Treatment of colorectal cancer hepatic metastases by hepatic artery chemotherapy

Hepatic arterial infusion of floxuridine and dexamethasone plus high-dose Mitomycin C for patients with unresectable hepatic metastases from colorectal carcinoma

BACKGROUND

In vitro data suggest increased cytotoxicity with Mitomycin C (Mit-C) and Floxuridine (FUDR). Based on these data, we performed a phase II trial of hepatic arterial infusion (HAI) of FUDR and Dexamethasone (Dex) plus high-dose Mit-C for patients with unresectable hepatic metastases from colorectal carcinoma.

METHODS

High-dose Mit-C (15 mg/m2) was added via the pump sideport to HAI FUDR and Dex for 14 days of a 28-day cycle. Mit-C was given on days 1 and 29, and FUDR was given indefinitely until disease progression or discontinuation of therapy due to toxicity.

RESULTS

Sixty-three patients with unresectable liver metastases were entered. The chemotherapy-naïve group (n = 26) and those previously treated (n = 37) had similar response and median survival: 73% and 70%, and 23 and 20 months, respectively. The major toxicities were liver bilomas (7.9%), elevation in bilirubin level >3 (22%), and biliary sclerosis (9.5%). Hematologic and gastrointestinal toxicity was less than 2%.

CONCLUSION

The addition of high-dose Mit-C to HAI FUDR and Dex produced a high response rate even in previously treated patients. The median survival was 21 months even though half the patients were previously treated with chemotherapy. Biliary toxicity was higher than expected; therefore, alternatives to high dose Mit-C should be investigated when exploring additions to HAI therapy with FUDR and Dex.

Regional chemotherapy of liver metastases from colorectal carcinoma: hepatic artery or portal vein infusion?

Hepatic artery infusion (HAI) chemotherapy has been well developed and is commonly used in the treatment of unresectable hepatic colorectal metastases. However, several important questions are unanswered, such as survival advantage over conventional systemic intravenous chemotherapy, long-term effects on the liver function, and prevention of complications, in particular cholangiosclerosis. Recent investigation into the blood supply of liver tumors challenges the adage that arterial flow is dominant. This review of the merits of regional HAI compared with portal venous infusion (PVI) chemotherapy shows a lack of conclusive data to favor either treatment modality, although a larger experience exists for HAI. Further studies need to be conducted.

Regional infusion of fluoropyrimidines for hepatic metastases of colorectal cancer

Recent reports on regional chemotherapy for hepatic metastases of colorectal origin are reviewed. Because of reported side effects and lack of evidence for its superiority over conventional intravenous administration, intra-arterial administration of fluoropyrimidines cannot be advised for routine use, but should be restricted to centres participating in clinical trials on this subject.

Effect of ligation of variant hepatic arterial structures on the completeness of regional chemotherapy infusion

Twenty-three patients with separate arterial supplies to both sides of the liver underwent unilateral arterial ligation and chemotherapy via the remaining artery. Radionuclide infusion studies revealed only 62 percent complete perfusion after left hepatic ligation and 90 percent after right hepatic artery ligation.

Treatment of metastatic colorectal cancer with hepatic artery combination chemotherapy

Treatment of patients with hepatic metastases from colorectal cancer using hepatic artery floxuridine (FUDR) has been reported to induce high partial remission rates and perhaps prolonged survival. However, several investigators, including our own group, have obtained response rates of only 30%. Alkylating agents can increase the efficacy of antimetabolites. Based on clinical data and pharmacokinetic considerations the authors have combined FUDR with mitomycin C and carmustine (BCNU) by the arterial route. Thirty-six patients with hepatic metastases from colorectal cancer received FUDR 0.3 mg/kg/day 2 weeks of 4, mitomycin C 15 mg/M2 over 1 hour every 8 weeks, and BCNU 150 mg/M2 over 1 hour every 8 weeks--all via the hepatic artery using Infusaid pumps (Infusaid, Sharon, MA). The mitomycin C and BCNU were alternated monthly at the start of each FUDR cycle. The patient characteristics were as follows: 78% hepatomegaly, 44% also extrahepatic tumor, 42% prior systemic 5-fluorouracil. Combined partial and complete response rates were independent of prior chemotherapy: 71% if untreated, 67% with prior 5-fluorouracil. Median survival for the combined response/stable disease group was 13.7 months from the start of hepatic artery chemotherapy, and 4.5 months for the six nonresponders. Based on these data the authors have begun a randomized trial comparing single-agent FUDR to the FUDR, mitomycin C, BCNU combination.