Liver Assessment in Women Receiving Adjuvant CMF Chemotherapy

Patterns of chemotherapy-induced hepatic injury and their implications for patients undergoing liver resection for colorectal liver metastases

BACKGROUND AND AIMS

Neoadjuvant chemotherapy is increasingly being used to enlarge the cohort of patients who can be offered hepatic resection for malignancy. However, the impact of these agents on the liver parenchyma itself, and their effects on clinical outcomes following hepatic resection remain unclear. This review identifies patterns of regimen-specific chemotherapy-induced hepatic injury and assesses their impact on outcomes following hepatic resection for colorectal liver metastases (CLM).

METHODS

An electronic search was performed using the MEDLINE (US Library of Congress) database from 1966 to May 2007 to identify relevant articles related to chemotherapy-induced hepatic injury and subsequent outcome following hepatic resection.

RESULTS

The use of the combination of 5-flourouracil and leucovorin is linked to the development of hepatic steatosis, and translates into increased postoperative infection rates. A form of non-alcoholic steatohepatitis (NASH) related to chemotherapy and otherwise known as chemotherapy-associated steatohepatitis (CASH) is closely linked to irinotecan-based therapy and is associated with inferior outcomes following hepatic surgery mainly due to hepatic insufficiency and poor regeneration. Data on sinusoidal obstruction syndrome (SOS) following treatment with oxaliplatin are less convincing, but there appears to be an increased risk for intra-operative bleeding and decreased hepatic reserve associated with the presence of SOS. Intra-arterial floxuridine therapy damages the extrahepatic biliary tree in addition to causing parenchymal liver damage, and has been shown to be associated with increased morbidity after hepatic resection.

CONCLUSION

Agent-specific patterns of damage are now being recognized with increasing use of neoadjuvant chemotherapy prior to surgery. The potential benefits and risks of these should be considered on an individual patient basis prior to hepatic resection.

Cirrhosis-like radiological pattern in patients with breast cancer

INTRODUCTION

Hepatic toxicity of breast cancer therapy is well known, usually consisting of elevation in the serum levels of hepatic enzymes or fatty infiltration of the liver. The chemotherapeutic agents most commonly linked to hepatotoxic effects are methotrexate, anthracyclines, taxanes and cyclophosphamide. There are few reports of patients with liver metastasis having radiological findings mimicking cirrhosis, both in the presence or the absence of prior systemic chemotherapy. Hepatotoxicity of antineoplastic drugs and cellular necrosis induced by response of liver metastases to chemotherapy may play a critical role in its physiopathology.

MATERIALS AND METHODS

This article reports a series of ten women with breast cancer (nine with liver metastasis) treated with chemotherapy or hormonotherapy.

RESULTS

They had low risk factors for hepatic disease, but developed a cirrhosis-like appearance in the computed tomography scan. The patient without liver metastasis is the second of this kind described in the literature. Relatively few reports have documented clinical sequelae of portal hypertension. In our series, three patients had oesophageal bleeding varices needing be hospitalised. To our knowledge, these are the first cases reported in the literature.

CONCLUSIONS

This suggests that some manifestations of portal hypertension may develop in association with the cirrhosis- like pattern induced by breast cancer therapy.

