Transbrachial hepatic arterial chemotherapy using an implanted infusion pump

Advances and directions in chemotherapy using implantable port systems for colorectal cancer: a historical review

With the recent advances in chemotherapy for colorectal cancer, the prognosis for patients with metastatic colorectal cancer has been significantly improved. The development of the implantable port system has also enabled patients to receive multiagent chemotherapy with a more satisfactory quality of life. Historically, chemotherapy using implantable port systems was begun to obtain an oncological benefit in the treatment of locoregional cancer. In the 1950s, there was an increasing interest in perfusion techniques for the application of chemotherapeutic agents, such as nitrogen mustard, in the locoregional treatment of metastatic cancer. Among them, the treatment of liver metastasis has interested oncologists for many years. On the other hand, implantable devices were developed during the intervening decades that have enabled patients with colorectal cancer with liver metastases to be treated effectively using hepatic arterial infusion; which became more common in the 1980s. The treatment of metastatic colorectal cancer increasingly requires a multimodal approach and multiple treatment options based not on convenience, but in terms of personalization and efficacy. Therefore, it is important to optimize the pharmacokinetics of chemotherapeutic agents. Implantable port systems for colorectal cancer patients have been essential for oncological practice, and the importance of these systems will remain unchanged in the near future.

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.

Dye-injection method for placement of an infusion catheter in regional hepatic chemotherapy

PURPOSE

To evaluate the usefulness of a dye-injection method in the placement of an infusion catheter and port via proximal branches of the axillary artery for hepatic infusion chemotherapy.

MATERIALS AND METHODS

Sixteen patients with surgically unresectable hepatic cancer underwent transfemoral hepatic arteriography. Then a 3-F coaxial catheter was inserted into a proximal branch of the left axillary artery. Dye injected through the coaxial catheter during the surgical procedure improved the visualization of the target branch. The coaxial catheter was also used as a guide for retrograde insertion through the target branch of an infusion catheter into the descending aorta.

RESULTS

In 13 of 16 patients (81%), catheterization was successful without exposure of the axillary artery. In these patients, the acromial-deltoid branch of the thoracoacromial artery was chosen as the target.

CONCLUSION

Injection of dye simplifies the surgical procedure for placement of a hepatic infusion catheter via proximal branches of the axillary artery. The depth and extent of incisions, as well as the risk of nerve injury, are reduced.

Treatment of colorectal cancer hepatic metastases by hepatic artery chemotherapy

Our clinical experience with 69 patients with metastatic colorectal cancer to the liver treated with hepatic artery chemotherapy is reviewed. All patients have had a minimum of six months follow-up. The Infusaid implantable drug delivery system was used by direct laparotomy in one third, and via the transaxillary approach in the remaining two thirds. Two thirds of the patients had at least 25 percent of the liver replaced with tumor. Chemotherapeutic agents included FUdR, mitomycin C, and BCNU. The overall response rate was 51 percent and 69 percent for the three-drug combination. Efficacy was not different in patients who had received prior systemic fluorouracil. Median survival from start of hepatic artery chemotherapy was one year.

The totally implantable infusion pump in treatment of metastatic colorectal cancer

Final evaluation of the Infusaid Pump system (Infusaid Corporation, Sharon, MA) for administration of regional chemotherapy must await completion of trials prospectively comparing survival of matched patients treated in this manner and patients treated by traditional systemic chemotherapy. A review of the current medical literature confirms our personal experience that response rates within the liver are high. Survival reports appear encouraging but this may represent an artifact in patient selection. An algorithm is presented to offer surgeons a reasonable and conservative means for selection of those colorectal cancer patients with metastatic involvement of the liver who are most likely to benefit from this system of drug delivery.

Treatment of hepatic metastases by transaxillary hepatic artery chemotherapy using an implanted drug pump

The objective of this study was to evaluate the feasibility of integrating an implantable, refillable drug infusion pump with transaxillary angiographic hepatic arterial catheterization. The implantation is performed under local anesthesia in the radiology suite. A 2-3 cm incision in the left upper arm is made through skin and subcutaneous tissue. Through an axillary artery puncture, a 5.3F polyethylene catheter is fluoroscopically placed into the hepatic artery. To minimize gastroduodenitis, the gastroduodenal artery is occluded with a Gianturco coil and Gelfoam. The Model 400 Infusaid pump is implanted in the upper chest and attached subcutaneously to the angiography catheter using a friction connector. Patients are discharged 2-3 days later. Over a two-year period, 20 such implants have been performed. Floxyuridine (FUdR) has been used by continuous infusion; mitomycin-C (MMC) and 1,3-bis-(2-chloroethyl)-1-nitrosourea (BCNU) by intermittent intra-arterial infusion. The pump/catheter system has been left in place for as long as 18 months. Partial responses in the colorectal cases are as follows: FUdR four of nine patients, MMC two of three, FUdR + MMC one of one, and FUdR + MMC + BCNU three of three. No arm vascular complications, hepatic arterial occlusions, peripheral emboli, pump malfunctions, or catheter occlusions took place over a total experience of 3210 patient days. Three catheter migrations occurred requiring repositioning in two patients, and three cracked catheters required replacement. This innovative approach offers a comfortable, convenient method for long-term ambulatory hepatic arterial chemotherapy obviating both laparotomy and extra-corporeal pumps.

