and institutional experience demonstrates that hepatic cryotherapy presents the anesthesiologist with an array of challenges, all of which are not intuitively apparent. Specifically, such issues as management of coexisting physiologic perturbations of the oncology patient, heat conservation during the procedure, and readiness for a more extensive procedure would be readily anticipated by most clinicians. Description and reasonable management of problems ranging from mild or moderate postoperative thrombocytopenia to the so-called cryoshock syndrome with the possibility of severe postoperative coagulopathy, renal dysfunction, and pulmonary complications, however, could emerge only with the education of experience. The goal of this article is to address the key issues faced by anesthesiologists consulted in the perioperative care of patients undergoing hepatic cryotherapy.
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Affiliation(s)
- K Littlewood
- Department of Anesthesiology, Virginia Commonwealth University, Richmond 23298-0459, USA.
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37
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Affiliation(s)
- G Falkson
- Department of Medical Oncology, Faculty of Medicine, University of Pretoria, Republic of South Africa
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38
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Sakai Y, Izumi N, Tazawa J, Yoshida T, Sakai H, Yauchi T, Hattori K, Tozuka S, Marumo F, Sato C. Treatment for advanced hepatocellular carcinoma by transarterial chemotherapy using reservoirs or one-shot arterial chemotherapy. J Chemother 1997; 9:347-51. [PMID: 9373790 DOI: 10.1179/joc.1997.9.5.347] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
A prospective trial was performed in patients with advanced hepatocellular carcinoma to assess the therapeutic efficacy of transcatheter arterial chemotherapy using implanted reservoirs (12 patients) or conventional transcatheter arterial chemotherapy (8 patients). Epirubicin at a dose of 40 mg/m2 was given every month in the former, while epirubicin at a dose of 60 mg/m2 was administered every 3 months in the latter. During the 6 months from the introduction of these therapies, hospitalized periods were shorter and total hospital costs were less in the reservoir group than in the conventional chemotherapy group (p < 0.05 and p < 0.01, respectively). Transcatheter arterial chemotherapy using implanted reservoirs can be carried out on a day-care basis and may be beneficial for the treatment of patients with advanced hepatocellular carcinoma.
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Affiliation(s)
- Y Sakai
- Second Department of Internal Medicine, Faculty of Medicine, Tokyo Medical and Dental University, Japan
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39
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Venook AP, Warren RS. Regional Chemotherapy Approaches for Primary and Metastatic Liver Tumors. Surg Oncol Clin N Am 1996. [DOI: 10.1016/s1055-3207(18)30391-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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40
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Sutanto-Ward E, Arisawa Y, Tremiterra S, Sigurdson ER. Regional chemotherapy for colorectal hepatic metastases: evidence for improved survival with new drug combinations. Ann Surg Oncol 1996; 3:36-43. [PMID: 8770300 DOI: 10.1007/bf02409049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND In patients with colorectal hepatic metastases, response rates with hepatic arterial infusion (HAI) FUdR (5-Fluoro-2-deoxyuridine) are significantly higher than with systemic fluoropyrimidines. We report a novel animal model of intrahepatic therapy for hepatic metastasis for the study of methods to increase response rates and improve survival. METHODS. BD-IX rats are injected intrasplenically with K12/TRb cells. When hepatic metastases are established, animals are treated with hepatic or systemic chemotherapy, and the response to treatment, survival, and cause of death is determined. RESULTS Significant responses were observed with low- and high-dose HAI FUdR (p = 0.03 and 0.001, respectively). Only high-dose FUdR controlled hepatic disease. HAI FUdR alone did not prolong survival compared with control, but combination systemic FUdR and HAI FUdR did (p = 0.04). Continuous HAI of either 5-fluorouridine or mitomycin C has not previously been reported. There was no significant difference in response to FUdR, 5-fluorouridine, or mitomycin C. However, combination HA bolus mitomycin C plus either HAI 5-fluorouridine or HAI mitomycin C showed synergy with improved survival compared with all treatment groups (p < 0.0001). CONCLUSIONS The combination of bolus hepatic artery mitomycin C with either HAI mitomycin C or HAI 5-fluorouridine yields significant response rates, and survival is improved by this novel combination therapy.
