Treatment of colorectal hepatic metastases by intrahepatic chemotherapy alone or as an adjuvant to complete or partial removal of metastatic disease

Pump Removal in Infected Patients with Hepatic Chemotherapy Pumps: When is it Necessary?

Hepatic chemotherapy pumps have been shown to be an effective and well-tolerated treatment for metastatic colorectal cancer confined to the liver. The importance of completing chemotherapy in long-term outcome makes it desirable to salvage hepatic pumps where possible. Concerns of persistent and systemic infection have resulted in premature removal of pumps in patients with infection. We report our experience in this clinical scenario. We placed 75 hepatic chemotherapy pumps from January 1998 to August 2005 for treatment of colorectal liver metastases. Information was collected on the patients’ courses of treatment, complications, and demographics via chart review. The rate of infection was 22.7% (n = 17), including eight infections localized to the abdomen (entailing five wound infections, three hepatic abscesses, and two pump pocket infections). Of these, two pumps had to be removed because of pump pocket infection, and these patients received more cycles of chemotherapy compared with the four removed for noninfectious complications (12.3 vs 3.2, P = 0.0349). Time to infection was found to be significantly higher in these patients (12.5 months) than in the patients with infections overall (4.87 months, P = 0.029), and age was found to be lower (42.5 vs 57.6 years, P = 0.0068).

Management strategies for colorectal liver metastases--Part II

Liver metastases are relatively common in colorectal cancer and a small proportion of patients may benefit from resection of these liver metastases. In a selected subgroup of patients, 5-year survival rates of 25-35% may be achieved following liver resection. These survival figures compare favourably with those of patients with untreated liver secondaries. In the second part of this review the surgical and non-surgical treatment options for treating colorectal liver metastases are examined in detail.

A pilot study of multimodality therapy for initially unresectable liver metastases from colorectal carcinoma: hepatic resection after hepatic arterial infusion chemotherapy and portal embolization

The prognosis of patients with unresectable liver metastases is poor, even if hepatic arterial infusion chemotherapy (HAI) or systemic chemotherapy is administered. A pilot study was performed to evaluate the feasibility and efficacy of multimodality therapy with hepatectomy after HAI and portal embolization for such patients. Eight patients with colorectal carcinoma and synchronous unresectable liver metastases underwent resection of the primary tumor and placement of a pump, followed by HAI with 5-fluorouracil and mitomycin C. Owing to shrinkage of the liver metastases, two patients could undergo extended right hepatic lobectomy after portal embolization, which was deemed to be essential to prevent post-operative hepatic failure. The median survival time of the eight patients was 30 months, with a response rate of 75%. Complications including sclerosing cholangitis and duodenal ulcer were observed in five patients (63%). Additional hepatectomy could be performed successfully after portal embolization without morbidity in two patients. These two patients are still alive more than 6 years after initiation of HAI and have been free of disease for more than 5 years after hepatectomy. Hepatectomy after HAI and portal embolization is feasible and may be an option to cure selected patients with initially unresectable liver metastases.

The need for a multidisciplinary approach in the treatment of advanced colorectal cancer: a critical review from a medical oncologist and surgeon

Over the last 10 years important advances have been made in the treatment of patients with advanced colorectal cancer, particularly with surgery either alone or in combination with radiotherapy. Furthermore, despite early scepticism, several chemotherapy studies have now reported significant clinical benefits with 5-FU-based regimens and promising results have also been reported with newer agents such as raltitrexed and irinotecan. Taken together these advances now enable a significant proportion of patients to undergo treatment which will improve their quality of life, prolong survival and even result in cure in certain cases. Patients with advanced colorectal cancer can only benefit from these important advances, however, if a truly multidisciplinary approach to patient care is adopted which requires integration of the roles of the surgeon, medical oncologist and radiotherapist.

A pilot study of adjuvant hepatic arterial infusion chemotherapy, associating 5-fluorouracil and leucovorin, after resection of colorectal cancer liver metastases

We initiated a pilot study of adjuvant hepatic arterial infusion chemotherapy (AHAIC) using 5-fluorouracil (5-FU) and leucovorin. Hepatic arterial infusion ports were placed in 15 consecutive patients undergoing curative resection of colorectal liver metastases. The chemotherapy regimen consisted of a weekly infusion of 5-FU (12 mg m 2 per day) and leucovorin (200 mg m 2 per day) for 12 months. The mean follow-up was 22 months (range 3-62 months, SD 21-37 months). There were no clinical or biological complications related to chemotherapy, except for sharp epigastric burns in four patients immediately after 5-FU infusions. Catheter irreversible occlusions led to early cessation of the treatment in three patients. Four of the 15 evaluable patients developed recurrent disease. The site of relapse was the liver in two patients and extra-hepatic sites in the two remaining patients. Three of these four patients died of their recurrent disease. These results suggest that 5-FU and leucovorin can be combined for AHAIC in a long duration regimen with a very low rate of side-effects. This protocol could be safely employed in a prospective randomized study in combination with 5-FU systemic infusions.

