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

Identifying Optimal Surgical Intervention-Based Chemotherapy for Gastric Cancer Patients With Liver Metastases

Background

This study aimed at evaluating the effects of surgical treatments-based chemotherapy in the treatment of gastric cancer with liver metastases (GCLM). It has not been established whether Liver-directed treatment (LDT) options such as hepatectomy and gastrectomy plus chemotherapy (HGCT), radiofrequency ablation and gastrectomy plus chemotherapy (RFAG), transarterial chemoembolization and gastrectomy plus chemotherapy (TACEG), gastrectomy plus chemotherapy (GCT) enhance the survival of GCLM patients.

Methods

We performed systematic literature searches in PubMed, EMBASE, and Cochrane library from inception to September 2021. We created a network plot to comprehensively analyze the direct and indirect evidence, based on a frequentist method. A contribution plot was used to determine inconsistencies, a forest plot was used to evaluate therapeutic effects, the publication bias was controlled by funnel plot, while the value of surface under the cumulative ranking curves (SUCRA) was calculated to estimate rank probability.

Results

A total of 23 retrospective studies were identified, involving 5472 GCLM patients. For OS and 1-, 2-, 3-year survival rate of all trials, meta-analysis of the direct comparisons showed significant better for HGCT treatments compared with GCT or PCT. In the comparison of the 5 treatments for 1-, 2-, 3-year survival rate, HGCT and RFAG were found to be more effective than GCT and PCT, respectively. By OS and 2-, 3-year survival rate analysis, RFAG was identified as the best option, followed by HGCT, TACEG, GCT and PCT. By 1-year survival rate analysis, HGCT and RFAG were identified as the most effective options.

Conclusion

HGCT and RFAG has remarkable survival benefits for GCLM patients when compared to TACEG, GCT and PCT. HGCT was found to exhibit superior therapeutic effects for GCLM patients for 1-year survival rate while RFAG was found to be a prospective therapeutic alternative for OS and 2-, 3-year survival rate.

Systematic Review Registration

identifier [10.37766/inplasy2020.12.0009].

Retrograde embolization technique of the right gastric artery during the implantation of port-catheter system for hepatic arterial infusion chemotherapy

Objective

This study aimed to introduce and evaluate a new embolization technique for the right gastric artery (RGA) during percutaneous implantation of a port-catheter system for hepatic arterial infusion chemotherapy (HAIC).

Methods

From January 2013 to January 2017, 159 patients with unresectable advanced liver cancer underwent percutaneous implantation of a port-catheter system. In 86 of these patients (56 men; aged 28–88 years; mean: 60.6 ​± ​12.0 years), in whom the RGA was obvious on arteriography, embolization of RGA was attempted using microcoils to protect the gastric mucosa during HAIC. In the first phase (first three years), antegrade embolization of the RGA using a 2.7 Fr microcatheter was performed in 55 patients. In the second phase (next two years), embolization of the RGA was attempted by combining antegrade embolization and retrograde embolization through the left gastric artery (LGA) in 31 patients. The success rates and the incidence of acute gastroduodenal mucosal toxicity (AGMT) in these two groups were compared.

Results

The total success rate of the RGA embolization was 70.9%. The success rate was 83.9% in 31 patients who underwent combined antegrade and retrograde embolization, which was significantly higher than that of antegrade embolization alone (63.6%) performed in 55 patients (p ​= ​0.047). No complications related to embolization of RGA were documented. The incidence of AGMT was 29.1% (16/55) in patients in the first phase, which was significantly higher than that in the patients in the second phase (9.7%, 3/31) (p ​= ​0.037).

Conclusion

A combination of retrograde embolization via LGA could increase the success rates of RGA embolization and reduce the incidence of AGMT after HAIC.

Irinotecan Hepatic Arterial Infusion Chemotherapy for Hepatic Metastases from Colorectal Cancer: A Phase II Clinical Study

Aims and background

The advantage of delivering chemotherapy by hepatic arterial infusion is the acquisition of a high concentration of the drug in the target. Irinotecan (CPT-11) is active for the treatment of advanced colorectal cancer. In phase I studies, doses of 20 mg/m2/d for 5 days given every 4 weeks as continuous infusion or 200 mg/m2 as a short 30-min infusion given every 3 weeks is recommended for phase II studies.

