Hepatic artery chemotherapy for colorectal liver metastases

Recurrence and Survival Outcomes after Hepatic Resection with or without Cryotherapy for Liver Metastases from Colorectal Carcinoma

BACKGROUND

Some reports support resection combined with cryotherapy for patients with multiple bilobar colorectal liver metastases (CRLM) that would otherwise be ineligible for curative treatments. This series demonstrates long-term results of 415 patients with CRLM who underwent resection with or without cryotherapy.

METHODS

Between April 1990 and January 2006, 291 patients were treated with resection only and 124 patients with combined resection and cryotherapy. Recurrence and survival outcomes were compared. Kaplan-Meier and Cox-regression analyses were used to identify significant prognostic indicators for survival.

RESULTS

Median length of follow-up was 25 months (range 1-124 months). The 30-day perioperative mortality rate was 3.1%. Overall median survival was 32 months (range 1-124 months), with 1-, 3- and 5-year survival values of 85%, 45% and 29%, respectively. The overall recurrence rates were 66% and 78% for resection and resection/cryotherapy groups, respectively. For the resection group, the median survival was 34 months, with 1-, 3- and 5- year survival values of 88%, 47% and 32%, respectively. The median survival for the resection/cryotherapy group was 29 months, with 1-, 3- and 5-year survival values of 84%, 43% and 24%, respectively (P = 0.206). Five factors were independently associated with an improved survival: absence of extrahepatic disease at diagnosis, well- or moderately-differentiated colorectal cancer, largest lesion size being 4 cm or less, a postoperative CEA of 5 ng/ml or less and absence of liver recurrence.

CONCLUSIONS

Long-term survival results of resection combined with cryotherapy for multiple bilobar CRLM are comparable to that of resection alone in selected patients.

Lung metastases after liver resection or cryotherapy for hepatic metastasis from colorectal cancer--there is a difference!

BACKGROUND

The most common site of colorectal extra-abdominal metastases is the lung. The relative risk of lung metastases after resection and cryotherapy has not previously been compared.

METHODS

All patients underwent an extensive preoperative staging including clinical examination, abdominal computed tomography (CT) and abdominal angio-CT to assess their hepatic disease. Two groups of patients were compared in this study (hepatic resection alone and hepatic cryotherapy with or without resection). A retrospective analysis of prospectively collected data was performed to assess the incidence and disease-free interval of pulmonary metastasis after surgical treatment of colorectal liver metastasis.

RESULTS

This paper clearly shows two differences regarding pulmonary metastases between patients treated with resection only and cryotherapy with or without resection. Among the 10 clinical variables, cryotherapy had the greatest correlation with pulmonary metastases (p=0.004). A patient who undergoes hepatic resection only has a probability of 35% for developing pulmonary recurrence, compared with 51% following cryotherapy. Cryotherapy was also independently associated with shorter pulmonary disease-free interval (p=0.036).

CONCLUSION

There clearly is a higher risk of pulmonary metastasis after cryotherapy than after resection, whether this is related to selection of patients or a direct deleterious procedural effect requires more study.

Longterm Results and Prognostic Indicators after Cryotherapy and Hepatic Arterial Chemotherapy With or Without Resection for Colorectal Liver Metastases in 224 Patients: Longterm Survival Can Be Achieved in Patients With Multiple Bilateral Liver Metastases

BACKGROUND

Only a minority of patients are suitable for liver resection for colorectal liver metastases. Cryotherapy was the first widely used ablative technique, achieving a median survival of more than 2 years. Patient selection is important, but the prognostic criteria have been controversial. The combined treatment modality of cryotherapy, resection, and hepatic arterial chemotherapy has been used in treating unresectable liver disease. Many centers would not surgically treat patients with multiple (five or more lesions) bilateral liver metastases. This series reports on longterm results after cryotherapy and hepatic arterial chemotherapy with or without liver resection in 224 patients with colorectal liver metastases, especially in patients with multiple bilateral liver disease, and identifies important prognostic determinants for survival.

