Hepatic artery ligation and 5-fluorouracil infusion for metastatic colon carcinoma and primary hepatoma

Prognostic and predictive value of circulating DNA for hepatic arterial infusion of chemotherapy for patients with colorectal cancer liver metastases

Hepatic arterial infusion (HAI) of chemotherapy is an experimental treatment option for patients with colorectal cancer liver metastases (CRCLM). The current study aimed to investigate the predictive and prognostic value of cell free DNA (cfDNA) in patients with CRCLM receiving HAI with oxaliplatin and systemic capecitabine. Plasma samples from 62 patients were investigated who were included into a single arm phase II study investigating HAI treatment for patients with CRCLM. The clinical outcome of the trial has been presented previously. In brief, treatment consisted of intrahepatic infusion of oxaliplatin 100 mg/m² every second week with concomitant oral capecitabine 3,500 mg/m² every second week for up to 12 cycles. Blood samples were drawn at baseline and follow-up and plasma was analyzed for cell free DNA using a direct fluorescent assay. The baseline level of plasma cfDNA was 0.92 ng/µl (95% CI 0.84-1.00). Patients with a baseline value of cfDNA above the 75th quartile had a median overall survival of 2.4 years (95% CI 0.7-2.8), compared with 3.9 years (95% CI 2.8-5.9) for patients below the 75th quartile (P=0.02). The baseline level of cfDNA was significantly lower (0.91 ng/µl, 95% CI 0.76-0.98) in patients who achieved an objective response compared to non-responders (1.79 ng/µl; 95% CI 0.99-2.57; P=0.02). The current study demonstrated a possible prognostic and predictive value of cfDNA for patients with CRCLM undergoing HAI with oxaliplatin and concomitant capecitabine.

Historical perspective: Two decades of progress in treating metastatic colorectal cancer

Colorectal cancer is the third most commonly diagnosed cancer in the United States. While screening methods strive to improve rates of early stage detection, 25% of patients have metastatic disease at the time of diagnosis, with the most common sites being the liver, lung, and peritoneum. While once perceived as hopeless, the last two decades have seen substantial strides in the medical, surgical, and regional therapies to treat metastatic disease offering significant improvements in survival.

Hepatic resection, hepatic arterial infusion pump therapy, and genetic biomarkers in the management of hepatic metastases from colorectal cancer

The liver is the most common site of colorectal cancer metastasis. Fortunately, improvements have been made in the care of patients with colorectal liver metastasis (CRLM). Effective management of CRLM requires a multidisciplinary approach that is tailored to individuals in order to achieve long-term survival, and cure. Resection and systemic chemotherapy provides benefit in selected individuals. An adjunct to resection and/or systemic chemotherapy is the use of hepatic arterial infusion pump (HAIP) therapy. Many studies show HAIP provides benefit for select patients with CRLM. Added to the crucible of a multidisciplinary approach to managing CRLM is the ever growing understanding of tumor biology and genetic profiling. In this review, we discuss the outcomes of resection, systemic therapies and HAIP therapy for CRLM. We also discuss the impact of recent advances in genetic profiling and mutational analysis, namely mutation of KRAS and BRAF, for this disease.

Gene expression of 5-fluorouracil metabolic enzymes in hepatocellular carcinoma and non-tumor tissue

5-fluorouracil (5-FU) is a basic agent used in chemotherapy. The aim of this study is to investigate the gene expression of 5-FU anabolic and catabolic enzymes in hepatocellular carcinoma (HCC) and non-tumor tissue, respectively to increase our knowledge of resistant mechanisms to 5-FU in HCC. The relative mRNA level of orotate phosphoribosyltransferase (OPRT), ribonucleotide reductase (RNR), dihydropyrimidine dehydrogenase (DPD) and target enzyme thymidylate synthase (TS), were analyzed in 30 matched samples of HCC (T) and non-tumor tissue (NT) using quantitative RT-PCR. The expression of OPRT, RNR-M1, RNR-M2 and TS is significantly higher in T compared with in NT (1.3-fold increase, 1.6-fold, 7.1-fold, 1.9-fold, respectively), but that of DPD showed no difference between T and NT. Our results show that HCC should not be treated with 5-FU alone because of its instability in liver.

