Preoperative hepatic and regional arterial chemotherapy in the prevention of liver metastasis after colorectal cancer surgery

Applications of image-guided locoregional transarterial chemotherapy in patients with inoperable colorectal cancer: a review

With the development of comprehensive treatment, locoregional transarterial chemotherapy has become an alternative conversion therapy, palliative therapy, and neoadjuvant therapy for many solid malignant tumors. Locoregional transarterial chemotherapy, which is most frequently used for treating liver cancer, has the characteristics of high regional efficacy and few systemic adverse reactions. In recent years, the number of relevant reports of locoregional chemotherapy for treating initially inoperable colorectal cancer (CRC), including non-metastatic and metastatic CRC, has gradually increased. However, the specific treatment options for such locoregional therapy are not the same, and its indications, medication regimens and combined treatments have not reached any consensus. In this review, the application status of locoregional transarterial chemotherapy in primary and metastatic CRC patients has been reviewed and summarized to provide a reference for future clinical work and scientific research.

Efficacy of various adjuvant chemotherapy methods in preventing liver metastasis from potentially curative colorectal cancer: A systematic review network meta-analysis of randomized clinical trials

PURPOSE

Various chemotherapy administration methods have been used to prevent liver metastasis (LM) in patients with colorectal cancer (CRC). This network meta-analysis evaluated the efficacy of these different methods in preventing LM in CRC patients who underwent curative surgery.

METHOD

A systematic search of randomized controlled trials reporting the efficacy of various adjuvant chemotherapy methods in patients with colorectal cancer who underwent curative surgery was conducted. The primary outcome was the LM rate.

RESULTS

This network meta-analysis included 19 studies reporting on 12,588 participants, comparing portal vein infusion chemotherapy (PVIC) versus hepatic arterial infusion chemotherapy (HAIC) versus systematic chemotherapy (SC) versus surgery alone. The HAIC group had the lowest LM rate when compared to the other three groups (odds ratio [OR] of PVIC vs. HAIC: 1.86; OR of SC vs. HAIC: 1.98; and HAIC vs. surgery alone: 0.43). The LM rate did not differ significantly between PVIC, SC, and surgery alone. The recurrence rates were lower for PVIC and HAIC than for surgery alone (the ORs for PVIC and HAIC were 0.73 [95% CI: 0.58-0.92] and 0.45 [95% CI: 0.26-0.77]). The mortality rates of patients undergoing PVIC and HAIC were lower than that of patients undergoing surgery alone (the ORs for PVIC and HAIC were 0.77 [95% CI: 0.64-0.93] and 0.49 [95% CI: 0.24-0.98]). Anastomotic leakage, cardiopulmonary leakage, diarrhea, nausea and vomiting, oral ulceration, wound infection, or ileus did not differ significantly between the four groups. PVIC showed the highest hepatic toxicity rate compared to those for SC, HAIC, and surgery alone.

CONCLUSION

HAIC might be a satisfactory method for preventing LM in patients with CRC undergoing curative surgery.

Impact of preoperative transcatheter rectal arterial chemoembolization with concurrent chemoradiotherapy on surgery and prognosis of patients with locally advanced rectal cancer

BACKGROUND AND OBJECTIVES

To analyze and evaluate the impact of preoperative transcatheter rectal arterial chemoembolization (TRACE) with concurrent chemoradiotherapy on surgery and prognosis of locally advanced rectal cancer (LARC).

METHODS

A total of 118 patients with LARC were enrolled in this nonrandomized prospective study. They were assigned into the experimental group receiving preoperative TRACE with concurrent chemoradiotherapy (TRACE-CRT group, N = 60) and the control group receiving only neoadjuvant chemoradiotherapy (CRT group, N = 58). All patients underwent surgery after their preoperative treatments.

RESULTS

All patients successfully completed the surgical operation. No significant differences were found in sphincter preservation rate and R0 resection rate between TRACE-CRT group and CRT group (p > 0.05). No significant differences were found between the two groups in terms of the perioperative indicators and postoperative complications except mean operation time (165.8 vs. 196.6 min, p < 0.001). Local recurrence occurred in 8 and 5 patients, respectively (p > 0.05). Distant metastasis occurred in 5 and 11 patients, respectively (p < 0.05).

CONCLUSIONS

Adding TRACE in the preoperative standard treatment for LARC did not increase perioperative complications. In addition, it has the potential advantage of preventing distant metastasis. It is worthy of further application and promotion in clinical practice.

Preoperative Hepatic and Regional Arterial Chemotherapy in Patients Who Underwent Curative Colorectal Cancer Resection: A Prospective, Multi-center, Randomized Controlled Trial

OBJECTIVE

To evaluate the effects of the addition of preoperative hepatic and regional arterial chemotherapy (PHRAC) on prognosis of stage II and III colorectal cancer (CRC) in a multicenter setting.

SUMMARY OF BACKGROUND DATA

Our previous single-center pilot trial suggested that PHRAC in combination with surgical resection could reduce the occurrence of liver metastasis (LM) and improve survival in CRC patients.

METHODS

A prospective multi-center randomized controlled trial was conducted from December 2008 to December 2012 at 5 hospitals in China. Eligible patients with clinical stage II or III CRC who underwent curative resection were randomized to receive PHRAC plus adjuvant therapy (PHRAC arm) or adjuvant therapy alone (control arm). The primary endpoint was DFS. Secondary endpoints were cumulative LM rates, overall survival (OS), and safety (NCT00643877).

RESULTS

A total of 688 patients from 5 centers in China were randomly assigned (1:1) to each arm. The five-year DFS rate was 77% in the PHRAC arm and 65% in the control arm (HR = 0.61, 95% CI 0.46-0.81; P = 0.001). The 5-year LM rates were 7% and 16% in the PHRAC and control arms, respectively (HR = 0.37, 95% CI 0.22-0.63; P < 0.001). The 5-year OS rate was 84% in the PHRAC arm and 76% in the control arm (HR = 0.61, 95% CI 0.43-0.86; P = 0.005). There were no significant differences regarding treatment related morbidity or mortality between the two arms.

CONCLUSIONS

The addition of PHRAC could improve DFS in patients with stage II and III CRC. It reduced the incidence of LM and improved OS without compromising patient safety.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT00643877.