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Affiliation(s)
- E Sutanto-Ward
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania 19111, USA
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41
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Venook AP, Ferrell LD, Roberts JP, Emond J, Frye JW, Ring E, Ascher NL, Lake JR. Liver transplantation for hepatocellular carcinoma: results with preoperative chemoembolization. LIVER TRANSPLANTATION AND SURGERY : OFFICIAL PUBLICATION OF THE AMERICAN ASSOCIATION FOR THE STUDY OF LIVER DISEASES AND THE INTERNATIONAL LIVER TRANSPLANTATION SOCIETY 1995; 1:242-8. [PMID: 9346574 DOI: 10.1002/lt.500010409] [Citation(s) in RCA: 52] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
At the University of California, San Francisco, 17 patients who met the following criteria-hepatic tumor unresectable because of location or inadequate liver reserve, no metastases, HBsAg negative, no tumor larger than 5 cm in diameter, and no more than three tumors--were enrolled prospectively in a protocol employing preoperative chemoembolization to assess whether orthotopic liver transplantation (OLT) could cure a majority of highly selected patients with hepatocellular carcinoma (HCC). Thirteen patients had biopsy-proven HCC, 2 had the fibrolamellar variant, and 2 had radiological findings of HCC but no biopsy confirmation. Fourteen had underlying liver disease. All arteriographically apparent lesions were chemoembolized using a mixture including Gelfoam powder, doxorubicin, mitomycin-c, and cisplatin. Eight patients with poor hepatic reserve were chemoembolized when a donor organ became available, whereas 9 patients were chemoembolized and then placed on the waiting list. The only complication of chemoembolization was a gangrenous gallbladder in 1 patient. Thirteen patients underwent liver transplantation (2 patients without prior histological confirmation of carcinoma had no identifiable tumor at OLT); 3 patients developed metastases between the time of enrollment and donor organ availability and subsequently died; and 1 patient underwent a trisegmentectomy. Ten of the 11 patients with biopsy-proven HCC who underwent transplantation remain free of recurrent cancer at a median of 40 months; 1 patient died at 6 months of lymphoproliferative disease with no cancer found at autopsy. Although the role of chemoembolization is uncertain, these data show that the majority of carefully selected patients with HCC may achieve long-term survival with OLT.
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Affiliation(s)
- A P Venook
- Department of Medicine, University of California, San Francisco, USA
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Lau WY, Leung TW, Ho S, Chan M, Leung NW, Lin J, Metreweli C, Li AK. Diagnostic pharmaco-scintigraphy with hepatic intra-arterial technetium-99m macroaggregated albumin in the determination of tumour to non-tumour uptake ratio in hepatocellular carcinoma. Br J Radiol 1994; 67:136-9. [PMID: 8130973 DOI: 10.1259/0007-1285-67-794-136] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Between October 1990 and March 1993, 124 patients who had hepatocellular carcinoma (HCC) underwent diagnostic pharmaco-scintigraphy with hepatic intraarterial technetium-99m macroaggregated albumin (TcMAA) to determine the tumourous to non-tumourous liver tissue uptake ratio (T/N ratio). There were 110 males and 14 females. Ages ranged from 16 to 73 with a median of 55 years. The range of T/N ratio was 0.7 to 19.3 with a median of 3.8. 12 patients with inoperable HCC were subsequently selected by predetermined criteria to undergo treatment with hepatic intraarterial yttrium-90 microspheres and the T/N ratios in these patients were validated by beta probe dosimetry and liquid scintillation count of multiple liver biopsies. The T/N ratio determined by preoperative diagnostic TcMAA scan correlated well with intraoperative beta probe dosimetry, with coefficient of correlation r = 0.82. Preoperative TcMAA scan also correlated well with liquid scintillation count of biopsy specimens, with r = 0.96. We conclude that TcMAA scan can be used to determine the T/N ratio in patients with HCC, thus allowing better selection of patients with inoperable tumours for loco-regional therapy.
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Affiliation(s)
- W Y Lau
- Joint Hepatocellular Carcinoma Study Group, Prince of Wales Hospital, Shatin, New Territories, Hong Kong
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