Regional hepatic chemotherapies in the treatment of colorectal cancer metastases to the liver

Anticancer Drugs for Intra-Arterial Treatment of Colorectal Cancer Liver Metastases: In-Vitro Screening after Short Exposure Time

To treat colorectal liver metastases, intra-arterial chemotherapies may complete therapeutic arsenal. Drugs using intra-arterially are very heterogeneous. The aim of this study was to select the most efficient drug on a panel of colorectal cancer (CRC) cell lines (Caco-2, HCT 116, HT 29, SW 48, SW 480, SW 620) exposed for 30 min to 12 cytotoxic agents (doxorubicin, epirubicin, idarubicin, 5-FU, raltitrexed, gemcitabine, cisplatin, oxaliplatin, mitomycin C, irinotecan, streptozocin, paclitaxel) at different concentrations. The effect on cell viability was measured using the WST-1 cell viability assay. For each drug and cell line, the IC₅₀ and IC₉₀ were calculated, which respectively correspond to the drug concentration (mg/mL) required to obtain 50% and 90% of cell death. We also quantified the cytotoxic index (CyI₉₀ = C Max/IC₉₀) to compare drug efficacy. The main findings of this study are that idarubicin emerged as the most cytotoxic agent to most of the tested CRC cell lines (Caco-2, HT29, HCT116, SW620 and SW480). Gemcitabine seemed to be the most efficient chemotherapy for SW48. Interestingly, the most commonly used cytotoxic agents in the systemic and intra-arterial treatment of colorectal liver metastasis (CRLM) (oxaliplatin, 5-FU, irinotecan) showed very limited cytotoxicity to all the cell lines.

How to increase the resectability of initially unresectable colorectal liver metastases: A surgical perspective

Although surgical resection is the only treatment of choice that can offer prolonged survival and a chance of cure in patients with colorectal liver metastases (CRLM), nearly 80% of patients are deemed to be unresectable at the time of diagnosis. Considerable efforts have been made to overcome this initial unresectability, including expanding the indication of surgery, the advent of conversion chemotherapy, and development and modification of specific surgical techniques, regulated under multidisciplinary approaches. In terms of specific surgical techniques, portal vein ligation/embolization can increase the volume of future liver remnant and thereby reduce the risk of hepatic insufficiency and death after major hepatectomy. For multiple bilobar CRLM that were traditionally considered unresectable even with preoperative chemotherapy and portal vein embolization, two-stage hepatectomy was introduced and has been adopted worldwide with acceptable short- and long-term outcomes. Recently, ALPPS (associating liver partition and portal vein ligation for staged hepatectomy) was reported as a novel variant of two-stage hepatectomy. Although issues regarding safety remain unresolved, rapid future liver remnant hypertrophy and subsequent shorter intervals between the two stages lead to a higher feasibility rate, reaching 98%. In addition, adding radiofrequency ablation and vascular resection and reconstruction techniques can allow expansion of the pool of patients with CRLM who are candidates for liver resection and thus a cure. In this review, we discuss specific techniques that may expand the criteria for resectability in patients with initially unresectable CRLM.

Prognostic value of ADC measurements in predicting overall survival in patients undergoing 90Y radioembolization for colorectal cancer liver metastases

AIM

To assess the ability of diffusion-weighted imaging (DWI) in predicting the overall survival in patients who underwent Yttrium 90 radioembolization (⁹⁰Y-RE) for colorectal liver metastases (CLM) with other well-established clinical and imaging parameters by comparing the pre- and post-treatment apparent diffusion coefficient (ADC) values of the lesions.

METHODS

A total of 81 metastatic lesions of 27 consecutive patients who underwent DWI before and after the ⁹⁰Y-RE session were enrolled in the study. ADC values were calculated from the entire (ADC_e) and peripheral (ADC_p) tumor on pre- and post-treatment DWI, and any relative increase in ADC >0% accepted as a functional imaging response. The impact of functional imaging response in addition to other well-known parameters including Response Evaluation Criteria in Solid Tumors (RECIST), hepatic tumor burden, Eastern Cooperative Oncology Group performance status (ECOG-PS) and the presence of extrahepatic metastases in predicting overall survival (OS) was assessed using Kaplan-Meier curves and Cox-regression analyses.

