Colorectal liver metastases – when surgery isn’t an option

The authors provided information on 4 different types of treatment for patients with colorectal cancer and liver metastases.

The liver is the most common site of metastasis (cancer spread) and disease recurrence (return) in colorectal cancer. Only 20-25% of patients with colorectal cancer liver metastases are suitable for surgical removal of the metastases at diagnosis. Locoregional therapy typically refers to administration of drugs or chemicals to the tumor, and this type of therapy is increasingly being used to make metastatic tumors more suitable for surgery. 

The authors aimed to review various locoregional therapies for liver metastases from colorectal cancer.

Hepatic Arterial Infusion Chemotherapy (HAIC): This describes a form of chemotherapy whereby a thin flexible tube is placed into the hepatic artery (the main artery of the liver), directly delivering chemotherapy drugs (such as floxuridine) to the liver. In a major study, HAIC using floxuridine was found to improve overall survival to 24.4 months compared to 20 months using traditional whole-body therapy with 5-flurouracil plus leucovorin. The time until disease progression was 9.8 months for HAIC compared to 7.3 months for whole-body therapy, but the progression of cancer to different organs was shorter in HAIC (7.7 months) compared to system-wide therapy (14.8 months).

In a review of 4,580 cases of liver metastases treated with HAIC using floxuridine and 5-fluroracil, gastrointestinal symptoms such as heartburn, indigestion, bloating and constipation (25%) and inflammation of the liver (22%) were found to be the most common treatment-related symptoms.

Conventional Trans-Arterial Chemoembolization (cTACE): This treatment consists of the administration of chemotherapeutic drugs followed by an agent that causes the blockage of blood vessels. When administered through the hepatic artery it increases the concentration of drug in the liver and reduces whole-body side effects. To date, the largest trial using cTACE evaluated the combination of mitomycin C (Mitozytrex) combined with gemcitabine (Gemzar) or irinonotecan (Campto) and was associated with a 1-year survival rate of 68% and a 2-year survival rate of 28%.

Post-embolization syndrome (fever, nausea, vomiting and pain) has been found to occur in about 67% of patients undergoing cTACE.

Drug-Eluting Bead Trans-Arterial Chemotherapy Embolization (DEB-TACE): This therapy involves the administration of tiny beads that contain chemotherapy drugs (typically irinotecan) through the hepatic artery. The beads become lodged between the tumor and normal tissue, allowing slow and controlled release of the drug to the tumor. In a study of 55 patients who were previously treated with several types of system-wide therapy, DEB-TACE using irinotecan was associated with a 1-year survival rate of 75% with an average survival time of 19 months and time without disease progression of 11 months. 7% of patients became suitable for surgery.

Approximately 30% of patients undergoing DEB-TACE with irinotecan will develop adverse complications, with the most commonly reported being abdominal pain, followed by vomiting, lack of energy and fever.

Radioembolization: This treatment involves delivering radioactive particles (typically Yttrium-90) to the tumor through the bloodstream. The particles lodge in the tumor and emit radiation that kills cancer cells. It is mostly used where alternatives have failed. In a study of 43 patients being treated with radioembolization, the average overall survival was 13.6 months, while 81% of patients showed a measurable response or stable disease (disease that gets neither better nor worse). Higher tumor response and longer survival times were associated with higher doses of Yttrium-90.

Post-embolization syndrome (fever, nausea, vomiting and pain) can occur in up to 50% of patients within 2 weeks of the procedure, but this is typically milder than with cTACE.

The authors provided an overview of locoregional therapies for liver metastases from colorectal cancer, and suggested that larger trials are needed to examine the effectiveness and safety of these treatments.

You should discuss these novel treatment options with your doctor.