Laparoscopic intraarterial catheterization with selective ICG fluorescence imaging in colorectal surgery

The quality of mesorectal resection is crucial for resection in rectal cancer, which should be performed by laparoscopy for better outcome. The use of indocyanine green (ICG) fluorescence is now routinely used in some centers to evaluate bowel perfusion. Previous studies have demonstrated in animal models that selective intra-arterial ICG staining can be used to define and visualize resection margins in rectal cancer. In this animal study, we investigate if laparoscopic intra-arterial catheterization is feasible and the staining of resection margins when performing total mesorectal excision with a laparoscopic medial to lateral approach is possible. In 4 pigs, laparoscopic catheterization of the inferior mesenteric artery (IMA) is performed using a seldinger technique. After a bolus injection of 10 ml ICG with a concentration of 0.25 mg/ml, a continuous intra-arterial perfusion was established at a rate of 2 ml/min. The quality of the staining was evaluated qualitatively. Laparoscopic catheterization was possible in all cases, and the average time for this was 30.25 ± 3.54 min. We observed a significant fluorescent signal in all areas of the IMA supplied, but not in other parts of the abdominal cavity or organs. In addition, the mesorectum showed a sharp border between stained and unstained tissue. Intraoperative isolated fluorescence augmentation of the rectum, including the mesorectum by laparoscopic catheterization, is feasible. Inferior mesenteric artery catheterization and ICG perfusion can provide a fluorescence-guided roadmap to identify the correct plane in total mesorectal excision, which should be investigated in further studies.

Transarterial chemoembolization with doxorubicin-loaded beads for inoperable or recurrent colorectal cancer

PURPOSE

We aimed to assess the safety and efficacy of transarterial chemoembolization (TACE) with doxorubicin-loaded CalliSpheres^® beads (DEB-TACE) for the treatment of patients with inoperable or recurrent colorectal cancer (CRC).

METHODS

This retrospective study recruited 12 consecutive patients with histology confirmation of CRC who received DEB-TACE between August 2017 and April 2020. There were 9 male and 3 female, with a mean age 62.5 ± 14.9 (range 29-84). Patients' characteristics, medical imaging data, complications and DEB-TACE procedure were retrospectively reviewed. The disease control rate was defined as the sum of complete response, partial response and stable disease.

RESULTS

DEB-TACE was successfully performed in all patients. All patients showed local disease control 1 month after DEB-TACE. Disease control rates were 90.9% and 70.0% at 3 and 6 months after DEB-TACE procedure, respectively. Disease-free interval was 11.0 to 81.8 months. Five patients (41.7%) received prior chemotherapy treatments. No severe complications or procedure-related deaths were observed. The median overall survival was 15.9 months, and median progression-free survival was 13.4 months.

CONCLUSION

DEB-TACE is a safe and effective treatment and could be a option for patients with inoperable or recurred CRC.

Differences in Liver Parenchyma are Measurable with CT Radiomics at Initial Colon Resection in Patients that Develop Hepatic Metastases from Stage II/III Colon Cancer

BACKGROUND

Currently, there are no methods to identify patients with an increased risk of liver metastases to guide patient selection for liver-directed therapies. We tried to determine whether quantitative image features (radiomics) of the liver obtained from preoperative staging CT scans at the time of initial colon resection differ in patients that subsequently develop liver metastases, extrahepatic metastases, or demonstrate prolonged disease-free survival.

METHODS

Patients who underwent resection of stage II/III colon cancer from 2004 to 2012 with available preoperative CT scans were included in this single-institution, retrospective case-control study. Patients were grouped by initial recurrence patterns: liver recurrence, extrahepatic recurrence, or no evidence of disease at 5 years. Radiomic features of the liver parenchyma extracted from CT images were compared across groups.

RESULTS

The cohort consisted of 120 patients divided evenly between three recurrence groups, with an equal number of stage II and III patients in each group. After adjusting for multiple comparisons, 44 of 254 (17%) imaging features displayed different distributions across the three patient groups (p < 0.05), with the clearest distinction between those with liver recurrence and no evidence of disease. Increased heterogeneity in the liver parenchyma by radiomic analysis was protective of liver metastases.

CONCLUSIONS

CT radiomics is a promising tool to identify patients at high risk of developing liver metastases and is worthy of further investigation and validation.

Prognostic and predictive value of circulating DNA for hepatic arterial infusion of chemotherapy for patients with colorectal cancer liver metastases

Hepatic arterial infusion (HAI) of chemotherapy is an experimental treatment option for patients with colorectal cancer liver metastases (CRCLM). The current study aimed to investigate the predictive and prognostic value of cell free DNA (cfDNA) in patients with CRCLM receiving HAI with oxaliplatin and systemic capecitabine. Plasma samples from 62 patients were investigated who were included into a single arm phase II study investigating HAI treatment for patients with CRCLM. The clinical outcome of the trial has been presented previously. In brief, treatment consisted of intrahepatic infusion of oxaliplatin 100 mg/m² every second week with concomitant oral capecitabine 3,500 mg/m² every second week for up to 12 cycles. Blood samples were drawn at baseline and follow-up and plasma was analyzed for cell free DNA using a direct fluorescent assay. The baseline level of plasma cfDNA was 0.92 ng/µl (95% CI 0.84-1.00). Patients with a baseline value of cfDNA above the 75th quartile had a median overall survival of 2.4 years (95% CI 0.7-2.8), compared with 3.9 years (95% CI 2.8-5.9) for patients below the 75th quartile (P=0.02). The baseline level of cfDNA was significantly lower (0.91 ng/µl, 95% CI 0.76-0.98) in patients who achieved an objective response compared to non-responders (1.79 ng/µl; 95% CI 0.99-2.57; P=0.02). The current study demonstrated a possible prognostic and predictive value of cfDNA for patients with CRCLM undergoing HAI with oxaliplatin and concomitant capecitabine.

