Combined regional and systemic chemotherapy by a mini-invasive approach for the treatment of colorectal liver metastases

Low-Molecular-Weight Heparin and Calcium Heparin in Thrombosis Prophylaxis in Patients with Percutaneous Arterial and Venous Ports for Colorectal Liver Metastases

Study Objective

The evaluation of low-molecular-weight heparin use to prevent arterial and venous thrombosis in patients with indwelling arterial Port-a-Cath implants.

Methods

From 1996 to March 2003 we placed 370 indwelling hepatic arterial catheters with a minimally invasive approach. The left distal subclavian artery was approached from beneath the left clavicle, then an angiographic study of the tumoral vascular district was performed and the gastroduodenal artery was occluded by an embolus. A polyurethane catheter was introduced distally into the hepatic artery and connected to a reservoir through a 3-4 cm long subcutaneous tunnel. In 90 patients a venous Port-a-Cath was placed for concurrent systemic chemotherapy. All 370 patients received regional chemotherapy and were treated with calcium heparin at a dose of 5000 IU twice a day and with low-molecular-weight heparin at prophylactic doses (dalteparin 2500 IU or nadroparin 3000 IU) during catheter permanence to prevent hepatic artery thrombosis. Intra-arterial trans-port radionuclide scans using technetium-99m-labeled micro-aggregated albumin were performed monthly to check the infusion distribution and hepatic artery patency. In the presence of anomalous patterns, thrombosis, pulmonary embolism or other complications, angiography and/or other diagnostic studies were performed to determine the cause of the vascular event and the local or systemic symptoms. The mean arterial and venous Port-a-Cath permanence times were 6 and 8 months, respectively.

Results

We observed episodes of hepatic artery thrombosis in 4.3% of patients. Three of these 17 patients were successfully treated by intra-arterial thrombolysis using urokinase. No venous thrombosis occurred as a consequence of regional and/or systemic chemotherapy, no episodes of arterial thrombosis were registered during arterial catheter permanence, nor did any hemorrhagic complications related to anti-coagulant therapy occur. Five patients treated with low-molecular-weight heparin required treatment suspension due to a platelet count of <40,000/dL.

Conclusion

Our experience suggests that low-molecular-weight heparin and/or calcium heparin at prophylactic doses could be useful in the prevention of arterial and venous thrombosis in patients with indwelling arterial catheters or venous Port-a-Cath treated with regional or systemic chemotherapy for hepatic metastases from colorectal cancer. The homogeneity of the patient group and the use of analogous chemotherapeutic drugs (fluoropyrimidines) avoided statistical contamination related to differences between kinds of cancer and between the chemotherapeutic agents used.

Surgical or percutaneous hepatic artery cannulation for chemotherapy

The principle underlying administration of hepatic arterial chemotherapy (HACT) is to increase the local concentration of cytotoxic chemotherapy while limiting systemic toxicity. The chemotherapy agent is infused into the hepatic artery distal to branches that serve the stomach, duodenum, and pancreas. The intra-arterial catheter is connected to a subcutaneously implanted reservoir to allow repeated sessions of chemotherapy. Percutaneous placement is now a reliable and reproducible technique in the hands of well-trained interventional radiologists. Hepatic arterial cannulation by an open surgical approach is currently reserved for cases where the decision for HACT is made in the course of an hepatic surgical procedure.

Interventional oncologic approaches to liver metastases

Metastatic liver disease is the most common cause of death in cancer patients. Complete surgical resection is currently considered the only curative treatment, with only about 25% of patients being amenable to surgery. Therefore, a variety of interventional oncologic techniques have been developed for treating secondary liver malignancies. The aim of these therapies is either to allow patients with unresectable tumors to become surgical candidates, provide curative treatment options in nonsurgical candidates, or improve survival in a palliative or even curative approach. Among these interventional therapies are transcatheter therapies such as portal vein embolization, hepatic artery infusion chemotherapy, transarterial chemoembolization, and radioembolization, as well as interstitial techniques, particularly radiofrequency ablation as the most commonly applied technique. The rationale, application and clinical results of each of these techniques are reviewed on the basis of the current literature. Future prospects such as gene therapy and immunotherapy are introduced.