Methods and study design

Twelve patients with a median liver substitution of 30% (20-50%) were enrolled, 6 progressed after a FOLFOX-induced partial response and 6 progressed after 5-fluorouracil and folinic acid. All patients had a surgically (n = 6) or angiographically placed port (n = 6). They received hepatic arterial infusion chemotherapy with CPT-11 (200 mg/m2) on an outpatient basis, every 3 weeks as a short 30-min infusion for six cycles.

Results

Four partial responses were observed (33%) lasting 24, 15, 12 and 8+ weeks, 3 stable disease (25%) lasting more than 12 weeks, and 5 progressions (41%). Six patients (50%) presented a >30% reduction in CEA. Toxicity was G2 diarrhea in 5 patients (41%) and G2 myelosuppression in 6 (50%); one patient had abdominal right upper quadrant pain requiring analgesics.

Conclusions

CPT-11 is active as hepatic arterial infusion chemotherapy in liver metastases from colorectal cancer and can rescue systemically pretreated patients. Our schedule seems safe, feasible and well accepted on an outpatient basis.

Irinotecan Hepatic Arterial Infusion Chemotherapy for Hepatic Metastases from Colorectal Cancer: Results of a Phase I Clinical Study

Background

Hepatic arterial infusion chemotherapy is a promising approach in liver metastases from colorectal cancer, but chemical hepatitis, biliary sclerosis, arterial thrombosis and right upper quadrant pain are limiting factors. Irinotecan (CPT-11) is an active drug in colorectal cancer. We planned a short hepatic arterial infusion of CPT-11 to describe the toxicity, to determine the dose-limiting toxicity, and to define the doses of CPT-11 to be recommended for phase II studies.

Patients and Methods

Fourteen patients with a median liver substitution of 30% (10-60%) were enrolled. All patients received hepatic arterial infusion chemotherapy with CPT-11 on an outpatient basis every 3 weeks as a short, 30-min infusion.

Results

At 240 mg/m2, 2 of 4 patients experienced grade 4 diarrhea and neutropenia, and 3 of them also reported grade 4 abdominal pain of the right upper quadrant. The maximum tolerated dose was reached at 240 mg/m2. The recommended doses of CPT-11 for phase II studies is 200 mg/m2, given every 3 weeks.

Conclusions

CPT-11 presents a low hepatic toxic profile and could be considered a new active drug, suitable for hepatic arterial infusion in liver metastases from colorectal cancer.

Survival of patients with non-resectable, chemotherapy-resistant colorectal cancer liver metastases undergoing conventional lipiodol-based transarterial chemoembolization (cTACE) palliatively versus neoadjuvantly prior to percutaneous thermal ablation

PURPOSE

To determine overall (OS) and progression-free survival (PFS) for cTACE alone and in combination with percutaneous thermal ablation in patients with non-resectable, chemotherapy-resistant colorectal cancer liver metastases (CRLM).

MATERIAL AND METHODS

The study included 452 patients undergoing 2654 repetitive cTACE treatments of CRLM. 233 patients were treated palliatively using only cTACE, whereas 219 patients were treated with cTACE in a neoadjuvant intend with subsequent thermal ablation (either microwave ablation or laser-induced thermotherapy). The chemotherapeutics agents used, in either single-, double-, or triple-combinations, included MitomycinC, Gemcitabine, Irinotecan, and Cisplatin. Several factors were analysed to determine their prognostic value in terms of OS and PFS.

RESULTS

Palliative use of cTACE resulted in a median OS and PFS of 12.6 and 5.9 months, whereas the neoadjuvant use of cTACE showed a median OS and PFS of 25.8 and 10.8 months. The differences in OS and PFS between the two groups were statistically significant (p < 0.001). Extrahepatic metastases were a significant prognostic factor in the OS and PFS analysis of the palliative and neoadjuvant group. In addition, number, location, and mean size of metastases were significant prognostic factors for OS and PFS in the neoadjuvant group. Sex, primary tumor location, T- and N-parameters of the TNM staging system, time of liver metastases appearance, ablation method, and patient age did not significantly impact OS and PFS in either patient group. The most distinct response to cTACE was observed in metastases that were treated with a triple-combination of chemotherapeutics (p = 0.021).

CONCLUSION

cTACE is an effective treatment option in advanced non-resectable CRLM. Chemoembolization followed by ablation further increases survival rates. A triple combination of chemotherapeutics improves response to cTACE.