Comparative Efficacy of Preoperative, Postoperative, and Perioperative Treatments for Resectable Colorectal Liver Metastases: A Network Meta-Analysis

Background: Several treatment strategies are used for management of resectable colorectal liver metastases. We performed a Bayesian network meta-analysis to compare preoperative, postoperative, or perioperative treatments, identifying the optimal approach. Methods: We searched reports of randomized controlled trials through the relevant databases. The primary outcome criterion was overall survival (OS). The secondary outcome measure was disease-free survival (DFS). We calculated the hazard ratio (HR) with the 95% credible interval (Crl) of the time-to-event data. Rank probabilities were evaluated by the probability of treatment rankings. Multiple treatment comparisons based on a Bayesian network integrated the efficacy of all included approaches. Results: Twenty-two eligible randomized controlled trials with 6,115 patients were included in the network meta-analysis. One treatment that resulted in a significant improvement in OS compared with surgery alone was hepatic arterial infusion (HAI) plus postoperative chemotherapy (CT) [HR = 0.74 with 95% Crl: (0.60, 0.94)]. With regard to the secondary outcome measure, three approaches that led to a significant improvement in DFS compared with surgery alone were HAI plus postoperative CT [HR = 1.44 with 95% Crl: (1.19, 1.75)], postoperative CT [HR = 1.14 with 95% Crl: (1.01, 1.29)], preoperative hepatic and regional arterial chemotherapy (PHRAC) plus preoperative CT [HR = 1.41 with 95% Crl: (1.03, 1.89)]. According to the results for the rank probabilities of the 11 treatments, the combination of HAI and bevacizumab plus postoperative CT showed the highest probability of benefitting OS, and PHRAC plus preoperative CT was most likely to benefit DFS. Conclusions: The combination of HAI and bevacizumab plus postoperative CT exhibited the greatest odds of being the most effective treatment for improving OS, and PHRAC plus preoperative CT exhibited the greatest odds of improving DFS. Further clinical studies are needed and justified.

Cryotherapy for liver metastases

BACKGROUND

The liver is affected by two of the most common groups of malignant tumours: primary liver tumours and liver metastases from colorectal carcinoma. Liver metastases are significantly more common than primary liver cancer and long-term survival rates reported for patients after radical surgical treatment is approximately 50%. However, R0 resection (resection for cure) is not feasible in the majority of patients. Cryotherapy is performed with the use of an image-guided cryoprobe which delivers liquid nitrogen or argon gas to the tumour tissue. The subsequent process of freezing is associated with formation of ice crystals, which directly damage exposed tissue, including cancer cells.

OBJECTIVES

To assess the beneficial and harmful effects of cryotherapy compared with no intervention, other ablation methods, or systemic treatments in people with liver metastases.

SEARCH METHODS

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE Ovid, Embase Ovid, and six other databases up to June 2018.

SELECTION CRITERIA

Randomised clinical trials assessing beneficial and harmful effects of cryotherapy and its comparators for liver metastases, irrespective of the location of the primary tumour.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We extracted information on participant characteristics, interventions, study outcomes, and data on the outcomes important for our review, as well as information on the design and methodology of the trials. Two review authors independently assessed risk of bias in each study. One review author performed data extraction and a second review author checked entries.

MAIN RESULTS

We found no randomised clinical trials comparing cryotherapy versus no intervention or versus systemic treatments; however, we identified one randomised clinical trial comparing cryotherapy with conventional surgery. The trial was conducted in Ukraine. The trial included 123 participants with solitary, or multiple unilobar or bilobar liver metastases; 63 participants received cryotherapy and 60 received conventional surgery. There were 36 women and 87 men. The primary sites for the metastases were colon and rectum (66.6%), stomach (7.3%), breast (6.5%), skin (4.9%), ovaries (4.1%), uterus (3.3%), kidney (3.3%), intestines (1.6%), pancreas (1.6%), and unknown (0.8%). The trial was not reported sufficiently enough to assess the risk of bias of the randomisation process, allocation concealment, or presence of blinding. It was also not possible to assess incomplete outcome data and selective outcome reporting bias. The certainty of evidence was low because of risk of bias and imprecision.The participants were followed for up to 10 years (minimum five months). The trial reported that the mortality at 10 years was 81% (51/63) in the cryotherapy group and 92% (55/60) in the conventional surgery group. The calculated by us relative risk (RR) with 95% Confidence Interval (CI) was: RR 0.88, 95% CI 0.77 to 1.02. We judged the evidence as low-certainty evidence. Regarding adverse events and complications, separately and in total, our calculation showed no evidence of a difference in recurrence of the malignancy in the liver: 86% (54/63) of the participants in the cryotherapy group and 95% (57/60) of the participants in the conventional surgery group developed a new malignancy (RR 0.90, 95% CI 0.80 to 1.01; low-certainty evidence). The frequency of reported complications was similar between the cryotherapy group and the conventional surgery group, except for postoperative pain. Both insignificant and pronounced pain were reported to be more common in the cryotherapy group while intense pain was reported to be more common in the conventional surgery group. However, the authors did not report whether there was any evidence of a difference. There were no intervention-related mortality or bile leakages.We identified no evidence for health-related quality of life, cancer mortality, or time to progression of liver metastases. The study reported tumour response in terms of the carcinoembryonic antigen level in 69% of participants, and reported results in the form of a graph for 30% of participants. The carcinoembryonic antigen level was lower in the cryotherapy group, and decreased to normal values faster in comparison with the control group (P < 0.05).

FUNDING

the trial did not provide information on funding.

AUTHORS' CONCLUSIONS

The evidence for the effectiveness of cryotherapy versus conventional surgery in people with liver metastases is of low certainty. We are uncertain about our estimate and cannot determine whether cryotherapy compared with conventional surgery is beneficial or harmful. We found no evidence for the benefits or harms of cryotherapy compared with no intervention, or versus systemic treatments.

Diagnostic performance of MRI- versus MDCT-categorized T3cd/T4 for identifying high-risk stage II or stage III colon cancers: a pilot study

PURPOSE

The aim of this study was to determine the diagnostic performance of magnetic resonance imaging (MRI)-categorized T3cd/T4 tumors for identifying high-risk stage II or stage III cancer in patients with curatively resectable colon cancer in comparison to that of multidetector computed tomography (MDCT).

MATERIALS AND METHODS

Thirty-eight patients with histopathologically indicated adenocarcinomas prospectively underwent MRI of the colon. Two radiologists independently and retrospectively assessed for T-category, including T3 substage (≤ T3ab vs. ≥ T3cd). The diagnostic accuracies and interreader agreements between assessments using each modality were compared using a pairwise comparison of receiver-operating characteristic curves and a weighted κ statistic, respectively.