Combined intra-arterial 5-fluorouracil and subcutaneous interferon-alpha therapy for highly advanced hepatocellular carcinoma

Because of the difficulties of low sensitivity for anticancer agents and giving sufficient dose because of poor liver function, chemotherapy may not play a central role for treatment of hepatocellular carcinoma (HCC) patients, especially those with liver cirrhosis. However, chemotherapy must be one of the important possibilities of multimodal treatment for advanced HCC, for which hepatic resection, percutaneous ablation, transcatheter arterial embolization and other general therapies would not be effective or even possible. Also, intra-arterial perfusion chemotherapy is a common therapy for HCC and it is not difficult to maintain; but the effective rate is not sufficient. Recently, the combination therapy of s.c. interferon (IFN)-alpha and intra-arterial 5-fluorouracil (5-FU) showed an outstandingly effective rate for intractable HCC (with portal vein thrombosis). In addition,recent preclinical and clinical studies have revealed that the mechanism of combination therapy may concern direct antitumor effects (through cell-cycle arrest and induction of apoptosis) and indirect actions (through immunocompetent cells and anti-angiogenic effect). For the further advance of HCC treatment and prognosis, this therapy might be a promising treatment modality and is expected to develop. In this review, we summarize recent clinical and preclinical data regarding IFN-alpha and 5-FU combination therapy and discuss the further prospects of this therapy.

Treatment of colorectal liver metastases by cryotherapy

One hundred fifty-eight procedures were performed on 136 patients with unresectable hepatic metastases using hepatic cryotherapy to ablate the tumors. The median age was 62 years. Patients included 90 males and 46 females. Fifty-eight patients had synchronous metastases, 55 had bilobar lesions, and 90 had precryo chemotherapy. Median preoperative carcinoembryonic antigen (CEA) level was 14.4 ng/dl. The numbers of lesions treated, frozen, and resected were two and one. Median survival of all patients was 30 months. Survival for 39 patients was 37 months. Patients with a CEA level > 100 ng/dl had a statistically worse survival rate than those with a level < 100 ng/dl (P < .001). Twenty patients underwent recryotherapy with median survival of 34 months. Recurrent disease developed in 78% of patients--82% of the patients developed liver recurrence. Complication rates were comparable to liver resection. Operative mortality was 3.7%. Hepatic cryotherapy is effective and safe in treating colorectal hepatic metastases under ultrasound guidance.

Malignant lymphoma of the stomach after chemotherapy for hepatocellular carcinoma

A rare case of malignant lymphoma of the stomach after treatment for hepatocellular carcinoma (HCC) is reported. A 72-year old man presented with a large mass on the right hypochondrium, which was diagnosed as HCC associated with chronic hepatitis C with cirrhosis. The inoperable tumor was treated conservatively with cisplatin, etoposide, carboplatin, and Lipiodol infused into the hepatic artery, together with transcatheter arterial embolization. The patient presented 38 months later with features suggestive of gastric ulceration. Endoscopy and histological examination of biopsy material confirmed the presence of malignant lymphoma of the stomach. He ultimately died as a result of hepatic failure. The clinical presentation suggests that gastric lymphoma was possibly related to the lymphotropic effect of hepatitis C virus (HCV) and exacerbated by intraarterial injection of the cytotoxic drugs.

Treatment of colorectal cancer: hepatic metastasis

Almost one-third of patients dying from colorectal cancer have tumor limited to the liver. Systemic chemotherapy is the appropriate palliative management of patients with metastases to the liver and other sites. For many patients with isolated hepatic metastases, systemic chemotherapy is also the most appropriate treatment. However, results with systemic chemotherapy indicate that one-third or less of patients will respond to such treatments, and long-term survival is rare. In this report we provide information concerning the natural history of colorectal hepatic metastases, followed by the expected benefits with systemic chemotherapy. This information provides background for the regional therapeutic strategies of surgical resection, cryosurgery, and hepatic artery chemotherapy. We discuss the selection factors appropriate for such treatments, morbidity and mortality, and the potential long-term benefits of such approaches. The last section focuses on surgical considerations in hepatic resection and hepatic artery chemotherapy.

