Hepatic arterial floxuridine and leucovorin for unresectable liver metastases from colorectal carcinoma. New dose schedules and survival update

Intra-arterial therapy for unresectable colorectal liver metastases: A meta-analysis

PURPOSE

To evaluate the efficacy of hepatic arterial infusion (HAI), conventional trans-arterial chemoembolization (cTACE), drug-eluting embolic trans-arterial chemoembolization (DEE-TACE), trans-arterial radioembolization (TARE) and their combinations with systemic chemotherapy (SCT) for unresectable colorectal liver metastases.

METHODS

A search was conducted on EMBASE, Scopus, PubMed and Web of Science for prospective non-randomized studies and randomized controlled trials (RCTs) from inception to 20^th June 2020. Survival data of patients were recovered from original Kaplan-Meier curves by exploiting a graphical reconstructive algorithm. One-stage meta-analyses were conducted for median overall survival (OS), survival rates (SR), and restricted mean survival time (RMST), while two-stage meta-analyses of proportions were conducted to determine response rates (RR) and conversion-to-resection rates (CRR).

RESULTS

71 prospective non-randomized studies and 21 RCTs were identified comprising 6,695 patients. Among patients treated beyond first line, DEE-TACE+SCT (n=152) had the best survival outcomes of median OS of 26.5 (95%-CI: 22.5-29.1) months and 3-year RMST of 23.6 (95%-CI: 21.8-25.5) months. Upon further stratification by publication year, DEE-TACE+SCT appears to consistently have the highest pooled survival rates at 1-year (81.9%) and 2-years (66.1%) in recent publications (2015-2020). DEE-TACE+SCT and HAI+SCT had the highest pooled-RRs of 56.7% (I²=0.90) and 62.6% (I²=0.87) respectively and pooled-CRRs of 35.5% (I²=0.00) and 30.3% (I²=0.80) respectively.

CONCLUSION

Albeit significant heterogeneity, paucity of high-quality evidence and the non-comparative nature of all analyses, the overall evidence suggests that patients treated with DEE-TACE+SCT may have the best oncological outcomes and greatest potential to be converted for resection.

New Trends in the Surgical Treatment of Colorectal Cancer Liver Metastases

Colorectal cancer is one of the most common solid tumors affecting people around the world. A significant proportion of patients with colorectal cancer will develop or will present with liver metastases. In some of these patients, the liver is the only site of metastatic disease. Thus, surgical treatment approaches are an appropriate and important treatment option in patients with liver-only colorectal cancer metastases. Resection of colorectal cancer liver metastases can produce long-term survival in selected patients, but the efficacy of liver resection as a solitary treatment is limited by two factors. First, a minority of patients with liver metastases have resectable disease. Second, the majority of patients who undergo successful liver resection for colorectal cancer metastases develop recurrent disease in the liver, extrahepatic sites, or both. In this paper, in addition to the results of liver resection for colorectal cancer metastases, we will review the results of cryoablation, heat ablation, and hepatic arterial chemotherapy using a surgically implanted pump. Each of these surgical treatment modalities can produce long-term survival in a subset of patients with liver-only colorectal cancer metastases, whereas systemic chemotherapy used alone rarely results in long-term survival in these patients. While surgical treatments provide the best chance for long-term survival or, in some cases, the best palliation in patients with colorectal cancer liver metastases, it is clear that further improvements in patient outcome will require multimodality therapy regimens.

Long-term results of hepatectomy after hepatic arterial infusion chemotherapy for initially unresectable hepatic colorectal metastases

BACKGROUND

The prognosis of unresectable hepatic colorectal metastases is poor even if chemotherapy is administered. The purpose of this study was to evaluate the long-term efficacy of hepatic arterial infusion (HAI) chemotherapy and hepatectomy following HAI for such condition.

METHODS

Seventy-two patients with unresectable hepatic colorectal metastases received continuous HAI of 5-fluorouracil.

RESULTS

The overall response rate was 38%. The median survival of all patients was 18 months. The overall 3-year survival rate was 18%. Seven patients (10%) survived more than 58 months. Of the eight patients with a complete response, seven developed liver and/or lung metastases, and of these, one patient undergoing additional hepatectomy has been disease-free and the other six receiving chemotherapy died of disease. Another complete-response case died of liver abscess. Of the 19 patients with a partial response, six could undergo hepatectomy after HAI. The overall 5-year survival rate of seven patients undergoing hepatectomy was 71%, whereas for patients without hepatectomy, the rate was 0%.

CONCLUSIONS

Most patients showing response after HAI for unresectable hepatic colorectal metastases had relapses. The long-term prognosis of patients undergoing hepatectomy after HAI was favorable. Therefore, when HAI makes liver metastases resectable, they should be resected.

Clinical Utility of Coaxial Reservoir System for Hepatic Arterial Infusion Chemotherapy

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.

A Complication-Free Course Ensures a Survival Advantage in Patients after Regional Therapy for Metastatic Colorectal Cancer

Hepatic artery infusional (HAI) chemotherapy has been shown to favorably impact outcome in patients with metastatic colorectal cancer, but complications often preclude complete treatment. The purpose of this study was to determine whether HAI complications impact survival in these patients. Patients undergoing HAI pump placement at our institution from September 2001 to July 2004 were separated into terciles based on the number of treatments completed: ≤1 (none), 2 to 4 (partial), and ≥5 (complete). Complications relating to pump placement or treatment were recorded for each and their impact on survival was determined. Kaplan-Meier survival in 15 patients receiving no treatment was significantly shorter than 7 patients completing therapy (P = 0.02). Thirty-three per cent of patients receiving no therapy were alive at 26 months, whereas 63 per cent of partially and 86 per cent of completely treated patients were alive at 32 and 30 months, respectively. Patients receiving no treatment had more overall complications (80%) and significantly (P < 0.05) more pump-related complications (60%) than those completing therapy (43% and 0%, respectively). Cox regression revealed a significant correlation to gender (hazard ratio, 3.9), tumor size (hazard ratio, 1.17), and carcinoembryonic antigen level (hazard ratio, 1.02) to survival. Patients receiving complete HAI treatment survive longer than those receiving no treatment. Potentially preventable pump-related complications not only impacted the patients’ ability to continue therapy, but survival times as well.

