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Bozzetti F, Bignami P, Baratti D. Surgical Strategies in Colorectal Cancer Metastatic to the Liver. TUMORI JOURNAL 2018; 86:1-7. [PMID: 10778758 DOI: 10.1177/030089160008600101] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Surgical resection remains a milestone in the treatment of colorectal metastases to the liver. There is a distinct subset of patients who benefit from surgical resection in terms of longer survival or definitive cure. The main effort of the surgical oncological regards the safety of the procedure and the adequacy of the recommendation. Many studies, some of them including multivariate analysis, have shown the presence of prognostic determinants of long-term survival and prognostic indexes of the outcome after hepatectomy. It is now accepted that liver resection should be done when the complete excision of all demonstrable tumor with clear resection margins is feasible. Major contra-indication is represented by the presence of extra-hepatic intra-abdominal disease or of unresectable lung metastatic deposits. There is a wide literature indicating that in very selected patients liver reresection and multiorgan synchronous or metachronous resections are beneficial. The role of neoadjuvant chemotherapy and especially postoperative adjuvant local (intra-hepatic) and systemic chemotherapy is promising and supported by recent multicenter randomised clinical trials.
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Affiliation(s)
- F Bozzetti
- Istituto Nazionale per lo Studio e la Cura dei Tumori, Milan, Italy.
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2
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Kulaylat MN, Gibbs JF. Regional treatment of colorectal liver metastasis. J Surg Oncol 2010; 101:693-8. [DOI: 10.1002/jso.21503] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Erinjeri JP, Salhab HM, Covey AM, Getrajdman GI, Brown KT. Arterial patency after repeated hepatic artery bland particle embolization. J Vasc Interv Radiol 2010; 21:522-6. [PMID: 20188589 DOI: 10.1016/j.jvir.2009.12.390] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2008] [Revised: 12/21/2009] [Accepted: 12/30/2009] [Indexed: 01/02/2023] Open
Abstract
PURPOSE To evaluate hepatic arterial patency after serial bland particle embolization procedures in patients with hepatocellular carcinoma (HCC). MATERIALS AND METHODS All patients with HCC who underwent five or more hepatic artery bland embolization procedures with permanent particulate and spherical embolic agents between September 1996 and December 2007 were retrospectively reviewed. Data analyzed included patient demographics, vessels embolized, embolic agent used, and duration of arterial patency. RESULTS Forty-three patients were identified who underwent five or more bland embolization procedures in the same arterial distribution. Of the 43 patients examined, 83% (n = 36) showed no change in the hepatic arterial tree after repeated bland embolization (mean treatment period of 48 months +/- 23). Six patients (13%) exhibited occlusion of a fifth-order or more distal vessel after an average of 5 embolizations +/- 2 over a period of 34 months +/- 27. A single case of vascular occlusion of a fourth-order vessel was observed after five embolizations over a period of 52 months. CONCLUSIONS Repeated bland embolization of the hepatic arteries in HCC preserves patency of the hepatic arterial vasculature despite the fact that embolization is carried out to complete stasis.
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Affiliation(s)
- Joseph P Erinjeri
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA.
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4
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Hebbar M, Pruvot FR, Romano O, Triboulet JP, de Gramont A. Integration of neoadjuvant and adjuvant chemotherapy in patients with resectable liver metastases from colorectal cancer. Cancer Treat Rev 2009; 35:668-75. [DOI: 10.1016/j.ctrv.2009.08.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2009] [Revised: 08/07/2009] [Accepted: 08/11/2009] [Indexed: 01/14/2023]
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Dizon DS, Schwartz J, Kemeny N. Regional chemotherapy: a focus on hepatic artery infusion for colorectal cancer liver metastases. Surg Oncol Clin N Am 2008; 17:759-71, viii. [PMID: 18722916 DOI: 10.1016/j.soc.2008.04.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Regional infusion strategies have been used as a treatment modality in multiple cancers, including ovarian, appendiceal, and colorectal cancers. Perhaps the most illustrative use of regional therapy is that of hepatic arterial infusion (HAI) for liver metastases from colorectal cancer. The administration of chemotherapy by HAI is logical and has theoretic advantages over systemic chemotherapy for the treatment of hepatic metastases from colorectal cancer. With the use of an appropriately chosen chemotherapy agent, HAI can generate an increase in hepatic tumor drug exposure as compared with intravenous delivery of the same agent. This article reviews the pharmacologic benefits of HAI therapy and the contemporary trials performed and underway.
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Affiliation(s)
- Don S Dizon
- Program in Women's Oncology, Department of Obstetrics and Gynecology, Women & Infants' Hospital, Warren Alpert Medical School of Brown University, 101 Dudley Street, Providence, RI 02905, USA.
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6
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Tanabe KK, Yoon SS. Surgical and Regional Therapy for Liver Metastases. Oncology 2007. [DOI: 10.1007/0-387-31056-8_94] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Parks R, Gonen M, Kemeny N, Jarnagin W, D'Angelica M, DeMatteo R, Garden OJ, Blumgart LH, Fong Y. Adjuvant chemotherapy improves survival after resection of hepatic colorectal metastases: analysis of data from two continents. J Am Coll Surg 2007; 204:753-61; discussion 761-3. [PMID: 17481478 DOI: 10.1016/j.jamcollsurg.2006.12.036] [Citation(s) in RCA: 147] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2006] [Revised: 12/14/2006] [Accepted: 12/14/2006] [Indexed: 12/29/2022]
Abstract
BACKGROUND In the US, systemic chemotherapy is often administered after liver resection for hepatic colorectal metastases, even though no clinical trials data directly support this practice. The bias in America for chemotherapeutic treatment has made studies difficult. Until recently, no well accepted staging systems existed to categorize these patients with liver metastases, who have greatly varied prognoses. STUDY DESIGN All liver resections from an American and from a European tertiary care center performed between 1991 and 1998 were assembled from two prospective databases. Of 792 liver resections, the 518 patients treated with no chemotherapy (379 American, 139 European) were compared with 274 patients treated (240 American, 34 European) with 5-FU-based adjuvant chemotherapy. Patients treated by all other treatment regimens, including regional chemotherapy, were excluded, as were patients who died perioperatively. Patient survival analysis was performed by log-rank, with stratification by the clinical risk score (CRS, a staging system grading risk of recurrence by five clinical parameters: node-positive primary, short disease-free interval, large (> 5 cm) liver tumor, multiple liver tumors, and high carcinoembryonic antigen). RESULTS Patients subjected to adjuvant chemotherapy had improved survival (p=0.007, log-rank test) even after stratification by clinical risk score (p=0.001, stratified log-rank test). In every clinical risk score category, patients subjected to adjuvant chemotherapy had a higher chance of survival (range 1.3 to 2.0 times). Adjuvant chemotherapy was an independent predictor of outcomes. CONCLUSIONS This large study, with patients stratified by risk of recurrence, demonstrates that systemic adjuvant chemotherapy, such as a 5-FU-based regimen, prolongs survival after hepatic resection for colorectal metastases.
