Arterial chemotherapy of 5-fluorouracil and mitomycin C in the treatment of liver metastases of colorectal cancer

The potential protective role of taurine against 5-fluorouracil-induced nephrotoxicity in adult male rats

Nephrotoxicity is common with the use of the chemotherapeutic agent 5-Fluorouracil (5-FU). The current study aimed to investigate the probable protective effect of taurine (TAU) against 5-FU-induced nephrotoxicity in rats using biochemical, histological and ultrastructural approaches. Twenty-four rats were equally divided into control, TAU, 5-FU and 5-FU+TAU groups. 5-FU significantly elevated levels of blood urea nitrogen (BUN), creatinine, and uric acid; while it reduced activities of superoxide dismutase (SOD), catalase (CAT), and glutathione peroxidase (GSH-Px). Also, 5-FU induced significant elevation in malondialdehyde (MDA) levels accompanied with marked decline in γ-glutamyltranspeptidase (GGT) and alkaline phosphatase (AP) levels in kidney tissues. These biochemical alterations were accompanied by histopathological changes marked by destruction of the normal renal structure, in addition to ultrastructural alterations represented by thickened and irregular glomerular basement membranes, congested glomerular capillaries, damaged lining fenestrated endothelium, mesangial cells hyperplasia with expanded mesangial matrix, and distorted podocyte's processes. Also, the proximal (PCT) and distal (DCT) convoluted tubules showed thickened basement membranes, destructed apical microvilli and loss of basal infoldings of their epithelial cells. Administration of TAU to 5-FU-treated rats reversed most of the biochemical, histological, and ultrastructural alterations. These results indicate that TAU has a protective effect against 5-FU-induced nephrotoxicity.

Systematic review and meta-analysis of hepatic arterial infusion chemotherapy as bridging therapy for colorectal liver metastases. Surg Oncol. 2015;24:162-171. [PMID: 26133575 DOI: 10.1016/j.suronc.2015.06.014]

BACKGROUND

Hepatic arterial infusion chemotherapy (HAIC) has been shown to be beneficial in the management of unresectable colorectal liver metastases (CRLM). This systematic review evaluates the potential role of HAIC as a neoadjuvant downstaging therapy, prior to hepatic resection with curative intent for initially unresectable CRLM.

METHODS

A literature search was conducted using Pubmed, EMBASE and Medline databases from January 2000 to November 2013. Studies adopting HAIC as a neoadjuvant bridging therapy for hepatic resection for CRLM were included.

RESULTS

Eleven studies (n = 1514) were included. HAIC response rate was 50% and achieved conversion to surgery rate in 18% of patients. The median overall and 5-year survival for patients who underwent conversion to hepatectomy was 53 months and 49% compared to 16 months and 3% for patients who did not undergo surgery. Meta-analysis demonstrated strong association between hepatectomy and improved 5-year survival (RR 0.56, 95% CI = 0.48-0.65, Z = 7.26, p < 0.00001).

CONCLUSION

For patients presenting with unresectable CRLM, HAIC in conjunction with current systemic chemotherapy may allow some patients to undergo resection and potentially provide long-term survival.

An overview of coagulation disorders in cancer patients. Surg Oncol. 2010;19:e33-e46. [PMID: 19394816 DOI: 10.1016/j.suronc.2009.03.008]

A diversity of coagulation disorders in cancer patients arise from tumor-specific growth characteristics, neoangiogenesis with impaired endothelial lining, defective myelopoiesis, hypoproteinemia or metastatic lesions growth with organ dysfunction. Recent investigations have found a clinically relevant correlation of coagulation disorders and tumor growth. These prompted new therapeutic strategies focused on growth factors with the aim to control tumor metastasis, particularly if used for the treatment of micrometastatic disease. However, such treatment may lead to the life threatening coagulation imbalance. A coagulation homeostasis may become further impaired after nonsurgical cancer therapy, especially after preoperative irradiation, which produces lesions precipitating both bleeding and thrombosis. Anticancer chemotherapy may affect liver function and decrease the synthesis of both procoagulation and anticoagulation factors. The most of chemotherapeutic protocols affect platelet synthesis, which arises as a principal dose-limiting side effect. It was observed both during combined systemic chemotherapy and local antitumor therapy. Although the side effects produced by chemotherapy are reversible, endothelial lesions may persist for many years after the anticancer treatment. Instead of cancer patients, there's a growing cohort of patients with nonmalignant diseases who use cytostatics in the perioperative period, and are candidates for surgical procedures not related to their malignant disease, i.e. hernia repair. In this patient population a special attention must be paid to the preoperative evaluation of coagulation status and thromboprophylaxis. This overview reminds the most common coagulation disorders in cancer patients in the perioperative period. It emphasizes the need for proper patient monitoring which may facilitate the diagnostics and treatment of cancer-related coagulation disorders in the perioperative setting.

