Flashcards in hepatobiliary Deck (16)
Successful resection generally requires:
preserving 2 contiguous functional liver segments
with adequate inflow, outflow, and biliary drainage
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
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. The pump is tested to verify the absence of extrahepatic perfusion prior to treatment.
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.