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Affiliation(s)
- Rowan Parks
- Department of Surgery, Royal Infirmary of Edinburgh, University of Edinburgh, Edinburgh, Scotland
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Nagashima I, Takada T, Nagawa H, Muto T, Okinaga K. Proposal of a new and simple staging system of colorectal liver metastasis. World J Gastroenterol 2006; 12:6961-5. [PMID: 17109517 PMCID: PMC4087339 DOI: 10.3748/wjg.v12.i43.6961] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To create a new, simple and useful staging system for colorectal liver metastasis analogous to the Tumor Node Metastasis classification system of International Union Against Cancer.
METHODS: A retrospective review was undertaken of 81 consecutive patients who underwent partial hepatectomy for colorectal liver metastases (group 1). Clinical and pathological features of both primary and metastatic liver cancers were entered into a multivariate analysis to determine independent variables helpful in accurately predicting long-term prognosis after hepatectomy. Using selected variables, we created a new staging system like TNM classification. The usefulness of the new staging system was examined in a series of 92 patients from another hospital (group 2).
RESULTS: Multivariate analysis showed that 81 patients in group 1 had significant multiple hepatic tumors with the largest tumor being more than 5 cm in diameter, resectable extrahepatic distant metastases, and independent prognostic factors for poor survival after hepatectomy. Using these three variables, we created a new staging system to classify patients with colorectal liver metastases. Finally, our new staging system classified the patients both in group 1 and in group 2.
CONCLUSION: Our new staging system of colorectal liver metastasis is simple and useful for staging patients.
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Affiliation(s)
- Ikuo Nagashima
- Department of Surgery, Teikyo University, School of Medicine, Tokyo 173-8605, Japan.
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Nagashima I, Takada T, Adachi M, Nagawa H, Muto T, Okinaga K. Proposal of criteria to select candidates with colorectal liver metastases for hepatic resection: Comparison of our scoring system to the positive number of risk factors. World J Gastroenterol 2006; 12:6305-9. [PMID: 17072953 PMCID: PMC4088138 DOI: 10.3748/wjg.v12.i39.6305] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To select accurately good candidates of hepatic resection for colorectal liver metastasis.
METHODS: Thirteen clinicopathological features, which were recognized only before or during surgery, were selected retrospectively in 81 consecutive patients in one hospital (GroupI). These features were entered into a multivariate analysis to determine independent and significant variables affecting long-term prognosis after hepatectomy. Using selected variables, we created a scoring formula to classify patients with colorectal liver metastases to select good candidates for hepatic resection. The usefulness of the new scoring system was examined in a series of 92 patients from another hospital (Group II), comparing the number of selected variables.
RESULTS: Among 81 patients of GroupI, multivariate analysis, i.e. Cox regression analysis, showed that multiple tumors, the largest tumor greater than 5 cm in diameter, and resectable extrahepatic metastases were significant and independent prognostic factors for poor survival after hepatectomy (P < 0.05). In addition, these three factors: serosa invasion, local lymph node metastases of primary cancers, and post-operative disease free interval less than 1 year including synchronous hepatic metastasis, were not significant, however, they were selected by a stepwise method of Cox regression analysis (0.05 < P < 0.20). Using these six variables, we created a new scoring formula to classify patients with colorectal liver metastases. Finally, our new scoring system not only classified patients in GroupIvery well, but also that in Group II, according to long-term outcomes after hepatic resection. The positive number of these six variables also classified them well.
CONCLUSION: Both, our new scoring system and the positive number of significant prognostic factors are useful to classify patients with colorectal liver metastases in the preoperative selection of good candidates for hepatic resection.
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Affiliation(s)
- Ikuo Nagashima
- Department of Surgery, Teikyo University School of Medicine, 2-11-1, Kaga, Itabashi-ku, Tokyo 173-8605, Japan. ac.jp
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Homsi J, Garrett CR. Hepatic arterial infusion of chemotherapy for hepatic metastases from colorectal cancer. Cancer Control 2006; 13:42-7. [PMID: 16508625 DOI: 10.1177/107327480601300106] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Sixty percent of colon cancer patients develop liver metastasis. Only 25% of those have potentially resectable hepatic metastases, and approximately 58% of those patients relapse. METHODS We review the indications and the technical aspects of hepatic artery infusion (HAI) of chemotherapy, as well as the efficacy, morbidity, and outcomes. RESULTS HAI of chemotherapy has been used following hepatic metastasectomy, in patients with unresectable metastases, or in combination with other agents. Floxuridine, the chemotherapeutic agent most studied, is administered through an implantable subcutaneous infusion pump connected to a surgically placed hepatic artery catheter, which delivers the chemotherapeutic agents at a slow fixed rate. Treatment-related toxicities include chemical hepatitis, biliary sclerosis, and peptic ulceration. Some trials report a survival benefit for HAI over systemic chemotherapy with acceptable toxicity. CONCLUSIONS Regional perfusion chemotherapy can be logistically and technically complicated to deliver. The development of newer systemic agents with superior efficacy in the treatment of metastatic colorectal cancer will likely diminish the role of regional perfusion therapy in the future.
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Affiliation(s)
- Jade Homsi
- Gastrointestinal Tumor Program, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
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Brooks AJ, Wang F, Alfredson M, Yan TD, Morris DL. Synchronous liver resection and cryotherapy for colorectal metastases: survival analysis. Surgeon 2005; 3:265-8. [PMID: 16121772 DOI: 10.1016/s1479-666x(05)80089-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION The value of synchronous liver resection and cryotherapy ablation remains controversial for colorectal metastases where complete resection is not possible by conventional liver surgery alone. OBJECTIVE To review the long-term survival of patients treated using this approach at our institution. METHODS A review was undertaken of data held in the prospectively collected liver surgery database of all patients who underwent synchronous liver resection and cryotherapy. Survival analysis was performed and data recorded on the total number of metastases at initial surgery and the number of lesions treated by cryoablation. RESULTS Ninety-three patients with colorectal metastases underwent synchronous liver resection and cryotherapy. Data were available on 86 patients with a median follow-up of 18 months (range 1-83). The median number of metastases at initial surgery was four (range 2-11) and the number of lesions treated by cryotherapy ablation was two (range 1-8). Eighty-four per cent had a hepatic artery catheter inserted at surgery and at least one cycle of post-operative hepatic artery chemotherapy. One-, three- and five-year survival was 85%, 43% and 19% respectively, with a median survival of 33 months (95% confidence interval 19.9-42.1). Site of recurrence was recorded and presented. CONCLUSIONS Patients with liver metastases that are not amenable to resection alone can achieve worthwhile median survival with synchronous liver resection and cryotherapy ablation.