Arterial therapies of colorectal cancer metastases to the liver

Intra-arterial therapies directed to the liver take advantage that liver tumors are fed by the hepatic artery while the liver vascularization is 30% arterial. Most common techniques of intra-arterial therapies for colorectal cancer liver metastases (CRLM) include intra-arterial hepatic chemotherapy (IAHC), transarterial chemoembolization (TACE), and radioembolization. Such treatments are used as salvage therapies because they provide response when systemic therapies are inefficient. They are also used as a first line therapy to produce maximal response in order to convert the patient from non-surgical to surgical. IAHC with FUDR or oxaliplatinum allow 90% response rate and conversion to surgery of 40% to 50% of initially inoperable patients. TACE is used in CRLM with promising response rate, namely due to the use of drug eluting beads that can be loaded with irinotecan which can elute the drug they contain after embolization in liver tumor. Radioembolization is a unique way of delivering a high tumoricidal dose of radiation (>100 Gy) to liver tumor without harming the healthy liver, and provided interesting results in salvage therapy, enough to be evaluated today in a randomized control trial in first line therapy where FOLFOX is proposed with and without additional radioembolization.

Intra-arterial hepatic chemotherapy for unresectable colorectal liver metastases: a review of medical devices complications in 3172 patients

Background

Hepatic artery infusion (HAI) is indicated to treat unresectable colorectal hepatic metastases, with recent applications as a neoadjuvant or adjuvant treatment. Traditionally performed with the infusion of fluoropyrimidine-based chemotherapy, it has been now tested with oxaliplatin or irinotecan and associated with systemic chemotherapy.

Methods

To evaluate the impact of medical devices complications we carried out a search of the published studies on HAI in unresectable colorectal liver metastases. Complications were pooled according to the applied medical system: 1) surgical catheter, 2) radiological catheter, and 3) fully implantable pump. The surgical catheter is inserted into the hepatic artery from the gastro-duodenal artery. The radiological catheter is inserted into the hepatic artery through a percutaneous transfemoral or transaxillar access. The fully implantable pump is a totally internal medical device connected to the arterial hepatic catheter during laparotomy.

Results

The selection criteria were met in 47/319 studies. The complications of surgical and radiological medical devices connected to a port were found in 16 and 14 studies respectively. Meanwhile, complications with a fully implantable pump were reported in 17 studies. The total number of complications reported in studies evaluating patients with surgical or radiological catheter were 322 (322/948, 34%) and 261 (261/722, 36.1%) respectively. In studies evaluating patients with a fully implantable pump, the total number of complications was 237 (237/1502, 15.8%). In 18/319 studies the number of cycles was reported. The median number of cycles with surgically and radiologically implanted catheters was 8 and 6 respectively. The fully implantable pump allows a median number of 12 cycles.

Conclusions

The fully implantable pump, maintaining a continuous infusion through the system, allows the lowest risk for thrombosis and infection and the best median number of cycles of loco-regional chemotherapy in HAI.

Modern multimodality approach to hepatic colorectal metastases: solutions and controversies

Hepatic resection for colorectal metastases, limited to the liver, has become the standard of care, and currently remains the only potentially curative therapy. Numerous single institutional reports have demonstrated long-term survival and there are no other treatment options that have shown a survival plateau. However, curative resection is possible in less than 25% of those patients with disease limited to the liver, which translates into only 5-10% of the original group developing colorectal cancer. To increase the number of patients who could benefit from hepatic resection, the last decade has seen considerable effort being directed towards novel approaches to permit curative hepatic resection such as: neoadjuvant systemic and regional chemotherapy, pre-operative portal vein embolization for hypertrophy of future liver remnant, staged hepatic resection and radio frequency ablation combined with resection for addressing multiple bilobar metastases. This article reviews development of these innovative multidisciplinary modalities and the aggressive surgical approach that has been adopted to extend the frontiers of surgical therapy for colorectal hepatic metastases.

In vivo migration of labeled autologous natural killer cells to liver metastases in patients with colon carcinoma

Background

Besides being the effectors of native anti-tumor cytotoxicity, NK cells participate in T-lymphocyte responses by promoting the maturation of dendritic cells (DC). Adherent NK (A-NK) cells constitute a subset of IL-2-stimulated NK cells which show increased expression of integrins and the ability to adhere to solid surface and to migrate, infiltrate, and destroy cancer. A critical issue in therapy of metastatic disease is the optimization of NK cell migration to tumor tissues and their persistence therein. This study compares localization to liver metastases of autologous A-NK cells administered via the systemic (intravenous, i.v.) versus locoregional (intraarterial, i.a.) routes.