Arterial therapy of hepatic colorectal metastases

Considerable experience of the treatment of irresectable hepatic colorectal metastases has accumulated over the past three decades. In this review, the rationale for hepatic artery treatment of colorectal metastases to the liver is presented and various access techniques and chemotherapeutic agents for infusion are discussed. Randomized trials of hepatic artery chemotherapy (HAC) are analysed, and the promising results of recent studies combining less toxic and more effective agents are summarized. Continuous infusion pumps provide the most reliable and long-lasting access for HAC. Appropriate surgical techniques and medical management can minimize complications. Although tumour progression is best controlled by HAC, a clear-cut survival advantage has yet to be demonstrated. While hepatic artery infusion chemotherapy cannot yet be recommended outside investigational protocols, the experience gained so far should stimulate further studies.

Surgical options in the treatment of hepatic metastasis from colorectal cancer

Current data indicate that liver resection is the only available treatment that regularly produces long-term survival with possible cure in patients with metastatic colorectal carcinoma to the liver. Although a number of clinical or pathologic factors predicts a poor outcome, the only absolute contraindications to liver resection are general health incompatible with recovery from major hepatic resection or clear evidence of wide dissemination of disease. Important areas for future study include the potential role of adjuvant regional chemotherapy after resection and cryoablation of "close" margins. For patients with unresectable disease, operative therapy also plays an important role. Multiple operative modalities hold promise in palliative treatment in the setting of clinically incurable disease. It is imperative that a large randomized trial of regional chemotherapy be performed allowing no crossover and with mortality as an endpoint. Additionally, the role of cryoablation begs systematic investigation to ensure proper use of this modality.

Hepatic arterial embolization with microencapsulated mitomycin C for unresectable hepatocellular carcinoma in cirrhosis

From 1986 to 1988, 35 patients with a hepatoma judged either inoperable or unresectable because of coexistent cirrhosis were treated with hepatic arterial embolization of mitomycin C microcapsules. Five of these 35 patients (14.5%) could not be treated because of inability to selectively cannulate the hepatic artery and were therefore excluded from the evaluation (feasibility rate, 86%). There were 24 men and six women with a median age of 57 years (range, 47 to 79) who could be classified as Okuda I (14 pts) or Okuda II (16 pts) and Child Class A:18 and Child Class B:12 in the remaining patients. A median dose of 0.5 mg mitomycin C/kg was administered to each subject and the treatment was repeated at 5 to 6 week intervals. Seventy courses were administered to these 30 patients (median, two courses/patient; range, 1 to 4). Minor complications were frequent (63%) but always either resolved spontaneously or after appropriate medical treatment. Neither severe renal nor hepatic toxicity was observed. No specific treatment related mortality was observed. When alpha-fetoprotein levels and tumor volume were assessed to evaluate the response to treatment using established criteria for identifying a response, an objective response was found in 43% of the cases treated. The actuarial median survival was 7 months and the 1-year actuarial survival was 36% (51% for those rated as Child Class A and 0% for those identified as Child Class B, P = 0.04 and 78% rated as Okuda Types I and 0% Okuda type II, P = 0.0001). The excellent quality of life and the increased survival rate experienced after mitomycin C microcapsule embolization suggest that this treatment modality can be used successfully in patients seen in the West who have unresectable hepatoma.

Regional treatment of hepatic metastases and hepatocellular carcinoma

Hepatic metastases represent a common site of dissemination for a number of primary malignancies related in part to the dual blood supply, large blood flow, and receptive environment of the hepatic parenchyma. Although this review focuses on regional therapy, we have included sections on systemic therapy to better interpret the results with intrahepatic therapy. We will also discuss the efficiency of hepatic arterial ligation, embolization, and radiotherapy of hepatic metastases. Primary gastrointestinal neoplasms are particularly prone to produce hepatic metastases. Because colorectal carcinoma metastasizes to the liver in up to 70% of patients with advanced disease, the treatment of hepatic metastases is a relevant topic. We will discuss the systemic and regional therapy of colorectal, gastric, and gallbladder cancers. Breast carcinoma and malignant melanoma frequently metastasize to the liver, and we have described systemic and regional treatments of these diseases. Because sarcomas are often treated by regional therapy, we have included a section on the treatment of hepatic sarcomas. Neuroendocrine tumors (carcinoid and islet cell), although often slow growing, frequently metastasize to the liver and then cause symptomatic problems. Much of the work done with embolization and hepatic ligation in the treatment of hepatic metastases has been performed in neuroendocrine tumors, and these studies, as well as the systemic and regional chemotherapy of hepatic metastases, will be described. The last section concerns the treatment of hepatocellular carcinoma. We have outlined the staging systems used. We then detail the results of systemic and intrahepatic therapy, embolization, and hepatic ligation in the treatment of hepatocellular carcinoma. Because hepatic metastases are a frequent problem, many patients are available for clinical investigation. It is hoped that newer strategies for the treatment of liver metastases will lead to higher response rates and perhaps control of local disease. These therapeutic approaches may also give us leads to the treatment of systemic disease.

