Combined Systemic and Hepatic Artery Infusion Pump Chemo-Therapy as a Liver-Directed Therapy for Colorectal Liver Metastasis-Review of Literature and Case Discussion

Abstract

Colorectal cancer (CRC) is the third most prevalent malignancy and the second most common cause of death in the US. Liver is the most common site of colorectal metastases. About 13% of patients with colorectal cancer have liver metastasis on initial presentation and 50% develop them during the disease course. Although systemic chemotherapy and immunotherapy are the mainstay treatment for patients with metastatic disease, for selected patients with predominant liver metastasis, liver-directed approaches may provide prolonged disease control when combined with systemic treatments. Hepatic artery infusion pump (HAIP) chemotherapy is an approach which allows direct infusion of chemotherapeutic into the liver and is especially useful in the setting of multifocal liver metastases. When combined with systemic chemotherapy, HAIP improves the response rate, provides more durable disease control, and in some patients leads to successful resection. To ensure safety, use of HAIP requires multidisciplinary collaboration between interventional radiologists, medical oncologists, hepatobiliary surgeons and treatment nurses. Here, we review the benefits and potential risks with this approach and provide our single institution experience on two CRC patients successfully treated with HAIP in combination with systemic chemotherapy. We provide our recommendations in adopting this technique in the current era for patient with colorectal liver metastases.

Keywords: FUDR; HAIP; colorectal cancer; liver metastasis.

Figure 1

Serial imaging studies of two representative cases treated with systemic and HAIP chemotherapy. (A–D) Serial CT images of Case 1. The patient initially presented with metastatic sigmoid colon cancer with bulky disease burden in the liver (A). After prolonged treatment with systemic FOLFIRI and panitumumab which led to good treatment response (B), she subsequently underwent surgical resection of the primary colon cancer and liver lesions and placement of HAIP. (C) CT scans after completion of systemic and HAIP chemotherapy showed post-surgical changes (arrows) which remain unchanged over the following three years (D) despite extrahepatic recurrence. (E–G) Serial imaging of Case 2. (E) Initial MRI showing multiple lesions in Case 2 who had just undergone sigmoid colectomy. The patient was treated with 4 cycles of chemotherapy followed by left liver resection, ablation of liver lesions and placement of HAIP. (F) CT after completion of adjuvant systemic and HAIP chemotherapy showed post-surgical changes which remain stable over the following five years (G).