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Affiliation(s)
- A J Brooks
- UNSW Department of Surgery St George Hospital, Sydney, Australia
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Hebbar M. Chemotherapy in patients with resectable liver metastases from colorectal cancer. CURRENT COLORECTAL CANCER REPORTS 2005. [DOI: 10.1007/s11888-005-0014-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Elias D, de Baere T, Sideris L, Ducreux M. Regional chemotherapeutic techniques for liver tumors: current knowledge and future directions. Surg Clin North Am 2004; 84:607-25. [PMID: 15062664 DOI: 10.1016/s0039-6109(03)00225-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
After a rather long period of stagnation, intra-arterial therapeutic approaches for treating liver tumors are currently progressing rapidly. These new modalities will increase the resectability of initially unresectable liver tumors after dramatic responses. At the same time, resectability rates are increasing with the assistance of local ablative physical treatments such as radiofrequency, resulting in an improvement of patients' median survival rates and quality of life.
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Affiliation(s)
- Dominique Elias
- Division of Surgical Oncology, Department of Surgery, Gustave Roussy Institute, Rue Camille Desmoulins, 94805, Villejuif, France.
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Abstract
Hepatic metastases are a frequent complication of colorectal cancer (CRC), affecting over half of all CRC patients. Resection of isolated metastases can result in long-term survival, but the majority of patients relapse, and most have unresectable disease. Hepatic arterial infusion (HAI) chemotherapy delivers high concentrations of cytotoxic agents directly to liver metastases with minimal systemic toxicities. Advances in surgical techniques, development of fully implantable pumps, and modification of drug regimens have decreased complications and improved patient tolerability. Randomized trials comparing HAI with systemic chemotherapy have demonstrated superior response rates and times to hepatic progression for unresectable disease, and have shown better times to progression and overall survival rates in the adjuvant setting following hepatic resection. HAI chemotherapy has unique toxicities, including chemical hepatitis and biliary sclerosis, which can be mitigated by the addition of dexamethasone to therapy. In an attempt to prevent extrahepatic progression, combinations of HAI with systemic chemotherapy, including newer agents such as irinotecan and oxaliplatin, are currently being investigated, with promising early results.
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Affiliation(s)
- Adam D Cohen
- Gastrointestinal Oncology Service, Solid Tumor Division, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
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Tono T, Kanoh T, Ohnishi T, Matsushita M, Nakano Y, Kimura Y, Iwazawa T, Yano H, Okamura J, Monden T. Adjuvant hepatic arterial infusion after curative resection of colorectal liver metastases using removable intra-arterial catheters with shape-memory alloy. J Surg Oncol 2004; 88:248-55. [PMID: 15565591 DOI: 10.1002/jso.20159] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND AND OBJECTIVES Although there are some reports that adjuvant hepatic arterial infusion (HAI) chemotherapy reduces the hepatic recurrence following curative resection of colorectal liver metastases, problems of indwelling catheters after chemotherapy cessation remains unsolved. The usefulness of adjuvant HAI was investigated using a removable port-catheter system. METHODS Spiral catheterstrade mark were attempted to be placed in 17 patients who underwent curative hepatectomy. The catheter contains a special shape-memory alloy at its tip, which allows stable fixation to the vascular wall without coiling so the catheter can be removed if necessary. 5-fluorouracil (5-FU) in total dose of 12 g was intra-arterially administered. RESULTS W spiral catheterstrade mark were successfully placed in the hepatic artery by percutaneous approach in 82% of the patients. All patients underwent scheduled chemotherapy without serious adverse events. Reservoir-catheter system was removed easily and uneventfully after discontinuation of the chemotherapy. 3D-CT angiography revealed that the hepatic artery was well preserved with short-term chemotherapy. Postoperative hepatic recurrence was observed only in 18% of the patients with the median follow-up time of 19.9 months. CONCLUSIONS Prophylactic 5-FU HAI using W spiral cathetertrade mark and subsequent catheter extirpation is a promising strategy following curative resection of colorectal liver metastases.
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Affiliation(s)
- Takeshi Tono
- Department of Surgery, NTT West Osaka Hospital, Tennoji-ku, Osaka, Osaka, Japan.
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Meyers MO, Sasson AR, Sigurdson ER. Locoregional strategies for colorectal hepatic metastases. Clin Colorectal Cancer 2003; 3:34-44. [PMID: 12777190 DOI: 10.3816/ccc.2003.n.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Hepatic colorectal metastases present a challenging problem in patients with recurrent colorectal cancer. Twenty percent of patients with recurrence will have liver metastases as a component of their disease, and only 10% of these patients will have isolated liver metastases that are resectable. Although systemic chemotherapy alone has not proven efficacious in the treatment of liver metastases, a number of options exist in managing these lesions. For those that are resectable, surgery remains the optimal treatment, with an expected 5-year survival rate of 33%-39% based on several large series. Hepatic artery chemotherapy is another adjunct treatment in patients undergoing resection and may further improve survival. This benefit may be even more pronounced when combined with systemic chemotherapy. Newer-generation agents are likely to further improve results. More recently, new therapeutic modalities have been used to treat unresectable lesions. These include hepatic artery chemotherapy and ablative techniques such as radiofrequency ablation and cryoablation. This article will highlight the data regarding hepatic resection for colorectal metastases, describe the rationale for and efficacy of hepatic arterial chemotherapy in the postoperative adjuvant setting and in unresectable liver disease, and review the current literature describing ablative techniques in the treatment of liver metastases.
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Affiliation(s)
- Michael O Meyers
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA 19111, USA
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17
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Abstract
Hepatic metastases occur in 60% of patients following resection for colorectal cancer. Liver resection is the only curative option, with one third of resected patients alive at five years. In those developing recurrence in the liver following resection, further liver surgery may be curative, with similar 5 years survival rates of about 30%. Until recently surgery was feasible in only 15-25% of patients with colorectal liver metastases. New strategies, such as downstaging chemotherapy, portal vein embolization and two-stage hepatectomy, may increase the resectability rate by 15%. Earlier detection of liver metastases would increase resectability, although good follow-up trials are lacking. Once suspected, colorectal liver metastases are staged by spiral CT, CT portography and MRI, which have similar overall accuracies. Mortality following liver resection is less than 5% in major centres, with a morbidity rate of 20% to 50%. Prognostic scoring systems can be used to predict the likely cure rate with resection. Pulmonary metastases occur in 10-25% of patients with resected colorectal cancer, but are limited to the lung in only 2% of cases. In these selected cases surgery provides long-term survival in 20-40%, and repeat lung resection has shown similar rates. For patients with unresectable disease, chemotherapy and ablation techniques have been demonstrated to prolong survival, although chemotherapy alone has been shown to improve quality of life.