Patients and methods

A-NK cells expanded ex-vivo with IL-2 and labeled with ¹¹¹In-oxine were injected i.a. in the liver of three colon carcinoma patients. After 30 days, each patient had a new preparation of ¹¹¹In-A-NK cells injected i.v. Migration of these cells to various organs was evaluated by SPET and their differential localization to normal and neoplastic liver was demonstrated after i.v. injection of ^99mTc-phytate.

Results

A-NK cells expressed a donor-dependent CD56⁺CD16⁺CD3^- (NK) or CD56⁺CD16⁺CD3⁺ (NKT) phenotype. When injected i.v., these cells localized to the lung before being visible in the spleen and liver. By contrast, localization of i.a. injected A-NK cells was virtually confined to the spleen and liver. Binding of A-NK cells to liver neoplastic tissues was observed only after i.a. injections.

Conclusion

This unique study design demonstrates that A-NK cells adoptively transferred to the liver via the intraarterial route have preferential access and substantial accumulation to the tumor site.

Colorectal liver metastases: regional chemotherapy via transarterial chemoembolization (TACE) and hepatic chemoperfusion: an update

Liver metastasis is one of the main problems encountered in colorectal cancer management as the liver is the most common metastatic site. Several treatment options are available, among which transarterial chemotherapy has proved effective in achieving some local tumour control, improving the quality of life through symptomatic control as well as survival time. The present paper is intended to provide an overview of the techniques, indications and results of regional chemotherapy, which comprises transarterial chemoembolization (TACE) and chemoperfusion. This treatment approach has symptomatic, palliative, adjuvant and potentially curative objectives. We reviewed the studies involving TACE and chemoperfusion of colorectal liver metastases during the last few years to update the previous reviews published on this subject. The results achieved were so variable, due to the variations in patient selection criteria and regimens used between the different studies. The median survival ranged from 9 to 62 months and the morphological response ranged from 14 to 76%. Technical aspects, results, and complications of this modality will be demonstrated with a detailed analysis and comments.

Laparoscopic hepatic artery catheterization for regional chemotherapy

BACKGROUND

Metastatic disease isolated to the liver is present at the time of diagnosis in 20-30% of patients with colorectal cancer. Only 10% of patients are eligible for resection. Systemic chemotherapy remains the primary treatment modality for such patients. The morbidity associated with regional chemotherapy is largely a result of the laparotomy required to place a hepatic arterial infusion pump in these debilitated patients. We discuss the main advantages of laparoscopic approach in comparison to both open procedure and percutaneous hepatic artery catheterization.

MATERIAL AND METHODS

From November 1993 to April 2004, 27 patients (16 males, 11 females) underwent laparoscopic placement of a hepatic artery catheter. The mean age was 64.9 years (46 to 82 years). 24 patients (88.8%) had bilobar disease precluding surgical resection of the liver metastases. There were four cases of non-colon cancers, all with liver metastases.

RESULTS

LHAC alone averaged 45-55 minutes. Mean blood loss of 151 cc (20-300 cc). Postoperatively, 16 patients (59.2%) had hepatic intra-arterial chemotherapy in the recovery room as a preplanned protocol. Average hospital stay was 8.4 days (3-25 days). Median follow-up period of 8.1 months. 22 patients with residual hepatic disease, in whom chemotherapy was successfully instituted, showed regression of their metastases, in 18 patients, CEA had improved at their one-month follow-up visit. Three complications: one catheter thrombosis, one partial catheter occlusion and one eroded catheter into the duodenum one year after.

CONCLUSIONS

In experienced hands, laparoscopic hepatic artery catheterization is a safe, feasible and minimally invasive technique for those patients with metachronous liver malignancies.

Coil embolization of an arteriobiliary fistula caused by hepatic intra-arterial chemotherapy

Arteriobiliary fistula is a rare complication of hepatic intra-arterial chemotherapy. We report successful coil embolization of an arteriobiliary fistula. An 80-year-old woman underwent percutaneous placement of an indwelling catheter into the replaced right hepatic artery for intra-arterial chemotherapy of liver metastases. Coil embolization of the left hepatic artery was not performed. The patient complained of abdominal pain during intra-arterial chemotherapy. Angiography revealed a fistula between the replaced right hepatic artery and the common bile duct. The fistula was successfully treated by coil embolization via the indwelling catheter, and the indwelling catheter was removed. Although such complications usually herald the termination of intra-arterial chemotherapy, the patient underwent percutaneous implantation of a new catheter-port system, and intra-arterial chemotherapy was restarted.

