Abstract
Despite significant improvements in systemic therapy for patients with colorectal liver metastases (crlms), response rates in the first-line setting are not optimal, and response rates in the second-line setting remain disappointing. Hepatic arterial infusion pump (haip) chemotherapy has been extensively studied in patients with crlms, but it remains infrequently used. We convened an expert panel to discuss the role of haip in the contemporary management of patients with crlm. Using a consensus process, we developed these statements: haip chemotherapy should be given in combination with systemic chemotherapy.haip chemotherapy should be offered in the context of a multidisciplinary program that includes expertise in hepatobiliary surgery, medical oncology, interventional radiology, nursing, and nuclear medicine.haip chemotherapy in combination with systemic therapy should be considered in patients with unresectable crlms who have progressed on first-line systemic treatment. In addition, haip chemotherapy is acceptable as first-line treatment in patients with unresectable colorectal liver metastases.haip chemotherapy is not recommended in the setting of extrahepatic disease outside the context of a clinical trial.haip chemotherapy in combination with systemic therapy is an option for select patients with resected colorectal liver metastases. These consensus statements provide a framework that clinicians who treat patients with crlm can use when considering treatment with haip.
Highlights
Over the past several years, important progress has been made in the treatment of patients with metastatic colorectal cancer
In patients with initially unresectable colorectal liver metastases, systemic therapy can, in up to 30% of patients, produce a tumour response sufficient to allow for resection and the possibility of long-term survival or cure[12,13]
The response rate to systemic therapy is good in untreated patients, response rates to chemotherapy in the second-line setting remain disappointing
Summary
Over the past several years, important progress has been made in the treatment of patients with metastatic colorectal cancer. In patients with initially unresectable colorectal liver metastases (crlms), systemic therapy can, in up to 30% of patients, produce a tumour response sufficient to allow for resection and the possibility of long-term survival or cure[12,13]. Given the limited efficacy of systemic therapy beyond the first-line setting, patients could benefit from other treatments that would increase response and resectability rates. The administration of chemotherapy directly to the hepatic artery allows for more selective treatment, increasing the delivery of certain cytotoxic agents to the tumour while minimizing systemic side effects. First-pass extraction in the liver improves the delivery of most agents, the pharmacokinetic characteristics of floxuridine (fudr)—short half-life, 95% first-pass extraction rate, and an increase in tumour exposure by a factor of 400 compared with systemic administration20—make it optimal for the haip technique. Given the complexities of interpreting the data and the desire for more effective therapy for patients with unresectable crlms, we convened an expert panel to discuss the role of haip in the contemporary management of patients with crlms
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