Unresectable Liver Metastases from Colorectal Cancer and Hepatic Arterial Infusion Chemotherapy: How, When and to Whom?

Abstract

We have read with great interest the article by Iguchi et al. [1], reporting their experiences with hepatic arterial infusion (HAI) of 5-fluorouracil (5FU) through a port-catheter in patients with inoperable liver metastases of colorectal cancer. On the one hand, HAI has been evaluated in liver metastases of colorectal origin in three meta-analyses [2– 4]. In all of them, a superior response rate in the experimental arm, favoring HAI, was observed. On the other hand, fluoropyrimidine HAI did not improve survival compared with systemic chemotherapy regimens based exclusively on fluoropirymidines. To our knowledge, randomized studies comparing HAI (alone or plus systemic chemotherapy) and conventional standard chemotherapy such as FOLFIRI (5FU plus Irinotecan) or FOLFOX (5FU plus Oxaliplatin) have not been published. Please note that in the referenced article FOLFIRI and FOLFOX regimens were misspelled (FORFOX and FOLFILI, respectively). In patients with initially unresectable metastases solely in the liver, maximizing the response rate in an attempt to render patients resectable is the holy grail for every oncologist [5] hoping to impact patients’ survival [6]. In this sense, HAI using a port-catheter system could be an interesting approach for the treatment of patients with preoperative intent. In fact, it permits the use of active drugs like floxuridine (FUDR) [7, 8], oxaliplatin [9, 10], and 5FU. Moreover, an ambulatory treatment option is possible thanks to the use of implantable intra-arterial devices. Interestingly enough, Iguchi et al. [1] did not find severe complications during or after HAI, unlike the treatment-related toxicities shown with older HAI regimens, which included chemical hepatitis, biliary sclerosis, and peptic ulceration or pump-related complications such as hepatic artery thrombosis, catheter displacement, hematomas, infections, and liver perfusion [11, 12]. Perhaps this treatment administration system will allow us to develop more reliable randomized clinical trials and offer a new opportunity to show the impact of HAI-based protocols on survival, especially in patients with potentially resectable liver metastases from colorectal cancer.