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Affiliation(s)
- G Fusai
- University Department of Surgery and Liver Transplant Unit, Royal Free Hospital, Royal Free and University College Medical School, Pond Street, London NW3 1QG, UK
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Miyanari N, Mori T, Takahashi K, Yasuno M. Evaluation of aggressively treated patients with unresectable multiple liver metastases from colorectal cancer. Dis Colon Rectum 2002; 45:1503-9. [PMID: 12432299 DOI: 10.1007/s10350-004-6458-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE The aim of this study was to assess the value of aggressively treating patients with unresectable liver metastases from colorectal cancer and a poor prognosis. METHODS From 1988 to 1999, 64 patients with unresectable multiple liver metastases from colorectal cancer who had received hepatic arterial infusion chemotherapy were investigated. All patients did not have synchronous extrahepatic metastases at the time of initiating our treatment. When liver metastases were suitable for resection after hepatic arterial infusion chemotherapy, we excised them and repeated prophylactic hepatic arterial infusion chemotherapy as long as possible. We evaluated the efficacy of hepatic arterial infusion chemotherapy by computed tomography and divided these patients into responders and nonresponders. We performed univariate analysis using the log-rank test to calculate predictive factors. In addition, the Cox proportional hazards model was used to perform multivariate analysis of factors related to survival. RESULTS The survival rate of all patients was 67.8 percent after 1 year and 10 percent after 5 years. However, the survival rate for 16 patients who received hepatectomy after hepatic arterial infusion chemotherapy was 35.1 percent after five years. Multivariate analysis demonstrated that the response after hepatic arterial infusion chemotherapy was the most indicative prognostic factor. CONCLUSIONS The prognosis of selected patients who responded to hepatic arterial infusion chemotherapy and received hepatectomy was improved. Applying aggressive treatment as outlined in our strategy may improve the chances of long-term survival.
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Affiliation(s)
- Nobutomo Miyanari
- Department of Surgery II, Kumamoto University Medical School, 1-1-1 Honjo, Kumamoto, Japan 860-8556
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Affiliation(s)
- Jerome Seidenfeld
- Technology Evaluation Center, Blue Cross and Blue Shield Association, Chicago, IL 60601-7680, USA
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Sasson AR, Watson JC, Sigurdson ER. Hepatic artery infusional chemotherapy for colorectal liver metastases. Cancer Treat Res 2002; 109:279-98. [PMID: 11775442 DOI: 10.1007/978-1-4757-3371-6_16] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- A R Sasson
- Fox Chase Cancer Center, Philadelphia, PA, USA
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Abstract
Approximately 60% of patients diagnosed with colorectal cancer (CRC) will go on to develop hepatic metastases. Although surgical resection is the only curative modality, a majority will not be able to undergo surgery. Alternative methods for treating this population have focused on the feasibility of hepatic arterial infusion (HAI) of chemotherapy. Randomized data in this field have been hampered due to small numbers of patients in some trials, or crossover between groups. However, most trials have suggested an improvement in both overall and progression-free survival with HAI therapy. Dose-limiting toxicity associated with HAI is related to hepatobiliary sclerosis, which has been reduced with the use of dexamethasone as part of the treatment. Current research is underway to improve the rate of extrahepatic metastases in patients undergoing HAI.
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Affiliation(s)
- Don S Dizon
- Gastrointestinal Oncology Service, Solid Tumor Division, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA
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Ruo L, DeMatteo RP, Blumgart LH. The role of adjuvant therapy after liver resection for colorectal cancer metastases. Clin Colorectal Cancer 2001; 1:154-66; discussion 167-8. [PMID: 12450428 DOI: 10.3816/ccc.2001.n.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Intrahepatic recurrence is common after major resection for colorectal cancer (CRC) metastases to the liver. In this review, the available data on different adjuvant therapies from systemic chemotherapy to regional approaches by direct perfusion of chemotherapeutic agents via the hepatic artery and portal vein will be discussed. Intraperitoneal administration of chemotherapy is another form of regional therapy. Novel approaches with immunotherapy and trials of neoadjuvant therapy in association with resection of CRC hepatic metastases have also been reported. The purpose of this review is to outline these various strategies and their role in combination with resection of CRC liver metastases. Although improved hepatic disease-free survival has been demonstrated with some strategies, overall survival is minimally affected and recurrence of metastatic disease at distant sites is still a major problem. Therefore, future directions should incorporate the use of new systemic agents effective against CRC metastases. Identification of subgroups through clinical features, molecular markers, proteins, or specific tumor properties may also help to individualize treatment.
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Affiliation(s)
- L Ruo
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA
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Abstract
The battle against malignancies of the liver is far from over, although tremendous strides have been made in the past decade, such as improved diagnostic capabilities, safe surgical resection, availability of safe nonsurgical ablative modalities, multimodality therapy, and aggressive approach to recurrent disease. Even after the best attempts at curative treatment, recurrence of primary and secondary malignancies of the liver continues to be the cause of demise for more than 70% of treated patients. The battle continues in the laboratories, where investigations are focused on delineating the pathophysiology of cancer on the molecular and genetic levels and mapping the patterns of cancer emergence and spread. The new millennium holds promise for formulating therapies that may improve disease-free survival for patients with malignancies of the liver.
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Affiliation(s)
- J I Tsao
- Department of Surgery, Tufts University School of Medicine, Burlington, Massachusetts, USA
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Tono T, Hasuike Y, Ohzato H, Takatsuka Y, Kikkawa N. Limited but definite efficacy of prophylactic hepatic arterial infusion chemotherapy after curative resection of colorectal liver metastases. Cancer 2000. [DOI: 10.1002/(sici)1097-0142(20000401)88:7<1549::aid-cncr8>3.0.co;2-k] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Dawas, Loizidou, Taylor. Recent trials in colorectal cancer. Colorectal Dis 2000; 2:45-9. [PMID: 23577935 DOI: 10.1046/j.1463-1318.2000.00128.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Dawas
- Department of Surgery, Royal Free and University College Medical School, University College London, London, UK
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Gambiez L, Denimal F, Karoui M, Dewailly V, Pruvot FR, Quandalle P. [Adjuvant intra-arterial chemotherapy after curative resection of liver metastasis from colorectal cancer. Results of a pilot study in 30 patients]. CHIRURGIE; MEMOIRES DE L'ACADEMIE DE CHIRURGIE 1999; 124:640-8. [PMID: 10676025 DOI: 10.1016/s0001-4001(99)00073-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Five-year survival after simple resection of liver metastases from colorectal carcinoma ranges from 20 to 40%. The aim was to study the reliability and long term results of adjuvant intra-arterial chemotherapy after resection of colorectal liver metastases. PATIENTS AND METHOD From 1991 to 1997, 30 patients after a complete resection of liver metastases from colorectal cancer were included (16 men, 14 women, mean age: 62 years). There were 2 stage I, 19 stages II, 2 stages III, 5 stages IV and 2 stages V according to Gayowski staging system. During laparotomy, a catheter was placed in the gastroduodenal artery in order to perfuse the proper hepatic artery. Chemotherapy included 5 Fluorouracil (12 mg/m2) and Leucovorin (200 mg/m2) and was administered once a week during six months. Mean follow-up was 52 months. RESULTS Adjuvant intra-arterial chemotherapy had to be interrupted before six months in 9 patients because leukopenia (n = 2), infection or obstruction of the catheter (n = 5), duodenal migration of the catheter (n = 1) and occurrence of multiple extrahepatic metastases (n = 1). No death was in relation with the method. Five-year survival rate was 41.8% for the global series. Five-year disease free survival rate was 21.4%. Causes of death were: hepatic recurrence only (n = 3), extrahepatic + hepatic recurrence (n = 4), extrahepatic recurrence (n = 2). Two patients died of another carcinoma (esophagus, ovary), without evidence of recurrence of the colorectal carcinoma. At the present, there is a recurrence in 4 living patients. CONCLUSION Although the benefit on survival is not significant, these results suggest a longest time of remission in patients with adjuvant intra-arterial chemotherapy. Trials comparing and/or combining this method to intravenous chemotherapy should be proposed in patients after resection of colorectal liver metastases.