Laparoscopic hepatic artery catheterization for regional chemotherapy

BACKGROUND

Metastatic disease isolated to the liver is present at the time of diagnosis in 20-30% of patients with colorectal cancer. Only 10% of patients are eligible for resection. Systemic chemotherapy remains the primary treatment modality for such patients. The morbidity associated with regional chemotherapy is largely a result of the laparotomy required to place a hepatic arterial infusion pump in these debilitated patients. We discuss the main advantages of laparoscopic approach in comparison to both open procedure and percutaneous hepatic artery catheterization.

MATERIAL AND METHODS

From November 1993 to April 2004, 27 patients (16 males, 11 females) underwent laparoscopic placement of a hepatic artery catheter. The mean age was 64.9 years (46 to 82 years). 24 patients (88.8%) had bilobar disease precluding surgical resection of the liver metastases. There were four cases of non-colon cancers, all with liver metastases.

RESULTS

LHAC alone averaged 45-55 minutes. Mean blood loss of 151 cc (20-300 cc). Postoperatively, 16 patients (59.2%) had hepatic intra-arterial chemotherapy in the recovery room as a preplanned protocol. Average hospital stay was 8.4 days (3-25 days). Median follow-up period of 8.1 months. 22 patients with residual hepatic disease, in whom chemotherapy was successfully instituted, showed regression of their metastases, in 18 patients, CEA had improved at their one-month follow-up visit. Three complications: one catheter thrombosis, one partial catheter occlusion and one eroded catheter into the duodenum one year after.

CONCLUSIONS

In experienced hands, laparoscopic hepatic artery catheterization is a safe, feasible and minimally invasive technique for those patients with metachronous liver malignancies.

The Past Decade of Experience With Isolated Hepatic Perfusion

Metastatic or primary unresectable cancers confined to the liver are the sole or life-limiting component of disease for many patients with colorectal cancer, ocular melanoma, neuroendocrine tumors, or primary colangio- or hepatocellular carcinomas. Regional treatment strategies including infusional chemotherapy and local ablative therapy are under investigation, but have limitations with respect to the clinical conditions under which they can be employed. Isolated hepatic perfusion (IHP) was first clinically applied over 40 years ago, but because of its technical complexity, the attendant potential morbidity, and the lack of documented efficacy, it has not enjoyed consistent or widespread evaluation. In light of the antitumor activity with isolated limb perfusion with tumor necrosis factor (TNF) and melphalan in patients with unresectable extremity sarcoma or in transit melanoma, this regimen has been administered via IHP at several centers worldwide for patients with unresectable liver cancers. IHP with TNF and melphalan can result in significant regression of advanced refractory cancers from multiple histologies confined to the liver. Patient selection is important to ensure good results with minimal morbidity and mortality. Work to define the appropriate clinical groups is ongoing at many clinical centers.

Regional therapy of liver metastases

Liver metastases usually represent disseminated cancer; therefore, systemic chemotherapy is always appropriate. However, in some instances, the liver is the only site of metastasis and regional control of liver tumors may have important palliative and survival benefits, including a possibility of cure in selected patients. This review identifies unique patient subgroups that may benefit from regional therapy of liver metastases, and considers different treatment options and when these different options may be indicated.

Hepatic arterial infusion chemotherapy for metastatic colorectal cancer: a concise overview

Patients with colorectal cancer commonly succumb to the sequelae of hepatic metastases. Response to systemic therapy is inadequate. Hepatic arterial infusion (HAI) exposes liver metastases to high local concentrations of drug. Herein, we review the randomized trials of HAI in colorectal cancer. Data for this review were identified by searches of MEDLINE and references from relevant articles using the search terms "infusion intra-arterial" and "colorectal cancer." Abstracts and reports from meetings were included only when they related directly to previously published work. Only papers published in English between 1966 and 2003 were included. Randomized trials (5-fluorouracil- (5-FU-) or fluordeoxyuridine- (FUDR-) based regimens) often demonstrated superior response rates for HAI as compared to systemic chemotherapy (primary treatment or post-resection). Enhanced survival has, however, shown only when HAI was combined with systemic chemotherapy in the post-resection setting. For 5-FU-based and perhaps other regimens, randomized trials of combined regional and systemic therapy versus systemic treatment alone may be needed in order to determine whether or not there is a survival advantage after HAI in unresectable patients, as has been recently demonstrated in resectable patients. A variety of agents other than 5-FU have also been given by HAI to patients with liver metastases from diverse cancers. Such regional therapy often yields encouraging response rates and impact on survival therefore merits investigation.

True versus mild hyperthermia during isolated hepatic perfusion: effects on melphalan pharmacokinetics and liver function

Hyperthermic antiblastic isolated hepatic perfusion (IHP) with melphalan has been recently proposed as an alternative therapeutic option for patients with unresectable liver tumors. Although melphalan-heat antiblastic synergism is at a maximum at temperatures higher than 41 degrees C, IHP has so far been performed in humans at lower temperatures. In this experimental work, we compared IHP under mild versus true hyperthermic conditions in terms of drug pharmacokinetics and liver function. Ten pigs were submitted to IHP with melphalan 1.5 mg/kg at a mean temperature of 40 degrees C (group A, n = 5) or 42 degrees C (group B, n = 5). After a 60-minute perfusion, a 15-minute washout was performed. Perfusate-to-plasma leakage was monitored using scintigraphy. Throughout perfusion, samples from the systemic blood, perfusate, and liver parenchyma were obtained to measure melphalan concentrations. Liver function was assessed using standard blood tests and the indocyanine green-based test. No deaths related to the IHP procedure were recorded. All animals had transient liver function impairment, with all liver function test results returning to normal within the observation period. At histologic examination, liver damage was similar under both hyperthermic conditions. Melphalan levels in the perfusate were not significantly different in the two study groups (the mean perfusate/plasma area under the curve from 0 to 60 minutes ratios were 463 and 501, respectively). These results correlated well with those obtained using the scintigraphic method. Liver drug concentrations remained unchanged after true hyperthermia IHP. Under true hyperthermic conditions, neither an increase in liver parenchyma toxicity nor changes in melphalan pharmacokinetics were observed. These findings support the use of true hyperthermia in the clinical setting to exploit fully the antitumor synergism between melphalan and heat.

