Proposal for a Clinical Classification of Liver Metastases

The Clinical Relevance of Tumor Marker Cea, Ca 19-9 in Regional Chemotherapy of Hepatic Metastases of Colorectal Carcinoma

Up to December 1986, 50 patients with documented hepatic metastases from colorectal carcinoma were treated with 5-fluoro-2-deoxyuridine (FUDR) using Infusaid pumps. The response of liver metastases to regional chemotherapy was studied by computerized tomography (CT) and carcino-embryonal antigen (CEA), and/or CA 19-9 antigen serum assays. Preoperative CEA values were pathological in 94% of the patients but only 48% had a pathological concentration of the antigen CA 19-9 of over 37 U/ml.

The course of CEA and CA 19-9 in combination with the arterial angio-CT reflected the response of liver metastases to regional chemotherapy. A decrease or normalisation of CEA and CA 19-9 after the beginning of therapy is an indication of partial or complete remission of metastases (68% of the patients showed lowered CEA serum values).

If the marker continues to rise in serum this is a danger signal of progression of liver metastases or of extrahepatic tumor spread if the tumor stage in the liver remains unchanged.

Proposal of a new and simple staging system of colorectal liver metastasis

AIM: To create a new, simple and useful staging system for colorectal liver metastasis analogous to the Tumor Node Metastasis classification system of International Union Against Cancer.

METHODS: A retrospective review was undertaken of 81 consecutive patients who underwent partial hepatectomy for colorectal liver metastases (group 1). Clinical and pathological features of both primary and metastatic liver cancers were entered into a multivariate analysis to determine independent variables helpful in accurately predicting long-term prognosis after hepatectomy. Using selected variables, we created a new staging system like TNM classification. The usefulness of the new staging system was examined in a series of 92 patients from another hospital (group 2).

RESULTS: Multivariate analysis showed that 81 patients in group 1 had significant multiple hepatic tumors with the largest tumor being more than 5 cm in diameter, resectable extrahepatic distant metastases, and independent prognostic factors for poor survival after hepatectomy. Using these three variables, we created a new staging system to classify patients with colorectal liver metastases. Finally, our new staging system classified the patients both in group 1 and in group 2.

CONCLUSION: Our new staging system of colorectal liver metastasis is simple and useful for staging patients.

[Transarterial chemoembolization of liver metastases of colorectal carcinoma using degradable starch microspheres (Spherex): personal investigations and review of the literature]

Since two decades transarterial chemoembolization (TACE) of liver metastases has been investigated in numerous studies. However, no standardized therapeutic procedure exists so far. The present study retrospectively investigated survival, response and side effects after TACE of liver metastases in 21 patients with colorectal cancer and results are compared with previous literature. A total of 68 TACE procedures were performed. A suspension of degradable starch microspheres (DSM, Spherex) and Mitomycin C was applied selectively into hepatic arteries via a transfemoral approach. DSM effect a temporary arterial occlusion. Follow-up studies were performed by contrast enhanced spiral computed tomography (CT). The median survival was 13.8 months. Therapeutic response (according to WHO) was observed only in three patients. The progression free interval was 5.8 months. Patients developed a postembolization-syndrome (abdominal pain, fever, nausea) and increased transaminases in 27-43% of all interventions. A gastric ulcer occurred after four, cholecystitis after two TACE. As already shown in most previous studies, regardless of the used agents, also this investigation underlines the moderate therapeutic effect of TACE on colorectal liver metastases. So far, no significant survival benefit has been shown in the literature and the response rates are rather limited. In general, complications of TACE seem to be rare, but should not to be underestimated. Compared to TACE with long or permanent arterial occlusion, postembolization syndrome seems to be less pronounced using DSM. As TACE is rather a palliative therapeutic approach, DSM therefore might be more suited. Further studies on TACE of liver metastases should focus on to the patients' quality of life.

Treatment for liver metastases from breast cancer: Results and prognostic factors

AIM: Liver metastases from breast cancer (BCLM) are associated with poor prognosis. Cytotoxic chemotherapy can result in regression of tumor lesions and a decrease in symptoms. Available data, in the literature, also suggest a subgroup of patients may benefit from surgery, but few talked about transcatheter arterial chemoembolization (TACE). We report the results of TACE and systemic chemotherapy for patients with liver metastases from breast cancer and evaluate the prognostic factors.

METHODS: Forty-eight patients with liver metastases, from proved breast primary cancer were treated with TACE or systemic chemotherapy between January 1995 and December 2000. Treatment results were assessed according to WHO criteria, along with analysis of prognostic factors for survival using Cox regression model.