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Affiliation(s)
- L Gambiez
- Service de chirurgie adulte Ouest, Hôpital Claude-Huriez, Lille, France
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Cromheecke M, de Jong KP, Hoekstra HJ. Current treatment for colorectal cancer metastatic to the liver. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 1999; 25:451-63. [PMID: 10527592 DOI: 10.1053/ejso.1999.0679] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Surgery is currently the only available treatment option which offers the potential for cure for patients with liver metastases from colorectal cancer. Of those who undergo a potentially curative operation for their primary tumour but subsequently recur, almost 80% will develop evidence of metastatic disease within the liver. Greater experience and improvements in technique in liver surgery, with an increasingly aggressive surgical approach to metastatic colorectal cancer to the liver, has resulted in prolonged disease-free survival with 5-year rates varying from 21% to 48%. In order to increase these numbers further and to treat patients not eligible for surgical therapy, new treatment modalities and strategies have been developed. This review presents an update of the current treatment for colorectal disease metastatic to the liver.
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Affiliation(s)
- M Cromheecke
- Department of Surgery, Division of Surgical Oncology, Groningen, The Netherlands
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30
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Ambiru S, Miyazaki M, Ito H, Nakagawa K, Shimizu H, Nakajima N. Adjuvant regional chemotherapy after hepatic resection for colorectal metastases. Br J Surg 1999; 86:1025-31. [PMID: 10460638 DOI: 10.1046/j.1365-2168.1999.01168.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND This study explored the possibility of achieving a better survival rate and reduced recurrence in the remaining liver in patients with colorectal hepatic metastases undergoing hepatic resection. Adjuvant postoperative regional chemotherapy was administered via the hepatic artery or the portal vein. METHODS A retrospective study was performed on 174 patients after hepatic resection for colorectal metastases. These comprised 78 patients who had hepatic artery infusion (HAI) chemotherapy (HAI group), 30 who had portal vein infusion (PVI) chemotherapy (PVI group) and 66 who had no regional chemotherapy (resection alone group). The three groups were compared with one another in terms of complications, survival rate and patterns of recurrence. RESULTS Severe complications did not occur at any point during adjuvant HAI or PVI chemotherapy. The 5-year disease-free survival rate of patients in the HAI, PVI and resection alone groups were 35, 13 and 9 per cent respectively, including six hospital deaths. Patients in the HAI group showed significantly improved recurrence rates in the remaining liver compared with the resection alone group (P = 0.03), and more prolonged disease-free and overall survival than those in the PVI (P = 0.01 and P = 0.02 respectively) and resection alone (P = 0.0001 and P = 0.0006 respectively) groups. CONCLUSION This study suggests that adjuvant HAI chemotherapy after hepatic resection may have therapeutic potential for improved management of patients with colorectal metastases.
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Affiliation(s)
- S Ambiru
- First Department of Surgery, Chiba University School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba 260-8677, Japan
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Bradley AL, Chapman WC, Wright JK, Marsh JW, Geevarghese S, Blair KT, Pinson CW. Surgical Experience with Hepatic Colorectal Metastasis. Am Surg 1999. [DOI: 10.1177/000313489906500610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
The outcome of 134 patients undergoing hepatic resection for colorectal metastasis was studied. Current follow-up was available in 98 per cent of patients, for more than 5 years in 58 patients, and totaling 360 patient-years. Patients (52% male) had an average age of 62 ± 1 years (standard error of the mean). Time lapse between the primary colon surgery and hepatic resection was a median of 16 months and a mean of 19 ± 1 months. Thirty-two (24%) were operated on within 6 months for both their primary tumor and hepatic metastasis. Intensive care unit and total hospital length of stay were a median of 1 and 7 days, respectively. Pathology reports demonstrated that on average there were 2.0 ± 0.1 lesions, with the largest lesion measuring 4.4 ± 0.2 cm. In 72 per cent of patients, the lesions were found in one lobe only. CEA was elevated in 83 per cent of patients preoperatively and was 60 ± 11 ng/mL before and 4.0 ± 0.5 ng/mL after hepatic resection. Patient survival was 81 per cent at 1 year, 50 per cent at 3 years, 36 per cent at 5 years, and 23 per cent at 10 years. Actual 5- and 10-year survival was 22 of 58 (38%) patients and 4 of 21 (19%) patients respectively. Disease-free survival was 58 per cent at 1 year, 27 per cent at 3 years, 16 per cent at 5 years, and 12 per cent at 7 years. Survival was much better for one to four lesions than for five or more lesions (P < 0.01). Several other potential risk factors did not affect survival, including whether the patient received chemotherapy after hepatic resection. There were 36 (43%) patients who recurred with hepatic involvement only, 27 (32%) including hepatic involvement and 21 (25%) with nonhepatic involvement only. There were 15 patients who went on to receive repeat hepatic resections, with a 5-year survival of 74 per cent and disease-free survival of 58 per cent. Hepatic resection provides the best outcome of any form of therapy for selected patients with isolated hepatic metastasis.