Complications After Percutaneous Transaxillary Implantation of a Catheter for Intraarterial Chemotherapy of Liver Tumors:Clinical Relevance and Management in 204 Patients

OBJECTIVE

The purposes of the study were to evaluate the complications of patients who underwent percutaneous transaxillary implantation of a permanent catheter-port system for intraarterial hepatic chemotherapy and determine their clinical relevance and specific management. SUBJECTS AND METHODS. Catheter-port systems were placed in 204 patients with liver tumors (86.7% from colorectal metastases). Under sonographic and fluoroscopic guidance, a 5.8-French catheter was placed in the hepatic artery and connected to a subcutaneous reservoir after embolization of the gastroduodenal and right gastric arteries. Floxuridine plus dexamethasone and systemic low-dose heparin were administered. During the follow-up period, complications were classified as clinically not significant (type 1), clinically significant not requiring interruption of intrahepatic chemotherapy (type 2), clinically significant needing temporary suppression of intrahepatic chemotherapy (type 3), and clinically significant causing permanent suppression of intrahepatic chemotherapy (type 4).

RESULTS

No complications occurred during the implantation procedures. The mean number of intrahepatic chemotherapy cycles was 8.1. The mean follow-up period was 270 days. Primary and secondary patency rates of the system were 71.6% and 91.2%, respectively. Temporary suppression of intrahepatic chemotherapy was necessary in 19.6% of the patients and definitive suppression, in 8.8%. Hepatic artery thrombosis, not recanalized by local thrombolysis, was the main cause of permanent intrahepatic chemotherapy interruption (4.4%). Catheter occlusions and cerebral complications were not observed. In 91.2% of the patients, intrahepatic chemotherapy could be completed.

CONCLUSION

Percutaneous implantation of a removable and reimplantable catheter-port system for intrahepatic chemotherapy can be a safe procedure to treat unresectable liver metastases from colorectal cancer. Technical and pharmacologic complications with variable clinical relevance occurred, and various specific management strategies were necessary to reduce their incidence.

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

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

Effects of Dexamethasone or Celecoxib on Biliary Toxicity after Hepatic Arterial Infusion of 5-Fluorodeoxyuridine in a Canine Model

Previous work has shown that in humans the dose-limiting toxicity for fluorodeoxyuridine [2-fluoro-5'-deoxyuridine (FdUrd)] when administered by hepatic arterial infusion is biliary sclerosis. The current study was undertaken to attempt to modify this toxicity in a canine model that has been demonstrated to closely mimic the clinical situation. Unlike previous studies using this model, in which animals were sacrificed after extensive fibrosis had already occurred, the current experiments were designed so that observations of pathology were made at an earlier time, when the initial inflammatory injury underlying the fibrotic process was still taking place. Implantable pumps were used to deliver FdUrd into the hepatic artery of animals at a rate of 0.3 mg/kg/day in the presence or absence of 10 mg/week dexamethasone or 100 mg/day of celecoxib for 35 days, at which time the animals were beginning to show signs of toxicity. After evaluation for radiological evidence of biliary obstruction, the animals were sacrificed and portions of their livers were processed for examination of microscopic pathology and 2-bromo-5'deoxyuridine labeling index. Dexamethasone treatment protected the animals from biliary sclerosis determined radiologically, further validating this model as being representative of the response in humans. Similarly the Cox-2 inhibitor, celecoxib, appeared to provide protection against radiological changes of biliary stricture, although possibly to a lesser degree than the resultant from dexamethasone. In addition, FdUrd treatment caused elevation of the DNA 2-bromo-5'deoxyuridine labeling index above control levels in biliary epithelial cells. Dexamethasone and celecoxib each significantly attenuated the FdUrd-induced elevation of DNA labeling index in biliary epithelium. These findings demonstrate the usefulness of this canine model for studying the mechanisms of drug-induced biliary sclerosis and reinforce the hypothesis that blocking inflammation may retard the progression of injury that eventually leads to fibrosis. This study suggests that clinical testing of celecoxib as a preventive for hepatic arterial-FdUrd induced biliary damage could prove valuable.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Isolated liver perfusion for non-resectable liver tumours: a review

Many treatments have been proposed for non-resectable primary or secondary hepatic cancer but the results have generally been disappointing. Isolated Hepatic Perfusion (IHP) was first attempted four decades ago but it gained acceptance only recently, after spectacular tumour responses were obtained by isolated limb perfusion with melphalan and tumour necrosis factor (TNF) for melanomas and sarcomas. Surgical isolation of the liver is a technically demanding operation that allows the safe administration of high doses of chemotherapeutics and TNF. Percutaneous techniques using balloon occlusion catheters are simpler but result in higher leakage rates from the perfusion circuit into the systemic circulation. Several phase I-II trials indicate that IHP can yield high tumour response rates, even when there is resistance to systemic chemotherapy. However, no significant advantage in overall survival has been demonstrated so far. IHP offers unique pharmacokinetic advantages for locoregional chemotherapy and biotherapy. It might also allow gene therapy with limited systemic exposure and toxicity. At present, IHP nevertheless remains an experimental treatment modality which should therefore be used in controlled trials only.