Intra-arterial hepatic chemotherapy for unresectable colorectal liver metastases: a review of medical devices complications in 3172 patients

Background

Hepatic artery infusion (HAI) is indicated to treat unresectable colorectal hepatic metastases, with recent applications as a neoadjuvant or adjuvant treatment. Traditionally performed with the infusion of fluoropyrimidine-based chemotherapy, it has been now tested with oxaliplatin or irinotecan and associated with systemic chemotherapy.

Methods

To evaluate the impact of medical devices complications we carried out a search of the published studies on HAI in unresectable colorectal liver metastases. Complications were pooled according to the applied medical system: 1) surgical catheter, 2) radiological catheter, and 3) fully implantable pump. The surgical catheter is inserted into the hepatic artery from the gastro-duodenal artery. The radiological catheter is inserted into the hepatic artery through a percutaneous transfemoral or transaxillar access. The fully implantable pump is a totally internal medical device connected to the arterial hepatic catheter during laparotomy.

Results

The selection criteria were met in 47/319 studies. The complications of surgical and radiological medical devices connected to a port were found in 16 and 14 studies respectively. Meanwhile, complications with a fully implantable pump were reported in 17 studies. The total number of complications reported in studies evaluating patients with surgical or radiological catheter were 322 (322/948, 34%) and 261 (261/722, 36.1%) respectively. In studies evaluating patients with a fully implantable pump, the total number of complications was 237 (237/1502, 15.8%). In 18/319 studies the number of cycles was reported. The median number of cycles with surgically and radiologically implanted catheters was 8 and 6 respectively. The fully implantable pump allows a median number of 12 cycles.

Conclusions

The fully implantable pump, maintaining a continuous infusion through the system, allows the lowest risk for thrombosis and infection and the best median number of cycles of loco-regional chemotherapy in HAI.

Hemorrhage associated with hepatic artery pseudoaneurysms after regional chemotherapy with floxuridine: case report

Pseudoaneurysms of the hepatic artery are a rare complication in patients with primary or secondary liver tumors treated with intra-arterial chemotherapy. We present two patients who developed this complication after placement of a catheter system into the gastroduodenal artery and initiation of regional chemotherapy with floxuridine. Diagnosis was made after symptomatic bleeding occurred, necessitating emergency angiography with coil embolization. Pseudoaneurysms usually occur after mechanical damage of the vessel wall, but the chemical toxicity of floxuridine may add to the development of vascular impairment.

Intra-hepatic Mitomycin C bolus infusion in the treatment of extensive liver metastases of breast cancer

BACKGROUND

In the treatment of extensive liver metastasis of breast cancer (LMBC), locally administered Mitomycin C (MMC) to the liver might be an effective approach with limited toxicity.

PATIENTS AND METHODS

We retrospectively reviewed the records of 30 patients with LMBC treated with intra-hepatic MMC at our institution. MMC (12 mg) was administered by transcatheter bolus infusion into the hepatic arteries every 4 weeks. Tumour response according to RECIST criteria, progression free survival (PFS), overall survival (OS) and duration of response (DR) were used to evaluate efficacy.

RESULTS

There was a local response in the liver and a global response in respectively 33 and 26%. The median PFS, DR and OS were 3, 4 and 7 months, respectively. There was more benefit in patients without documented metastases outside the liver and without severe liver dysfunction. Thrombocytopenia, leucocytopenia and an allergic reaction were observed after MMC administration in 20 (67%), 12 (40%) and 4 patients (13%), respectively.

CONCLUSION

Intra-hepatic MMC bolus infusion as treatment of extensive LMBC is associated with limited toxicity and has a significant response rate in the liver. Prospective investigations are required to define the place of this modality for treating patients with breast cancer liver metastases.