STUDY DESIGN

A longterm retrospective analysis was performed of prospectively collected clinical data of 224 patients with colorectal liver metastases who received cryotherapy and hepatic arterial chemotherapy with or without resection. Morbidity, mortality, recurrence, and survival rates were reported and Kaplan-Meier and Cox regression analysis were used to identify prognostic indicators.

RESULTS

Median length of followup was 26 months (range 1 to 130 months). Perioperative mortality rate was 0.4% and morbidity rate was 21%. Cryosite, remaining liver, and extrahepatic recurrence rates were 39%, 62%, and 67%, respectively. Median survival was 31 months (range 1 to 130 months) with 1-, 3-, and 5-year survival rates of 87%, 43%, and 23%, respectively. Ninety-one patients had five or more bilateral lesions. Median and 5-year survival was 31 months (2 to 88 months) and 26%, respectively. Four factors were independently associated with favorable survival outcomes: cryotherapy with resection, complete tumor eradication, low pre- and postoperative CEA levels.

CONCLUSIONS

Cryotherapy and hepatic arterial chemotherapy with or without resection can achieve long survival advantage in patients with unresectable colorectal liver metastases.

Hepatic cryotherapy and regional chemotherapy with or without resection for liver metastases from colorectal carcinoma: how many are too many?

BACKGROUND

The number of hepatic metastases for which resection or ablation is appropriate remains controversial.

METHODS

A retrospective analysis was performed of prospectively collected data from patients with liver metastases from colorectal carcinoma who underwent hepatic cryotherapy and hepatic arterial chemotherapy (HAC) with or without undergoing resection. Patients routinely had preoperative bone scans, chest computed tomography (CT) scans, and abdominal angio-CT scans. Positron emission tomography scans were unavailable. All patients were followed until June 2002 or until death occurred. Kaplan-Meier and Cox regression methods were used to evaluate the impact of 17 potentially prognostic factors on survival.

RESULTS

One hundred seventy-two patients who underwent hepatic cryotherapy and HAC with or without undergoing liver resection for in situ eradication of metastases formed the basis of this report. One patient (0.6%) died postoperatively from myocardial infarction. The morbidity rate was 27.9%. The median survival was 28 months (range, 0-98 months). The factors age < or = 50 years, well-differentiated or moderately differentiated primary tumor, small cryolesions (<3.5 cm), complete eradication of extrahepatic metastases at cryotherapy, and low preoperative carcinoembryonic antigen (CEA) levels were associated independently with a favorable outcome. In addition, a univariate analysis showed that the absence of untreated extrahepatic disease at laparotomy, postoperative CEA normalization, and a large decline in CEA levels were significant statistically. The number of lesions was not prognostic. One hundred forty-six patients (84.9%) who underwent a complete operation had 1-year, 2-year, 3-year, 4-year, and 5-year survival rates of 89%, 65%, 41%, 24%, and 19%, respectively. The median survival of patients with 1 metastasis, 2 metastases, 3 metastases, 4 metastases, 5 metastases, 6 or 7 metastases, and 8-12 metastases were 32 months, 29 months, 30 months, 31 months, 27 months, 37 months, and 21 months, respectively (P=0.7859). Twenty-five patients had 6 or 7 lesions, and their 5-year survival rate was 25%.

CONCLUSIONS

When all colorectal hepatic lesions were eradicated, the numbers of hepatic metastases were not prognostic of survival in patients with liver metastases from colorectal carcinoma.

Hepatic artery access ports: recognizing and avoiding the problems

BACKGROUND

Regional approaches to the management of hepatic tumours are appropriate in some clinical situations and include hepatic arterial chemotherapy (HAC) and selective internal radiation therapy (SIRT). Both require access to the hepatic artery, which is conveniently achieved with a subcutaneously placed port. Placement and use of these ports may be associated with a variety of technical problems which can impact adversely on the outcome of the treatment. The present paper outlines the problems related to port usage for regional hepatic therapies, with emphasis on the technical aspects of insertion and interpretation and management of subsequent problems.

METHODS

Hepatic artery port placement was attempted in 129 patients for use with either SIRT and/or HAC. Ports were used or flushed at monthly intervals.