RESULTS

Twenty-nine patients (76.3%) were histopathologically diagnosed with high-risk stage II or stage III colon cancer. The false-positive rate with MRI was lower than that with MDCT (0% vs. 7.9% for reader 1, 2.6% vs. 10.6% for reader 2). The diagnostic performance of MRI was better than that of MDCT across both readers (AUC: 0.707 vs. 0.506 [P = 0.032] for reader 1, 0.651 vs. 0.485 [P = 0.055] for reader 2). Moreover, MRI interreader agreement for the assessment of T3cd/T4 was significantly better than that of MDCT (κ = 0.821 vs. 0.391 [P = 0.017]).

CONCLUSION

The diagnostic performance of MR imaging of the colon may be better than that of MDCT for identifying high-risk stage II or stage III cases. Particularly, colon MRI reduced the false-positive rate and improved the interreader agreement, although further studies with a larger sample size are required.

Development and Validation of a Nomogram for Preoperative Prediction of Perineural Invasion in Colorectal Cancer

Background

In colorectal cancer (CRC), perineural invasion (PNI) is usually identified histologically in biopsy or resection specimens and is considered a high-risk feature for recurrence of CRC and is an indicator for adjuvant therapy. Preoperative identification of PNI could help determine the need for adjuvant therapy and the approach to surgical resection. This study aimed to develop and validate a nomogram for the preoperative prediction of PNI in patients with CRC.

Material/Methods

A total of 664 patients with CRC from a single center were classified into a training dataset (n=468) and a validation dataset (n=196). The least absolute shrinkage and selection operator (LASSO) regression model was used to select potentially relevant features. Multivariate logistic regression analysis was used to develop the nomogram. The performance of the nomogram was assessed based on its calibration, discrimination, and clinical utility.

Results

The nomogram consisted of five clinical features and provided good calibration and discrimination in the training dataset, with an area under the curve (AUC) of 0.704 (95% CI, 0.657–0.751). Application of the nomogram in the validation cohort showed acceptable discrimination, with the AUC of 0.692 (95% CI, 0.617–0.766) and good calibration. Decision curve analysis (DCA) showed that the nomogram was clinically useful.

Conclusions

The nomogram developed in this study might allow clinicians to predict the risk of PNI in patients with CRC preoperatively. The nomogram showed favorable discrimination and calibration values, which may help optimize preoperative treatment decision-making for patients with CRC.

Chinese guidelines for the diagnosis and comprehensive treatment of colorectal liver metastases (version 2018)

The liver is the most common anatomical site for hematogenous metastases of colorectal cancer, and colorectal liver metastases is one of the most difficult and challenging points in the treatment of colorectal cancer. To improve the diagnosis and comprehensive treatment in China, the Guidelines have been edited and revised several times since 2008, including the overall evaluation, personalized treatment goals and comprehensive treatments, to prevent the occurrence of liver metastases, improve the resection rate of liver metastases and survival. The revised Guideline includes the diagnosis and follow-up, prevention, MDT effect, surgery and local ablative treatment, neoadjuvant and adjuvant therapy, and comprehensive treatment, and with advanced experience, latest results, detailed content, and strong operability.

Synthetic lethality of glutaminolysis inhibition, autophagy inactivation and asparagine depletion in colon cancer

Cancer cells reprogram metabolism to coordinate their rapid growth. They addict on glutamine metabolism for adenosine triphosphate generation and macromolecule biosynthesis. In this study, we report that glutamine deprivation retarded cell growth and induced prosurvival autophagy. Autophagy inhibition by chloroquine significantly enhanced glutamine starvation induced growth inhibition and apoptosis activation. Asparagine deprivation by L-asparaginase exacerbated growth inhibition induced by glutamine starvation and autophagy blockage. Similar to glutamine starvation, inhibition of glutamine metabolism with a chemical inhibitor currently under clinical evaluation was synthetically lethal with chloroquine and L-asparaginase, drugs approved for the treatment of malaria and leukemia, respectively. In conclusion, inhibiting glutaminolysis was synthetically lethal with autophagy inhibition and asparagine depletion. Therefore, targeting glutaminolysis could be a promising approach for colorectal cancer treatment.

Does the Site of the Primary Affect Outcomes When Ablating Colorectal Liver Metastases with Radiofrequency Ablation?

PURPOSE

To determine whether primary tumor side was a predictor of radiofrequency ablation (RFA) outcome in colorectal liver metastases (CRLM).

MATERIALS AND METHODS

The institutional review board approved this retrospective study. Written informed consent was obtained from all patients. From January 2007 to December 2013, 102 patients underwent RFA of metachronous CRLM were enrolled in this study with propensity score matching method. Recurrence rate (RR) and overall survival (OS) were analyzed between two patients cohorts with primary left-side colorectal cancer (LSCRC) or primary right-side colon cancer (RSCC).

RESULTS

The total RR was 59.8% in all patients. Patients in LSCRC cohort had lower RR and non-local recurrence (NLR) rate than those in RSCC patients' cohort (49.0 vs 70.6%, p = 0.026 and 21.6 vs 41.2%, p = 0.033). Five-year OS was 14 and 30% for RSCC and LSCRC, respectively. There was a significant difference between two cohorts in median OS (29.4 vs 40.3 months for RSCC and LSCRC, respectively, p = 0.042). Univariate analysis showed that primary tumor side, the number of liver metastases, tumor size, carcinoembryonic antigen level, differentiation, TNM stage, active chemotherapy and RFA boundary were significant in predicting OS. When these variables were subsequently entered in a multivariate model, RSCC (p < 0.001; hazard ratio [HR], 6.2) and tumor size (> 3 cm) (p = 0.006; HR, 3.9) were significant.

CONCLUSION

LSCRC and tumor size (≤ 3 cm) are independent predictors of RFA in CRLM and yield the better oncologic outcomes.

A novel approach to inoperable or recurrent rectal cancer by chemoembolization: A new arrow in our quiver?

Purpose

Assess the feasibility, safety and efficacy of TACE with irinotecan loaded micro particles (debiri) for the treatment of locally advanced rectal cancer patients.