RESULTS: The median follow-up was 28 mo (1-72 mo). Response rates were calculated for the TACE group and chemotherapy group, being 35.7% and 7.1%, respectively. The difference was significant. The one-, two- and three-year Survival rates for the TACE group were 63.04%, 30.35%, and 13.01%, and those for the systemic chemotherapy group were 33.88%, 11.29%, and 0%. According to univariate analysis, variables significantly associated with survival were the lymph node status of the primary cancer, the clinical stage of liver metastases, the Child-Pugh grade, loss of weight. Other factors such as age, the intervals between the primary to the metastases, the maximal diameter of the liver metastases, the number of liver metastases, extrahepatic metastasis showed no prognostic significances. These factors mentioned above such as the lymph node status of the primary cancer, the clinical stage of liver metastases, the Child-Pugh grade, loss of weight were also independent factors in multivariate analysis.

CONCLUSION: TACE treatment of liver metastases from breast cancer may prolong survival in certain patients. This approach offers new promise for the curative treatment of the patients with metastatic breast cancer.

Factors influencing response rates for advanced colorectal cancer chemotherapy

BACKGROUND

The activity of various chemotherapy regimens used in the treatment of advanced colorectal cancer is assessed by different groups of investigators and in various trials by what appear to be common criteria. However, there may be substantial inter-trial variation in the interpretation and application of these criteria which contributes to differences in response rates reported for the same regimen.

MATERIALS AND METHODS

This paper reviews the most prominent studies in this field and examines the factors which may influence the assessment of activity in clinical trials such as patient selection, the definition and application of response criteria, the methods of assessment of time to progression and duration of response, factors related to the therapeutic regimen and statistical methods. Each factor is critically discussed.

RESULTS

The analysis confirms that there is a large variability among the different studies and that an inter-trial comparison is often impossible, with subsequent difficulties for clinicians in determining the true impact of therapies.

DISCUSSION

After briefly commenting on the various issues, this review makes recommendations about how to achieve consistency among trials, for instance by using standard criteria, by extending the use of randomization even in phase II trials and by evaluating high quality, well conducted clinical trials in a meta-analysis, thereby making possible comparison across trials. The conclusions, although specific to colorectal cancer, are also applicable to other advanced malignancies.

Pharmacokinetics of vinorelbine in patients with liver metastases

BACKGROUND

The main elimination pathway of vinorelbine is hepatic metabolism, and the clearance of vinorelbine could be reduced in patients with liver metastases.

OBJECTIVES

To study the pharmacokinetics of vinorelbine in patients who have advanced breast cancer with or without liver metastases and to study the relationship between hepatic function and vinorelbine clearance.

PATIENTS AND METHODS

We studied 29 patients with advanced breast cancer: 19 with liver metastases and 10 control patients with extrahepatic metastases (mean age, 61 years; age range, 38 to 81 years). The vinorelbine dose was 30 mg/m2 as a short intravenous infusion; the dose was reduced by 50% in patients with bilirubin > 2 mg/dl. Patients were classified by ultrasonographic estimation of the liver volume replaced by tumor (%LVRT). Standard liver function tests and a monoethylglycinexylidide test (a quantitative liver function test based on lidocaine metabolite formation) were performed. Vinorelbine was assayed in plasma by HPLC with fluorescence detection. Vinorelbine determination was impossible in two patients with more than 75% LVRT because of interferences. Pharmacokinetic parameters were calculated with a noncompartimental method and compared by means of the Kruskal-Wallis test.

RESULTS

A lower vinorelbine clearance rate was observed in the five patients with more than 75% LVRT (22.9 L/hr/m2) compared with the 10 patients with no liver metastases (48.0 L/hr/m2) and the 12 patients with 25% to 75% LVRT (45.3 L/hr/m2). Terminal elimination half-life and apparent volume of distribution were not significantly different among groups. The monoethylglycinexylidide test had a significant correlation with vinorelbine clearance. (r2 = 0.70; p = 10(-4).

CONCLUSIONS

These results support vinorelbine dose reduction in patients with severe liver failure but not in patients with moderate secondary liver involvement. The monoethylglycinexylidide test may prove to be useful for vinorelbine dose individualization.