Clinical implications of AEG-1 in liver metastasis of colorectal cancer

The aim of the study was to investigate the role of AEG-1 in colorectal cancer and the relationship between AEG-1 protein expression and pathological characteristics and prognosis in colorectal cancer. The AEG-1 mRNA and protein expression level between the tumor cells from the cases with liver metastasis and those from the ones without live metastasis were detected by RT-PCR and immunohistochemistry staining. The relationship between AEG-1 and clinicopathological parameters of colorectal cancer was determined. AEG-1 expressed positively in 218 (41.92%) of the 520 cases examined. It showed that both mRNA and protein level AEG-1 were over-expressed in the cases with liver metastasis compared with those without liver metastasis (P=0.01). After immunohistochemistry analysis, the expression of AEG-1 protein was related to age, Duke's stage and distant metastasis (P=0.001, 0.001 and 0.016, respectively). After survival analysis, the cases with highly expressed AEG-1 protein attained a significantly poorer postoperative disease-specific survival than those with none/low-expressed AEG-1 protein (P=0.001). In the Cox regression test, histological grade, Duke's stage and AEG-1 were detected as the independent prognostic factors (P=0.035, 0.001 and 0.010, respectively). AEG-1 protein may be a potential new early liver metastasis biomarker of colorectal cancer.

Practical vascular anatomy in the preparation of radioembolization

As the incidence of primary and metastatic liver cancer continues to increase, the use of minimally invasive techniques as a treatment option is becoming more common. Radioembolization, a form of intra-arterial brachytherapy, is a technique where particles of glass or resin, impregnated with the isotope 90yttrium (90Y), are infused through a catheter directly into the hepatic arteries. This modality is based on the fact that hepatic malignancies receive their blood supply from the hepatic artery, whereas normal hepatocytes are perfused mostly from the portal circulation, which allows delivery of high doses to the tumor vasculature with relative sparing of normal liver tissue. This has been shown to be effective for both primary and metastatic tumors. A variety of complications may be related to hepatic intra-arterial treatments, especially to the gastroduodenal region. These complications are known to come from inadvertent extrahepatic infusion of 90Y particles, through arteries originating from the hepatic arterial branches such as the falciform artery, cystic artery, arteries from the pancreaticoduodenal arcade, gastroduodenal artery, or right gastric artery. Surgeons and interventional radiologists rely on accurate imaging and assessment of the hepatic arterial supply. It is important to know the common anatomic variations and technical considerations before radioembolization. We recommend an aggressive occlusion of all the above-mentioned arteries; further, clinicians should watch out for any other aberrant branches, and if in doubt, they ought to be coiled.

Embolisation of the right gastric artery in patients undergoing hepatic arterial infusion chemotherapy using two possible approach routes

We used a retrospective non-randomised study to investigate the clinical effect of selective embolisation of the right gastric artery before hepatic arterial infusion chemotherapy (HAIC) using a port-catheter system. We evaluated whether the hepatic artery or the left gastric artery is the better approach for selecting the right gastric artery. A total of 367 patients (244 men and 123 women; mean age, 64.1 years) with unresectable advanced liver cancer underwent percutaneous implantation of a port-catheter system. In 294 of these patients, right gastric arterial embolisation with microcoils was attempted before placement of the port-catheter system to prevent gastric mucosal lesions. Approach was either through the hepatic artery (175 patients) or through the left gastric artery (119 patients), with success rates in catheterising the right gastric artery of 78.3% and 77.3%, respectively. If the attempt was unsuccessful, the catheter was redirected to the alternative approach, which increased the final success rate to 96.3%. Only seven patients experienced gastroduodenal mucosal lesions acutely after HAIC, as revealed by endoscopy. Embolisation of the right gastric artery is a feasible procedure that can reduce the incidence of gastric mucosal lesions associated with HAIC. Approach through either the hepatic artery or the left gastric artery is equally acceptable.