Intrahepatic chemotherapy for unresectable hepatocellular carcinoma

From 1976 to 1983, 28 patients (24 male and four female) with unresectable hepatocellular carcinoma (HCC) were treated by intraarterial chemotherapy at the Istituto Nazionale Tumori of Milan, Milan, Italy. Tumors were retrospectively classified by a previously proposed staging system. Two patients were classified as Stage I and 26 as Stage II. Liver cirrhosis was present only in the males (in 50% of them). Nineteen patients were treated with doxorubicin (Adriamycin [Adria Laboratories, Columbus, OH]) and nine with 5-fluorouracil. Systemic toxicity was mild, but the treatment induced hepatic toxicity (ascites, clinical jaundice, or biochemical impairment) in 18% of noncirrhotic and 66% of cirrhotic patients. Clinical reduction of hepatomegaly was observed in 50% of noncirrhotic versus 16% of cirrhotic patients. Doxorubicin was effective in 66% of noncirrhotic patients and 20% of cirrhotic patients, with an overall response rate of 42%. 5-fluorouracil was effective only in patients without cirrhosis, with an overall response rate of 22%. Overall median actuarial survival was 3.5 months, with a significant difference between noncirrhotic and cirrhotic patients (6 versus 2 months, respectively). Overall median survival of patients who responded to the treatment was 13 versus 2 months for nonresponders (P less than 0.001). Liver cirrhosis was the most important prognostic factor in terms of liver toxicity, response rate, and survival. This study emphasized the negative impact of the treatment on cirrhotic patients. Also, the real value of intraarterial administration of doxorubicin was investigated.

Duodenal epithelial atypia. A specific complication of hepatic arterial infusion chemotherapy

Severe duodenal lesions developed in five patients during hepatic arterial infusion (HAI) employing 5-floxuridine (FUDR) as the basic antineoplastic agent. These lesions comprised ulcerative as well as proliferative processes. Striking structural distortion with cellular pleomorphism of the affected duodenal mucosa were the histological hallmark in all cases. These lesions are a specific complication of HAI chemotherapy and should not be misinterpreted as malignancy.

Hepatic artery ligation for liver metastasis in colorectal carcinoma

From April 1975 to January 1982, 97 patients with greater than or equal to 50% of the liver involved with metastasis from colorectal carcinoma underwent hepatic artery ligation. The purpose was to evaluate median survival times in relation to performance status, synchronous intraabdominal metastasis, pulmonary metastasis, liver function tests (alkaline phosphatase, serum glutamic oxaloacetic transaminase (SGOT), lactate dehydrogenase (LDH), total bilirubin, and Dukes' staging. Results reveal that for performance status 0 to 1 (normal or symptoms, but ambulatory), median survival time was 12.3 months; status 2 to 3 (in bed less than or greater than 50% of time), 8.3 months; status 4 (100% bedridden), 2.6 months, (P less than 0.01). Median survival time in patients with only intrahepatic metastasis was 10 months versus 7 months for synchronous intraabdominal metastasis (P less than 0.01). For 20 patients with pulmonary metastasis undergoing hepatic artery ligation, the median survival time was 8.8 months (P less than 0.05). The median survival time in patients whose alkaline phosphatase was 2 times normal was 12.4 months, whereas, if alkaline phosphatase was 2 times to 4 times or greater than 4 times normal, median survival times were 7.1 and 6.9 months, respectively (P less than 0.01). Factors that adversely affect survival for hepatic artery ligation are extrahepatic metastasis, poor performance status, and elevated liver function tests (alkaline phosphatase 2 times normal). The overall median survival time in this study is 9.5 months with certain subgroups achieving 12.4 months' survival.

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.