High-Dose Intra-Arterial plus Intraperitoneal Chemotherapy Combined with Hemofiltration in Liver Metastases from Colorectal Cancer

Aims

Twenty-three patients with liver metastases from colorectal cancer were entered into a prospective, phase II pilot study to evaluate the efficacy and feasibility of intra-arterial high-dose chemoterapy (IAHC) + intraperitoneal chemotherapy (IPC) combined with hemofiltration.

Methods

All patients had abdominal laparotomy to position a hepatic artery infusion port and in 15 cases an implantable system for IPC. A double-lumen filtration catheter was placed in the vena cava via the saphenous or femoral vien and connected to a modified hemofiltration unit. The treatment schedule consisted of mitomycin (30-50 mg/m2) and epirubicin (60-90) mg/m2) as IAHC combined with cisplatin (60 mg/m2) given in a 2000 ml saline solution by IPC. The high-dose IAHC-IPC was followed by 4 cycles of intra-arterial standard dose chemotherapy through the arterial port-a-cath (6 mg/m2 mitomycin and 20 mg/m2 epirubicin) and if possible by another cycle of high dose IAHC-IPC.

Results

We delivered a toal of 31 cycles of IAHC, 21 of which were combined with IPC. Ten cycles of IAHC were administered without concurrent IPC because of painful adhesions, clinical contraindications or patient refusal. Seven of 23 patients (30%) were pretreated and with progressive disease after systemic chemotherapy. Among 22 evaluable patients, we obtained 2 complete remissions (9%) and 11 partial remissions (50%); moreover, 4 of 7 pretreated patients obtained a response to treatment. As a result, an objective tumor response was observed in 59% of patients (13/22). Therefore, a dose-response behavior was demonstrated also in tumors with a low chemosensitivity. The median duration of response and survival was 10 and 14 months, respectively. Toxicity was usually mild, but we reported one toxic death due to treatment complications.

Conclusions

Further prospective randomized studies are needed to confirm the results of our study.

Cell kinetics of colorectal liver metastases

PURPOSE

Liver metastases are the main cause of death in patients with colorectal cancer. We defined the proliferative activity of a metastatic liver cell population to investigate its potential role as an indicator of clinical outcome in patients with metastatic disease of the colorectum.

METHODS

The S-phase cell fraction, evaluated as in vitro [3H]thymidine-labeling index, was determined on liver metastases of primary colorectal cancers from 75 patients.

RESULTS

Cell proliferation was not related to the degree of liver involvement, the site of the primary cancer, or the time of presentation of liver metastases. Survival at 2 years was statistically different for patients with slowly proliferating (78 percent) or rapidly proliferating liver metastases (47 percent) (P = 0.024). The risk of death for patients with high [3H]thymidine-labeling index lesions was consistently threefold that of patients with low [3H]thymidine-labeling index lesions throughout the observation period. Bivariate analysis showed that cell proliferation was a further prognostic discriminant within the subsets characterized by a different degree of liver involvement.

CONCLUSIONS

These results indicate that cell proliferation is a good prognostic marker even in patients with liver metastases from colorectal cancer. The clinical implications of the marker could be further potentiated by considering it in association with some clinical aspects of known prognostic relevance.

Regional chemotherapy in liver metastases of colorectal carcinoma: monitoring with arterial computed tomography

Continuous chemotherapy was administered to 82 patients through the hepatic artery via Infusaid pumps. In order to obtain a primary status and to evaluate the success of therapy, the perfusion patterns of the liver and of the existing tumor masses in the liver were estimated by conducting arterial angiocomputed tomographies (AACTs) immediately after pump implantation of every 3 months thereafter. In 70% of the patients, findings showed both liver lobes to be homogeneously perfused, 24% demonstrated distinct inhomogeneities. The response of the latter cases should depend primarily on the efficacy of the administered cytostatic agent. Six percent of the patients showed selective perfusion of either the left or right hepatic lobe. In these cases, only the perfused liver regions exhibited stable disease or regression of the metastases, whereas the metastases of the nonperfused regions progressed. At 3-month follow-up, the majority of the patients (50-57%) showed homogeneous hepatic perfusion. Inhomogeneities were found in 26-36% of the patients, 12 patients demonstrated incomplete perfusion. There was no association between the perfusion patterns of the metastases or of the prechemotherapeutic liver involvement and the response of the metastases to regional chemotherapy. In regional chemotherapy, liver perfusion should be controlled both intraoperatively or directly postoperatively and during therapy.