Results

We assessed the Edmonton Symptom Assessment System (ESAS). The tool is designed to assess nine common symptoms in cancer patients: pain, tiredness, nausea, depression, anxiety, drowsiness, appetite, wellbeing and shortness of breath. The ESAS score was 7 in 10/12 (83%) patients before treatment and 6 in 2/12 (16.5%) patients. After treatment in 6/12 (50%) patients the score dropped to 3; 3/12 (33%) reported 4, 1/12 (8%) reported 2. All patients experienced local control disease with a degree of citoreduction; in 4 cases (33%) we observed outstanding responses with a dramatic reduction in the tumors size which led us to surgical radical resections.

Materials and methods

We run a prospective mono-institutional study where we recruited, 12 non- consecutive patients with histology confirmation of rectal cancer, inoperable and not treatable due to severe comorbidities, or pelvic recurrence/progression after curative treatment, chemotherapy, radiotherapy and/or surgery. Their performance status (PS) ECOG was 2-3. Twelve patients (10 male and 2 female) with a median age 71 (range 56-89) were recruited in the study.

Conclusions

The study has met the primary endpoint and showed encouraging activity. Debiri could be a possible option for locally advanced/inoperable or recurred rectal cancer patients. Further trials are warranted to validate this methodic in early stages.

Liver-directed therapy in metastatic colorectal cancer

INTRODUCTION

Colorectal cancer is a significant global health issue with over 1 million cases diagnosed annually throughout the world. 15% of patients diagnosed with colorectal cancer will have liver metastases and 60% will develop liver metastases if they have metastatic disease. Oligometastatic colorectal cancer confined to the liver represents an intermediate state in the evolution of metastatic capacity that opens the opportunity for local interventions. Areas covered: The literature supports long-term survival if patients undergo liver resection of colorectal metastases. This article reviews the liver-directed therapeutic strategies available for the management of metastatic liver disease including hepatic arterial infusion therapy, radiofrequency ablation, radiation therapy and transarterial chemoembolization. Expert commentary: Great advances have been made with the use of liver directed therapies. In the USA using hepatic arterial infusions with FUDR and Decadron along with systemic therapy, 5 year survivals after liver resection have improved. In Europe with the use of HAI of Oxaliplatin, more patients have been able to get to resection and have obtained higher survival rates, even in second line therapy. New advances in ablative therapy have improved results to get all disease treated at resection for the treatment of reccurrence.

Randomized Controlled Trial of Intraportal Chemotherapy Combined With Adjuvant Chemotherapy (mFOLFOX6) for Stage II and III Colon Cancer

OBJECTIVES

The optimal time to initiate adjuvant chemotherapy after surgery in patients with colon cancer is not clear. We investigated the benefit of combined intraportal chemotherapy administered during radical surgery with adjuvant chemotherapy for treating stage II and III colon cancer.

METHODS

Patients were randomly assigned to OCTREE arm (intraportal chemotherapy plus mFOLFOX6) or a standard adjuvant chemotherapy arm (mFOLFOX6). The primary study endpoint was disease-free survival. The secondary endpoints included metastasis-free survival, overall survival, and safety.

RESULTS

The intent-to-treat population comprised 237 patients. With a median follow-up of 44 months, the hazard ratio (OCTREE vs mFOLFOX6) was 0.66 (95% confidence interval, 0.43-0.90), a 34% risk reduction in favor of OCTREE (P = 0.016). The 3-year disease-free survival rate was 85.2% for OCTREE and 75.6% for mFOLFOX6 alone (P = 0.030). The 3-year metastasis-free survival rates were 87.6% for OCTREE and 78.0% for mFOLFOX6 (P = 0.035). Patients had lower distant metastatic rate in the OCTREE arm (12.7% vs 22.7%; P = 0.044), when compared with the mFOLFOX6 arm. The 3-year overall survival was no significant difference between 2 arms (P = 0.178). Neutropenia occurred in 12.7% of the patients receiving OCTREE and in 2.5% of the patients receiving mFOLFOX6 (P = 0.003) within 2 weeks of surgery, and grade 3 or 4 toxicity event was no difference between 2 regimens.

CONCLUSIONS

Combination of intraoperative intraportal chemotherapy with mFOLFOX6 reduced the occurrence of distant metastases and improved disease-free survival in patients with stage II and stage III colon cancer.

SFRP2 augments WNT16B signaling to promote therapeutic resistance in the damaged tumor microenvironment

Most tumors initially respond to cytotoxic treatments, but acquired resistance often follows. The tumor microenvironment (TME) is a major barrier to clinical success by compromising therapeutic efficacy, and pathological relevance of multiple soluble factors released by a therapeutically remodeled TME remains largely unexplored. Here we show that the secreted frizzled-related protein 2 (SFRP2), a Wnt pathway modulator, is produced by human primary fibroblasts after genotoxic treatments. SFRP2 induction is remarkable in tumor stroma, with transcription mainly modulated by the nuclear factor-κB (NF-κB) complex, a property shared by several effectors of the DNA damage secretory program. Instead of directly altering canonical Wnt signaling, SFRP2 augments β-catenin activities initiated by WNT16B, another soluble factor from DNA-damaged stroma. WNT16B recognizes cancer cell surface receptors including frizzled (FZD) 3/4/6, a process enhanced by SFRP2, coordinated by the co-receptor LRP6 but subject to abrogation by DKK1. Importantly, we found WNT16B plays a central role in promoting advanced malignancies particularly acquired resistance by counteracting cell death, an effect that can be minimized by a neutralizing antibody co-administered with classical chemotherapy. Furthermore, DNA damage-triggered expression of WNT16B is systemic, imaged by significant induction among diverse solid organs and circulation in peripheral blood, thereby holding promise as not only a TME-derived anticancer target but also a novel biomarker for clinical evaluation of treatment efficacy. Overall, our study substantiates the biological complexity and pathological implication of a therapy-activated TME, and provides the proof of principle of co-targeting tumor and the TME to prevent acquired resistance, with the aim of improving intervention outcome in an era of precision medicine.

A systematic review and meta-analysis to reappraise the role of adjuvant hepatic arterial infusion for colorectal cancer liver metastases

OBJECTIVE

The potential benefit of adjuvant hepatic arterial infusion remains unknown for patients with colorectal liver metastases after radical hepatic resection. The principle aim of this study was to investigate the long-term outcome of adjuvant hepatic arterial infusion.