Genetic detection of liver micrometastases that are undetectable histologically

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Intrahepatic arterial infusion of chemotherapy: pharmacologic principles

Hepatic arterial (HA) infusional chemotherapy possesses a number of constraints not found with systemic chemotherapy. The drug used should have activity in a dose-responsive way without significant hepatic toxicity. The drug must also possess suitable pharmacokinetic properties, namely, a high total body clearance and hepatic extraction, so as to generate high hepatic and low systemic exposures. Of the drugs examined for HA use, 5-fluoro-2'-deoxyuridine (FUDR, floxuridine) demonstrates the best properties. In HA infusional therapy, the catheter is positioned to deliver drug directly to the liver only and must be connected to a reliable pumping mechanism. Surgical implantation of catheters and pumps provides a safe and reliable means to infuse HA FUDR. HA FUDR delivery via an implanted system in the treatment of colorectal liver metastases represents the largest application of HA therapy and provides a basis for future advances when combined with other regional and systemic treatments.

Isolation perfusion of the liver

Thousands of patients die annually from unresectable metastatic or primary hepatic cancers confined to liver. Isolated hepatic perfusion (IHP) is a regional treatment strategy in which the vascular supply to the liver is isolated and perfused with a therapeutic regimen using an extracorporeal circuit consisting of a reservoir, heat exchanger, and oxygenator. Drug doses that would cause severe toxicities if delivered systemically can be confined to the liver by isolated hepatic perfusion, resulting in the ability to intensify treatment to the cancer-burdened region of the body. Agents and mechanisms commonly used in IHP include melphaIan, hyperthermia, and tumor necrosis factor. IHP appears to be efficacious for patients with advanced disease, as reflected by large tumor size, high number of lesions, or significant overall tumor burden in the liver. In addition, responses are observed for patients whose cancer is refractory to systemic and hepatic arterial infusion chemotherapy. Recent clinical trials have demonstrated that IHP has anti-tumor efficacy against primary hepatic neoplasms and metastases from various primary tumors, such as colorectal carcinoma, ocular melanoma, and neuroendocrine tumors. Current studies demonstrate that combining hepatic arterial infusion with floxuridine after IHP for patients with colorectal cancer metastases is associated with significant and durable response rates. Continued clinical evaluation is warranted for the use of IHP in the treatment of unresectable liver metastases.

Protracted hepatic arterial infusion with low-dose cisplatin plus 5-fluorouracil for unresectable liver metastases from colorectal cancer

BACKGROUND

Hepatic arterial infusion (HAI) chemotherapy is a treatment option for unresectable liver metastases from colorectal cancer, but it is not yet a standard treatment. The aims of this study were to demonstrate the efficacy of protracted HAI chemotherapy with low-dose cisplatin plus 5-fluorouracil for patients with unresectable liver metastases from colorectal cancer.

METHODS

Twenty-two patients with unresectable liver metastases from colorectal cancer were treated with continuous HAI of 300 mg/m2 5-fluorouracil for 5 days a week and 6 mg/m2 cisplatin for 2 hours on 5 consecutive days a week. The plasma concentrations of cisplatin and 5-fluorouracil during the treatment were measured for a pharmacokinetic study.

RESULTS

Of the 22 patients, 2 had a complete response, 13 had a partial response, 6 had stable disease, and 1 had progressive disease, and the response rate was 68% (15/22). The median survival time was 17 months, and 1-, 2-, and 3-year survival rates were 59%, 26%, and 13%, respectively. Progressive disease was the reason for treatment discontinuation in 10 (45%) of the 22 patients, and 9 (41%) patients had to stop the treatment because of complications. Systemic toxicity was minimal. The pharmacokinetic study showed a high degree of hepatic extraction for both cisplatin and 5-fluorouracil during the treatment.

CONCLUSIONS

The treatment regimen described herein thus appears to be efficacious regarding the tumor response and survival for patients with unresectable liver metastases from colorectal cancer.

Regional chemotherapy of nonresectable colorectal liver metastases with mitoxantrone, 5-fluorouracil, folinic acid, and mitomycin C may prolong survival

BACKGROUND

Regional chemotherapy of isolated, nonresectable colorectal liver metastases (CRLMs) by hepatic artery infusion (HAI) has the advantages of high response rates and the possibility of downstaging and resection of CRLMs. 5-Fluorodeoxyuridine (5-FUDR) has been the drug studied in most Phase II and III trials. The meta-analysis of the Phase III trials comparing HAI with systemic or supportive therapy confirmed an advantage for response and even survival for HAI. Hepatic artery infusion with 5-FUDR, however, is hepatotoxic, inducing sclerosing cholangitis (SC). The authors have introduced 5-fluorouracil (5-FU) with folinic acid for HAI and found equal effectivity but no SC when compared with HAI with 5-FUDR. Now, they report a new combination chemotherapy protocol based on HAI with 5-FU with FA and on in vitro Phase II studies suggesting mitoxantrone and mitomycin C as active drugs for HAI in CRLM. PATIENTS AND METHODS Between February 1993 and August 2000, 63 patients with CRLM were treated with HAI using mitoxantrone, 5-FU with FA, and mitomycin C (MFFM) via port catheters with a protocol planing up to 11 cycles of treatment. Toxicity and response were analyzed according to World Health Organization (WHO) criteria, and survival was analyzed according to Kaplan-Meier. All patients were treated with more than two HAI cycles.

RESULTS

The objective response rate (complete remission and partial remission) was 54% and primary intrahepatic progression (progressive disease) occurred in 4.8%, whereas in 41.3% of the patients the intrahepatic disease was evaluated as no change. Median survival times from the first diagnosis of CRLM or start of HAI were 25.7 months and 23.7 months, respectively, and 7 patients lived longer than 40 months. Grade 3 toxicity according to WHO occurred in 34.9%, and Grade 4 occurred in 3.2%. No toxic death or SC occurred.