RESULTS

The median OS of the patients was 10 months (range, 6-20 months) while the median OS of the responders being significantly longer than the non-responders for ADC_e and ADC_p (median 11 vs 7 months, P = 0.003; median 12 vs. 7 months, P < 0.0001, respectively). The RECIST score was also significantly affected the OS (progressive or stable disease median 8 months vs. partial response 15 indent months, P = 0.019). The other parameters including hepatic tumor burden, gender, ECOG score, the involvement of the liver lobes, and the presence of extrahepatic metastases were not associated with the OS. In multivariate analysis, only ADC_p remained as an independent predictor of OS (P = 0.003, HR = 19.878).

CONCLUSION

Any increase in relative ADC_p or ADC_e values after Y90-RE treatment was associated with longer OS in CLM patients, and DWI seems to be valuable imaging biomarker in predicting OS in CLM patients during the early post-interventional period after ⁹⁰Y-RE.

Prospective phase II trial of combination hepatic artery infusion and systemic chemotherapy for unresectable colorectal liver metastases: Long term results and curative potential

BACKGROUND/OBJECTIVES

Combination hepatic artery infusion (HAI) and systemic (SYS) chemotherapy for unresectable CRLM results in high tumor-response rates. This study represents an update of long-term survival and conversion to resectability in patients with unresectable CRLM treated with HAI and SYS chemotherapy in a phase II study.

METHOD

The primary endpoint was complete resection. Multivariate and landmark analysis assessed the effect of complete resection on progression-free (PFS) and overall survival (OS).

RESULTS

From 2007 to 2012, 64 patients with median of 13 tumors were enrolled; 67% had prior chemotherapy. 33 patients (52%) were converted to resection. Median follow-up among survivors was 81 months. Median PFS and OS were 13 and 38 months, respectively, with 5-year-OS of 36%. Chemotherapy-naïve patients had 5-year-OS of 51%. Conversion to resection was the only independent factor prognostic of improved PFS and OS. Nine of 64 patients (14%) are NED (five since initial resection, three after resection of recurrent disease, one from chemotherapy alone) at median follow-up of 86 months from treatment initiation, and 72 months from last operative intervention.

CONCLUSION

Combination HAI and SYS is an effective therapy for high-volume unresectable CRLM, resulting in a high rate of resection, long-term survival, and the potential for cure.

Minimally Invasive Liver Surgery for Hepatic Colorectal Metastases

Minimally invasive surgery has been cautiously introduced in surgical oncology over the last two decades due to a concern of compromised oncological outcomes. Recently, it has been adopted in liver surgery for colorectal metastases. Colorectal cancer is a major cause of cancer-related death in the USA. In addition, liver metastasis is the most common site of distant disease and its resection improves survival. While open resection was the standard of care, laparoscopic liver surgery has become the standard of care for minor liver resections. Laparoscopic liver surgery provides equivalent oncological outcomes with better perioperative results compared to open liver surgery. Robotic liver surgery has been introduced as it is believed to overcome some of the limitations of laparoscopy. Finally, laparoscopic radio-frequency ablation and microwave coagulation can be used as adjuncts in minimally invasive surgery to complement or replace surgical resection when not possible.

Comparative Effectiveness of Hepatic Artery Based Therapies for Unresectable Colorectal Liver Metastases: A Meta-Analysis

Background

Patients with unresectable Colorectal Liver Metastases (CRLM) are increasingly being managed using Hepatic Artery Based Therapies (HAT), including Hepatic Arterial Infusion (HAI), Radioembolization (RE), and Transcatheter Arterial Chemoembolization (TACE). Limited data is available on the comparative effectiveness of these options. We hypothesized that outcomes in terms of survival and toxicity were equivalent across the three strategies.