[Repeat liver resection in colorectal liver metastases]

For patients with recurrent operable liver metastases from colorectal cancer operative resection is the only chance of getting rid of their tumorous disease for a longer time. As there are not therapeutic alternatives more and more authors are reporting on repeated resections of liver metastases. From 1986 to 1994 we performed 12 recurrent liver resections with curative intent in 8 patients suffering from liver metastases of colorectal cancer: 4 synchronous and 4 metachronous metastases were removed, the primary procedure being anatomic hemihepatectomy in 5 cases and segmentectomy or bisegmentectomy in 3 cases. The mean time interval between the first and the second resections was 14 (4-23) months. Two patients underwent 4 consecutive liver resections because of recurrent metastases. In these cases the interval between the second, third and fourth procedures was 10 months. The postoperative complication rate was 16% and not a single patient died in hospital. Three patients died an average of 28 (9-54) months after the last liver resection, and the other 5 patients are still alive after an average of 14 (4-28) months: 3 are free of tumor and 2 have recurrent metastases in the liver. Compared with untreated or only locally treated cases, patients in whom operative risk is low can achieve prolonged survival times after resections of colorectal metastases to the liver.

A pilot study of hepatic artery floxuridine combined with systemic 5-fluorouracil and leucovorin. A potential adjuvant program after resection of colorectal hepatic metastases

BACKGROUND

Most patients with colorectal carcinoma metastatic to the liver have relapses after surgical resection of hepatic metastases with failures divided equally between hepatic and extrahepatic sites. A pilot study was begun using a regimen combining intrahepatic floxuridine (FUDR) and systemic 5-fluorouracil (5-FU) and leucovorin (LV) to determine its safety and efficacy.

METHODS

Because this was a pilot study, 21 patients with unresectable hepatic metastases from colorectal carcinoma were treated to assess the regimen's toxicity. Eight patients had liver metastases that were resected completely; then they received treatment. FUDR was given by hepatic arterial pump through a 14-day continuous infusion at 0.25 mg/kg/day. Systemic therapy consisted of LV 200 mg/m2 and 5-FU 280 mg/m2 using a bolus dose of 5-FU for 5 days with escalation of the 5-FU dose in separate patient cohorts. The maximally tolerated 5-FU dose was 325 mg/m2.

RESULTS

The median survival in the 21 unresectable patients was 16 months with a partial response rate of 56% (10 of 18 evaluable patients; 95% confidence interval, 38-79%). The major systemic toxicity was diarrhea, Grade 3 or 4, in 54% of patients being treated in the 4-week regimen and 19%, in the 5-week regimen. The level of hepatic toxicity was similar to that in previous studies using intrahepatic chemotherapy alone, i.e., 48% of patients had a 200% increase in alkaline phosphatase levels and 10% had bilirubin elevations of more than 3.0 mg/dl (one patient had documented biliary sclerosis). All eight patients treated with adjuvant therapy were alive without disease after a median follow-up of 23 months.

CONCLUSIONS

Systemic 5-FU and LV can be combined safely with intraarterial FUDR without loss of efficacy or increased biliary toxicity. Eight patients treated with this regimen as adjuvant therapy after liver metastasis resection were alive and disease-free after a median follow-up of 23 months.

Active specific immunotherapy with Newcastle-disease-virus-modified autologous tumor cells following resection of liver metastases in colorectal cancer. First evaluation of clinical response of a phase II-trial

A group of 23 colorectal cancer patients were treated by a new type of active specific immunotherapy (ASI) following complete surgical resection of liver metastases (RO resection). For ASI treatment we used a vaccine consisting of 1 x 10(7) autologous, irradiated (200 Gy) metastases-derived tumor cells incubated with 32 hemagglutination units (HU) of Newcastle disease virus (NDV). The adjuvant vaccine therapy was started 2 weeks after surgery and was repeated five times at 14-days intervals followed by one boost 3 months later. The delayed-type hypersensitivity (DTH) skin reactions to the vaccine were measured as well as the DTH reactions to a challenge test of 1 x 10(7) non-virus-modified autologous tumor cells from liver metastases or 1 x 10(7) autologous normal liver cells. In addition 32 HU NDV alone and a standard antigen test (Merieux test) were applied pre- and post-vaccination. The vaccination was well tolerated. In 13 of 23 patients an increasing reactivity against the vaccine was observed during the vaccination procedure. Nine patients (40%) experienced an increased DTH reactivity against autologous tumor cells following vaccination, while 17% or fewer showed an increased reactivity to Merieux test antigens, NDV, or normal liver cells. The increased antitumor response was not correlated to responsiveness to NDV alone, autologous liver cells, enzymes and culture medium used for vaccine preparation or standard antigens (Merieux test). After a follow-up of at least 18 months 61% of the vaccinated patients developed tumor recurrence in comparison to 87% of a matched control groups from the same institution that had been only surgically treated. The results of this phase II trial are encouraging and should stimulate further prospective randomized studies.