[A new method for isolated regional perfusion of the liver in vivo. Experimental studies (author's transl)]

The canine liver was isolated from its blood supply and perfused for one hour normothermically be means of a new catheter and a perfusion system consisting of oxygenator, pump and heat-exchanger. Hemodynamic parameters, blood gas analyses, and tissue metabolites were evaluated during experiments. The venous return from the lower body and portal vein (1.113/1min) could be maintained with the catheter system so that the mean systemic arterial pressure was within normal limits. With a perfusion rate through the liver 0,55 ml/min/g and perfusion pressure of 10 cm H2O there was an adequate tissue perfusion; this was also shown by blood gas analyses and tissue metabolite concentrations. Using dye dilution methods the isolation of the liver was tested. This showed a leakage of 6-7% of the total perfusion volume. This new method makes it possible to carry out an isolated, normothermic, liver perfusion for one hour without irreversible tissue damage.

Improved regional selectivity of hepatic arterial BCNU with degradable microspheres

Starch microspheres 40 micrometers in diameter, which are rapidly degraded by serum amylase, have been administered through hepatic arterial catheters to five patients with primary and metastatic liver cancer to determine whether (1) arterial blood flow through the liver could be temporarily blocked, and (2) such occlusion at the level of the arteriolar capillary bed would enhance regional uptake and catabolism and decrease systemic exposure to simultaneously administered hepatic arterial bischlorethylnitrosourea (BCNU). It was possible with 10 ml of microspheres (9 X 10(6) microspheres/ml) injected into the hepatic artery to transiently (for 15-30 minutes) reduce hepatic flow by 80-100% in the five patients. When BCNU (50 mg/m2 in one minute) was given with microspheres there was a 30-90% reduction in systemic nitrosourea exposure and in peak levels. No myelosuppression was noted and hepatic toxicity consisted of acute pain due to BCNU and 1.5-2.0 fold transient enzyme elevations. One patient with cholangiocarcinoma showed a partial response lasting three months; three patients had stable disease and one patient with colon carcinoma had progressive disease. Thus, this pilot study suggests that concurrent intra-arterial microspheres and BCNU may have the potential to improve selective regional drug effect with marked diminution in systemic toxicity.

[Importance of graft arterialization in rat liver transplantation]

68 LEW-livers were grafted orthotopically into LEW; 18 with and 50 without rearterialization of the graft. 73.3% of the recipients without arterialization died of ischemic damage of the donor livers and bile ducts. The other animals survived indefinitely (more than 120 days). However, 73.3% of the recipients with graft arterialization survived more than 120 days, three animals 8-23 days. Only one recipient died of bile duct complications on the first postoperative day. These results suggest the importance of graft arterialization in rat liver transplantation, despite the observation that all untreated animals survive after complete dissection of the arterial blood flow to liver. Intraoperatively rats can tolerate acute occlusion of portal vein and vena cava inferior up to 50 min without any bypass for the decompression of splanchnic blood flow. We examined the formation of arterial collateral blood supply in the dearterialized livers by application of gelatin-medium. On day 3 we observed collateral vessels in the hilus of dearterialized livers which mainly originated from the gastroduodenal region and were connected to the remaining arterial system of the liver. Complete arterialization was shown on day 7. In the hepatic graft without arterialization the arterial collaterals were not seen until day 7, and complete arterial blood flow was demonstrated after three postoperative weeks.

[Approaches to a selective chemotherapy of hepatocellular carcinoma (author's transl)]

1. An improvement of the chemotherapy of hepatocellular carcinoma with adriamycin or 5-fluorouracil and a reduction of side effects has been achieved by intra-arterial administration of the drugs. This treatment provides a somewhat extended survival but no cure. 2. The treatment of hepatocellular carcinoma in patients by reduction of an inactive precursor of a cytocidal alkylating agent by azoreductase of the tumor showed no therapeutic effect. 3. A selective hepatocellular uptake of drugs coupled to asialoglycoproteins has been described. An application of this concept for the chemotherapy of hepatocellular carcinoma seems doubtful since a loss of binding proteins for desialylated glycoproteins during experimental hepatocarcinogenesis has been demonstrated. 4. The increased uptake of 5-fluorouridine in hepatomas after induction of a tissue-specific depletion of uridine 5'-triphosphate and cytidine 5'-triphosphate provides an effective experimental chemotherapy with limited side effects. A clinical use of this new concept for the chemotherapy of hepatocellular carcinoma may serve as a useful approach.