CONCLUSIONS

Our new HAI protocol with MFFM seems to be superior to HAI with 5-FUDR, 5-FU with FA, and systemic chemotherapy with 5-FU and FA at acceptable toxicity. Currently, HAI with MFFM is compared with systemic chemotherapy using 5-FU and FA intravenously in a randomized Phase III trial.

Review article: non-systemic chemotherapy in the treatment of colorectal cancer-portal vein, hepatic arterial and intraperitoneal approaches

Loco-regional chemotherapy, an alternative to systemic chemotherapy in the management of colorectal cancer, has been evaluated in both adjuvant and palliative settings. The rationale for loco-regional delivery is to achieve higher dose concentrations of drugs at the tumour site or at the most common sites of tumour recurrence, while limiting systemic exposure and associated toxicity. Adjuvant intraportal chemotherapy and palliative hepa-tic arterial chemotherapy have been most extensively investigated. Intraperitoneal chemotherapy has also been studied as an adjuvant treatment after complete resection of colorectal cancer or cytoreductive surgery in patients with established peritoneal carcinomatosis. The results obtained have been disappointing, and none of these procedures can be considered as a standard therapeutic option today. However, methodological difficulties were encountered in most published studies, and the investigated schedules and doses may not have been optimal. New combinations of cytotoxic drugs and new indications are currently under consideration. Promising results have recently been published for adjuvant intraperitoneal chemotherapy and hepatic arterial chemotherapy following surgical resection of hepatic metastases, but additional well-designed multicentre phase III trials are needed to determine the true benefits of these treatment modalities and to address the issues of cost and quality of life.

Intraarterial chemotherapy of liver metastases: implantation of a microcatheter-port system with use of modified fixed catheter tip technique

A new method was developed to implant a microcatheter-port system for repeat intraarterial chemotherapy of liver metastases. The microcatheter-port system was successfully implanted in all 20 patients reported in this study, and the only complications were one early occlusion of the hepatic artery and one dislocation of the implanted catheter.

Combined regional and systemic chemotherapy by a mini-invasive approach for the treatment of colorectal liver metastases

From February 1996 to December 1998, 95 patients affected with colorectal liver metastases underwent the positioning of an intraarterial hepatic catheter by a transcutaneous subclavian access, under local anesthesia. All patients were evaluated for catheter implantation complications. Moreover, 61 patients of 95 treated at our center were retrospectively evaluated for results of chemotherapy performed with two different schedules of hepatic artery infusion (HAI) combined with systemic chemotherapy (SC). Eleven patients (group A) were treated with combined SC (5-fluorouracil continuous infusion) and HAI (floxuridine). A subsequent 50 patients underwent HAI (floxuridine, 4 cycles) followed, if a response or stable disease were observed, by combined SC and HAI (group B). Three cases of aneurysm of subclavian artery occurred, which were treated by the positioning of a radiologic arterial stent and the reimplantation of the catheter by a femoral access. Thrombosis of the hepatic artery was registered in four cases. We observed 10.5% occurrence of dislocation of the catheter, which was always moved again in the hepatic artery. In group A, with 45% clinical objective response rate and 10% stable disease rate, median survival time and median time to extrahepatic progression were 9 and 6 months, respectively. In group B, we observed 44% clinical objective responses and 26% stable disease after HAI. Patients without disease progression and therefore submitted to sequential SC and HAI had a median survival time of 21 months and a median time to extrahepatic progression of 16 months. The development of the mini-invasive technique of implantation of an arterial port can avoid laparotomy for HAI. Percutaneous implantation of an arterial port has a low rate of technical complications. HAI followed by combined systemic and regional chemotherapy has good results in terms of survival and time to extrahepatic progression.

Hepatic-arterial chemotherapy

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.

Alternating hepatic arterial infusion and systemic chemotherapy for liver metastases from colorectal cancer: a phase II trial using intermittent percutaneous hepatic arterial access

PURPOSE

To evaluate the objective response to a short course of hepatic arterial infusion (HAI) using temporary, percutaneously placed catheters alternating with systemic prolonged continuous infusion fluorouracil (ci 5-FU) and daily oral leucovorin (L).

PATIENTS AND METHODS

Eligible patients were previously untreated (except for adjuvant therapy) adults with liver-predominant metastases, with Eastern Cooperative Oncology Group performance status of 0 to 2. Treatment regimen included HAI with fluorodeoxyuridine (FUDR) 60 mg/m2/d and L 15 mg/m2/d continuously infused daily for 4 days. After a 1-week rest, ci 5-FU was administered through a central venous access device using a dose of 180 mg/m2/d with a fixed dose of oral L at 5 mg/m2/d for 21 out of 28 days. Cycles were repeated every 6 weeks. After four cycles of therapy, patients were maintained on ci 5-FU and daily oral L until evidence of progression.

RESULTS

Forty-three patients were enrolled onto this trial. One patient was ineligible. The objective response rate for all patients (17 partial, zero complete) was 41% (95% confidence interval [CI], 26% to 56%). Five patients were not able to receive at least one complete cycle of HAI. Among patients who received at least one complete cycle of HAI, the response rate was 46% (95% CI, 30% to 62%). Five patients underwent a liver resection after enrolling onto the protocol. At the time of analysis, estimated median time to progression was 6 months, and estimated median overall survival was 13 months.

CONCLUSION

The objective response rate was comparable to that achieved with more prolonged and more frequent HAI using FUDR. This approach should be studied as an acceptable alternative to surgically placed hepatic arterial catheters/pumps and may have a role as neoadjuvant therapy for liver metastases that are unresectable, as well as an adjuvant role for patients with resected hepatic metastatic colorectal cancer.