Imaging of hypoxia-driven gene expression in an orthotopic liver tumor model

The purpose of this study was to monitor hypoxia in an orthotopic liver tumor model using a hypoxia-sensitive reporter imaging system and to image enhanced gene expression after clamping the hepatic artery. C6 and RH7777 Morris hepatoma cells were transduced with a triple reporter gene (HSV1-tk/green fluorescent protein/firefly luciferase-triple fusion), placed under the control of a HIF-1-inducible hypoxia responsive element (HRE). The cells showed inducible luciferase activity and green fluorescent protein expression in vitro. Isolated reporter-transduced Morris hepatoma cells were used to produce tumors in livers of nude rats, and the effect of hepatic artery clamping was evaluated. Tumor hypoxia was shown by immunofluorescence microscopy with the hypoxia marker EF5 [2-(2-nitro-1H-imidazol-1-yl)-N-(2,2,3,3,3-pentafluoropropyl acetamide)] and the fluorescent perfusion marker Hoechst 33342, and by pO(2) electrode measurements. For tumor hypoxia imaging with the HRE-responsive reporter, both luciferase bioluminescence and [(18)F]2'-fluoro-2'-deoxyarabinofuranosyl-5-ethyluracil positron emission tomography was done, and the presence of hypoxia in Morris hepatoma tumors were successfully imaged by both techniques. Transient clamping of the hepatic artery caused cessation of tumor perfusion and severe hypoxia in liver tumors, but not in adjacent liver tissue. These results show that the orthotopic reporter-transduced RH7777 Morris hepatomas are natively hypoxic and poorly perfused in this animal model, and that the magnitude of hypoxia can be monitored using a HRE-responsive reporter system for both bioluminescence and positron emission tomography imaging. However, the severity of tumor ischemia after permanent ligation of the hepatic artery limits our ability to image severe hypoxia in this animal model.

Intraoperative margin re-resection for colorectal liver metastases

OBJECTIVE

Evaluate recurrence and survival in patients who underwent intraoperative margin re-resection for colorectal cancer liver (CRC) metastases.

DESIGN

Retrospective analysis.

SETTING

University Hospital, Cincinnati, Ohio. Academic medical center.

PARTICIPANTS

Cohort of 118 patients who underwent resection of CRC liver metastases between 1992 and 2004. All patients were divided into 3 groups: resection margin (MOR) less than 1 cm (n = 64), MOR greater than 1 cm (n = 33), and re-resection margin (re-MOR) greater than 1 cm (n = 21).

RESULTS

Patients with a margin greater than 1 cm, when compared with re-MOR greater than 1 had decreased incidence of liver and distant recurrence (p < 0.05) as well as improved disease-free survival (39.2 vs 22.9 months, p = 0.023). Differences in overall survival (58.6 vs 44.2 months, p = 0.14) were not significant.

CONCLUSION

Intraoperative re-resection is associated with an increased risk of local and distant recurrence, which may be a reflection of both inadequate surgery and underlying tumor biology.

FDG PET in preoperative assessment of colorectal liver metastases combining "evidence-based practice" and "technology assessment" methods to develop departmental imaging protocols: should FDG PET be routinely used in the preoperative assessment of patients with colorectal liver metastases?

In today's environment of progressively evolving and expensive imaging modalities, radiologists are asked to justify the use of resources to patients, referring physicians, hospital management, and third party payers. With this aim, the radiologist may use "top-down" or "bottom-up" "evidence-based practice" (EBP) techniques. "Top-down" suggests that the practitioner should wait until a higher authority, external to their practice, generates a solution to practice dilemmas (e.g., National Institute for Health and Clinical Excellence [NICE] guidelines). "Bottom-up" however, is based on the theory that the ordinary practitioner is best served by a decentralized approach to problem solving that is internal to their practice. The technology assessment framework modeled by Mackenzie and Dixon comprehensively assesses the effects of imaging using levels of efficacy including diagnostic performance, diagnostic impact, and therapeutic impact, impact on health and cost effectiveness. In this article, we describe how issues regarding new imaging modalities in ordinary radiology practice can be addressed by using stepwise "bottom-up" EBP techniques combined with the technology assessment framework. We also detail how EBP techniques form an integral part of practice-based learning among radiology residents as part of noninterpretive residency training. The following clinical scenario is used: your hospital's chief hepatobiliary surgeon writes to your department regarding the lack of access to 18-fluoro-2-deoxy-D-glucose positron emission tomography in the preoperative assessment of patients with colorectal cancer liver metastases under consideration for hepatic resection. How would you approach this problem? Here is how we would do it.

Right gastric artery embolization prior to treatment with yttrium-90 microspheres

PURPOSE

Intra-arterial infusion of yttrium-90 microspheres is a form of radiation treatment for unresectable hepatic neoplasms. Misdeposition of particles in the gastroduodenal area such as the right gastric artery (RGA) may occur with serious consequences. We present a series of patients who underwent a detailed vascular study followed by RGA embolization. Special emphasis is placed on anatomic variations and technical considerations.

METHODS

In a 1 year period, 27 patients were treated. Initial vascular evaluation was performed, with careful attention to anatomic variants or extrahepatic arterial supply, especially to the gastroduodenal area. Embolization of such arteries was planned if needed. RGA embolization was performed antegradely from the hepatic artery or retrogradely via the left gastric artery (LGA). Postprocedural follow-up included clinical interview and gastroscopy if necessary.

