Results of 27 cases with hepatic metastases treated by combination chemotherapy

Sites of metastasis and association with clinical outcome in advanced stage cancer patients treated with immunotherapy

Background

Selecting the appropriate patients to receive immunotherapy (IO) remains a challenge due to the lack of optimal biomarkers. The presence of liver metastases has been implicated as a poor prognostic factor in patients with metastatic cancer. We investigated the association between sites of metastatic disease and clinical outcomes in patients receiving IO.

Methods

We conducted a retrospective review of 90 patients treated on IO-based phase 1 clinical trials at Winship Cancer Institute of Emory University between 2009 and 2017. Overall survival (OS) and progression-free survival (PFS) were measured from the first dose of IO to date of death or hospice referral and clinical or radiographic progression, respectively. Clinical benefit (CB) was defined as a best response of complete response (CR), partial response (PR), or stable disease (SD). Univariate analysis (UVA) and Multivariate analysis (MVA) were carried out using Cox proportional hazard model or logistic regression model. Covariates included age, whether IO is indicated for the patient’s histology, ECOG performance status, Royal Marsden Hospital (RMH) risk group, number of metastatic sites, and histology.

Results

The median age was 63 years and 53% of patients were men. The most common histologies were melanoma (33%) and gastrointestinal cancers (22%). Most patients (73.3%) had more than one site of distant metastasis. Sites of metastasis collected were lymph node (n = 58), liver (n = 40), lung (n = 37), bone (n = 24), and brain (n = 8). Most patients (80.7%) were RMH good risk. Most patients (n = 62) had received 2+ prior lines of systemic treatment before receiving IO on trial; 27 patients (30.0%) received prior ICB. Liver metastases were associated with significantly shorter OS (HR: 0.38, CI: 0.17–0.84, p = 0.017). Patients with liver metastasis also trended towards having shorter PFS (HR: 0.70, CI: 0.41–1.19, p = 0.188). The median OS was substantially longer for patients without liver metastases (21.9 vs. 8.1 months, p = 0.0048).

Conclusions

Liver metastases may be a poor prognostic factor in patients receiving IO on phase 1 clinical trials. The presence of liver metastases may warrant consideration in updated prognostic models if these findings are validated in a larger prospective cohort.

Factors influencing survival in patients with hepatic metastases from adenocarcinoma of the colon or rectum

The median survival of all patients with hepatic metastases from colorectal cancer referred to the Sidney Farber Cancer Institute during a five-year period was 12.5 months. Two major factors influenced survival. The first was extent of disease at presentation. The second was the histologic grade of the cancer. The median survival of patients presenting with the least disease, characterized by less than four liver nodules visible on liver scan (n = 38), normal liver size on physical examination (n = 60), normal liver function test results (n = 30), and normal performance status (n = 91), was between 18 and 24 months, regardless of treatment. The median survival of those few patients (n = 13) who had objective responses to a variety of treatments, most of whom also had minimal disease at presentation, was also 24 months. Patients whose tumors were poorly differentiated or who had abnormal performance status or weight loss of greater than 10 per cent at presentation survived only six months (median). Those with four or more liver nodules, hepatomegaly (greater than 16-cm vertical span on physical examination), or abnormal liver function test results, survived ten, eight, and 12 months (median), respectively. It is concluded that a significant group of patients survived longer than would have been predicted by earlier literature surveys after the diagnosis of colorectal cancer metastatic to the liver. It is suggested that future therapeutic trials, using survival as a measure of response of patients with liver metastases from colorectal cancer, must be prospectively controlled before selection factors can be differentiated from significant therapy effect.

Regional management of liver metastases. I

This is the first of a two part series. In this issue, Part I presents the natural history of liver metastasis and various proposed staging systems. Indications for surgical resection, which remains the treatment of choice are reviewed. For the majority of patients with unresectable metastases of the liver, various regional treatment approaches seem to give higher response rates than systemic chemotherapy. Technical aspects and therapeutic results of infusion chemotherapy via the hepatic artery and ligation of hepatic artery alone are considered. The totally implantable pump represents and advance in long-term infusion chemotherapy.

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

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

Quadruple chemotherapy for advanced malignant disease

The results of treatment of 48 cases of advanced cancer by quadruple chemotherapy are reported. In only 4 patients was an objective remission obtained, although equivocal remissions were observed in 9 patients. This report is at variance with other recent reports. The reasons for the discrepancy are discussed, and while combination chemotherapy may prove more effective if used earlier in the natural history of malignant disease, in this series the technique does not appear to offer any greater chance of remission than chemotherapeutic agents used singly.