RESULTS

Successful port insertion was achieved in 127 patients, of whom 87 received HAC alone, seven received SIRT alone, 28 patients received both and in five patients the port was never used. Methylene blue injection was used to identify anomalous arterial anatomy, which was found in 26 of 95 patients (27%), and significant extrahepatic 'access', which was seen in 25 patients (26%) after initial placement. Forty-six instances of technical problems preventing continued use of the port occurred in 43 patients after a median of 4 (0-36) cycles of chemotherapy, including hepatic artery thrombosis (n = 26), catheter blockage (n = 4), duodenal fistula (n = 3), gastrointestinal (GI) bleeding (n = 3), side-effects (n = 3), access problems (n = 3), extravasation (n = 3) and infection (n = 1).

CONCLUSION

Methods used to identify, manage and in some instances prevent the occurrence of these problems are discussed.

Patterns of serum CEA fall after hepatic arterial chemotherapy as sole therapy and combined with cryotherapy for colorectal metastases

BACKGROUND

Hepatic artery chemotherapy (HAC) and cryoablation are treatments for unresectable liver metastases from colorectal carcinomas. Our centre has previously published data that describe survival statistics of patients after each of these treatments. It has also been established that serial serum carcinoembryonic antigen (CEA) concentrations may be used to monitor disease progress, and that the magnitude of fall is prognostic for both treatments. The pattern of fall of CEA following cryotherapy and regional chemotherapy has not previously been compared.

METHODS

In this study, we examined 26 HAC patients and 24 cryotherapy patients.

RESULTS

The mean percentage of the pre-treatment CEA concentration for the HAC group was 60.5% at 50 days and 29.4% at 150 days, and for the cryotherapy group 24.9% at 50 days and 24.3% at 150 days. Calculating the difference between means revealed a significantly different mean fall in the cryotherapy group at 50 days (P < 0.001) and a difference in mean fall at 150 days (P > 0.1) which was not significant. In patients who responded to hepatic artery chemotherapy, the eventual CEA fall was very similar in magnitude.

CONCLUSIONS

The pattern of fall of CEA differs in these two treatments.

Fluorodeoxyuridine causes bilomas after hepatic cryotherapy

BACKGROUND AND OBJECTIVES

Hepatic cryotherapy is a method of in situ cytodestruction used for unresectable liver tumours that can be combined with regional cytotoxic administration. We have used intra-arterial chemotherapy with 5-fluorouracil (5-FU) after hepatic cryotherapy but changed to 5-fluorodeoxyuridine (FUDR) because of the arterial toxicity of 5-FU. A new complication was seen.

METHODS

A retrospective case note study was performed of 130 patients who had undergone hepatic cryotherapy followed by regional chemotherapy at our centre. Seven patients received FUDR; 123 received 5-FU.

RESULTS

Biloma at the cryotherapy sites was seen in three patients in the FUDR group; two other patients in this group had other types of hepatic collection. Our previous experience with intra-arterial 5-FU in 123 patients after hepatic cryotherapy showed no evidence of this syndrome.

CONCLUSIONS

Intra-arterial FUDR should not be used after hepatic cryotherapy, at least during the immediate postoperative period.

Radiologically placed hepatic artery catheter allows selection of patients with high-volume liver metastases for regional chemotherapy

Regional chemotherapy has achieved high response rates in hepatic metastases from colorectal cancer and has been shown to improve survival significantly. The present paper reports the use of pre-operative regional therapy to establish marker response as a means of selection of patients for surgery. Fourteen patients underwent radiologically placed hepatic artery catheter (HAC) for chemotherapy. In the 11 patients with carcino-embryonic antigen (CEA) fall the patient proceeded to open surgical placement of HAC. The predictive effect of CEA fall following radiological HAC was good. Non-responding patients are clearly spared the discomfort and inconvenience and costs of an unnecessary operation.

