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Flashcards in hepatobiliary Deck (16)

Successful resection generally requires:

preserving 2 contiguous functional liver segments
with adequate inflow, outflow, and biliary drainage


unresectable mCRC

Cases that require resection of all 3 hepatic veins, both portal veins, or the retrohepatic vena cava to achieve negative margins


Resect liver mets with unresectable diesease elsewhere?


Van Cutsem E, Cervantes A, Adam R, et al. ESMO consensus guidelines for the management of patients with metastatic colorectal cancer. Ann Oncol. 2016;27:1386-1422


Is there an established benefit to chemo after complete resection of liver CRC mets?


Khoo E, O'Neill S, Brown E, et al. Systematic review of systemic adjuvant, neoadjuvant and perioperative chemotherapy for resectable colorectal-liver metastases. HPB (Oxford). 2016;18:485-493


phase 2 CELIM trial

first-line cetuximab with FOLFOX or FOLFIRI in 111 patients with unresectable CRLM.

objective response rate (ORR) was 66%, and 36 patients (34%) were able to ultimately undergo complete resection of liver metastase


The phase 2 OLIVIA trial

Overall tumor response rates were 81% and 62%, respectively, in the bevacizumab/FOLFOXIRI and bevacizumab/mFOLFOX-6 groups; complete resection rates were 49% and 23%, respectively. Toxicity was high, however, with 95% of patients in the bevacizumab/FOLFOXIRI group and 84% in the bevacizumab/mFOLFOX-6 group


Collision trial

The ongoing prospective, randomized, phase 3 COLLISION trial is comparing surgery versus thermal ablation (RFA or MWA) in 618 patients with CRLM and at least 1 target lesion measuring 3 cm or less; the primary endpoint is OS


Indications for radioembolization for liver CRC

Radioembolization is recommended for patients with bulky and/or bilobar liver metastases who are not candidates for resection or ablation


outcomes for radioembolization for liver CRC

It is associated with improved hepatic response and prolonged PFS, but it does not appear to extend survival.


toxicity for radioembolization for liver CRC



Technical aspects of hepatic artery infusion

The HAI delivery system involves a pump implanted within the abdominal wall and a catheter introduced through the gastroduodenal artery.[21] The pump is tested to verify the absence of extrahepatic perfusion prior to treatment.[21]


The phase 3 CALGB 9481 trial

only randomized head-to-head comparison to date of HAI chemotherapy (alone) versus systemic chemotherapy in unresectable CRLM.


Outcomes in CALGB 9481

Compared with systemic chemotherapy, HAI-delivered chemotherapy significantly improved OS, ORR, and time to hepatic progression.


Flaw, or problem with CALBG 9481

Time to extrahepatic progression, was significantly shorter following HAI. Now given concurrently with systemic chemo.


Complications of hepatic artery infusion

MSKCC data: (22%) experienced 1 or more pump-related complications. Approximately one-half of complications involved the hepatic arterial system, most commonly arterial thrombosis (n = 33), extrahepatic perfusion (n = 16), and incomplete hepatic perfusion (n = 12). A significant fraction occur late and a significant fraction are salvageable.


most clinically significant complication of hepatic artery infusion:

In the adjuvant HAI cohort, biliary sclerosis was associated with abnormal postoperative flow scans, postoperative infectious complications, and larger doses of FUDR per cycle. No cases of biliary sclerosis were directly fatal, and the complication did not adversely affect survival. The median survival for those without and with biliary sclerosis was 47.2 months and 61.0 months, respectively (P = .316)