Fatty liver and transaminase changes with adjuvant tamoxifen therapy

We investigated the time it took to develop fatty liver and changes in serum aspartate aminotransferase and alanine aminotransferase levels in patients with breast cancer treated with adjuvant tamoxifen. Liver sonography to detect fatty liver and measurement of serum aspartate and alanine aminotransferase levels were performed regularly for patients with early breast cancer. The results were compared in groups of patients with and without adjuvant tamoxifen as well as those on chemotherapy. Eighty-two of 156 patients treated with tamoxifen developed fatty liver, compared with eight of 62 patients not taking it. Fatty liver appeared as early as 3 months after beginning tamoxifen and was detected within 2 years in most cases. It persisted for 48 months after discontinuing tamoxifen in 17 of the 82 patients who developed it. The incidence of fatty liver in patients receiving both chemotherapy and tamoxifen was the same as that in patients receiving tamoxifen alone. While 115 patients had elevations of aspartate aminotransferase, alanine aminotransferase or both, the magnitude of the elevation was clinically significant in only 32 patients. Patients on both chemotherapy and tamoxifen had a higher incidence of elevated transaminases than those on tamoxifen alone. Adjuvant tamoxifen increases the incidence of fatty liver, but has only a minimal effect on aspartate aminotransferase and alanine aminotransferase. Fatty liver may appear as early as 3 months after beginning tamoxifen and may persist for more than 4 years after discontinuing it. Therefore, long-term follow-up is warranted. Chemotherapy is not clearly associated with fatty liver, but may cause a greater degree of hepatocellular damage than does tamoxifen.

Hepatic capsular retraction in metastatic carcinoma of the breast occurring with increase or decrease in size of subjacent metastasis

OBJECTIVE

We evaluated the prevalence and significance of hepatic capsular retraction in hepatic metastases from breast cancer and correlated these with metastatic number, size, change in size over time, breast tumor histopathology, chemotherapeutic regimen, and tumor-receptor status.

MATERIALS AND METHODS

Abdominal CT scans of 200 consecutive women with breast carcinoma (mean age, 57 years; range, 33-81 years), obtained over a 7-month period, were retrospectively reviewed. Fifty-eight women had hepatic metastases. Two hundred seventy-two CT scans, including present and prior examinations (mean [+/- SD], 4.6 +/- 2 per patient), were evaluated. The number and diameter of liver metastases at all examinations, chemotherapeutic agents used, histopathologic diagnosis of breast tumor, and tumor-receptor status were compared in patients with and without capsular retraction. Descriptive analyses of the variables and comparisons of means and proportions as well as correlations were conducted.

RESULTS

Hepatic capsular retraction was observed in 29 patients with hepatic metastases (50%). Retraction ranged from 1 to 10 mm in depth. Patients with capsular retraction had significantly larger metastases than those without retraction (p < 0.05). The associations between retraction and increase in size of the subjacent metastasis and between retraction and decrease in size were statistically significant (p < 0.05). Capsular retraction was independent of the number of hepatic metastases, histopathologic diagnosis, tumor-receptor status, and chemotherapeutic regimen.

CONCLUSION

Hepatic capsular retraction is common in patients with hepatic metastases from breast cancer and is associated with larger metastases and both increase and decrease in subjacent lesion size. It is unrelated to lesion number, histopathology, receptor status, or chemotherapeutic regimen.

Alterations in laboratory test results during adjuvant breast cancer treatment

An increasing number of women is treated with adjuvant cyclophosphamide, methotrexate and 5-fluorouracil therapy for breast cancer. The effects of the chemotherapy on many laboratory tests are, however, inadequately known. This study investigates the effects of the treatment on various laboratory tests. Fifteen premenopausal women receiving adjuvant cyclophosphamide, methotrexate and 5-fluorouracil chemotherapy and optional radiotherapy were included in the study. Common hormonal, biochemical, hematological, protein and lipid laboratory tests were taken serially during a 10-month follow-up. Twelve women became amenorrheic. Their serum follicle stimulating hormone and luteinising hormone concentrations increased accordingly. Other serum hormones (testosterone, androstenedione, sex hormone-binding globulin, prolactin, dehydroepiandrosterone sulfate, cortisol, parathyroid hormone and thyroid hormones) changed only slightly. Hemoglobin concentration and white blood cell count decreased slightly. Serum alanine aminotransferase, alkaline phosphatase, lactate dehydrogenase, creatine kinase, angiotensin-converting enzyme, amylase, glucose, potassium, phosphate, urea and triglycerides concentrations increased slightly whereas serum bilirubin, haptoglobin, and immunoglobulin A and M decreased slightly. Serum alpha1-antitrypsin fluctuated around the baseline concentration. Other test results remained at their pretreatment concentrations. With the exception of increases in serum gonadotrophins, the changes observed were slight and the mean concentrations remained within reference limits. Therefore, cyclophosphamide, methotrexate and 5-fluorouracil adjuvant treatment is unlikely to complicate the diagnosis of other diseases.