Anesthetic considerations for hepatic cryotherapy

The evolution of hepatic cryotherapy as an accepted treatment for patients with non-resectable hepatic malignancy has required concurrent evaluation and development of perioperative anesthetic management of these cases. Review of published and institutional experience demonstrates that hepatic cryotherapy presents the anesthesiologist with an array of challenges, all of which are not intuitively apparent. Specifically, such issues as management of coexisting physiologic perturbations of the oncology patient, heat conservation during the procedure, and readiness for a more extensive procedure would be readily anticipated by most clinicians. Description and reasonable management of problems ranging from mild or moderate postoperative thrombocytopenia to the so-called cryoshock syndrome with the possibility of severe postoperative coagulopathy, renal dysfunction, and pulmonary complications, however, could emerge only with the education of experience. The goal of this article is to address the key issues faced by anesthesiologists consulted in the perioperative care of patients undergoing hepatic cryotherapy.

Multiple bilobar liver metastases: cryotherapy for residual lesions after liver resection

BACKGROUND AND OBJECTIVES

Most patients with colorectal liver metastases are not eligible for resection because they have multiple lesions or because of anatomical constraints. We report the use of cryotherapy to destroy residual metastases following liver resection in patients with disease too widespread for treatment by resection alone.

METHODS

Twenty patients with bilobar disease confined to the liver (median 3; range 2-8 lesions) were treated in this way. Seventeen patients also received regional chemotherapy postoperatively.

RESULTS

Morbidity was high, but there were no procedure-related deaths and only one patient's hospital stay exceeded 24 days. Significant destruction of tumor, as evidenced by a decline in CEA levels, occurred within 3 months of surgery in all patients (P < 0.001). Median duration of follow-up was 15 (6-53) months. Survival rates at 1 and 2 years were 88% and 60%, respectively, and median survival was 32 months. Seven patients remain well and seven are alive with recurrent liver and/or other metastases.

CONCLUSIONS

Although this is not a control study, it would appear that some patients with irresectable liver metastases benefit from this multimodality approach.

Previous intravenous chemotherapy does not alter response rate or survival time of patients with hepatic metastases from colorectal cancer treated by hepatic artery chemotherapy

BACKGROUND

The present paper addressed the issue of whether pretreatment with intravenous (i.v.) chemotherapy affects response rate or survival in patients receiving hepatic artery chemotherapy (HAC).

METHODS

Case note reviews of 164 patients treated in a teaching hospital from June 1990 to July 1996 were carried out.

RESULTS

The response rate and carcino-embryonic antigen (CEA) fall in the two groups was almost identical. There was a nonsignificant survival advantage in the non-pretreatment group.

CONCLUSIONS

Previous administration of i.v. chemotherapy did not affect the CEA response of patients receiving HAC.

Major upper gastrointestinal haemorrhage associated with hepatic arterial chemoperfusion

BACKGROUND

The present study reviews the nature of upper gastrointestinal complications of hepatic arterial chemoperfusion at a tertiary referral centre for the treatment of hepatic malignancy.

METHODS

The patients involved in the present study all had major upper gastrointestinal (GI) haemorrhage and were undergoing hepatic arterial chemoperfusion.

RESULTS

Eight patients had major upper GI haemorrhage. Three of these patients were not referred for surgical management, and all three patients died. The five patients who were admitted or transferred to our unit and who underwent surgery all survived.

CONCLUSIONS

These complications are probably caused by extravasation of 5-fluorouracil (5-FU) following thrombosis of the gastroduodenal artery. The resulting cavity may perforate into the hepatic artery, portal vein, duodenum or biliary tree. Surgeons and oncologists should be aware of these complications. If upper abdominal pain occurs, chemoperfusion should cease immediately and an urgent investigation, which may include catheter angiography, gastroscopy and computed tomography (CT) scanning, should be carried out to exclude an hepatic artery pseudo-aneurysm.

Primary resection and synchronous regional hepatic chemotherapy or cryotherapy for colorectal cancer with liver metastases

Twenty-two patients with colorectal cancer and synchronous unresectable hepatic metastases were treated by resection the primary tumour with concurrent insertion of an Infusaid infusaport system for regional chemoperfusion (hepatic arterial 20, portal venous 2). Four patients in addition had cryotherapy the liver metastases. Morbidity from the synchronous procedures was minimal. Median survival was 10 months. Four patients with poorly-differentiated tumours had a poor response, with a median survival of 3.75 months.