RESULTS

RGA embolization was performed in 9 patients presenting with primary (n = 3) or metastatic liver tumors (n = 6). Six patients underwent antegrade RGA embolization and 3 had embolization done retrogradely via the LGA. Retrograde access was chosen for anatomic reasons. None of the patients complained of gastroduodenal symptoms.

CONCLUSION

RGA embolization can help minimize the gastroduodenal deposition of radioactive particles. RGA embolization should routinely be carried out. The procedure can be performed, with similar technical success, by both anterograde and retrograde approaches.

Evaluation of Extrahepatic Perfusion of Anticancer Drugs in the Right Gastric Arterial Region on Fused Images Using Combined CT/SPECT: Is Extrahepatic Perfusion Predictive of Gastric Toxicity?

BACKGROUND

Hepatic arterial infusion (HAI) chemotherapy is effective for treating primary and metastatic carcinomas of the liver. Since hepatic arteries also supply the stomach and duodenum, HAI may result in unwanted infusion into the upper gastrointestinal tract and consequent gastric toxicity. Using fused images obtained with a combined SPECT/CT system, we assessed extrahepatic perfusion (EHP) and its correlation with gastrointestinal toxicity in patients receiving HAI.

METHODS

We studied 41 patients with primary or metastatic carcinoma of the liver who received HAI chemotherapy consisting of 5-fluorouracil and cisplatin. All underwent abdominal SPECT using a (99m)Tc-MAA (185 MBq) instrument and an injection rate of 0.1 ml/min, identical to the chemotherapy infusion rate. Delivery was through an implantable port. We analyzed the distribution of the anticancer agent on fused images and the relationship between EHP of the right gastric arterial region and gastric toxicity. All patients underwent esophagogastroduodenoscopy (EGDS).

RESULTS

Of the 41 patients, 11 (27%) manifested enhancement of the duodenal and gastric pyloric region on fused images. EGDS at the time of reservoir placement detected gastric ulcers in 10 of these patients.

CONCLUSION

Fusion imaging with combined SPECT/CT reflects the actual distribution of the infused anticancer agents. The detection of EHP on fused images is predictive of the direct gastric toxicity from anticancer agents in patients undergoing HAI.

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.

Feasibility study of ambulatory continuous infusion of 5-fluorouracil followed by cisplatin through hepatic artery for metastatic colorectal cancer

PURPOSE

A great synergy has been reported in a number of preclinical studies when 5-fluorouracil (5-FU) precedes cisplatin (CDDP). The objective of this study was to determine the feasibility of ambulatory continuous infusion of 5-FU followed by CDDP through hepatic artery for metastatic colorectal cancer.

PATIENTS AND METHODS

Seventeen patients with unresectable liver metastases, who underwent primary tumor resection, were treated with 5-FU (450 mg/m2/day) for seven consecutive days followed by CDDP (100 mg/body/week) for seven consecutive days, each administered continuously by using a balloon pump via Infuse-A-Port catheter inserted into common hepatic artery. The doses of drugs were reduced 20% in patients older than 70 years. The treatment was repeated every 4-6 weeks until disease progression.

RESULTS

Of 17 assessable patients, nine patients showed PR (53%; 95% CI, 29.3-76.7%) and eight patients had SD (47%; 95% CI, 23.3-70.7%), with disease control rate of 100%. The median overall survival was 26 months (95% CI: 17.5-41 months) and TTP 14 months (95% CI: 11-20.3 months). Two patients (11.8%), who showed progression due to collateral feeding arteries, responded to HAI again after occlusion. Grade 3 toxicity included leukopenia (12%) and anemia (24%). Grade 4 toxicity was absent. Four patients (23.5%) progressed at extrahepatic sites.

CONCLUSIONS

This sequential combination of 5-FU followed by CDDP through hepatic artery is active and safe in an outpatient setting, and warrants further multi-institutional study, although prevention of micrometastasis would be mandatory to further prolong overall survival.

The significance and clinical factors associated with a subcentimeter resection of colorectal liver metastases

BACKGROUND

Prognosis after resection of colorectal liver metastases is influenced by various factors. A positive margin of resection (MOR) has been shown to adversely influence prognosis. Although a 1-cm MOR has been accepted as adequate, the data to support this guideline are sparse.