METHODS

Eligible trials were identified from Embase, PubMed, the Web of Science, and the Cochrane library since their inception to June 1, 2014. Patients with colorectal liver metastases, who underwent radical hepatic resection and received adjuvant hepatic arterial infusion, were enrolled. The study outcomes included 5-year disease-free and overall survival rate, respectively. Hazard ratio with a 95 % confidence interval was used to measure the pooled effect according to a random effects model or fixed effects model, depending on the heterogeneity between the included studies. The statistical heterogeneity between trials was detected by I (2) test. Sensitivity analyses were also carried out.

RESULTS

A total of nine studies containing 1057 patients were included. The comparison indicated that the overall pooled hazard ratio for 5-year overall survival was 0.75 (95 % CI: 0.56-0.99, p = 0.048). The hazard ratio for 5-year disease-free survival rate was 0.61 (95 % CI: 0.48-0.79, p = 0.001). When compared with systemic chemotherapy alone, adjuvant hepatic arterial infusion plus systemic chemotherapy also improved the long-term survival.

CONCLUSIONS

Adjuvant hepatic arterial infusion improved the 5-year disease-free and overall survival rate, respectively. It should be recommended for patients with a high risk of recurrence, but these findings require prospective confirmation.

Hepatic arterial infusional chemotherapy in the management of colorectal cancer liver metastases

Colorectal liver metastases (CRLM) receive their blood supply predominantly through the hepatic artery. Intra-arterial drug delivery can optimize the dose and time exposure of chemotherapy to tumor cells while limiting systemic toxicity. Chemotherapy is most commonly administered through a catheter surgically placed in the gastroduodenal artery and connected to a subcutaneous pump. Due to its pharmacokinetics features, floxuridine is the most commonly used drug in the USA with hepatic arterial infusional (HAI) chemotherapy. To date, many clinical trials have shown the positive impact of HAI in the management of CRLM. Hence, in unresectable patients, HAI is associated with high response rates and commonly enables subsequent resection in both chemonaive and previously treated patients. Outcomes in patients converted to complete resection are similar to patients who present with initially resectable disease. In the adjuvant setting, HAI with floxuridine improves survival as well as hepatic and overall disease-free survival after complete resection of CRLM, as compared with 5-FU alone, in three of four randomized studies. To date, no trials have compared HAI combined with modern chemotherapy alone to modern chemotherapy alone in the adjuvant setting.

Inferior mesenteric artery chemoembolization and chemotherapy for advanced rectal cancer: report of a clinical case

Patients with advanced and incurable colorectal cancer have a very poor prognosis. Curative-intent resection was performed in 70%-90% of cases in reported series of colorectal cancer, sometimes after neoadjuvant chemotherapy and radiotherapy. The remaining 10%-30% of patients are treated with palliative intent, where treatment is aimed at relieving disease-related symptoms and improving quality of life. The provision of palliative care for these patients is complicated and outcomes are often disappointing. Although there are many available options including a variety of surgical and nonsurgical interventions, the best management remains controversial. Transarterial chemoembolization with irinotecan-loaded drug-eluting beads (DEBIRI) is an effective, minimally invasive procedure performed by interventional radiologists that allows intra-arterial drug delivery to stop vascular feeding and exert local cytotoxic effects. We here report on a patient treated with DEBIRI followed by systemic chemotherapy with the FOLFOX regimen for locally advanced, inoperable colorectal cancer.

Neoadjuvant chemotherapy followed by surgery versus surgery alone for colorectal cancer: meta-analysis of randomized controlled trials

Effects of neoadjuvant chemotherapy (NAC) on colorectal cancer (CRC) have been largely studied, while its survival and surgical benefits remain controversial. This study aimed to perform a meta-analysis of randomized controlled trials (RCTs), comparing efficacy and safety of NAC plus surgery with surgery alone (SA) for CRC. We searched systematically databases of MEDLINE, EMBASE, and the Cochrane Library for RCTs comparing NAC and surgery with SA for treating CRC. References of relevant articles and reviews, conference proceedings, and ongoing trial databases were also screened. Primary outcomes included overall and disease-free survivals, total and perioperative mortalities, recurrence, and metastasis. Meta-analysis was performed where possible comparing parameters using relative risks (RRs). Safely analysis was then performed. Outcomes for stages II and III tumors were also meta-analyzed, respectively. Our study was conducted according to intention-to-treat analysis. A total of 6 RCTs comparing NAC (n=1393) with SA (n=1358) published from 2002 to 2012 were identified. Compared with SA, NAC tended to reduce overall recurrences (21.86% vs 25.15%, RR: 0.70, 95% confidence interval [CI]: 0.32-1.56, P=0.09), and prevent vascular invasion (32.30% vs 43.12%, RR: 0.73, 95% CI: 0.53-1.00, P=0.05); and significantly lowered distant metastasis (15.58% vs 23.80%, RR: 0.66, 95% CI: 0.50-0.86, P=0.002), especially liver metastasis rate (13.00% vs 18.25%, RR: 0.71, 95% CI: 0.51-0.99, P=0.04), and associated with higher incidence of ypT0-2 cases upon resection (13.04% vs 6.42%, RR: 2.36, 95% CI: 1.02-5.44, P=0.04). All other parameters were comparable. NAC-related side-effects were generally mild. NAC mainly benefited patients with stage III disease. NAC could prevent recurrence and metastasis, associates with better tumor stages upon resection, and potentially impedes vascular invasion among CRC patients. NAC does not contribute to significant survival benefits for CRC, and compares favorably with SA in tumor-free resection rates, nodal status upon resection, and postsurgical complications. This level 1a evidence does not support NAC to obviously outweigh SA in terms of survival and surgical benefits for CRC currently.

Cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy improves survival for patients with peritoneal carcinomatosis from colorectal cancer: a phase II study from a Chinese center

Background

Peritoneal carcinomatosis (PC) is a difficult clinical challenge in colorectal cancer (CRC) because conventional treatment modalities could not produce significant survival benefit, which highlights the acute need for new treatment strategies. Our previous case-control study demonstrated the potential survival advantage of cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) over CRS alone. This phase II study was to further investigate the efficacy and adverse events of CRS+HIPEC for Chinese patients with CRC PC.

Methods

A total of 60 consecutive CRC PC patients underwent 63 procedures consisting of CRS+HIPEC and postoperative chemotherapy, all by a designated team focusing on this combined treatment modality. All the clinico-pathological information was systematically integrated into a prospective database. The primary end point was disease-specific overall survival (OS), and the secondary end points were perioperative safety profiles.

