An experimental minimally invasive perfusion technique for the treatment of liver metastases

Percutaneous Isolated Hepatic Perfusion for the Treatment of Unresectable Liver Malignancies

Liver malignancies are a major burden of disease worldwide. The long-term prognosis for patients with unresectable tumors remains poor, despite advances in systemic chemotherapy, targeted agents, and minimally invasive therapies such as ablation, chemoembolization, and radioembolization. Thus, the demand for new and better treatments for malignant liver tumors remains high. Surgical isolated hepatic perfusion (IHP) has been shown to be effective in patients with various hepatic malignancies, but is complex, associated with high complication rates and not repeatable. Percutaneous isolated liver perfusion (PHP) is a novel minimally invasive, repeatable, and safer alternative to IHP. PHP is rapidly gaining interest and the number of procedures performed in Europe now exceeds 200. This review discusses the indications, technique and patient management of PHP and provides an overview of the available data.

Recent trends and future perspectives in isolated hepatic perfusion in the treatment of liver tumors

Isolated hepatic perfusion (IHP) involves a method of complete vascular isolation of the liver to enable treatment of liver tumors with high drug doses without systemic toxicity. Recent clinical studies have mainly employed IHP with melphalan with or without tumor necrosis factor-alpha and mild hyperthermia. The results of these studies demonstrate that high response and survival rates can be achieved with IHP. The current status, recent developments and future perspectives of IHP are discussed in this review.

Advances in regional chemotherapy of the liver

INTRODUCTION

Primary and secondary liver tumors resemble some of the most common causes of cancer and represent a major clinical problem owing to the poor prognosis. First-line therapeutic concepts are mainly based on surgical resection and/or systemic chemotherapy (SCT). However, many patients are not suitable for surgery or have failed SCT, although the total tumor load is still limited, which makes a regional therapy approach appealing.

AREAS COVERED

This review focuses on different types of transarterial instillation of chemotherapy, which encompasses conventional and drug-eluting transarterial chemoembolization (TACE), hepatic arterial infusion (HAI) chemotherapy and isolated hepatic perfusion (ILP).

EXPERT OPINION

TACE can be regarded as the treatment of choice in patients with multinodular hepatocellular carcinoma, but it should still be performed as a lipiodol-based regimen, while the value of doxorubicin-eluting beads needs to be exploited in further randomized controlled trials (RCTs). For patients with colorectal liver metastases, HAI chemotherapy has been challenged by the advent of more effective SCT, but encouraging results have been observed for the combination of the most recent, active drugs given by means of HAI with SCT. Nevertheless, data from RCTs comparing SCT with this transarterial regional therapy approach, as well as with TACE and ILP, are urgently needed.

Management of isolated nonresectable liver metastases in colorectal cancer patients: a case-control study of isolated hepatic perfusion with melphalan versus systemic chemotherapy

BACKGROUND

To compare the median overall survival of patients with isolated nonresectable liver metastases in comparable groups of patients treated with either isolated hepatic perfusion (IHP) with melphalan or systemic chemotherapy.

PATIENTS AND METHODS

Colorectal cancer patients with isolated liver metastases, who underwent IHP, were included in this study. The control group consisted of a subgroup of colorectal cancer patients with liver metastases only, who were enrolled in the randomized CApecitabine, IRinotecan, Oxaliplatin (CAIRO) phase III study.

RESULTS

Ninety-nine patients were treated with IHP, and 111 patients were included in the control group. All patient characteristics were comparable except for age. Median follow-up was 78.1 months for IHP versus 54.7 months in the control group. Median overall survival was 25.0 [95% confidence interval (CI) 19.4-30.6] months for IHP and 21.7 (95% CI 19.6-23.8) months for systemic treatment and did not differ significantly (P = 0.29). Treatment-related mortality was 2% for the systemic treatment and 6% for IHP (P = 0.11).

CONCLUSION

Compared with a patient group with comparable characteristics treated with systemic chemotherapy, IHP does not provide a benefit in overall survival in patients with isolated nonresectable colorectal liver metastases. Currently, the use of IHP cannot be advocated outside the scope of clinical studies.

Bio-chemotherapeutic strategies and the (dis) utility of hypoxic perfusion of liver, abdomen and pelvis using balloon catheter techniques

AIMS

To review the development and current status of balloon catheter mediated hypoxic perfusion of abdomen, pelvis and liver for treatment of locally advanced malignancies. Within this context we focus on the addition of tumour necrosis factor-alpha (TNF) to these minimal invasive perfusion procedures.

METHODS

A literature search on these topics was carried out in PubMed for indexed articles and in all issues of Regional Cancer Treatment. The findings were related to our own experiences.

RESULTS

Hypoxic abdominal (HAP) and hypoxic pelvic perfusion (HPP) using balloon catheters, are currently applied modalities for treatment of a wide variety of abdominal and pelvic tumours, yet scientific validation of these procedures is poor. Following the results of several Phase I-II trials, both treatments are associated with severe systemic toxicity, significant morbidity and even mortality. The degree of systemic leakage associated with these procedures prohibits addition of TNF. For leakage free liver perfusion surgery is still required, as with current balloon catheter techniques it is not possible to perform leakage free isolated hypoxic hepatic perfusion (IHHP), using either orthograde or retrograde hepatic flow. Experimental and clinical observations suggest that within any perfusion setting, the utilization of TNF is only indicated for treatment of highly vascularised tumours and not for treatment of colorectal tumours.

CONCLUSION

Balloon catheter technology in its present form does not provide adequate leakage control in any of these settings and is therefore associated with considerable toxicity. It is associated with poor response rates and cannot be considered in any setting as a standard of care.

Isolated hepatic perfusion for the treatment of colorectal metastases confined to the liver: recent trends and perspectives

Isolated hepatic perfusion (IHP) involves a method of complete vascular isolation of the liver to allow treatment of liver tumours with toxic systemic doses. The recent clinical studies mainly employed IHP with melphalan with or without tumour necrosis factor-alpha (TNF-alpha) and mild hyperthermia. The results of these studies show that high response rates and high survival rates can be achieved by IHP. In this article, the current status, recent developments and future perspectives of IHP are discussed.