Therapeutic approaches to metastasis confined to the liver

Liver metastases nearly always represent disseminated cancer, and systemic therapies are usually indicated. However, in a minority of patients--some with colorectal cancer, others with selected tumors--management of the hepatic disease may be clinically important and even curative. This review identifies unique patient subgroups and novel treatment approaches that may be indicated in patients with liver metastases.

Current status of isolated hepatic perfusion with or without tumor necrosis factor for the treatment of unresectable cancers confined to liver

Metastatic or primary unresectable cancers confined to the liver are the sole or life-limiting component of disease for many patients with colorectal cancer, ocular melanoma, neuroendocrine tumors or primary colangio- or hepatocellular carcinomas. A number of regional treatment strategies including infusional chemotherapy and local ablative therapy are under clinical development and attest to the difficulty in adequately treating this condition. Isolated hepatic perfusion (IHP) was first clinically applied over 40 years ago, but because of its technical complexity, the attendant potential morbidity, and the lack of documented efficacy, it has not gained widespread application. In light of the remarkable antitumor activity with isolated limb perfusion with tumor necrosis factor (TNF) and melphalan in patients with unresectable extremity sarcoma or in transit melanoma, this regimen has been administered via IHP at several centers worldwide for unresectable liver cancers. IHP with TNF and melphalan can result in significant regression of advanced refractory cancers confined to the liver and, with additional clinical development, will most likely be a more routinely considered option for patients with this condition.

Technique and results of hyperthermic isolated hepatic perfusion with tumor necrosis factor and melphalan for the treatment of unresectable hepatic malignancies

BACKGROUND

For a variety of histologies, the liver represents the only or the dominant site of metastatic disease. Regional treatment of the liver has the theoretic advantage of maximizing drug delivery while minimizing systemic toxicity. This article describes the technique of isolated hepatic perfusion using tumor necrosis factor and melphalan under conditions of moderate hyperthermia for the treatment of unresectable liver tumors.

STUDY DESIGN

Fifty patients with biopsy-proved unresectable primary or metastatic cancer to the liver were treated. Isolated hepatic perfusion was performed for 60 minutes under conditions of moderate hyperthermia during a laparotomy with inflow through the gastroduodenal artery and outflow through an isolated segment of inferior vena cava. During isolated hepatic perfusion portal and infrahepatic blood flow were shunted externally by a centrifugal pump to the axillary vein. Complete vascular isolation was confirmed intraoperatively using a continuous 131I-labeled serum albumin leak monitoring system. Operative and perfusion parameters were recorded.

RESULTS

By using a standard operative technique to achieve complete vascular isolation of the liver during perfusion, there was no leak ofperfusate detected in 48 of 50 patients as determined by the continuous leak monitoring system and absence of detectable systemic tumor necrosis factor levels. Operating time, transfusion requirements, and blood loss were within the range expected for a major operative procedure. Stable hemodynamic and perfusion parameters were achieved consistently and all patients successfully completed the 60-minute perfusion. Two patients (4%) died as a result of treatment and significant tumor regression was observed in 75%.

CONCLUSIONS

Isolated hepatic perfusion is a technique that can be used to deliver high doses of chemotherapy or biologic therapy regionally and without systemic exposure. By using a standard operative technique, continuous intraoperative leak monitoring, and an external veno-veno bypass circuit, this procedure can be done safely and with acceptable morbidity and mortality. This article demonstrates that sustained and complete vascular isolation of the liver can be achieved and indicates further study is warranted to better define the role of isolated hepatic perfusion in the treatment of unresectable liver tumors.

Survival after resection of multiple hepatic colorectal metastases

BACKGROUND

Hepatic resection is potentially curative in selected patients with colorectal metastases. It is a widely held practice that multiple colorectal hepatic metastases are not resected, although outcome after removal of four or more metastases is not well defined.

METHODS

Patients with four or more colorectal hepatic metastases who submitted to resection were identified from a prospective database. Number of metastases was determined by serial sectioning of the gross specimen at the time of resection. Demographic data, tumor characteristics, complications, and survival were analyzed.

RESULTS

From August 1985 to September 1998, 155 patients with four or more metastatic tumors (range 4-20) underwent potentially curative resection by extended hepatectomy (39%), lobectomy (42%), or multiple segmental resections (19%). Operative morbidity and mortality were 26% and 1%, respectively. Actuarial 5-year survival was 23% for the entire group (median = 32 months) and there were 12 actual 5-year survivors. On multivariate analysis, only number of hepatic tumors (P = .005) and the presence of a positive margin (P = .003) were independent predictors of poor survival.

CONCLUSIONS

Hepatic resection in patients with four or more colorectal metastases can achieve long-term survival although the results are less favorable as the number of tumors increases. Number of hepatic metastases alone should not be used as a sole contraindication to resection, but it is clear that the majority of patients will not be cured after resection of multiple lesions.

Global approach to hepatic metastases from colorectal cancer: indication and outcome of intra-arterial chemotherapy and other hepatic-directed treatments

Liver metastases of colorectal cancer is present in more than 20% of new diagnosed patients and in 40-60% of relapsed patients. It is a life-threatening prognostic aspect. Hepatic resection, when possible, is the best therapeutic modality, although the overall survival rate is still low (30%). Angiography and intraoperative ultrasonography are useful for resection. The number of hepatic metastases and the surgical margin are probably the most significant prognostic factors. Colorectal cancer may spread predominantly to the liver making regional treatment strategies viable options. Subtotal hepatic resections and segmentectomies are potentially curable procedures for single or small numbers of hepatic metastases without other sites of disease. However, there have been no prospective randomized trials comparing patients with unresected liver metastases and resected metastases. Regional chemotherapy with floxuridine seems usefull combined with hepatic resection or as palliative therapy. Gastric ulcer and biliary sclerosis are the main related toxicities. Patients with localized, unresectable hepatic metastases or concomitant bad medical condition may be candidates for radiation, percutaneous ethanol injection, cryosurgery, percutaneous radiofrequency, hypoxic flow-stop perfusions with bioreductive alkylating agents, hepatic arterial ligation, embolization and chemoembolization. These new hepatic-directed modalities of treatment are being investigated and may offer new approaches to providing palliation and prolonging survival. This review will report the possibilities of intra-arterial chemotherapy and other novel hepatic-directed approaches to the treatment of liver metastases from colorectal cancer.