Methods

A meta-analysis was performed using a prospectively registered search strategy at PROSPERO (CRD42013003861) that utilized studies from PubMed (2003–2013). Primary outcome was median overall survival (OS). Secondary outcomes were treatment toxicity, tumor response, and conversion of the tumor to resectable. Additional covariates included prior or concurrent systemic therapy.

Results

Of 491 studies screened, 90 were selected for analyses—52 (n = 3,000 patients) HAI, 24 (n = 1,268) RE, 14 (n = 1,038) TACE. The median OS (95% CI) for patients receiving HAT in the first-line were RE 29.4 vs. HAI 21.4 vs. TACE 15.2 months (p = 0.97, 0.69 respectively). For patients failing at least one line of prior systemic therapy, the survival outcomes were TACE 21.3 (20.6–22.4) months vs. HAI 13.2 (12.2–14.2) months vs. RE 10.7 (9.5–12.0). Grade 3–4 toxicity for HAT alone was 40% in the HAI group, 19% in the RE group, and 18% in the TACE groups, which was increased with the addition of systemic chemotherapy. Level 1 evidence was available in 5 studies for HAI, 2 studies for RE and 1 for TACE.

Conclusion

HAI, RE, and TACE are equally effective in patients with unresectable CRLM with marginal differences in survival.

A rat model designed for the continuous intraarterial infusion of cyclosporine

BACKGROUND

Limb allotransplantation is not a life-saving treatment. However, large doses of immunosuppressive agents are needed. There is an urgent need to increase the selectivity and targeting of drugs.

METHODS

We designed a rat model for intraarterial infusion of cyclosporine (CSA) based on the hindlimb replanted model to simulate the limb allotransplantation. To investigate whether intraartery infusion could improve the drug's distribution, we infused CSA 4.0 mg/kg per day continuously into either the superficial epigastric artery (IA group) or superficial epigastric vein (IV group) of Lewis rats.

RESULTS

On day 10, CSA concentrations were measured in skin, muscle, and bone tissues of hindlimb. Samples were taken from different parts of the bilateral hindlimbs in the IA group and right hindlimb only in the IV group. Tissue concentrations of the perfusion side were much higher in IA group. Systemic concentrations of IA group were higher than IV group.

CONCLUSIONS

These results warrant further research in our next limb allotransplantation model.

Surgical management of colorectal liver metastases: a European perspective

The treatment of colorectal cancer metastatic to the liver is increasingly complex as a result of changes in the patient population, advances in preoperative staging, changing definitions of resectability, advances in surgical technique and the expanding chemotherapeutic armamentarium. Management of these patients within a multidisciplinary team is increasingly important and associated with better outcomes. In patients with irresectable hepatic metastases, high secondary resection rates can be achieved with multiagent chemotherapy when managed in conjunction with a liver specialist. Perioperative mortality rates are reducing but morbidity remains high, and enhanced recovery could help reduce morbidity. Despite the advancing age and comorbidity of the patient population, multimodal management is likely to lead to further improvements in perioperative and long-term outcomes.

Colorectal liver metastases

The diagnosis and management of CRLM is complex and requires a multidisciplinary team approach for optimal outcomes. Over the past several decades, the 5-year survival following resection of CRLM has increased and the criteria for resection have broadened substantially. Even patients with multiple, bilateral CRLM, previously thought unresectable, may now be candidates for resection. Two-stage hepatectomy, repeat curative-intent hepatectomy, and even selected resection of extrahepatic metastases have further increased the number of patients who may be treated with curative intent. Multiple liver-directed therapies exist to treat unresectable, incurable patients with adequate survival benefit and morbidity rates.

FDG-PET-CT and whole-body MRI for triage in patients planned for radioembolisation therapy

PURPOSE

The purpose was to evaluate the potential of FDG-PET-CT and whole-body MRI (WB-MRI) as diagnostic triage methods for patients planned for radioembolisation of metastatic liver disease.