Colorectal metastases to the liver: present status of management

The management of patients with hepatic metastases from colorectal carcinoma is controversial. While a "no treatment" attitude still persists, other patients undergo systemic chemotherapy with very limited results. Other possible options are hepatic resection and locoregional treatments. One hundred twenty-three patients with hepatic metastases from colorectal cancer were treated at the authors' institution over a period of 15 years. Thirty-nine patients underwent hepatic resection while 84 underwent various forms of locoregional treatment. Several patients in the latter group were registered in one national (RNSI) Phase 2 study and one international (EORTC) Phase 3 trial. The authors' experience confirms the opinion that hepatic resection can be performed with the aim of curing in patients with isolated metastases. A five-year survival rate can be achieved in 25 to 30 percent of the resectable patients. Patients with unresectable extrahepatic disease or multiple bilateral metastases are usually excluded from resection. In other cases, hepatic resection should be carried out when technically possible. The value of adjuvant chemotherapy to the remaining liver has to be tested in prospective randomized trials. Patients with diffuse metastases can benefit from locoregional infusion of chemotherapeutic agents. Symptoms improve in most patients; objective responses vary from 53 to 83 percent of the cases, which is a higher rate than that reported for systemic chemotherapy. Survival may be prolonged in respect to untreated patients but this has not been demonstrated yet by prospective randomized studies. Current trends are continuous infusion of chemotherapeutic agents and experimentation of new drugs or drug combinations. Future improvements may be achieved by adding hepatic arterial ischemia, hyperthermia, or radiation therapy. As these kinds of treatments are still experimental, they should be applied to the patients only in the context of prospective clinical trials.

Regional chemotherapy of liver metastases from colorectal carcinoma: hepatic artery or portal vein infusion?

Hepatic artery infusion (HAI) chemotherapy has been well developed and is commonly used in the treatment of unresectable hepatic colorectal metastases. However, several important questions are unanswered, such as survival advantage over conventional systemic intravenous chemotherapy, long-term effects on the liver function, and prevention of complications, in particular cholangiosclerosis. Recent investigation into the blood supply of liver tumors challenges the adage that arterial flow is dominant. This review of the merits of regional HAI compared with portal venous infusion (PVI) chemotherapy shows a lack of conclusive data to favor either treatment modality, although a larger experience exists for HAI. Further studies need to be conducted.

Effects of 2'-deoxy-5-fluorouridine on regenerating liver following partial hepatectomy in the rat

This study evaluated the effect of 2'-deoxy-5-fluorouridine (FUDR) on the regeneration of the liver following partial (68%) hepatectomy in the rat. Male Sprague-Dawley rats weighing between 190 and 240 g underwent partial hepatectomy under ether anesthesia. Twelve hours postoperatively rats received intraperitoneal injections of 2'-deoxy-5-fluorouridine or 0.9% NaCl solution as follows: Group I, 0.9% NaCl solution (n = 49); Group II, 89 mg 2'-deoxy-5-fluorouridine/kg of body weight (n = 25); and Group III, 178 mg 2'-deoxy-5-fluorouridine/kg of body weight (n = 24). Sham groups underwent celiotomy and liver palpation followed by 0.9% NaCl solution injections (n = 5) or low dose 2'-deoxy-5-fluorouridine (n = 5) and high dose 2'-deoxy-5-fluorouridine (n = 5). The regenerative ability of the liver was evaluated by weight and deoxyribonucleic acid synthesis in the liver remnant.

RESULT

Both low and high dose 2'-deoxy-5-fluorouridine delayed the peak of deoxyribonucleic acid synthesis from 36 to 72 hr as compared to control animals which had maximal synthesis at 25 to 36 hr postoperatively (P less than 0.01). Weight of the liver remnants demonstrated a similar pattern.

CONCLUSION

High doses of 2'-deoxy-5-fluorouridine administered intraperitoneally delay, but do not inhibit, liver regeneration following partial (68%) hepatectomy as reflected by DNA synthesis and weight of the remnant.