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Affiliation(s)
- Anne L. Bradley
- Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, Tennessee
| | - William C. Chapman
- Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, Tennessee
| | - J. Kelly Wright
- Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, Tennessee
| | - John W. Marsh
- Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sunil Geevarghese
- Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, Tennessee
| | - K. Taylor Blair
- Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, Tennessee
| | - C. Wright Pinson
- Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, Tennessee
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Ambiru S, Miyazaki M, Isono T, Ito H, Nakagawa K, Shimizu H, Kusashio K, Furuya S, Nakajima N. Hepatic resection for colorectal metastases: analysis of prognostic factors. Dis Colon Rectum 1999; 42:632-9. [PMID: 10344686 DOI: 10.1007/bf02234142] [Citation(s) in RCA: 135] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Hepatic resection affords the best hope of survival for patients with colorectal carcinoma metastatic to the liver. However, recurrences are observed in about 60 percent of patients after curative hepatic resection. The purpose of this study was to examine the prognostic factors of patients undergoing curative hepatic resection for colorectal metastases. METHODS Between April 1984 and September 1997, 168 patients underwent curative hepatic resection for colorectal metastases. The clinicopathologic factors studied for prognostic value were gender, age, primary site, nodal status of primary tumor, time of metastases, preoperative serum level of carcinoembryonic antigen, hepatic tumor size and distribution, number of metastases, type of hepatic resection, resection margin, presence of micrometastases in resected specimen and microscopic fibrous pseudocapsule between the hepatic tumor and surrounding hepatic parenchyma, nodal status of hepatoduodenal ligament, adjuvant regional chemotherapy, and perioperative transfusion. RESULTS The overall survival was 42 percent at three years and 26 percent at five years, including a 3.5 percent 60-day surgical mortality rate. Thirty-one percent of patients had micrometastases located at a median distance of 3 mm from the metastatic tumor edge. Presence of microscopic fibrous pseudocapsule was observed in 28 percent of patients. Univariate and multivariate analyses showed that significant prognostic factors for survival were nodal status of primary tumor, number of metastases, resection margin, microscopic fibrous pseudocapsule, and adjuvant regional chemotherapy. CONCLUSIONS We conclude that 1) hepatic resection is effective in select patients with colorectal metastases; 2) adequate resection margin and adjuvant regional chemotherapy can improve outcome; and 3) microscopic fibrous pseudocapsule may offer additional postoperative information as an independent prognostic factor.
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Affiliation(s)
- S Ambiru
- First Department of Surgery, Chiba University School of Medicine, Japan
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Nagashima I, Oka T, Hamada C, Naruse K, Osada T, Muto T. Histopathological prognostic factors influencing long-term prognosis after surgical resection for hepatic metastases from colorectal cancer. Am J Gastroenterol 1999; 94:739-43. [PMID: 10086660 DOI: 10.1111/j.1572-0241.1999.00945.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE We aimed to present new histopathological features of metastatic liver nodules as more reliable prognostic factors after surgical resection for colorectal metastatic cancer. METHODS Clinicopathological features, including newly proposed histopathological ones, of 63 consecutive patients were reviewed retrospectively to determine which most strongly correlated with long-term prognosis after hepatectomy for metastatic tumors from colorectal cancers, using univariate and multivariate analysis. RESULTS The 1-, 3-, and 5-year cancer-related survival rates after hepatectomy were 87.8%, 55.2%, and 47.3%, respectively. New histopathological features we proposed, which are expansive growth, marginal fibrosis, and peritumorous lymphocytic infiltration of hepatic tumor, were significant prognostic factors for cancer-related survival after hepatectomy in an univariate analysis. Also in a multivariate analysis, i.e., a stepwise Cox regression analysis, infiltrative, i.e., not expansive, growth of hepatic tumor was one of significant and independent poor prognostic factors for survival after hepatectomy, with moderate to severe lymphatic vessel involvement of the primary colorectal lesion, microscopic cancer invasion at the surgical margin of hepatectomy, and extrahepatic distant metastases. CONCLUSIONS Our results suggest that our proposed new histopathological features of hepatic metastases were good predictors of prognosis after surgical resection for hepatic metastases from colorectal cancer. Especially, infiltrative growth of hepatic tumor is strongly correlated with a poor prognosis after hepatectomy.
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Affiliation(s)
- I Nagashima
- First Department of Surgery, Pathology, and Medical Epidemiology, University of Tokyo, Japan
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Abstract
BACKGROUND Surgical resection is the only potentially curative treatment for colorectal liver metastases, with 5-year survival rates approaching 40 per cent. However, at present only 20-25 per cent of such lesions are deemed resectable. This review examines developments in neoadjuvant and adjuvant treatments of colorectal liver metastases that aim to improve the results of surgical management of this disease. METHODS A literature review was undertaken based on a Medline search from 1970 to May 1998. RESULTS Further evolution in surgical technique is unlikely to lead to a dramatic increase in the resectability rate of colorectal liver metastases. Recent developments in neoadjuvant and adjuvant chemotherapy schedules, together with a range of interventional radiological procedures and interstitial lytic techniques, show promise in terms of extending the limits of resectability and decreasing recurrence rates associated with these lesions. Using multimodality regimens 5-year survival rates of 40 per cent are now being reported for lesions that were initially considered irresectable. CONCLUSION Patients with colorectal liver metastases should be assessed in units that can offer all the specialist techniques necessary to deliver optimum care. Incorporation of newer neoadjuvant and adjuvant treatments into management strategies should occur in the setting of randomized trials.
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Affiliation(s)
- J G Geoghegan
- Klinikum der Friedrich Schiller Universität Jena, Abteilung für Allgemeine und Viszerale Chirurgie, Germany
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36
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Choti MA, Bulkley GB. Management of hepatic metastases. LIVER TRANSPLANTATION AND SURGERY : OFFICIAL PUBLICATION OF THE AMERICAN ASSOCIATION FOR THE STUDY OF LIVER DISEASES AND THE INTERNATIONAL LIVER TRANSPLANTATION SOCIETY 1999; 5:65-80. [PMID: 9873095 DOI: 10.1002/lt.500050113] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Although the liver is the most common site of metastatic disease from a variety of tumor types, isolated hepatic metastases most commonly occur from colorectal cancer and, less frequently, from neuroendocrine tumors, gastrointestinal sarcoma, ocular melanoma, and others. Complete evaluation of the extent of metastatic disease, both intrahepatically and extrahepatically, is important before considering treatment options. Based on a preponderance of uncontrolled studies for hepatic metastatic colorectal carcinoma, surgical resection offers the only potential for cure of selected patients with completely resected disease, with 5-year survival rates of 25% to 46%. Systemic and hepatic arterial infusion chemotherapy may be useful treatment options in patients with unresectable disease and possibly as an adjuvant treatment after liver resection. Other techniques of local tumor ablation, including cryotherapy and radiofrequency ablation, although promising, remain unproved. Management of hepatic metastases from neuroendocrine tumors and other noncolorectal primary tumors should be individualized based on the patient's clinical course, extent of disease, and symptoms.