METHODS

Our hepatobiliary database was queried for patients who underwent liver resection for colorectal metastases between January 1992 and July 2003. All patients were divided into three groups: MOR <.5 cm (group A), .5 to 1 cm (group B), and >1 cm (group C). Operative reports from each hepatic resection were analyzed to determine local factors that may have contributed to a subcentimeter MOR.

RESULTS

A total of 112 patients (67 men and 45 women) underwent liver resection for colorectal metastases with negative margins. Fifty-three patients were in group A, 26 patients were in group B, and 33 patients were in group C. Group C demonstrated decreased local recurrence (LR; P = .003), distant recurrence (DR; P = .008), and disease-free recurrence (P = .002). A significant difference in the overall time to LR (P = .003), time to DR (P = .003), and disease-free survival (P = .002) was also demonstrated. Factors associated with a subcentimeter MOR included nonanatomical resection (P = .043), proximity to a major vessel (P = .003), and central location (P = .002).

CONCLUSIONS

A <1-cm resection for colorectal liver metastases is associated with increased LR and DR, as well as decreased disease-free survival. When a nonanatomical resection is performed, a MOR >1 cm should be attempted, because an adequate margin is often underestimated. Considerations should be made for extended resections when tumors are centrally located or near major vessels.

Combination treatment of CC531-lac-Z rat liver metastases by chemoembolization with pemetrexed disodium and gemcitabine

PURPOSE

The aim of this study was to evaluate the combination effect of pemetrexed disodium (MTA; Alimta; LY 231514) and gemcitabine (GEM) administered by hepatic artery and portal vein chemoembolization (HACE and PVCE) in a colorectal cancer rat liver metastasis model.

MATERIALS AND METHODS

Proliferation studies on CC531-lac-Z rat colon cancer cells were performed using the MTT assay to obtain the optimal combination schedule of the two antineoplastic agents. To generate diffuse liver metastasis, 4 x 10(6) tumor cells were implanted into the portal vein of male WAG/Rij rats. MTA (30 mg/kg, 60 mg/kg, and 90 mg/kg) was administered locoregionally by portal vein chemoembolization (PVCE) and compared with repeated systemic intravenous injection. GEM (50 mg/kg) was also given locoregionally by hepatic artery chemoembolization (HACE) as well as systemically. All routes of administration were examined alone as well as in combination. Efficacy of treatment in terms of liver metastases burden was determined at the end of the experiment by measuring the beta-galactosidase activity of CC531-lac-Z cells with a chemoluminescence assay.

RESULTS

Combination experiments in vitro showed a more than additive tumor cell reduction after sequential exposure to MTA preceding GEM (observed/expected ratio [O/E] = 0.73). Experiments with the reverse sequence (GEM-->MTA) resulted only in additive combination effects (O/E ratio = 1.08). Simultaneous drug exposure showed less than additive combination effects (O/E ratios > or = 1.25). In vivo, locoregional administration by HACE with GEM was significantly more effective than systemic intravenous bolus treatment (P = 0.03). Portal vein chemoembolization with MTA performed immediately after tumor cell inoculation was ineffective. Repeated systemic treatment with MTA yielded a slight reduction in tumor cell load that was significant versus control at the medium and high doses (60 mg/kg, P = 0.009; 90 mg/kg, P = 0.046) but not versus intraportal chemoembolization. The combination treatment of systemic (60 and 90 mg/kg) or locoregional (60 mg/kg) MTA with HACE using GEM (50 mg/kg) resulted in more than 80% tumor growth inhibition; this antineoplastic combination effect was maximally additive.

CONCLUSION

A regimen-dependent synergistic combination effect of both drugs was found in vitro. In animals, hepatic artery chemoembolization with GEM was superior to systemic intravenous bolus treatment. Portal vein chemoembolization with MTA was ineffective. The optimal in vitro regimen of MTA (intravenous or PVCE) preceding GEM (HACE) resulted in a maximally additive tumor growth inhibition. The results indicate that MTA and GEM can successfully be combined and favor further evaluation in patients.

Efficacy of the Left Gastric Artery as a Route for Catheterization of the Right Gastric Artery

OBJECTIVE

Our aim was to evaluate the efficacy of the left gastric artery as a route for embolization of the right gastric artery before port-catheter implantation for hepatic artery infusion chemotherapy.

MATERIALS AND METHODS

In 88 patients (61 men and 27 women; mean age, 63.4 years; range, 25-83 years) with unresectable advanced liver cancer, retrograde catheterization of the right gastric artery through the left gastric artery was performed to embolize the right gastric artery.

