Local Therapy For Colorectal Liver Metastases

By Isabella Martire, MD, Board Certified In Oncology

Isabella C. Martire, MD, AC

. https://www.isabellamartire-md.com/

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Local Therapy For Colorectal Liver Metastases

Surgery, radiofrequency and microwave ablation, radioembolization, hepatic artery infusion therapy are some of the options available for metastatic colorectal cancer to the liver. Surgery is appropriate for patients with isolated liver metastasis and it is curative in 20% of the cases. Adjuvant chemotherapy after complete resection has not shown improvement in overall survival.

Chemotherapy can be used in the preoperative stage as neoadjuvant to render unresectable disease to resectable. Preoperative cetuximab with FOLFOX or FOLFIRI was able to render 34% of the patients enrolled in the CELIM trial to undergo complete resection of their liver metastasis and with FOLFOX/bevacizumab the complete resection rate was 49%.

Radiofrequency and microwave ablation are an option for patients with liver metastasis who are poor surgical candidates or post resection recurrence. The procedure is very successful, disease-free survival is 26 months and overall survival 36 months according to the Sloan-Kettering cancer center data. Results are better if tumor size is < 3 centimeters.

Radioembolization is for bulky disease and Yttrium-90 has low toxicity.

With hepatic artery infusion therapy the chemotherapy is injected directly in the hepatic artery giving higher local concentration of the drug while sparing normal hepatocytes. Floxuridine is the drug of choice because short half-life and high hepatic clearance.

Hepatic arterial infusion showed improved response rate and overall survival compared to systemic chemotherapy. Extrahepatic progression occurred earlier with hepatic arterial infusion compared with system chemotherapy. Side effects like diarrhea, stomatitis and neutropenia were higher with systemic chemotherapy.

Hepatic arterial infusion and systemic chemotherapy have been combined to downstage a patient to complete resection. With the combined modality 47% of patients were converted to complete resection with improved overall survival and disease-free survival. Conversion to resection resulted in a 63% rate of five-year survival.

Adjuvant hepatic arterial infusion plus systemic chemotherapy improves disease free survival and overall survival as well with a median overall survival of 72 months. Hepatic artery infusion complications are related to the pump, arterial thromboses, extrahepatic perfusion, hemorrhage, infection, catheter occlusion. Liver directed therapies have improved outcomes in metastatic colorectal cancer.