BNCT dose distribution in liver with epithermal D–D and D–T fusion-based neutron beams

Recently, a new application of boron neutron capture therapy (BNCT) treatment has been introduced. Results have indicated that liver tumors can be treated by BNCT after removal of the liver from the body. At Lawrence Berkeley National Laboratory, compact neutron generators based on (2)H(d,n)(3)He (D-D) or (3)H(t,n)(4)He (D-T) fusion reactions are being developed. Preliminary simulations of the applicability of 2.45 MeV D-D fusion and 14.1 MeV D-T fusion neutrons for in vivo liver tumor BNCT, without removing the liver from the body, have been carried out. MCNP simulations were performed in order to find a moderator configuration for creating a neutron beam of optimal neutron energy and to create a source model for dose calculations with the simulation environment for radiotherapy applications (SERA) treatment planning program. SERA dose calculations were performed in a patient model based on CT scans of the body. The BNCT dose distribution in liver and surrounding healthy organs was calculated with rectangular beam aperture sizes of 20 cm x 20 cm and 25 cm x 25 cm. Collimator thicknesses of 10 and 15 cm were used. The beam strength to obtain a practical treatment time was studied. In this paper, the beam shaping assemblies for D-D and D-T neutron generators and dose calculation results are presented.

Complications After Percutaneous Transaxillary Implantation of a Catheter for Intraarterial Chemotherapy of Liver Tumors:Clinical Relevance and Management in 204 Patients

OBJECTIVE

The purposes of the study were to evaluate the complications of patients who underwent percutaneous transaxillary implantation of a permanent catheter-port system for intraarterial hepatic chemotherapy and determine their clinical relevance and specific management. SUBJECTS AND METHODS. Catheter-port systems were placed in 204 patients with liver tumors (86.7% from colorectal metastases). Under sonographic and fluoroscopic guidance, a 5.8-French catheter was placed in the hepatic artery and connected to a subcutaneous reservoir after embolization of the gastroduodenal and right gastric arteries. Floxuridine plus dexamethasone and systemic low-dose heparin were administered. During the follow-up period, complications were classified as clinically not significant (type 1), clinically significant not requiring interruption of intrahepatic chemotherapy (type 2), clinically significant needing temporary suppression of intrahepatic chemotherapy (type 3), and clinically significant causing permanent suppression of intrahepatic chemotherapy (type 4).

RESULTS

No complications occurred during the implantation procedures. The mean number of intrahepatic chemotherapy cycles was 8.1. The mean follow-up period was 270 days. Primary and secondary patency rates of the system were 71.6% and 91.2%, respectively. Temporary suppression of intrahepatic chemotherapy was necessary in 19.6% of the patients and definitive suppression, in 8.8%. Hepatic artery thrombosis, not recanalized by local thrombolysis, was the main cause of permanent intrahepatic chemotherapy interruption (4.4%). Catheter occlusions and cerebral complications were not observed. In 91.2% of the patients, intrahepatic chemotherapy could be completed.

CONCLUSION

Percutaneous implantation of a removable and reimplantable catheter-port system for intrahepatic chemotherapy can be a safe procedure to treat unresectable liver metastases from colorectal cancer. Technical and pharmacologic complications with variable clinical relevance occurred, and various specific management strategies were necessary to reduce their incidence.

Regional chemotherapeutic techniques for liver tumors: current knowledge and future directions

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.

Angiography for diagnosis and treatment of colorectal cancer

AIM: To evaluate the role of preoperative angiography in the diagnosis and treatment of colorectal cancer.

METHODS: The authors performed selective arterial cannulation by Seldinger's method in 47 patients to locate the primary cancer and to diagnose metastasis to the liver. Each patient was then given intra-arterial regional chemotherapy, and received 5-fluorouracil (5-Fu, 1000 mg), mitomycin C (MMC, 20 mg), and cisplatinum (CDDP, 80 mg).