RESULTS

The right gastric artery was successfully catheterized and embolized in 79 patients (89.8%). In two of the nine patients in whom the procedure was not successful, we found that no right gastric artery existed after we succeeded in retrograde advancement of the microcatheter toward the hepatic site. The only procedure-related complication was misplacement of a microcoil into the hepatic artery site in two patients.

CONCLUSION

The left gastric artery is an appropriate route for selective embolization of the right gastric artery as preparation for long-term hepatic artery infusion chemotherapy.

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.

Value of Transcatheter Arterial Embolization with Coils and n-Butyl Cyanoacrylate for Long-term Hepatic Arterial Infusion Chemotherapy

PURPOSE

To assess the value of transcatheter arterial embolization (TAE) of splanchnic arterial branches to allow continuous application of repeat hepatic arterial infusion chemotherapy (HAIC).

MATERIALS AND METHODS

In 128 patients with unresectable advanced liver cancer, percutaneous implantation of a port catheter system and TAE of splanchnic arteries with coils and/or n-butyl cyanoacrylate (NBCA) were performed. Parameters included (a) methods selected for catheter placement; (b) embolic materials used (coils and/or NBCA, number of coils, administration rate of NBCA-iodized oil) for TAE of splanchnic arteries, details of embolized arteries, and frequency of recanalization; (c) ability to prevent gastrointestinal symptoms by avoiding inflow of anticancer drugs into extrahepatic adjacent organs and to maintain distribution of contrast agents in liver, as well as management of difficulties encountered; (d) complications related to catheter system implantation or to long-term HAIC and management of such complications; and (e) final success in performing scheduled HAIC while maintaining distribution over liver via a single route without gastrointestinal symptoms caused by inflow of anticancer drugs. Fisher exact test was used to compare recanalization rate between coil-embolized and NBCA- or NBCA-coil-embolized arteries, and frequency of heterogeneously poor distribution was compared between patients with single and those with multiple hepatic arteries.

RESULTS

Embolization was successful during first catheterization in 326 arteries and during follow-up in 10. In 119 (93.0%) of 128 patients, repeat HAIC was effective until death or the time of this writing (observation period, 2-47 months). HAIC was continued in two patients, although anticancer drugs did not distribute to all liver tumors. Arteries once embolized with coils alone spontaneously recanalized at a significantly higher rate than those with NBCA (eight of 192 vs one of 144, P =.048). Rate of heterogeneously poor distribution was significantly higher in those with two or more hepatic arteries than in those with one (seven of 17 vs nine of 111, P =.001).

CONCLUSION

TAE for various splanchnic organs is useful for efficient performance of long-term HAIC.

Liver metastases: neoadjuvant downsizing with transarterial chemoembolization before laser-induced thermotherapy

PURPOSE

To evaluate a treatment protocol with repeated transarterial chemoembolization (TACE) before laser-induced thermotherapy (LITT) in patients with unresectable liver metastases that are too large for LITT alone.

MATERIALS AND METHODS

One hundred sixty-two patients who had unresectable liver metastases, with the largest lesion as large as 80 mm in diameter, and no more than four lesions were treated with repeated TACE between March 1999 and December 2001. TACE was performed with a maximum of 10 mg/m2 mitomycin for chemotherapy and a maximum of 15 mL/m2 of iodized oil and microspheres for vessel occlusion. Tumor volume before and during treatment was measured at magnetic resonance (MR) imaging. If the diameter of the tumor decreased to less than 50 mm, the patients were treated with MR imaging-guided LITT 4-6 weeks following embolization.

RESULTS

Eighty-two patients (62 with metastases from colorectal cancer, 14 with metastases from breast cancer, and six with metastases from other primary tumors) responded to TACE, with a mean reduction in tumor size of 35% +/- 14 (SD), and were treated with LITT. Each patient underwent two to seven TACE treatments (mean, 4.3) prior to LITT. In 47 patients, no reduction in tumor size was achieved, which led to further follow-up. In 33 patients, disease progression was found, with either an increasing size of the lesions (n = 18) or newly developing metastases (n = 15), and these results led to further TACE treatments or change to systemic chemotherapy. Median survival of patients who responded to this combined treatment was 26.2 months; in patients treated with only TACE, median survival was 12.8 months (range, 0.3-29.4 months).