Comparative efficacy of antitumor treatment for liver metastases from colorectal cancer

A retrospective study of 37 colorectal cancer patients with synchronous liver metastases was made. Of these patents, 6 who had undergone primary tumor removal were treated with considerable success by hepatic arterial infusion of 5-FU and mitomycin C. Ten patients who underwent primary tumor excision were treated by oral chemotherapy using fluorinated pyrimidines. These patients survived about 23 months. On the other hand, 12 patients after primary tumor removal without cancer chemotherapy survived for about 10 months. Six patients without antitumor treatment for both primary tumor and hepatic metastasis survived about 5.2 months. The overall results of this study suggest that intrahepatic arterial infusion is of practical importance for hepatic metastases from colorectal cancer and that oral chemotherapy is indeed effective for selected patients.

The practicality of chronic hepatic artery infusion therapy of primary and metastatic hepatic malignancies: ten-year results of 124 patients in a prospective protocol

Ten-year results are presented of 124 patients with malignancy apparently limited to the distribution of the hepatic artery, treated to prospective protocol with continuous infusion of 5-FUdR through an hepatic artery catheter. Nearly all patients had moderate to massive hepatic replacement. Of 88 patients with colorectal carcinoma, 64 (73%) had clinically objective and subjective remission. Median survival for responders was 13 months; for the entire group, ten months. Of 13 patients with hepatoma, nine had clinically significant regression with a median survival of 11 months. Ten patients had carcinoma of the gall bladder or bile duct with seven obtaining clinically significant regression. Complications encountered are discussed and are similar to other series. Of the patients experiencing clinically significant remission, all but one reached the complete independence performance status, and 84% reached normal activity levels. Thus, for hepatic localized tumor, this therapy is worthwhile and practical.

Angiography after temporary inhibition of blood flow followed by intraarterial 5-FU infusion in the treatment of liver metastases

Temporary inhibition of the blood flow to the liver was performed in 20 patients with metastases by tightening slings around the hepatic artery for 16 hours. Infusion of 5-FU started two days later through a catheter in the gastroduodenal artery. The response to the treatment as revealed by angiography was swelling of the liver and necrosis of the metastases. Thirteen patients responded favourably to the treatment. Complications such as abscess formation, 5-FU leakage, thrombosis of the hepatic artery and development of aneurysm at the entry of the infusion catheter occurred in some patients.

Transient hepatic dearterialization followed by regional intra-arterial 5-fluorouracil infusion as treatment for liver tumors

Twenty consecutive patients with secondary liver tumors were treated with a new method of liver dearterialization, performed by transient occlusion of the hepatic artery with strangulating slings, and followed by regional intra-arterial infusion of 5-fluorouracil. Tumor regression was confirmed by angiography, laboratory tests and symptom relief in more than 50% of the patients. For patients with metastatic colorectal carcinoma the mean survival time after operation was 17 months and the median survival time was 11 months. The most common complications were abscesses and aneurysms. The treatment is judged suitable for patients with a tumor of moderate severity involving both liver lobes and without extrahepatic tumor growth.

Colorectal cancer: the modern treatment of disseminated disease - a review

Most patients who develop cancer of the large bowel will eventually develop recurrence and will therefore be considered for treatment of that recurrence. There exists very great confusion as to the efficacy of the various treatment options available. This review has attempted to evaluate critically the claim for therapeutic efficacy of the various treatment options, with particular regard to patients with liver metastases from primary tumours of the large bowel. A case can be made out for surgical removal of recurrent or disseminated colorectal cancer, but there is no evidence that any form of treatment other than total surgical excision will result in prolonged patient survival. All forms of treatment can be effective in palliating symptomatic patients. Therefore, with the exception of total surgical excision of recurrent tumour, treatment should be reserved for those patients with symptoms, and the choice of treatment offered should be weighed against possible side-effects.

Salvage and palliation of patients with metastatic colorectal cancer

The natural history of colorectal cancer is briefly discussed. A review of the literature shows that survival figures have not improved significantly in the past three decades. The results of chemotherapy and surgery in advanced disease are presented. It is concluded from these data that hepatic artery ligation and infusion chemotherapy or, in selected cases, resection with adjuvant chemotherapy may improve palliation and survival in patients with hepatic metastases from colorectal cancer.