Regional treatment of hepatic metastases and hepatocellular carcinoma

Hepatic metastases represent a common site of dissemination for a number of primary malignancies related in part to the dual blood supply, large blood flow, and receptive environment of the hepatic parenchyma. Although this review focuses on regional therapy, we have included sections on systemic therapy to better interpret the results with intrahepatic therapy. We will also discuss the efficiency of hepatic arterial ligation, embolization, and radiotherapy of hepatic metastases. Primary gastrointestinal neoplasms are particularly prone to produce hepatic metastases. Because colorectal carcinoma metastasizes to the liver in up to 70% of patients with advanced disease, the treatment of hepatic metastases is a relevant topic. We will discuss the systemic and regional therapy of colorectal, gastric, and gallbladder cancers. Breast carcinoma and malignant melanoma frequently metastasize to the liver, and we have described systemic and regional treatments of these diseases. Because sarcomas are often treated by regional therapy, we have included a section on the treatment of hepatic sarcomas. Neuroendocrine tumors (carcinoid and islet cell), although often slow growing, frequently metastasize to the liver and then cause symptomatic problems. Much of the work done with embolization and hepatic ligation in the treatment of hepatic metastases has been performed in neuroendocrine tumors, and these studies, as well as the systemic and regional chemotherapy of hepatic metastases, will be described. The last section concerns the treatment of hepatocellular carcinoma. We have outlined the staging systems used. We then detail the results of systemic and intrahepatic therapy, embolization, and hepatic ligation in the treatment of hepatocellular carcinoma. Because hepatic metastases are a frequent problem, many patients are available for clinical investigation. It is hoped that newer strategies for the treatment of liver metastases will lead to higher response rates and perhaps control of local disease. These therapeutic approaches may also give us leads to the treatment of systemic disease.

Determinants of survival in patients with unresectable colorectal liver metastases

Prognostic indicators in 67 patients with unresectable colorectal liver metastases were analyzed. These patients were identified to have isolated hepatic metastases after extensive radiological evaluation and demonstrated good performance status without evidence of liver failure. Univariate analysis revealed 6 of 22 factors that were associated with survival: alkaline phosphatase (AP), lactic dehydrogenase (LDH), occult intra-abdominal extrahepatic disease, percent hepatic replacement by tumor (PHR), sex, and carcinoembryonic antigen (CEA). A multivariate analysis identified two independent factors that jointly influenced survival: AP and PHR. Patients with an AP greater than 175 U/liter had a greater than threefold relative risk of dying compared with patients with AP less than or equal to 175 U/liter (P = 0.0001). Patients with PHR II or III (25-75%, greater than 75%) also had a greater than threefold relative risk of dying compared with patients with PHR 1 (less than 25%; P = 0.0074). Our patient population is typical of that being entered into trials examining experimental therapies. Alkaline phosphatase and extent of liver involvement by tumor are significant prognostic indicators that should be accounted for in such studies.

Assessment of serial carcinoembryonic antigen: determinations to monitor the therapeutic progress and prognosis of metastatic liver disease treated by regional chemotherapy

It is difficult, time-consuming, and expensive to evaluate the therapeutic efficacy of regional chemotherapy of metastatic liver disease by means of imaging procedures. Therefore it was the aim of this study to find out whether serial carcinoembryonic antigen (CEA) determinations yield reliable data on the therapeutic progress and the individual prognosis of these patients. Since there exists no generally accepted modality to assess CEA curves of patients receiving chemotherapy, we developed our own criterion and tested it in a group of 35 patients. For each patient an individual reference level (CEA-means) was fixed which was obtained as the arithmetical mean of serial CEA values taken during the first three courses of chemotherapy (reference time). On the basis of CEA-means the marker curves of the 35 patients could be divided into two groups. After the reference time the CEA values of group 1 (12 patients) never decreased below CEA-means. Survival of these patients was significantly (P = 0.00001) shorter than that of the 23 patients (group 2) who showed a decrease in their CEA curves below CEA-means after the reference time. Beyond this it could be observed that the improvement in survival was significantly greater in those patients who showed a CEA decrease below CEA-means for a prolonged period (3 months). This difference in prognosis is not an artefact due to different pretherapeutic conditions but is a sign of different responses to therapy. The decrease in CEA values below the individual reference level (CEA-means) is a certain sign of the efficacy of the chosen chemotherapy. A continuous rise of the CEA curve above CEA-means signifies an ineffective intrahepatic chemotherapy or extrahepatic tumor manifestation. In this case an intensive diagnostic workup of the patient and possibly a modification of the therapy are indicated.