Aggressive surgical approach to recurrent tumors after hepatectomy for metastatic spread of colorectal cancer to the liver

BACKGROUND

Liver resection is currently accepted as the only potential cure for patients with metastases of colorectal tumors in the liver. However, cancer will recur in more than 70% of patients.

METHODS

In the 7 years to December 1997, 60 patients underwent liver resections for colorectal metastases at our institute. Of these, 20 patients had repeated surgical resections for recurrent disease of the liver and other organs. Another 2 patients had undergone previous hepatectomy elsewhere. The clinical data for these patients were reviewed.

RESULTS

The median interval between the 2 resections was 16 months. Eighteen hepatectomies, 6 lung resections, and 1 pancreatoduodenectomy were performed in 22 patients. Operative mortality and complication rates were 0% and 18%, respectively. At a median follow-up of 25 months after repeated resection, the survival rate in these patients was 73% at 2 years (12 of 16 evaluable patients are surviving) and 22% at 5 years (2 of 10 evaluable patients are surviving); the median survival time was 44 months.

CONCLUSIONS

Repeated resections for recurrent colorectal metastases yield comparable results to first liver resections in operative mortality and morbidity rates, survival time, and pattern of recurrence. Although the number of patients surviving more than 5 years is still limited, the absence of other proven treatments supports the concept of an aggressive resectional approach for these patients.

Liver intraarterial chemotherapy: use of the femoral artery for percutaneous implantation of catheter-port systems

To provide intraarterial chemotherapy of the liver in 30 outpatients with colorectal cancer metastases and other malignancies, 32 catheter-port systems were implanted percutaneously via the femoral artery. Mean patency was 229 days. Percutaneous placement was feasible and safe. Compared with surgical placement, the overall complication rate (12%) was comparable or less.

Non-surgical treatment for liver metastases

The liver is a common site for developing metastatic disease. Although any malignancy can spread to the liver, the direct passage of blood from the gastrointestinal tract to the liver via the portal circulation results in a high rate of liver metastasis from gastrointestinal tract tumours. Various radiographical tests including computed tomography and magnetic resonance imaging can detect the majority of liver metastases. Surgical resection if feasible is the treatment of choice since it produces a 5-year survival rate of about 30%. However, the majority of the patients relapse after hepatic resection, 50% relapsing in the liver. Systemic chemotherapy produces response rates of 15-30% with a median survival of 10-12 months. It is estimated that 30,000 patients each year in the USA are candidates for regional hepatic therapy. Hepatic arterial chemotherapy, hepatic artery embolization, chemoembolization, cryosurgery, ethanol injection of the tumour and radiation therapy are being investigated as potential treatment options for such patients.

Extrahepatic regional chemotherapy: use of technetium-99m labeled macroaggregated albumin

The purpose of this study was to verify the applicability of nuclear techniques with technetium-99m labeled macroaggregated albumin (Tc-99m-MAA) in extrahepatic regional chemotherapy. Of 98 patients in whom arterial Port-a-caths were implanted by transcutaneous access, 13 were treated by regional extrahepatic chemotherapy (breast, one; pancreas, four; kidney, one; uterus, three; vagina, two; bladder, two). In all 13 patients, Tc-99m-MAA was slowly infused intraarterially. The examination showed the perfusion of the area with the neoplasm and excluded the presence of important misperfusions of Tc-99m-MAA to the nearest areas. To detect the presence of an arteriovenous shunt with systemic misperfusion, an anterior image of the thorax was obtained in all patients and an index of misperfusion was calculated. In 12 patients, the index was < 5%; in one patient it was about 40%. In conclusion, our preliminary experience concerns the monitoring of intraarterial infusion chemotherapy of extrahepatic districts. In all 13 patients, we evaluated the correct positioning of the intraarterial catheter and the distribution pattern of the arterial flow, with a semiquantitative indication of arteriovenous shunting. This method gave us an instrument of study that was inexpensive, harmless, and free of collateral complications.

Sorbitol removal by the metastatic liver: a predictor of systemic toxicity of intra-arterial chemotherapy in patients with liver metastases

BACKGROUND/AIM

Hepatic arteriovenous shunting in the metastatic liver reduces the advantages of intraarterial infusion of chemotherapeutic agents because of the passage of drugs into the systemic circulation. The aim of this study was to quantitatively assess spontaneous functional hepatic arteriovenous shunting in patients with liver metastases and to determine its implication in the increase in systemic toxic effects of intra-arterial infusion chemotherapy with floxuridine.

METHODS

Twenty-five patients who underwent implantation of arterial ports for regional chemotherapy of liver metastases were studied. Functional hepatic arterio-venous shunting was evaluated through the bioavailability of intra-arterially administered D-sorbitol, a safe, natural compound whose kinetic features make its hepatic clearance flow dependent. In addition, D-sorbitol hepatic clearance (a parameter reflecting functional liver blood flow) and common liver function tests were evaluated for each studied patient. Patients were then grouped with respect to the percentage of medically-assessed liver occupation by metastases and with respect to systemic toxicity of the chemotherapeutic treatment. Both univariate and multivariate analyses by Student's t-test and stepwise logistic regression, respectively, were performed in both groups for each of the evaluated parameters (age, liver function tests, D-sorbitol hepatic clearance and arterial bioavailability).