Uptake of 5-fluorouracil during isolated perfusion of the canine liver

This study describes a technique of hepatic isolated perfusion in dogs. The uptake of 14C-labeled 5 fluorouracil (5-FU) by the normal canine liver was fourfold greater when isolated perfusion was used than when peripheral intravenous administration or hepatic artery infusion were applied. Systemic leakage of 5-FU was small during, and even following, hepatic isolated perfusion. This technique, which maximizes chemotherapy delivery to the liver while minimizing systemic toxicity, may be useful in the treatment of primary and metastatic hepatic malignancies.

Hepatic arterial infusion chemotherapy for cancer of the liver

Hepatic artery infusion chemotherapy (HAIC) provides objective palliation for unresectable primary and secondary liver neoplasms. By utilizing HAIC rather than systemic chemotherapy, a greater concentration of the chemotherapeutic agent(s) within the liver is achieved with a comparative decrease in toxic side effects. A review of pertinent literature disclosed response rates of 50-71% associated with the administration of 5-fluorouracil (5-FU) and 5-fluoro-2-deoxyuridine (5-FUDR) via the hepatic artery, whereas response rates of 0-25% have been tabulated for systemic chemotherapy.

Gas-forming intrahepatic abscess: a possible complication of arterial infusion chemotherapy

Three cases of intrahepatic gas-forming abscesses are presented with liver metastases and indwelling hepatic artery catheters for drug infusion. This may represent a further complication of intrahepatic arterial drug infusion. Possible etiologies along with future prospects for this form of therapy are discussed.

Intermittent occlusion of the hepatic artery and infusion chemotherapy for carcinoma of the liver

Twenty-nine patients with hepatocellular or metastatic colon carcinoma were included in the present study. A system of staging the extent of disease was developed to provide a guideline for patient selection and evaluation of the results of therapy. Sixteen patients received intraarterial infusion chemotherapy only and thirteen were treated by a combination of intermittent occlusion of the hepatic artery and infusion chemotherapy. In this latter group intermittent occlusion of the hepatic artery was employed as an alternative to hepatic artery ligation. Patients in either group having disease confined to the liver experienced good response to treatment, had a low incidence of drug-related complications, and survived for relatively long periods. The study confirmed that intermittent occlusion of the hepatic artery is a safe procedure and that it is not accompanied by an increase in morbidity or mortality. The rationale for using this technic and the advantages it has over hepatic artery ligation were presented. The procedure is currently being utilized with increasing frequency in patients in relatively early stages of the disease. Accumulation of more material and longer periods of follow-up are required to determine the therapeutic advantages of the new method over infusion chemotherapy alone.

Hepatic artery ligation and adriamycin infusion chemotherapy for hepatoma

Two patients with hepatoma of the liver were treated with ligation of the hepatic artery and continuous infusion of adriamycin into the distal arterial branch. Both patients had tumor replacing 60-75% of the normal liver parenchyma. There was clinical improvement and objective shrinkage of the tumor by liver scan lasting for 5 and 7 months. But both cases died 7 and 11 months later, probably of cardiac toxicity (total dose of adriamycin = 500 mg/m2).

Nonsystemic treatment of metastatic tumors of the liver--a review

Hepatic metastasis is usually quite resistant to conventional systemic chemotherapy. Nonsystemic treatment of metastatic tumors of the liver include surgical resection; infusion of chemotherapeutic agent(s), either via hepatic artery or portal vein; ligation of hepatic artery; radiotherapy; and other more investigative approaches (isolation perfusion, cryosurgery, liver transplantation, etc). The relative applicability, results, and limitations of each of these therapeutic modalities are reviewed.

Dearterialization of the liver for metastatic cancer. Clinical, angiographic and pathologic observations

Five cases of dearterialization of the liver for metastatic cancer are presented. Subjective and objective improvement was accomplished in three patients. Pre- and postoperative arteriography demonstrates the extent of devascularization and the routes of reestablished collateral. Microscopic studies demonstrated effects on tumor and on hepatic parenchyma and biochemical data indicate the extent and duration of hepatic dysfunction.

Surgical management of patients with primary operable colorectal cancer and synchronous liver metastases

The surgical results were analyzed of 217 patients who had undergone operation for primary colorectal cancer and were found to have synchronous liver metastases. It is recommended that patients with primary operable colorectal cancer who are found to have synchronous liver metastases should at least have an adequate resection of the primary lesion. If the primary lesion is resectable for cure and there are solitary hepatic metastases, then excision of these seems warranted. In most cases this can be accomplished by simple excision or wedge resection, although occasional cases may require lobectomy.