CONCLUSION

With repeated TACE, reduction in size of primary unresectable hepatic metastases is achieved in 50.6% of cases and allows local ablative treatments such as MR imaging-guided LITT.

Angiography for diagnosis and treatment of colorectal cancer

AIM: To evaluate the role of preoperative angiography in the diagnosis and treatment of colorectal cancer.

METHODS: The authors performed selective arterial cannulation by Seldinger's method in 47 patients to locate the primary cancer and to diagnose metastasis to the liver. Each patient was then given intra-arterial regional chemotherapy, and received 5-fluorouracil (5-Fu, 1000 mg), mitomycin C (MMC, 20 mg), and cisplatinum (CDDP, 80 mg).

RESULTS: The location and shape of each tumor were observed, including metastatic tumors in the liver, in 42 of the 47 (89.4%) patients. The site of the primary tumor was difficult to identify in 5 cases because the patients had a recurrence of cancer. Arterial chemotherapy was performed successfully in all patients. The authors recorded no partial or significant morbidity resulted from angiography. The only incident was bleeding from the artery puncture site in one patient, which was successfully stopped by general medication.

CONCLUSION: Preoperative selective arterial angiography can help the diagnosis and locate primary tumors and to detect liver metastasis. At the same time, regional arterial chemotherapy can be an important form of preoperative therapy.

Current treatment for liver metastases from colorectal cancer

The liver is the commonest site of distant metastasis of colorectal cancer and nearly half of the patients with colorectal cancer ultimately develop liver involved during the course of their diseases. Surgery is the only therapy that offers the possibility of cure for patients with hepatic metastatic diseases. Five-year survival rates after resection of all detectable liver metastases can be up to 40%. Unfortunately, only 25% of patients with colorectal liver metastases are candidates for liver resection, while the others are not amenable to surgical resection. Regional therapies such as radiofrequency ablation and cryotherapy may be offered to patients with isolated unresectable metastases but no extrahepatic diseases. Hepatic artery catheter chemotherapy and chemoembolization and portal vein embolization are often used for the patients with extensive liver metastases but without extrahepatic diseases, which are not suitable for regional ablation. For the patients with metastatic colorectal cancer beyond the liver, systemic chemotherapy is a more appropriate choice. Immunotherapy is also a good option when other therapies are used in combination to enhance the efficacy. Selective internal radiation therapy is a new radiation method which can be used in patients given other routine therapies without effects.

Embolization of the right gastric artery before hepatic arterial infusion chemotherapy to prevent gastric mucosal lesions: approach through the hepatic artery versus the left gastric artery

OBJECTIVE

The purpose of our study was to evaluate whether the hepatic artery or the left gastric artery is the better route of approach for selective embolization of the right gastric artery before hepatic arterial infusion chemotherapy using a port-catheter system.

SUBJECTS AND METHODS

Eighty-six patients (56 men, 30 women; mean age, 62.1 years) with unresectable advanced liver cancer underwent percutaneous implantation of a port-catheter system. In the 75 patients who had not undergone gastrectomy, right gastric artery embolization was performed before port-catheter system placement to prevent gastric mucosal lesions. In 43 patients, the approach for embolization was through a microcatheter inserted from the hepatic artery site, and in the remaining 32 patients, the approach was from the left gastric artery. The success rates of these two groups were compared.

RESULTS

Embolization was successfully accomplished at the first attempt in 72.1% of the 43 patients in whom the microcatheter was inserted from the hepatic artery site. In contrast, in 93.8% of 32 patients, embolization was successfully performed through the left gastric artery. The success rate of embolization was significantly higher in the latter group (p = 0.0173, chi-square test). A second attempt in which the catheter was redirected to another approach, performed on the same day in a majority of patients, resulted in successful embolization in an additional eight patients, with a final success rate of 92.0%.

CONCLUSION

Embolization of the right gastric artery using microcoils through a microcatheter advanced through the left gastric artery may be the preferred method for the preparation of repeated hepatic artery infusion.

Radiofrequency ablation of hepatic tumors

Radiofrequency thermal ablation is receiving increasing attention as an alternative to standard surgical therapies for the treatment of liver neoplasms. Benefits over surgical resection include the anticipated reduction in morbidity and mortality, low cost, suitability for real time image guidance, the ability to perform ablative procedures on outpatients, and the potential application in a wider spectrum of patients, including nonsurgical candidates. This review examines reported clinical results of this new therapeutic technique, potential complications, current limitations, thermal ablation mechanisms, as well as technical features and diagnostic modalities used in the procedure.