Current Strategies Using Hepatic Arterial Infusion Chemotherapy for the Treatment of Colorectal Cancer

In recent years, a number of phase III clinical trials have reported median survival times approaching 20 months using modern combination chemotherapy for metastatic colorectal cancer (CRC). Despite the advances in systemic therapy, this approach is still considered palliative because long-term survival or cure is extremely rare. Surgery or the use of ablative techniques may result in prolonged survival for patients with liver metastases, but only a minority of cases are suitable for local therapy. Hepatic arterial infusion (HAI) therapy involves local delivery of drug to liver metastases, resulting in higher intrahepatic drug levels and a consequent doubling in response rates compared with systemic chemotherapy. Despite higher response rates, demonstrating a survival advantage for HAI has been more challenging. Recently, a number of studies have been published that appear to address some of the inadequacies of earlier trials and have demonstrated encouraging results. This review assimilates the current data on HAI for CRC and includes an assessment of new chemotherapeutic agents delivered via HAI, neoadjuvant HAI, HAI combined with systemic chemotherapy, the use of HAI for early-stage colorectal cancer, and future trials. Continued progress in the field of HAI therapy may reduce the morbidity and mortality associated with CRC, so continued research in this area should be encouraged.

Comparative evaluation of immune response after laparoscopical and open total mesorectal excisions with anal sphincter preservation in patients with rectal cancer

AIM: The study of immune response of open versus laparoscopical total mesorectal excision with anal sphincter preservation in patients with rectal cancer has not been reported yet. The dissected retroperitoneal area that contacts directly with carbon dioxide is extensive in laparoscopic total mesorectal excision with anal sphincter preservation surgery. It is important to clarify whether the immune response of laparoscopic total mesorectal excision with anal sphincter preservation (LTME with ASP) in patients with rectal cancer is suppressed more severely than that of open surgery (OTME with ASP). This study was designed to compare the immune functions after laparoscopic and open total mesorectal excision with anal sphincter preservation for rectal cancer.

METHODS: This study involved 45 patients undergoing laparoscopic (n = 20) and open (n = 25) total mesorectal excisions with anal sphincter preservation for rectal cancer. Serum interleukin-2 (IL-2), interleukin-6 (IL-6), tumor necrosis factor α (TNF_α) were assayed preoperatively and on days 1 and 5 postoperatively. CD3⁺ and CD56⁺ T lymphocyte count, CD3^- and CD56⁺ natural killer cell (NK) count and immunoglobulin (IgG/IgM/IgA) were assayed preoperatively and on day 5 postoperatively. The numbers of CD3⁺ and CD56⁺ T lymphocytes and CD3^- and CD56⁺ NK cells were counted using flow cytometry. An enzyme-linked immunosorbent assay (ELISA) was used for IL-2, IL-6 and TNF_α determination. And IgG, IgM, and IgA were assayed using immunonephelometry.

RESULTS: The demographic data of the two groups had no difference. The preoperative levels of CD3⁺ and CD56⁺ T lymphocyte count, CD3^- and CD56⁺ NK count, serum IgG, IgM, IgA, IL-2, IL-6 and TNF_α also had no significant difference in the two groups (P > 0.05). The CD3⁺ and CD56⁺ T lymphocyte counts had no obvious changes after surgery in laparoscopic (d = -0.79% ± 3.83%) and open (d = 0.42% ± 2.09%) groups. The CD3^- and CD56⁺ NK counts were decreased postoperatively in both laparoscopic (d = -7.23% ± 11.33%) and open (d = -9.21% ± 13.93%) groups. The differences of the determined values of serum IgG, IgM and IgA on the fifth day after operation subtracted those before operation were -2.56 ± 2.14 g/L, -252.35 ± 392.94 mg/L, -506.15 ± 912.24 mg/L in laparoscopic group, and -1.81 ± 2.10 g/L, -282.72 ± 356.75 mg/L, -252.20 ± 396.28 mg/L in open group, respectively. The levels of IL-2 were decreased after operation in both groups. However, the levels of IL-6 were decreased after laparoscopic surgery (d₁ = -23.14 ± 263.97 ng/L and d₅ = -40.08 ± 272.03 ng/L), and increased after open surgery (d₁ = 27.38 ± 129.14 ng/L and d₅ = 21.67 ± 234.31 ng/L). The TNF_α levels were not elevated after surgery in both groups. There were no significant differences in the numbers of CD3⁺ and CD56⁺ T lymphocytes and CD3^- and CD56⁺ NK cells, the levels of IgG, IgM, IgA, IL-2, IL-6 and TNF_α between the two groups (P > 0.05).

CONCLUSION: There are no differences in immune responses between the patients having laparoscopic total mesorectal excision with anal sphincter preservation and those undergone open surgery for rectal cancer.