MATERIALS AND METHODS

135 patients with multifocal liver metastases were evaluated for potential palliative therapy with radioembolisation using 90-Yttrium microspheres. All patients were examined consecutively with FDG-PET-CT and WB-MRI for exclusion of relevant extra-hepatic tumor manifestations. All patients underwent 99mTc-albumine angiography followed by scintigraphy to exclude significant hepato-pulmonary shunting.

RESULTS

Out of the 135 patients included into the pre-therapeutic diagnostic algorithm, 56% were eligible and received radioembolisation, while 44% could not be treated. In 91% the exclusion criteria was diagnosis of significant extra-hepatic metastatic disease. In 85% exclusion diagnosis was made concordantly by both FDG-PET-CT and WB-MRI, in 9% diagnosis was provided by PET-CT, in 6% by WB-MRI alone. Patient-based sensitivity for detection of extra-hepatic disease was 94% for PET-CT and 91% for WB-MRI. False-positive diagnosis of extrahepatic disease leading to exclusion for radioembolisation therapy was made in 2% of patients, in one patient by PET-CT and in one patient by WB-MRI alone. Overall, specificity for inclusion of radioembolisation therapy by combining both modalities was 99%. In 9% of patients angiographic diagnosis made radioembolisation impossible, in 7% solely the angiographic findings were decisive.

CONCLUSION

Both FDG-PET-CT and WB-MRI are efficient diagnostic triage methods for patients planned for radioembolisation of liver metastases. Overall, FDG-PET-CT shows a trend to higher diagnostic accuracy compared to WB-MRI and may be used as imaging method of choice as a standalone examination. In combination, both modalities exhibited high sensitivity for the diagnosis of extra-hepatic tumor manifestations and result in high specificity.

Hepatic arterial infusion (HAI) with PEGylated liposomes containing 5-FU improves tumor control of liver metastases in a rat model

PURPOSE

To investigate the cytostatic effect of 5-fluorouracil (5-FU) encapsulated in polyethylene glycol (PEG) liposomes with or without degradable starch microspheres (DSM) in a long-term trial using a rat liver tumor model.

MATERIALS AND METHODS

The cytostatics were applied once either as a hepatic arterial infusion (HAI) or were systemically infused via the tail vein. Seven groups were compared with respect to tumor growth and survival times: 5-FU HAI (group I), 5-FU + DSM HAI (group II), PEG-5-FU HAI (group III), PEG-5-FU + DSM HAI (group IV), NaCl HAI (group V), 5-FU i.v. (group VI), and PEG-5-FU i.v. (group VII).

RESULTS

Seven and 14 days after treatment in groups III and IV, only group IV had significantly inhibited tumor growth on day 21 compared to the groups treated intravenously. On day 28, none of the animals from the intravenously treated groups were still alive compared to a significantly longer survival time of 6 and 8 weeks in groups III and IV.

CONCLUSION

Locoregional therapy with 5-fluorouracil encapsulated in PEGylated liposomes may further improve the treatment success with longer-lasting tumor regression and prolonged survival times.

Culture and characterization of thymic epithelium from autoimmune NZB and NZB/W mice

Autoimmune NZB and NZB/W mice display early abnormalities in thymus histology, T cell development, and mature T cell function. Abnormalities in the subcapsular/medullary thymic epithelium (TE) can also be inferred from the early disappearance of thymulin from NZB. It has also been reported that NZB thymic epithelial cells do not grow in culture conditions that support the growth of these cells from other strains of mice. In order to study the contribution of TE to the abnormal T cell development and function in NZB and NZB/W mice, we have devised a culture system which supports the growth of TE cells from these mice. The method involves the use of culture vessels coated with extracellular matrix produced by a rat thymic epithelial cell line. TEA3A1, and selective low-calcium, low-serum medium. In addition TEA3A1 cells have been used as an antigen to generate monoclonal antibodies specific for subcapsular/medullary TE. These antibodies, as well as others already available, have been used to show that the culture conditions described here select for cells displaying subcapsular/medullary TE markers, whereas markers for cortical TE and macrophages are absent.