A comparison of misonidazole sensitized radiation therapy to radiation therapy alone for the palliation of hepatic metastases: results of a Radiation Therapy Oncology Group randomized prospective trial

Between May 1980 and July 1983, the RTOG conducted a randomized prospective study comparing external radiation therapy and misonidazole to radiation therapy alone for patients with hepatic metastases. Two hundred fourteen patients were accessioned to this study of whom 187 were evaluable. Radiation therapy was delivered to the whole liver to a dose of 21.0 Gy in 7 fractions. Misonidazole was administered orally, 1.5 gm/m2 daily 4-6 hr before each treatment. Patients in the two treatment groups were evenly distributed with respect to stratification variables including primary site, extent of metastatic disease, and Karnofsky Performance Score (KPS). End points examined included amelioration of hepatic pain, improvement of KPS and alkaline phosphatase, decrease in liver and tumor size, and survival. The addition of misonidazole did not significantly improve the therapeutic response to radiation therapy in any of the parameters studied. Hepatic irradiation was effective in relieving abdominal pain with 80% of the symptomatic patients achieving improvement following therapy. Pain was completely relieved in 54% of these patients. Patients with liver metastases from colon carcinoma improved more frequently than those with metastases from other primary tumor sites (p = 0.02). Relief of pain occurred more frequently in patients treated with radiation therapy and misonidazole (87%) compared with radiation therapy alone (74%) (p = 0.08). Palliation of pain was prompt, occurring within a median of 1.7 weeks from the initiation of treatment, and 94% of patients who improved did so within 6 weeks of treatment. The median duration of response was 13.0 weeks in the symptomatic patients; 52% of those surviving 3 months remained improved. KPS improved in 28% of patients. Serial CT scans revealed a partial response in 7% and a marginal response in 13% of patients. One patient had a complete response to treatment. The median survival of patients treated in this series was 4.2 months with no difference between the two treatment groups. Patients with metastases from colon carcinoma and an initial KPS of 80 or more (48% of the patient population) had a median survival of 5.8 months with radiation therapy alone compared with 6.6 months with radiation therapy and misonidazole (p = 0.36). There was no significant treatment related morbidity. Radiation therapy remains an excellent palliative tool for the management of patients with symptomatic hepatic metastases. Further research must continue to identify new methods of selectivity enhancing the tumor response to radiation therapy.

Primary and metastatic tumors of the liver associated with cirrhosis. A study based on laparoscopy and autopsy

In a series of 2,538 cases of cirrhosis seen at laparoscopy there were 140 primary liver carcinomas and 19 cases of metastases to a cirrhotic liver out of a total of 167 extrahepatic neoplasms associated with cirrhosis. In an autopsy series of 1,073 cases of cirrhosis there were 190 primary liver carcinomas and 22 cases of metastases to a cirrhotic liver out of a total of 98 extrahepatic neoplasms. In another autopsy series of 498 cases of cirrhosis there were 71 primary liver carcinomas and 18 cases of metastases to a cirrhotic liver out of a total of 58 extrahepatic neoplasms. The laparoscopy series showed a predominance (31.8%) of esophageal tumors associated with cirrhosis, but these tumors rarely gave rise to liver metastases (3.7%); in the autopsy series there was a predominance (35.3%) of tumors of the portal territory, giving rise to metastases in cirrhotic livers in 35.2% of cases.

A proposed classification system for liver metastasis from colorectal carcinoma

A proposed classification system for liver metastasis from colorectal carcinoma is presented. This proposed system utilizes the prognostic factors of the extent of hepatic involvement by metastasis at the time of laparotomy, performance status, preoperative serum alkaline phosphatase level, and the presence or absence of extrahepatic intraabdominal disease at the time of laparotomy. Because of the several different modes of treatment for liver metastasis from colorectal carcinoma, it is necessary that a liver classification system be adopted so that different treatment groups will be comparable. The proposed system utilizes the extent of hepatic involvement by metastasis at laparotomy with a division into three subsets of patients described by a Roman numeral. Roman numeral I represents less than or equal to 25 per cent involvement of the liver by metastasis; Roman numeral II represents greater than 25 per cent but less than or equal to 50 per cent involvement by liver metastasis, and Roman numeral III represents greater than 50 per cent involvement by liver metastasis. An Arabic subscript number is used to describe the patients' performance status. Alkaline phosphatase levels are described by a subscript letter with a representing less than two times normal alkaline phosphatase, b representing greater than two times, but less than four times normal levels, and c representing greater than four times normal levels. At the time of laparotomy extrahepatic intra-abdominal disease is represented by the superscript letter E.