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Affiliation(s)
- M A Choti
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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37
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Lorenz M, Müller HH, Schramm H, Gassel HJ, Rau HG, Ridwelski K, Hauss J, Stieger R, Jauch KW, Bechstein WO, Encke A. Randomized trial of surgery versus surgery followed by adjuvant hepatic arterial infusion with 5-fluorouracil and folinic acid for liver metastases of colorectal cancer. German Cooperative on Liver Metastases (Arbeitsgruppe Lebermetastasen). Ann Surg 1998; 228:756-62. [PMID: 9860474 PMCID: PMC1191593 DOI: 10.1097/00000658-199812000-00006] [Citation(s) in RCA: 246] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To determine the impact of adjuvant hepatic arterial infusion (HAI) on survival relative to resection alone in patients with radical resection of colorectal liver metastases. SUMMARY BACKGROUND DATA Nearly 40% to 50% of all patients with colorectal carcinoma develop liver metastases. Curative resection results in a 5-year survival rate of 25% to 30%. Intrahepatic recurrence occurs after a median of 9 to 12 months in up to 60% of patients. The authors hypothesized that adjuvant intraarterial infusion of 5-fluorouracil (5-FU) might decrease the rate of intrahepatic recurrence and improve survival in patients with radical resection of colorectal liver metastases. METHODS Between April 5, 1991, and December 31, 1996, patients with colorectal liver metastases from 26 hospitals were stratified by the number of metastases and the site of the primary tumor and randomized to resection of the liver metastases followed by adjuvant HAI of 5-FU (1000 mg/m2 per day for 5 days as a continuous 24-hour infusion) plus folinic acid (200 mg/m2 per day for 5 days as a short infusion), or liver resection only. RESULTS The first planned intention-to-treat interim analysis after inclusion of 226 patients and 91 events (deaths) showed a median survival of 34.5 months for patients with adjuvant therapy versus 40.8 months for control patients. The median time to progression was 14.2 months for the chemotherapy group versus 13.7 months for the control group. Grade 3 and 4 toxicities (World Health Organization), mainly stomatitis (57.6%) and nausea (55.4%), occurred in 25.6% of cycles and 62.9% of patients. CONCLUSION According to this planned interim analysis, adjuvant HAI, when used in this dose and schedule in patients with resection of colorectal liver metastases, reduced the risk of death at best by 15%, but at worst the risk of death was doubled. Thus, the chance of detecting an expected 50% improvement in survival by the use of HAI was only 5%. Patient accrual was therefore terminated.
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38
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Heniford BT, Arca MJ, Iannitti DA, Walsh RM, Gagner M. Laparoscopic cryoablation of hepatic metastases. SEMINARS IN SURGICAL ONCOLOGY 1998; 15:194-201. [PMID: 9779632 DOI: 10.1002/(sici)1098-2388(199810/11)15:3<194::aid-ssu9>3.0.co;2-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Cryosurgery for liver metastases may improve survival for unresectable hepatic metastases. The laparoscopic approach to managing these tumors is a novel method fostered by increasing surgeon and patient interest in minimally invasive surgical techniques and the development of laparoscopic ultrasound and cryoprobes. A retrospective review of our patients who underwent laparoscopic cryoablation of hepatic tumors from April 1996 to December 1997 was conducted. We report on this experience and comment on the feasibility and safety of the procedure based on this early trial.
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Affiliation(s)
- B T Heniford
- Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina 28232, USA
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39
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Okuno K, Yasutomi M, Hida J, Kayama H, Nakai T, Funai S, Koh K. Longterm effects of hepatic arterial interleukin-2-based immunochemotherapy after potentially curative resection of colorectal liver metastases. J Am Coll Surg 1998; 187:271-5. [PMID: 9740184 DOI: 10.1016/s1072-7515(98)00157-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Our previous study of hepatic arterial infusion of interleukin-2 (IL-2)-based immunochemotherapy demonstrated a high response rate of patients with unresectable liver metastases. In this study, we applied this therapy to the prevention of liver recurrence in patients who underwent potentially curative resection of liver metastases. STUDY DESIGN A pilot study was conducted of 18 patients with liver metastases from primary colorectal cancer who underwent potentially curative liver resection followed by adjuvant immunochemotherapy. The regimen consisted of a weekly hepatic arterial infusion of IL-2 (1.4-2.1 X 10(6) U) and 5-fluorouracil (250 mg) and a bolus of mitomycin C (2-4 mg) for 6 months. RESULTS Among 18 patients, 14 are still alive with a median postoperative survival of 52 months (as of April 1998). The 5-year overall survival rate was 75%. Although recurrent cancer developed in 6 of the 18 patients, no patients had recurrence in the residual liver. This complete prevention of liver recurrence is believed to have contributed to the high 5-year survival rate (75%) as compared with the survival rate of patients treated with surgery alone (average, 30%-40%) or with several other forms of adjuvant therapy. CONCLUSIONS Interleukin-2-based immunochemotherapy is useful in combination with liver resection for the prevention of liver recurrence in colorectal cancer patients with liver metastases. A multicenter randomized trial is recommended.
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Affiliation(s)
- K Okuno
- First Department of Surgery, Kinki University School of Medicine, Osaka, Japan
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40
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Köhne CH, Lorenz M, Herrmann R. Colorectal cancer liver metastasis: local treatment for a systemic disease? Ann Oncol 1998; 9:967-71. [PMID: 9818069 DOI: 10.1023/a:1008463712683] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- C H Köhne
- Abteilung Hämatologie und Onkologie, Universität Rostock, Germany.
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Abstract
BACKGROUND AND OBJECTIVES Hepatic cryotherapy is a method of in situ cytodestruction used for unresectable liver tumours that can be combined with regional cytotoxic administration. We have used intra-arterial chemotherapy with 5-fluorouracil (5-FU) after hepatic cryotherapy but changed to 5-fluorodeoxyuridine (FUDR) because of the arterial toxicity of 5-FU. A new complication was seen. METHODS A retrospective case note study was performed of 130 patients who had undergone hepatic cryotherapy followed by regional chemotherapy at our centre. Seven patients received FUDR; 123 received 5-FU. RESULTS Biloma at the cryotherapy sites was seen in three patients in the FUDR group; two other patients in this group had other types of hepatic collection. Our previous experience with intra-arterial 5-FU in 123 patients after hepatic cryotherapy showed no evidence of this syndrome. CONCLUSIONS Intra-arterial FUDR should not be used after hepatic cryotherapy, at least during the immediate postoperative period.
