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

Management of Hepatocellular Carcinoma: A Review

Importance

Hepatocellular carcinoma (HCC) is the sixth most common malignancy and fourth leading cause of cancer-related death worldwide. Recent advances in systemic and locoregional therapies have led to changes in many guidelines regarding systemic therapy, as well as the possibility to downstage patients to undergo resection. This review examines the advances in surgical and medical therapies relative to multidisciplinary treatment strategies for HCC.

Observations

HCC is a major health problem worldwide. The obesity epidemic has made nonalcoholic fatty liver disease a major risk factor for the development of HCC. Multiple societies, such as the American Association for the Study of Liver Diseases, the European Association for the Study of the Liver, the Asian Pacific Association for the Study of the Liver, and the National Comprehensive Cancer Network, provide guidelines for screening at-risk patients, as well as define staging systems to guide optimal treatment strategies. The Barcelona Clinic Liver Cancer staging system is widely accepted and has recently undergone updates with the introduction of new systemic therapies and stage migration.

Conclusions and Relevance

The treatment of patients with HCC should involve a multidisciplinary approach with collaboration among surgeons, medical oncologists, radiation oncologists, and interventional radiologists to provide optimal care. Treatment paradigms must consider both tumor and patient-related factors such as extent of liver disease, which is a main driver of morbidity and mortality. The advent of more effective systemic and locoregional therapies has prolonged survival among patients with advanced disease and allowed some patients to undergo surgical intervention who would otherwise have disease considered unresectable.

Combination therapies plus transarterial chemoembolization in hepatocellular carcinoma: a snapshot of clinical trial progress

INTRODUCTION

Unfortunately, some hepatocellular carcinoma (HCC) patients do not qualify for curative-intent treatments such as surgical resection or transplantation. Hence, locoregional treatments such as transarterial chemoembolization (TACE) remain instrumental in the treatment of HCC. Systemic therapy has improved over the past decade with the introduction of combination atezolizumab and bevacizumab as the new standard of care for advanced disease. These new therapies are currently under investigation in combination with TACE.

AREA COVERED

Combination therapies with TACE including systemic therapies, locoregional therapies, and immunotherapies are reviewed.

EXPERT OPINION

There has been limited progress in the management of advanced and intermediate HCC. Recent advances in the management of advanced disease with systemic therapy could be beneficial in combination with TACE for the treatment of intermediate stage disease. Immune based therapies are potentially beneficial in combination with TACE because TACE may produce increased antigen release and immune recognition.

Cryosurgical ablation of unresectable hepatic metastases

BACKGROUND AND OBJECTIVES

Recent advancements in the technology of cryosurgery along with the development and refinement of intraoperative ultrasound have led to a feasible alternative for some patients with unresectable hepatic malignancy. This paper reports our first year's experience with cryosurgical ablation of unresectable hepatic malignancies.

METHODS

From May 1996 to July 1997, 12 patients with colorectal hepatic metastases underwent exploration for possible resection and/or cryosurgery. At surgery, three patients had extensive disease and were not candidates for any surgical treatment, three underwent formal right hepatic lobectomy, five underwent a combination of resection and cryoablation, while one underwent cryoablation alone.

RESULTS

In the six patients who received cryosurgery, the mean number of metastatic lesions was four (range 1-6). The mean number of lesions frozen was two (range 1-4) with a mean size of 2.5 cm. (range 1-5 cm). There were no intraoperative deaths and no major postoperative complications. All patients were discharged home in stable condition with a mean hospital stay of eight days (range 5-14 days). At a mean follow-up of 17.3 months (range 10-22) three patients were alive with disease and three were disease free.

CONCLUSIONS

Cryosurgical ablation is a safe method of treating unresectable hepatic malignancies and it may extend survival in carefully selected patients.

Cryosurgical ablation of hepatic tumors

BACKGROUND

Cryosurgical ablation of hepatic tumors relies on nonspecific tissue necrosis due to freezing as well as microvascular thrombosis. Patients with selected primary and metastatic hepatic malignancies who are not candidates for surgical resection are afforded potentially curative benefit using this technique.

METHODS

Forty patients underwent cryosurgery for hepatic malignancy related to colorectal metastasis (n = 27), hepatocellular carcinoma (n = 8), metastatic breast (n = 2), metastatic neuroendocrine (n = 2), and metastatic ovarian carcinoma (n = 1). Intraoperative ultrasound (IOUS) was used in all patients to help locate the tumor and guide the cryosurgical trocar to the lesions.