Prognostic factors in 165 elderly colorectal cancer patients

AIM: To analyse the prognostic factors in 165 colorectal patients aged ≥ 70.

METHODS: One hundred and sixty-five elderly patients with colorectal cancer diagnosed by histology were entered into the retrospective study between 1994 and 2001. Patients were given optimal operation alone, chemotherapy after operation, or chemotherapy alone according to tumor stage, histology, physical strength, and co-morbid problems. Survival rate was calculated by Kaplan-Meier method, and compared with meaningful variances by Log-rank method. Prognostic factors were analyzed by Cox regression.

RESULTS: The 1, 2, 3, 4, 5 year survival rate (all-cause mortality) was 87.76%, 65.96%, 52.05%, 42.77%, 40.51%, respectively. The mean survival time was 41.89 ± 2.33 months (95%CI: 37.33-46.45 months), and the median survival time was 37 months. Univariate analysis showed that factors such as age, nodal metastasis, treatment method, Duke’s stage, gross findings, kind of histology, and degree of differentiation had influences on the survival rate. Multivariate analysis showed that factors such as treatment method, Duke’s stage, kind of histology and degree of differentiation were independent prognostic factors.

CONCLUSION: This study suggests that the prognosis of elderly colorectal cancer patients is influenced by several factors. Most of elderly patients can endure surgery and/or chemotherapy, and have a long-time survival and good quality of life.

Toxicities and therapeutic effect of 5-fluorouracil controlled release implant on tumor-bearing rats

AIM: To investigate the toxicities, biodistribution and anticancer effect of 5-fluorouracil controlled release implant (5-FUCI) on Walker 256 carcinosarcoma cells in Wistar rats.

METHODS: Experiment 1: Wistar rats were randomly divided into three groups (27 rats per group). Blank implant was implanted in left lobe of the liver, and rats were treated with saline solution (in group A) or 5-fluorouracil (subcutaneous injection, group B). 5-FUCI was inserted in left lobe of the liver (group C). The gastrointestinal and hematological toxicities were observed and contents of element F in group C were assayed. Experiment 2: on day 6 after Walker-256 carcinosarcoma transplantation in left lobe of the liver, 5-FUCI was implanted in right lobe of the liver (group E) or left lobe (group F), and rats in control group (group D) were inserted blank implant. Tumor inhibition rate and survival time were investigated.

RESULTS: 5-FUCI showed no obvious toxic effect, extraction of Evan’s blue from gastrointestinal tissue was normal, the peripheral white blood cells and bone marrow nucleated cells were not reduced, compared with control group (P > 0.05). Histological examination revealed that there were no visible changes in small intestinal mucosa, The concentration of 5-fluorouracil in left lobe of the liver was 9.84, 28, 34 times as much as those of right lobe of the liver, heart and kidney respectively after the implantation in group C. They kept a high level of fluorouracil in left lobe of the liver, ranging from (4.414% ± 0.482%) to (7.800% ± 0.804%), for eight weeks. Survival days were 28.0 ± 2.2, 30.0 ± 3.2 and 38.7 ± 6.7 d in group D, E and F, respectively.

CONCLUSION: 5-FUCI shows no obvious toxicities to gastrointestinal tract and myelotoxicity. After implantation, it kept a high level of 5- fluorouracil in surrounding tissues of the implant for eight weeks. Its antitumor effect on Walker-256 carcinosarcoma is demonstrated.

Angiography for diagnosis and treatment of colorectal cancer

AIM: To evaluate the role of preoperative angiography in the diagnosis and treatment of colorectal cancer.

METHODS: The authors performed selective arterial cannulation by Seldinger's method in 47 patients to locate the primary cancer and to diagnose metastasis to the liver. Each patient was then given intra-arterial regional chemotherapy, and received 5-fluorouracil (5-Fu, 1000 mg), mitomycin C (MMC, 20 mg), and cisplatinum (CDDP, 80 mg).

RESULTS: The location and shape of each tumor were observed, including metastatic tumors in the liver, in 42 of the 47 (89.4%) patients. The site of the primary tumor was difficult to identify in 5 cases because the patients had a recurrence of cancer. Arterial chemotherapy was performed successfully in all patients. The authors recorded no partial or significant morbidity resulted from angiography. The only incident was bleeding from the artery puncture site in one patient, which was successfully stopped by general medication.

CONCLUSION: Preoperative selective arterial angiography can help the diagnosis and locate primary tumors and to detect liver metastasis. At the same time, regional arterial chemotherapy can be an important form of preoperative therapy.