RESULTS: The location and shape of each tumor were observed, including metastatic tumors in the liver, in 42 of the 47 (89.4%) patients. The site of the primary tumor was difficult to identify in 5 cases because the patients had a recurrence of cancer. Arterial chemotherapy was performed successfully in all patients. The authors recorded no partial or significant morbidity resulted from angiography. The only incident was bleeding from the artery puncture site in one patient, which was successfully stopped by general medication.

CONCLUSION: Preoperative selective arterial angiography can help the diagnosis and locate primary tumors and to detect liver metastasis. At the same time, regional arterial chemotherapy can be an important form of preoperative therapy.

Radiologic placement of side-hole catheter with tip fixation for hepatic arterial infusion chemotherapy

PURPOSE

To investigate the technical outcome of radiologic catheter placement with use of a side-hole catheter with distal fixation for hepatic arterial infusion chemotherapy.

MATERIALS AND METHODS

Between January 1993 and September 1999, 426 patients were referred to our department to undergo intraarterial infusion chemotherapy for unresectable malignant liver tumors. A subclavian artery was exposed under local anesthesia and a catheter was inserted. After inserting the tip of the side-hole catheter into the gastroduodenal artery, splenic artery, or peripheral branch of the hepatic artery, the catheter tip was fixed to the vessel with use of coils and a mixture of n-butyl cyanoacrylate (NBCA) and iodized oil. The proximal end of the catheter was connected to an implanted port, and the port system was embedded subcutaneously.

RESULTS

Placement was successful in 425 of 426 patients (99.8%) in a mean time of 76 minutes. Catheter dislodgement was noted in 12 patients (2.8%). Cumulative patency rates of the hepatic artery calculated according to the Kaplan-Meier method for the entire group were 91.0%, 81.4%, and 58.1% at 6 months and 1 and 2 years, respectively. Complications related to catheter placement were observed in nine cases and included dysfunction of the implanted system (n = 3), significant bleeding around the implanted port (n = 2), improper infusion of NBCA and iodized oil (n = 2), and cerebral infarction (n = 2).

CONCLUSION

Radiologic catheter placement via a subclavian artery with side-hole catheter placement with distal fixation for hepatic arterial infusion chemotherapy is a highly successful procedure with a reduced risk of catheter dislodgment and arterial occlusion.

Arterial chemotherapy of 5-fluorouracil and mitomycin C in the treatment of liver metastases of colorectal cancer

AIM: Regional chemotherapy using hepatic artery catheters is a good method of treating patients with colorectal cancer liver metastases. We investigated the survival of patients with liver metastases from colorectal cancer using 5-fluorouracil (5-FU) and mitomycin C Cthrough implantable hepatic arterial infusion port.

METHODS: Seventy-five patients with inoperable liver metastases from colorectal cancer were included between March, 1992 and November, 2001. We placed implantable hepatic arterial catheter (HAC) port by laparotomy.5-FU, 1000 mg/m²/d continuous infusion for five days every four weeks, was delivered in the hepatic arterial catheter through the port. Mitomycin C, 30 mg/m²/d infusion in the first day every cycle through the port. Response to the treatment was evaluated by serial determinations of plasma CEA and imaging techniques consisting of computerized tomography and sonography of liver.

RESULTS: Sixty-eight were performed hepatic artery chemotherapy and fifty-six were followed up among seventy-five HAC patients. Twenty-six patients (46.4%) have responded and 4 complete remission were achieved. Eight patients (14.3%) had stable liver metastases. Twenty-two patients (39.3%) were progressed with increased tumor size and number. Twenty-nine patients (51.8%) had a decreased serum CEA level, while 10 patients (17.9%) were stable and 17 patients (30.4%) had an increased serum CEA level. There were no operative death in this series. Complications, which occurred in 18 patients (32.1%), were as followed: hepatic artery thrombosis in 11, Upper gastric and intestinal bleeding in 3, liver abscess in 1, pocket infection in 1, cholangitis in 1, and hepatic artery pseudo-aneurysm in one patient.

CONCLUSION: Combined infusion of 5-FU and mitomycin C by hepatic artery catheter port is an effective treatment for liver metastases from colorectal cancer. The high response and lower complication rates prove the adjuvant treatment of colorectal cancer with this treatment.

The role of adjuvant therapy after liver resection for colorectal cancer metastases

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.