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Affiliation(s)
- P S Soon
- Department of Surgery, University of New South Wales and St. George Hospital, Sydney, Australia
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42
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Edney JA. 50 years of breast, endocrine, and oncologic surgery at the Southwestern Surgical Congress: earlier diagnosis and improved outcomes. Am J Surg 1998; 175:92S-98S. [PMID: 9558057 DOI: 10.1016/s0002-9610(98)00065-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- J A Edney
- Department of Surgery, University of Nebraska Medical Center, Omaha 68198-3280, USA
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43
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Hewitt PM, Dwerryhouse SJ, Zhao J, Morris DL. Multiple bilobar liver metastases: cryotherapy for residual lesions after liver resection. J Surg Oncol 1998; 67:112-6. [PMID: 9486782 DOI: 10.1002/(sici)1096-9098(199802)67:2<112::aid-jso7>3.0.co;2-d] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND OBJECTIVES Most patients with colorectal liver metastases are not eligible for resection because they have multiple lesions or because of anatomical constraints. We report the use of cryotherapy to destroy residual metastases following liver resection in patients with disease too widespread for treatment by resection alone. METHODS Twenty patients with bilobar disease confined to the liver (median 3; range 2-8 lesions) were treated in this way. Seventeen patients also received regional chemotherapy postoperatively. RESULTS Morbidity was high, but there were no procedure-related deaths and only one patient's hospital stay exceeded 24 days. Significant destruction of tumor, as evidenced by a decline in CEA levels, occurred within 3 months of surgery in all patients (P < 0.001). Median duration of follow-up was 15 (6-53) months. Survival rates at 1 and 2 years were 88% and 60%, respectively, and median survival was 32 months. Seven patients remain well and seven are alive with recurrent liver and/or other metastases. CONCLUSIONS Although this is not a control study, it would appear that some patients with irresectable liver metastases benefit from this multimodality approach.
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Affiliation(s)
- P M Hewitt
- Department of Surgery, University of New South Wales, St. George Hospital, Kogarah, Sydney, Australia
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44
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VanderMeer TJ, Callery MP, Meyers WC. The approach to the patient with single and multiple liver metastases, pulmonary metastases, and intra-abdominal metastases from colorectal carcinoma. Hematol Oncol Clin North Am 1997; 11:759-77. [PMID: 9257154 DOI: 10.1016/s0889-8588(05)70459-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Recurrent colorectal carcinoma constitutes a major health care problem, with 90,000 patients diagnosed annually with metastatic disease. Recent advances have offered treatment to selected patients with liver, lung, and intra-abdominal metastases. Resection of liver secondary tumors improves 5-year survival from 0% to approximately 30% and offers the only possibility for cure. As experience mounts, hepatic surgery can be performed with quite acceptable morbidity and mortality. Adjuvant therapies are being developed that may improve results with surgery alone. Cryoablation is a new technique that appears to effectively eradicate liver tumors, but its role remains to be defined. In patients with unresectable disease, the benefit of hepatic artery infusion of chemotherapy is unproven. Resection of pulmonary metastases significantly improves survival in patients with solitary nodules. Consistent data regarding the benefit of pulmonary metastatectomy in patients with multiple nodules are not available. Combined cytoreductive surgery and intraperitoneal hyperthermic chemotherapy is being investigated as a treatment for peritoneal carcinomatosis from colorectal cancer. Although selected patients may benefit, this combined treatment modality appears to be less effective in patients with colorectal cancer than with other types of cancer.
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Affiliation(s)
- T J VanderMeer
- Department of Surgery, University of Massachusetts Medical Center, Worcester, USA
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Abstract
Carcinoma of the colon and rectum currently ranks as the second leading cause of death from cancer in the United States. Surgery remains the cornerstone of treatment for colorectal cancer but has inherent limitations imposed by the biology and stage of the tumor and its location. Ultimately, 50% of patients who undergo curative resection develop local, regional, or widespread recurrence. These statistics have remained relatively constant over several decades despite improved methods of early diagnosis and surgical treatment but may change as new multimodality treatment regimens are developed and clinically evaluated. This article summarizes the surgical management of colorectal cancer and discusses issues pertaining to postoperative surveillance and the diagnosis and management of local or widespread cancer recurrence.
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Affiliation(s)
- F E Eckhauser
- Department of Surgery, University of Michigan Medical Center, Ann Arbor, USA
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46
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Wacker FK, Boese-Landgraf J, Wagner A, Albrecht D, Wolf KJ, Fobbe F. Minimally invasive catheter implantation for regional chemotherapy of the liver: a new percutaneous transsubclavian approach. Cardiovasc Intervent Radiol 1997; 20:128-32. [PMID: 9030504 DOI: 10.1007/s002709900120] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE Development of a percutaneously implantable catheter system for regional chemotherapy of liver metastases and its application in patients with surgically implanted but dislocated catheters. METHODS Thirty-three patients with liver metastases of colorectal tumors were submitted to percutaneous puncture of the subclavian artery and insertion of a catheter whose tip was placed in the proper hepatic artery and whose end was subcutaneously connected with an infusion pump. RESULTS The mean duration of therapy via the percutaneously inserted catheter was 27 weeks (+/-14 weeks). The most frequent complication was disconnection of the therapy catheter from the tube of the infusion pump. Eighty percent of all complications were corrected by reintervention. The therapy drop-out rate due to catheter-associated complications was 9%. CONCLUSION Percutaneous insertion of a catheter for regional chemotherapy of the liver is a relatively uncomplicated method with high patient acceptance and simple access for reintervention.
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Affiliation(s)
- F K Wacker
- Department of Radiology, Benjamin Franklin University Hospital, Free University Berlin, Hindenburgdamm 30, D-12200 Berlin, Germany
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47
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Abstract
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.
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Affiliation(s)
- Y Fong
- Colorectal Service, Department of Surgery, Gastrointestinal Oncology Service, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA
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48
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Abstract
Patients with cancer recurrence limited to the liver alone after a first liver resection may be candidates for a repeat resection. Some 191 second and ten third liver resections for recurrent colorectal metastases, and 128 second and ten third liver resections for recurrent hepatocellular carcinoma (HCC), were evaluated after reviewing the literature. The 5-year survival rate after second liver resection for colorectal metastases was 26 per cent with a median survival time of 30 months. Mortality and morbidity rates were 1.2 and 27.4 per cent respectively. The 5-year survival rate after second resection for HCC was 40 per cent with a median survival time of 40 months. The operative mortality rate was 2.3 per cent; morbidity occurred in 13 per cent of patients with HCC. Survival after primary colorectal resection was significantly better for patients with metachronous metastases than for those with synchronous disease; survival correlated with a long interval between the first and second liver resection (in both colorectal liver cancer and HCC). Repeated liver resection may be performed in selected patients and yield a similar survival to that obtained after first liver resection.
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Affiliation(s)
- N Neeleman
- Department of Surgery, Lund University Hospital, Sweden
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49
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Vauthey JN, Marsh RDW, Cendan JC, Chu NM, Copeland EM. Arterial therapy of hepatic colorectal metastases. Br J Surg 1996; 83:447-55. [PMID: 8665231 DOI: 10.1002/bjs.1800830405] [Citation(s) in RCA: 50] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- J N Vauthey
- Department of Surgery, College of Medicine, University of Florida, Gainesville 32610-0286, USA
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50
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Schlag PM, Hünerbein M, Hohenberger P. Surgical and multimodality approaches to liver metastases. Curr Top Microbiol Immunol 1996; 213 ( Pt 3):241-55. [PMID: 8815008 DOI: 10.1007/978-3-642-80071-9_14] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- P M Schlag
- Virchow Hospital, Humboldt University, Berlin, Germany
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