Results

By the most recent database update, the median follow-up was 29.9 (range 3.5–108.9) months. The peritoneal cancer index (PCI) ≤20 was in 47.0% of patients, complete cytoreductive surgery (CC0-1) was performed in 53.0% of patients. The median OS was 16.0 (95% confidence interval [CI] 12.2–19.8) months, and the 1-, 2-, 3-, and 5-year survival rates were 70.5%, 34.2%, 22.0% and 22.0%, respectively. Mortality and grades 3 to 5 morbidity rates in postoperative 30 days were 0.0% and 30.2%, respectively. Univariate analysis identified 3 parameters with significant effects on OS: PCI ≤20, CC0-1 and adjuvant chemotherapy over 6 cycles. On multivariate analysis, however, only CC0-1 and adjuvant chemotherapy ≥6 cycles were found to be independent factors for OS benefit.

Discussion

CRS+HIPEC at a specialized treatment center could improve OS for selected CRC PC patients from China, with acceptable perioperative safety.

Adjuvant treatment of hepatocellular carcinoma after orthotopic liver transplantation: do we really need this?

Hepatocellular carcinoma (HCC) continues to rise and is still a major cause of mortality. Orthotopic liver transplantation (OLT) continues to give patients the best chance for cure, but recurrence of the disease remains a problem. Even with the implementation of the Milan criteria, recurrence rates have been shown to be 8-15% in most studies and even higher in patients who are beyond the Milan criteria. Therefore, several investigators have looked into the value of adjuvant therapy using systemic cytotoxic chemotherapy in HCC after OLT. Unfortunately, most of the trials are very small, and the results have been disappointing. But trials using Licartin seem to be promising, and other drugs such as FOLFOX and sorafenib warrant further investigation based on their efficacy in the advanced disease. In this review, we will review the current data on efficacy and rationale of adjuvant treatment for HCC after OLT including novel biomarkers.

Clinical significance of and future perspectives for hepatic arterial infusion chemotherapy in patients with liver metastases from colorectal cancer

The most common site of metastases in patients with colorectal cancer is the liver. Hepatic resection is considered to be the treatment of choice for liver metastasis from colorectal cancer; however, hepatic resection can be performed in only 20 or 25% of all patients. Recurrence develops in the remnant liver or other organs after hepatic resection in over half of all patients with liver-only metastasis. Hepatic arterial infusion (HAI) chemotherapy can provide relatively high concentrations of drugs to microscopic or macroscopic metastases in the liver, with less toxicity than systemic administration. Meta-analyses have shown HAI chemotherapy to have a significantly higher response rate than systemic chemotherapy and its effect on extrahepatic metastases is negligible. HAI chemotherapy provides much better local control of liver metastases from colorectal cancer than systemic chemotherapy. However, well-controlled studies are needed to elucidate the optimal treatment strategies for neoadjuvant and postoperative adjuvant chemotherapy that optimally combine HAI chemotherapy, molecular targeted agents, and systemic chemotherapy such as FOLFOX or FOLFIRI.

Objective response and time to progression on sequential treatment with sunitinib and sorafenib in metastatic renal cell carcinoma

Patients with metastatic renal cell carcinoma (mRCC) are often treated sequentially with targeted agents, although the optimal strategy is not known. A retrospective, registry-based study has been carried out to assess correlation between clinical response and progression-free survival in patients with mRCC treated sequentially with tyrosine-kinase inhibitors (TKIs) sunitinib and sorafenib. Data on 218 mRCC patients treated with sunitinib and sorafenib who completed therapy with both TKIs were obtained from a database of mRCC patients. Standard nonparametric methods were used to assess correlation between response, PFS and length of treatment on the two agents. A strong correlation between responses to first- versus second TKI was observed (p < 0.001). No significant association was noted between the duration of therapy with the two TKIs (p = 0.056), although there was a weak statistically significant correlation between progression-free survival times in the subgroup patients who discontinued treatment because of disease progression. In conclusion, the duration of response on first TKI is of limited value in selecting mRCC patients for sequential TKI therapy. There is a strong correlation between the types of tumour response on the first- versus the second TKI.

Combination adjuvant chemotherapy with oxaliplatin, 5-fluorouracil and leucovorin after liver transplantation for hepatocellular carcinoma: a preliminary open-label study

The purpose of this study was to evaluate the efficacy of postoperative adjuvant chemotherapy with FOLFOX regimen on the outcome after LT for HCC patients who did not meet the Milan criteria. Ninety-five consecutive HCC patients with liver cirrhosis undergoing LT were enrolled. Fifty-eight who did not meet the Milan criteria were randomized to open-label treatment with or without adjuvant chemotherapy after LT (n = 29/group). The FOLFOX chemotherapy protocol comprised 3-week cycles of oxaliplatin 100 mg/m(2) on day 1, leucovorin (calcium folinate, CF) 200 mg/m(2) on day 1 followed by 3-day, and 5-fluorouracil (5-FU) 2000 mg/m(2) as a 48-h continuous infusion, for up to six courses in the 1st year after transplantation. Median survival was extended by 4.57 months by combination chemotherapy. The 1- and 3-year survival rates were 89.7% and 79.3% with chemotherapy versus 69.0% and 62.1% without chemotherapy. The cumulative 1-year survival was significantly increased by chemotherapy (log-rank test, P = 0.043). The 6-month tumor-free survival rate was 24.1% higher with chemotherapy than without. The recurrence rate after LT was significantly different between the two groups at 6 months (P = 0.036), but not at 3 years (P = 0.102). The chemotherapy regimen was generally well tolerated. Post-LT adjuvant chemotherapy with oxaliplatin/5-FU/CF could not prevent tumor recurrence post-LT but may contribute to improve the survival of HCC patients who do not meet the Milan criteria. These results should be verified in a larger sample with a longer follow-up period.

Experimentally induced liver metastases from colorectal cancer can be prevented by mononuclear phagocyte-mediated monoclonal antibody therapy

BACKGROUND & AIMS

Development of liver metastases is a frequent complication in patients with colorectal cancer (CRC), even after successful resection of the primary tumor. As such, post-operative adjuvant therapies that aim to eliminate residual disease after surgery may improve patient outcome.