Chemotherapy-related hepatotoxicity causing imaging findings resembling cirrhosis

In this article, we describe three women in whom changes in the liver resembling cirrhosis occurred during systemic chemotherapy for metastatic breast carcinoma. All three patients were treated with tamoxifen as part of their chemotherapeutic regimen. Abnormalities of biochemical liver tests were associated with the development of a cirrhosis-like appearance of the liver on computed tomography. In two of the patients, hepatic metastases were proved at biopsy. The third patient had no radiologic evidence of metastatic disease. Chemotherapy for metastatic breast carcinoma may cause striking morphologic changes in the liver that resemble cirrhosis. Of importance, these changes should not be mistaken for the development or progression of liver metastases. Alternatively, because of the changes produced by chemotherapeutic agents, detection of metastases on computed tomography alone may be more difficult. Supplementary magnetic resonance imaging may be helpful in selected cases.

The effect of prior adjuvant chemotherapy on survival in metastatic breast cancer

Some adjuvantly treated patients develop recurrent breast cancer and little is known about the effect of prior adjuvant chemotherapy on subsequent response rates to systemic therapy or on overall survival. We describe our retrospective comparison of 179 patients who received doxorubicin containing adjuvant chemotherapy and developed recurrent breast cancer on University of Arizona Cancer Center clinical trials with 202 non-adjuvantly treated patients entered onto clinical protocols for recurrent or metastatic breast cancer during the same period. Adjuvant failures had a shorter median survival from the date of onset of recurrent disease (18 months versus 28 months, P less than 0.001), a lower response rate to initial combination chemotherapy (38% versus 69%, P = 0.001), and a high incidence of CNS involvement at the time of relapse (11%). In patients having recurrent or metastatic breast cancer, a history of prior adjuvant chemotherapy appears to identify a subgroup who will have a higher incidence of CNS involvement, a lower response rate to chemotherapy and a shorter survival with metastatic disease. These findings may help explain the failure of improved relapse free survival seen in many adjuvant chemotherapy trials to result in improved overall survival.

Chemotherapy of breast cancer: current views and results

The paper critically reviews major accomplishments achieved with the use of chemotherapy in the treatment of various stages of breast cancer. In spite of innumerable clinical trials, there is no evidence that in advanced breast cancer the addition of more drugs, either in concomitant, sequential or alternating fashion, to known effective combinations, was able to significantly improve the incidence and the magnitude of objective response or its median duration or survival. The addition of endocrine therapy to chemotherapy has failed so far to improve the most important end-point, i.e. total survival. Second-line chemotherapy is only moderately effective for a fairly short period of time. Thus, in women with advanced breast cancer excessive tumor cell burden and permanent drug resistance remain the major obstacles to obtaining complete remission and long-term disease free survival. In the adjuvant setting, the initial trials with combination chemotherapy have achieved consistent results, particularly in women with minimal axillary node involvement. Unless a woman has undergone a surgical breast-saving procedure, postoperative radiotherapy does not appear to play an important therapeutic role, either with or without concomitant or sequential chemotherapy. Present results would suggest that in advanced breast cancer little progress can be expected in the near future. Therefore, medical oncologists should focus on the correct application of established drug regimens, using a sequential flow of hormonal manipulations and cytotoxic chemotherapy. In high-risk groups, full dose adjuvant polydrug therapy given for a relatively short period of time appears to be at present the only means able to significantly decrease the failure rate following local regional treatment. Present consistent achievements, which appear devoid of important delay morbidity (e.g. cancerogenesis, chronic organ damage) will require further clinical research to identify more effective and less toxic treatments.