RESULTS

Indications for cryosurgical ablation included bilobar and centrally located disease, poor medical risk, insufficient hepatic reserve, and involved margin after wedge resection. Major complications included hepatic parenchyma cracking requiring transfusion in 5 patients, 1 postoperative biliary stenosis, and 1 inferior vena cava injury. There were 3 postoperative deaths from non-hepatic-related events. Based on Kaplan-Meier analysis the estimated overall survival for patients with hepatocellular carcinoma (60% at 18 months) was compared with patients with colorectal metastases (30% at 18 months). Nine patients (23%) are currently free of disease with an average follow-up of 17.7 months. The pattern of failure was identified at the site of cryosurgical ablation in 2 of 88 lesions.

CONCLUSIONS

Cryosurgical ablation of selected hepatic malignancies is a safe and viable treatment for patients not amenable to surgical resection.

Treatment of liver metastases from colorectal cancer with hepatic artery occlusion, intraportal 5-fluorouracil infusion, and oral allopurinol. A randomized clinical trial

BACKGROUND

Regional therapy for colorectal liver metastases aimed at prolonging survival has not been tested fully in a randomized trial with untreated control subjects. This study explored the efficacy of temporary hepatic artery occlusion followed by intraportal infusion of 5-fluorouracil (5-FU) and oral allopurinol as biochemical modulators in prolonging the survival of patients with nonresectable liver metastases and no extrahepatic cancer.

METHODS

Eighty-four patients were considered for randomization, of whom 24 were excluded at laparotomy because of extrahepatic cancer (n = 17) or resectable lesions (n = 5). In two patients, no cancer was identified in the liver. Thirty-two patients were allocated to receive treatment, and 28 were allocated to receive no regional or systemic treatment. Six patients were excluded after randomization because of major protocol violations.

RESULTS

The median survival time for patients was 17 months (range, 0-66), and for control subjects, the median was 8 months (range, 0-31). Log rank analysis demonstrated a significant survival benefit for treatment versus no treatment (P = 0.0039). (In two patients, early death was due to toxicity from the wrong dose of 5-FU and the wrong route of administration, respectively; the mean and median survival were reduced by 1 month).

CONCLUSION

This study identified a treatment modality that prolongs survival in patients with nonresectable liver metastases and no extrahepatic metastases from colorectal cancer, suggesting that control subjects receiving no therapy may not be necessary in future randomized trials.

Synergistic antitumor effects of carboplatin and interferons on hepatic metastases of colon carcinoma 26 and M5076 reticulum cell sarcoma

The effects of combination therapy including various antitumor agents and interferon on mice bearing hepatic metastases of colon carcinoma 26 were determined. Combined treatment with interferon-alpha A/D and carboplatin (CBDCA) was associated with a considerably more pronounced antitumor effect than was treatment with either drug alone. Murine interferon-beta and -gamma each also potentiated the antitumor activity of CBDCA. Combination therapy with interferon-alpha A/D and CBDCA also resulted in marked inhibition of hepatic metastasis of M5076 reticulum cell sarcoma. However, interferon-beta did not potentiate the antitumor activity of CBDCA against either subcutaneously implanted colon carcinoma 26 or pulmonary metastases of this tumor. Thus, in our model the combined administration of interferon and CBDCA was associated with a synergistic antitumor effect on hepatic metastases alone.

Effects of antitumor agents on subcutaneous implants and hepatic metastases of colon carcinoma 26 in mice

We investigated the responses of experimentally produced hepatic metastases of colon carcinoma 26 tumor and subcutaneously (SC) implanted colon carcinoma 26 tumor in mice to 17 clinically-used and one under-development antitumor agents using same dose regimen. In intravenous administrations on days 7 and 14, there were no significant differences in their responses to most of the tested agents. However, there were big differences in the responses to some of the agents. Nimustine more effectively prolonged the lifespan of SC implanted tumor-bearing mice than of mice bearing hepatic metastases. Mitomycin C was, however, considerably more effective on hepatic metastases than on SC implanted tumor. ME2303, a new fluorinated anthracycline derivative, showed a similar effect to doxorubicin on both tumors. However, administrations of ME2303 on days 7, 11 and 15 showed more marked antitumor effect only on hepatic metastases than administrations on days 7 and 14. Doxorubicin was less active against both tumors for administrations on days 7, 11 and 15 than for those on days 7 and 14. These results suggest the importance of the site of tumor growth for the action of some drugs. ME2303 may be active against hepatic metastases if it is administered by multiple injections.