Abstract
Aggressive treatment of colorectal cancer (crc) liver metastases can yield long-term survival and cure. Unfortunately, most patients present with technically unresectable metastases; conventional therapy in such patients consists of systemic therapy. Despite advances in the effectiveness of systemic therapy in the first-line setting, the tumour response rate and median survival remain low in the second-line setting. The preferential blood supply from the hepatic artery to crc liver metastases allows for excellent regional delivery of chemotherapy. Here, we review efficacy and safety data for hepatic artery infusion (hai) pump chemotherapy in patients with metastatic crc from the 5-fluorouracil era and from the era of modern chemotherapy. In selected patients with liver-only or liver-dominant disease who have progressed on first-line chemotherapy, hai combined with systemic agents is a viable therapeutic option when performed at experienced centres. Furthermore, significantly improved survival has been demonstrated with adjuvant hai therapy after liver resection in the phase iii setting. The complication rates and local toxicities associated with hai pump therapy are infrequent at experienced centres and can be managed with careful follow-up and early intervention. The major obstacles to the wide adoption of hai therapy include technical expertise for pump insertion and maintenance, and for floxuridine dose modification. The creation of formal preceptor-focused education and training in hai therapy for interdisciplinary medical professionals might encourage the creation and expansion of this liver-directed approach.
Highlights
Colorectal cancer is the third leading cause of cancer death in Canada[1]
Significantly improved survival has been demonstrated with adjuvant hai therapy after liver resection in the phase iii setting
All of the studies included in the meta-analysis by Mocellin et al used hai alone, without concurrent administration of systemic chemotherapy, because all of the studies were conducted before approval of irinotecan and oxaliplatin
Summary
Colorectal cancer (crc) is the third leading cause of cancer death in Canada[1]. Despite the implementation of crc screening programs, the public health burden of crc remains significant. Surgical resection of liver metastases can lead to long-term disease-free survival, but only a small proportion of patients have disease amenable to resection. Recognition of differences in the blood supply to metastases compared with that to normal liver parenchyma has allowed for the development of hepatic arterial delivery of systemic chemotherapeutic agents. Studies of hepatic arterial infusion (hai) pump therapy demonstrated significant tumour response rates, with encouraging survival data, at a time when systemic therapy was associated with tumour response rates of less than 20%, and median overall survival was limited to less than 18 months. Since the end of the 1990s, significant progress has been made with a number of chemotherapeutic and biologic agents approved for the treatment of metastatic crc, and median overall survival is reaching up to 24 months[4] in patients with liver-limited metastasis. KO and KARANICOLAS for the terms “hepatic artery infusion pump,” “hai,” and “colorectal cancer.” Relevant studies were reviewed by both authors
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