Regional hepatic chemotherapy using an implantable drug infusion pump

Regional infusion of chemotherapeutic agents in the treatment of liver cancer can greatly increase tumor exposure to certain drugs. Exposure is 100 times greater with floxuridine, 6 times greater with mitomycin C, and 6 times greater with BCNU. The Model 400 Infusaid implantable, refillable drug infusion pump overcomes much of the discomfort and inconvenience associated with previously employed extracorporeal systems. Our experience with our first 50 patients has been presented herein. Forty-one patients had metastatic colorectal cancer, 3 primary cancers, and 6 other metastatic cancers. Eleven pumps and 11 catheters were implanted at laparotomy. Thirty-nine patients had their pumps integrated to angiographically placed catheters. In over 260 patient months there were no pump malfunctions and only one infection. There were no vascular complications in the patients with angiographically placed catheters. Chemotherapeutic programs included floxuridine, floxuridine and radiotherapy, or floxuridine with mitomycin C and BCNU. In 18 patients with evaluable metastatic colorectal cancer who received hepatic arterial combination chemotherapy, there were therapeutic responses in 13 and disease stabilization in 4. The pumps were well tolerated by patients. They offer a reasonable approach to long-term ambulatory regional hepatic chemotherapy.

Regional management of liver metastases. I

This is the first of a two part series. In this issue, Part I presents the natural history of liver metastasis and various proposed staging systems. Indications for surgical resection, which remains the treatment of choice are reviewed. For the majority of patients with unresectable metastases of the liver, various regional treatment approaches seem to give higher response rates than systemic chemotherapy. Technical aspects and therapeutic results of infusion chemotherapy via the hepatic artery and ligation of hepatic artery alone are considered. The totally implantable pump represents and advance in long-term infusion chemotherapy.

Intra-arterial chemotherapy using an implantable infusion pump and liver irradiation for the treatment of hepatic metastases

Liver metastases are a common cause of death in colon carcinoma. The dual blood supply of the liver permits regional perfusion while hepatic catabolism fo 5-fluorouracil (FU), floxuridine (FUdR) permit higher drug exposures than systemic (IV) administration. We have studied the effect of continuous intra-arterial chemotherapy (FU: 5-10 mg/kg/day and FUdR: 0.2 mg/kg/day) and whole liver irradiation (1000 rad every 4 weeks, total dose of 3000 rad) for metastatic colon carcinoma to liver. Eighteen patients with metastases to liver only are reported using this combination therapy. Seven patients had percutaneous placement of a catheter via the brachial artery, two had operative placement of a catheter via the gastroduodenal artery, all of which were connected to the Cormed infusor system, nine had operative placement of the Infusaid implantable pump with catheter placement into the hepatic artery via the gastroduodenal artery. The median survival for the entire group was 241 days. In those patients whose liver function tests (bilirubin and alkaline phosphatase) were less than two times normal, the median survival was 770 days. The median survival of the patients with greater than two times normal LFT's was 178 days. Two patients died of complications of the treatment. One who developed irreversible radiation hepatitis but at autopsy had only two areas of microscopic tumor foci in the liver and another who had received only 15 days of infusion and 1000 rad to liver. This patient developed irreversible chemical enteritis secondary to chemotherapy infusion into the superior mesenteric artery. Three patients have undergone abdominal reexploration and one at autopsy, who were found to have no gross evidence of tumor in the liver despite previous pathologic confirmation. It appears that some patients with minimal tumor burdens can have sterilization of their tumors. There were three cases of reversible liver function abnormalities. Complications associated with conventional intra-arterial chemotherapy (artery thrombosis, catheter sepsis and dislodgement, pump infusion variation and pump failure) were not seen with the Infusaid delivery system. The pump is refilled every 2-3 weeks via percutaneous puncture. All therapy was given on an outpatient basis. Pump acceptance and tolerance was 100%. Intra-arterial chemotherapy can now be accomplished without the morbidity associated with it in the past. The combination of chemotherapy and liver irradiation may offer improved survival in selected patients.