RESULTS

Arterial bioavailability of D-sorbitol ranged between 0.05 and 0.72 and was significantly greater in patients with more than 50% liver occupation (0.39+/-0.19) compared with those with minor liver involvement (0.17+/-0.13; p = 0.003); it was also significantly greater in patients experiencing high-grade systemic toxicity (0.40+/-0.19) compared with those with low-grade toxicity (0.16+/-0.11; p<0.001). Multivariate analysis showed that arterial bioavailability of D-sorbitol was the only parameter among those evaluated which was able to predict systemic toxicity of this kind of chemotherapy.

CONCLUSIONS

Our results show that, in the metastatic liver, arterial bioavailability of D-sorbitol, an index of functional arteriovenous shunting, varies widely, is significantly greater in patients with massive liver occupation and it is a good predictor of systemic toxicity of intra-arterial regional chemotherapy with floxuridine.

Management of hepatic metastases

Although the liver is the most common site of metastatic disease from a variety of tumor types, isolated hepatic metastases most commonly occur from colorectal cancer and, less frequently, from neuroendocrine tumors, gastrointestinal sarcoma, ocular melanoma, and others. Complete evaluation of the extent of metastatic disease, both intrahepatically and extrahepatically, is important before considering treatment options. Based on a preponderance of uncontrolled studies for hepatic metastatic colorectal carcinoma, surgical resection offers the only potential for cure of selected patients with completely resected disease, with 5-year survival rates of 25% to 46%. Systemic and hepatic arterial infusion chemotherapy may be useful treatment options in patients with unresectable disease and possibly as an adjuvant treatment after liver resection. Other techniques of local tumor ablation, including cryotherapy and radiofrequency ablation, although promising, remain unproved. Management of hepatic metastases from neuroendocrine tumors and other noncolorectal primary tumors should be individualized based on the patient's clinical course, extent of disease, and symptoms.

Complications and technical limitations of hepatic arterial infusion catheter placement for chemotherapy

PURPOSE

To determine the rate of complications associated with hepatic arterial infusion (HAI) catheter placement, as well as technical success related to liver perfusion.

MATERIALS AND METHODS

The authors reviewed 44 patients who underwent 106 HAI catheter placements, including 15 men and 29 women with an average age of 55 years (range, 32-82 years). One to nine placements were performed per patient with 61 (58%) via the left brachial artery, 40 (38%) via the right femoral artery, and five (4%) via the left femoral artery. Chemoinfusion lasted 4 days, with initial catheter placement assessed on technetium-99m macroaggregated albumin (MAA) perfusion scans, as well as daily abdominal radiographs.

RESULTS

One hundred attempted hepatic arterial catheter placements were completed. Liver perfusion was global in 66 (66%) cases, in the right lobe only in 28 (28%) cases, and in the left lobe only in six (6%) cases. Eight (8%) had gastrointestinal (GI) tract perfusion; this was eliminated in seven cases (7%) after catheter repositioning. Forty-six (43%) placement attempts required embolization of 62 GI vessels to preclude GI chemoinfusion. Complications included one cerebrovascular accident (related to removal of a left brachial catheter), eight brachial artery thromboses (four that required emergent thrombectomy), six hepatic arterial dissections, four hepatic arterial thromboses, and four catheter malfunctions.

CONCLUSIONS

HAI catheter placement via the left brachial artery has increased complications. Nearly one-half of placements required embolization of GI vessels to preclude GI perfusion. Global perfusion is possible in two-thirds of cases.

Comparison of 5-fluoro-2'-deoxyuridine with 5-fluorouracil and their role in the treatment of colorectal cancer

Despite more than 30 years of intensive studies on new drugs against advanced colorectal cancer, the fluoropyrimidines remain the drugs of choice for systemic treatment and for hepatic artery infusion (HAI). This overview describes new developments in advanced colorectal cancer chemotherapy, providing a rationale for more effective use of the fluoropyrimidines, with biochemical modulation, scheduling or by revealing biochemical mechanisms of action that correlate with antitumour activity. In human colorectal cancer cell lines and various animal tumour model systems 5-fluoro-2'-deoxyuridine (FdUrd) is more effective than 5-fluorouracil (5-FU). Comparably, FdUrd's modulation by leucovorin (LV) is more potent than 5-FU. In animal studies it is shown that intermittent high-bolus administration of FdUrd generates better antitumour activity, compared with equal toxic doses or any other schedule of 5-FU. These effects are related to prolonged-thymidylate synthase (TS) inhibition and the prevention of TS induction, rather than RNA incorporation. Preclinical studies with modulators such as N-phosphonacetyl-L-aspartate (PALA), WR-2721, mitomycin C and platinum derivatives provide a rationale for clinical use in the future. The first choice systemic chemotherapy of patients with advanced colorectal cancer remains 5-FU combined with LV. Some improvement in therapeutic efficacy has been achieved with locoregional HAI. In randomised studies HAI FdUrd improves the quality of life and survival as compared with optimal systemic therapy. Chronomodulation decreases toxicity, allowing dose intensification, while modulators such as LV or dexamethasone increase survival of patients treated with HAI FdUrd to 86% after 1 year. In conclusion, the clinical use of FdUrd has not been fully explored. Intermittent high-dose FdUrd, chronomodulation together with the use of modulators or drugs focused on prolonged TS inhibition, should be studied in large randomised studies.

[Penetrating duodenal ulcer as a complication of a hepatic artery port catheter in hepatic metastasis of sigmoid carcinoma]

CASE REPORT

We report a typical complication of hepatic artery infusion therapy (HAI) in a patient with colon cancer metastatic to the liver. One year after the last HAI-therapy the patient presented with upper gastrointestinal bleeding. Endoscopy showed a large duodenic ulcer penetrating into an adjacent hepatic colon cancer metastasis. The hepatic artery catheter was visible at the ground of the duodenic ulcer.

CONCLUSION

Thirty-five percent of patients under HAI-therapy develop gastric/duodenic ulcers. The severity of the HAI complication presented here, however, is quite uncommon.