Response to regional chemotherapy in patients with variant hepatic arterial anatomy

Hepatic artery access ports: recognizing and avoiding the problems

BACKGROUND

Regional approaches to the management of hepatic tumours are appropriate in some clinical situations and include hepatic arterial chemotherapy (HAC) and selective internal radiation therapy (SIRT). Both require access to the hepatic artery, which is conveniently achieved with a subcutaneously placed port. Placement and use of these ports may be associated with a variety of technical problems which can impact adversely on the outcome of the treatment. The present paper outlines the problems related to port usage for regional hepatic therapies, with emphasis on the technical aspects of insertion and interpretation and management of subsequent problems.

METHODS

Hepatic artery port placement was attempted in 129 patients for use with either SIRT and/or HAC. Ports were used or flushed at monthly intervals.

RESULTS

Successful port insertion was achieved in 127 patients, of whom 87 received HAC alone, seven received SIRT alone, 28 patients received both and in five patients the port was never used. Methylene blue injection was used to identify anomalous arterial anatomy, which was found in 26 of 95 patients (27%), and significant extrahepatic 'access', which was seen in 25 patients (26%) after initial placement. Forty-six instances of technical problems preventing continued use of the port occurred in 43 patients after a median of 4 (0-36) cycles of chemotherapy, including hepatic artery thrombosis (n = 26), catheter blockage (n = 4), duodenal fistula (n = 3), gastrointestinal (GI) bleeding (n = 3), side-effects (n = 3), access problems (n = 3), extravasation (n = 3) and infection (n = 1).

CONCLUSION

Methods used to identify, manage and in some instances prevent the occurrence of these problems are discussed.

[Adjuvant intra-arterial chemotherapy after curative resection of liver metastasis from colorectal cancer. Results of a pilot study in 30 patients]

OBJECTIVE

Five-year survival after simple resection of liver metastases from colorectal carcinoma ranges from 20 to 40%. The aim was to study the reliability and long term results of adjuvant intra-arterial chemotherapy after resection of colorectal liver metastases.

PATIENTS AND METHOD

From 1991 to 1997, 30 patients after a complete resection of liver metastases from colorectal cancer were included (16 men, 14 women, mean age: 62 years). There were 2 stage I, 19 stages II, 2 stages III, 5 stages IV and 2 stages V according to Gayowski staging system. During laparotomy, a catheter was placed in the gastroduodenal artery in order to perfuse the proper hepatic artery. Chemotherapy included 5 Fluorouracil (12 mg/m2) and Leucovorin (200 mg/m2) and was administered once a week during six months. Mean follow-up was 52 months.

RESULTS

Adjuvant intra-arterial chemotherapy had to be interrupted before six months in 9 patients because leukopenia (n = 2), infection or obstruction of the catheter (n = 5), duodenal migration of the catheter (n = 1) and occurrence of multiple extrahepatic metastases (n = 1). No death was in relation with the method. Five-year survival rate was 41.8% for the global series. Five-year disease free survival rate was 21.4%. Causes of death were: hepatic recurrence only (n = 3), extrahepatic + hepatic recurrence (n = 4), extrahepatic recurrence (n = 2). Two patients died of another carcinoma (esophagus, ovary), without evidence of recurrence of the colorectal carcinoma. At the present, there is a recurrence in 4 living patients.

CONCLUSION

Although the benefit on survival is not significant, these results suggest a longest time of remission in patients with adjuvant intra-arterial chemotherapy. Trials comparing and/or combining this method to intravenous chemotherapy should be proposed in patients after resection of colorectal liver metastases.