METHODS

We used a colon carcinoma liver metastases model, in which CC531s colon carcinoma cells are injected into the portal circulation by a surgical procedure. As injected tumor cells are arrested in the liver, this model is suitable for investigating the interaction of tumor cells with the liver microenvironment. By administering tumor specific monoclonal antibodies (mAb) directly post-operatively, we were able to determine the effect of antibody therapy on eradication of arrested tumor cells and subsequent liver metastases outgrowth.

RESULTS

We showed that post-operative treatment with tumor specific monoclonal antibodies (mAb) prevents liver metastases outgrowth. Antibody-dependent phagocytosis (ADPh) was the main mechanism involved, as enhanced uptake of tumor cells by innate mononuclear phagocytes in the liver was observed after mAb therapy. Furthermore, Kupffer cells (KC) were identified as the most prominent effector cells, as depletion of KC abolished therapeutic efficacy. This was partly compensated by monocytes when animals were treated with a high mAb dose, but monocytes were unable to phagocytose tumor cells when rats were treated with low mAb doses.

CONCLUSIONS

The finding that KC and monocytes can eliminate tumor cells through ADPh has important and promising clinical implications for designing new adjuvant therapies for patients undergoing CRC resection.

Multi-institutional study of risk factors of liver metastasis from colorectal cancer: correlation with CD10 expression

BACKGROUND

The risk factors for liver metastasis from colorectal cancer are still unclear. We therefore evaluated the relationships between various clinicopathological factors, including CD10 expression, liver metastasis, and survival, in patients with colorectal cancer.

METHODS

Clinicopathological data for 1,025 patients with stage II or III colorectal cancer who underwent curative surgery in four participating hospitals were collected and evaluated. Three pathologists examined focal dedifferentiation, venous invasion, and CD10 expression without knowledge of the clinical outcome.

RESULTS

Univariate analysis showed that pathological T (pT), pathological N (pN), venous invasion, focal dedifferentiation, and CD10 expression were significantly associated with liver metastasis. Multivariate analysis selected pT, pN, and CD10 expression as significant risk factors for liver metastasis. pT, pN and CD10 were also shown by univariate and multivariate analyses to be significantly associated with disease-free survival. The incidence of liver metastasis was 3% in pN0 patients with CD10-negative or pT2 or pT3 tumors and 28% in pN2 patients with CD10-positive or pT4 tumors.

CONCLUSIONS

CD10 expression is a significant risk factor for liver metastasis in patients with colorectal cancer and is correlated with prognosis. Patients with a high risk of liver metastasis can be selected on the basis of pT, pN, and CD10 expression.

Immunogene therapy against colon cancer metastasis using an adenovirus vector expressing CD40 ligand

BACKGROUND

Colon cancer is one of the most common cancers worldwide, and liver metastasis is a poor prognostic factor for all types of digestive cancers, including colon cancer. We studied CD40 ligand (CD40L)-mediated immunogene therapy for metastatic liver cancer in rats.

METHODS

We studied whether in vitro infection of a rat colon cancer cell line (RCN9) with an adenoviral-vector that expresses the CD40L (AxCAmCD40L) induced CD40L expression. In vivo to confirm the antitumor effect induced by AxCAmCD40L, the tumor cells that had been transduced by AxCAmCD40L were implanted into the subcutaneous tissues of syngenic rats (prevention model) or AxCAmCD40L was injected into the tumor tissues of the rats (treatment model). Furthermore, immune cells including NK cells, cytotoxic T cells, and tumor-specific antibodies induced by AxCAmCD40L were examined.

RESULTS

Immunogene therapy using AxCAmCD40L suppressed the tumor growth strongly or reduced tumor size in the prevention model and treatment model. NK cells, cytotoxic T cells, and tumor-specific antibodies contributed to this antitumor effect in both groups.

CONCLUSION

These observations suggest that CD40L-mediated immunogene therapy for metastatic colon cancer in the liver and lungs is effective and is mediated by the activation of both the cellular and humoral immune systems.

The perioperative period is an underutilized window of therapeutic opportunity in patients with colorectal cancer

OBJECTIVE

In this review, we address the underlying mechanisms by which surgery augments metastases outgrowth and how these insights can be used to develop perioperative therapeutic strategies for prevention of tumor recurrence.

SUMMARY BACKGROUND DATA

Surgical removal of the primary tumor provides the best chance of long-term disease-free survival for patients with colorectal cancer (CRC). Unfortunately, a significant part of CRC patients will develop metastases, even after successful resection of the primary tumor. Paradoxically, it is now becoming clear that surgery itself contributes to development of both local recurrences and distant metastases.

METHODS

Data for this review were identified by searches of PubMed and references from relevant articles using the search terms "surgery," "CRC," and "metastases."

RESULTS

Surgical trauma and concomitant wound-healing processes induce local and systemic changes, including impairment of tissue integrity and production of inflammatory mediators and angiogenic factors. This can lead to immune suppression and enhanced growth or adhesion of tumor cells, all of which increase the chance of exfoliated tumor cells developing into secondary malignancies.

CONCLUSIONS

Because surgery remains the appropriate and necessary means of treatment for most CRC patients, new adjuvant therapeutic strategies that prevent tumor recurrence after surgery need to be explored since the perioperative therapeutic window of opportunity offers promising means of improving patient outcome but is unfortunately underutilized.

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.

Accomplishments in 2007 in the management of curable metastatic colorectal cancer

Overview of the Disease IncidencePrognosisCurrent Therapy Standards Colorectal Liver Metastases (CRLM) Resectable TumorsStrategies To Convert Nonresectable Liver Metastases to Resectable StatusSynchronous Colorectal Liver MetastasesPredictors of Survival After Resection of CRLMPeritoneal Carcinomatosis (PC) From Colorectal CancerColorectal Pulmonary Metastases (CRPM)Colorectal Liver Metastases With Extrahepatic DiseaseAccomplishments (or Lack of Accomplishments) During the Year Therapy New Staging SystemPreventive Measures for CRLMSystemic ChemotherapySelective Internal Radiation Therapy (SIRT)Proposed Definition of Cure From CRLMBasic ScienceWhat Needs To Be Done? Optimizing Patient CareControversies and DisagreementsFuture Directions Comments on ResearchObstacles to Progress.