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Janczewski LM, Joung RH, Borhani AA, Lewandowski RJ, Velichko YS, Mulcahy MF, Mahalingam D, Law J, Bowman C, Keswani RN, Poylin VY, Bentrem DJ, Merkow RP. Safety and feasibility of establishing an adjuvant hepatic artery infusion program. HPB (Oxford) 2023:S1365-182X(23)02013-0. [PMID: 38383208 DOI: 10.1016/j.hpb.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 10/30/2023] [Accepted: 12/12/2023] [Indexed: 02/23/2024]
Abstract
BACKGROUND Hepatic artery infusion (HAI) is less frequently used in the adjuvant setting for resectable colorectal liver metastasis (CRLM) due to concerns regarding toxicity. Our objective was to evaluate the safety and feasibility of establishing an adjuvant HAI program. METHODS Patients who underwent HAI pump placement between January 2019 and February 2023 for CRLM were identified. Complications and HAI delivery were compared between patients who received HAI in the unresectable and adjuvant settings. RESULTS Of 51 patients, 23 received HAI for unresectable CRLM and 28 in the adjuvant setting. Patients with unresectable CRLM more commonly had bilobar disease (n = 23/23 vs n = 18/28, p < 0.01) and more preoperative liver metastases (median 10 [IQR 6-15] vs 4 [IQR 3-7], p < 0.01). Biliary sclerosis was the most common complication (n = 2/23 vs n = 4/28); however, there were no differences in postoperative or HAI-specific complications. In the most recent two years, 0 patients in the unresectable group vs 2 patients in the adjuvant group developed biliary sclerosis. All patients were initiated on HAI with no difference in treatment times or dose reductions. CONCLUSION Adjuvant HAI is safe and feasible for patients with resectable CRLM. HAI programs can carefully consider including patients with resectable CRLM if managed by an experienced multidisciplinary team with quality assurance controls in place.
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Affiliation(s)
- Lauren M Janczewski
- Department of Surgery, Northwestern University Feinberg School of Medicine, University, Chicago, IL, USA
| | - Rachel H Joung
- Department of Surgery, Northwestern University Feinberg School of Medicine, University, Chicago, IL, USA
| | - Amir A Borhani
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Robert J Lewandowski
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Yury S Velichko
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mary F Mulcahy
- Department of Medicine, Division of Hematology and Oncology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Devalingam Mahalingam
- Department of Medicine, Division of Hematology and Oncology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jennifer Law
- Department of Pharmacy, Northwestern Medicine, Chicago, IL, USA
| | - Caitlin Bowman
- Department of Pharmacy, Northwestern Medicine, Chicago, IL, USA
| | - Rajesh N Keswani
- Department of Medicine, Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Vitaliy Y Poylin
- Department of Surgery, Northwestern University Feinberg School of Medicine, University, Chicago, IL, USA
| | - David J Bentrem
- Department of Surgery, Northwestern University Feinberg School of Medicine, University, Chicago, IL, USA; Department of Surgery, Jesse Brown Veterans' Affairs Medical Center, Chicago, IL, USA
| | - Ryan P Merkow
- Department of Surgery, Division of Surgical Oncology, University of Chicago, Chicago, IL, USA.
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Sharib JM, Creasy JM, Wildman-Tobrine B, Kim C, Uronis H, Hsu SD, Strickle JH, Gholami S, Cavna M, Merkow RP, Kingham P, Kemeny N, Zani S, Jarnagin WR, Allen PJ, D’Angelica MI, Lidsky ME. Hepatic Artery Infusion Pumps: A Surgical Toolkit for Intraoperative Decision-Making and Management of Hepatic Artery Infusion-Specific Complications. Ann Surg 2022; 276:943-956. [PMID: 36346892 PMCID: PMC9700364 DOI: 10.1097/sla.0000000000005434] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Hepatic artery infusion (HAI) is a liver-directed therapy that delivers high-dose chemotherapy to the liver through the hepatic arterial system for colorectal liver metastases and intrahepatic cholangiocarcinoma. Utilization of HAI is rapidly expanding worldwide. OBJECTIVE AND METHODS This review describes the conduct of HAI pump implantation, with focus on common technical pitfalls and their associated solutions. Perioperative identification and management of common postoperative complications is also described. RESULTS HAI therapy is most commonly performed with the surgical implantation of a subcutaneous pump, and placement of its catheter into the hepatic arterial system for inline flow of pump chemotherapy directly to the liver. Intraoperative challenges and abnormal hepatic perfusion can arise due to aberrant anatomy, vascular disease, technical or patient factors. However, solutions to prevent or overcome technical pitfalls are present for the majority of cases. Postoperative HAI-specific complications arise in 22% to 28% of patients in the form of pump pocket (8%-18%), catheter (10%-26%), vascular (5%-10%), or biliary (2%-8%) complications. The majority of patients can be rescued from these complications with early identification and aggressive intervention to continue to deliver safe and effective HAI therapy. CONCLUSIONS This HAI toolkit provides the HAI team a reference to manage commonly encountered HAI-specific perioperative obstacles and complications. Overcoming these challenges is critical to ensure safe and effective pump implantation and delivery of HAI therapy, and key to successful implementation of new programs and expansion of HAI to patients who may benefit from such a highly specialized treatment strategy.
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Affiliation(s)
- Jeremy M. Sharib
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - John M. Creasy
- Department of Surgery, Duke University Medical Center, Durham, NC
| | | | - Charles Kim
- Department of Radiology, Duke University Medical Center, Durham, NC
| | - Hope Uronis
- Department of Medicine, Duke University Medical Center, Durham, NC
| | | | - John H. Strickle
- Department of Medicine, Duke University Medical Center, Durham, NC
| | - Sepideh Gholami
- Department of Surgery, University of California-Davis, Sacramento, CA
| | - Michael Cavna
- Department of Surgery, University of Ken-tucky, Lexington, KY
| | - Ryan P. Merkow
- Surgical Outcomes and Quality improvement Center, Department of Surgery, Feinberg School of Medicine, North-western University, Chicago, IL
| | - Peter Kingham
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Nancy Kemeny
- Department of Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Sabino Zani
- Department of Surgery, Duke University Medical Center, Durham, NC
| | | | - Peter J. Allen
- Department of Surgery, Duke University Medical Center, Durham, NC
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Napier KJ, Lidsky ME, James OG, Wildman-Tobriner B. Hepatic Arterial Infusion Pumps: What the Radiologist Needs to Know. Radiographics 2021; 41:895-908. [PMID: 33769890 DOI: 10.1148/rg.2021200130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Hepatic arterial infusion (HAI) entails the surgical implantation of a subcutaneous pump to deliver chemotherapeutic agents directly to the liver in the setting of primary or secondary liver cancer. The purpose of HAI chemotherapy is to maximize hepatic drug concentrations while minimizing systemic toxicity, facilitating more effective treatment. HAI is used in combination with systemic chemotherapy and can be considered in several clinical scenarios, including adjuvant therapy, conversion of unresectable disease to resectable disease, and unresectable disease. Radiologists are key members of the multidisciplinary team involved in the selection and management of these patients with complex liver disease. As these devices begin to be used at more sites across the country, radiologists should become familiar with the guiding principles behind pump placement, expected imaging appearances of these devices, and potential associated complications. The authors provide an overview of HAI therapy, with a focus on the key imaging findings associated with this treatment that radiologists may encounter. ©RSNA, 2021.
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Affiliation(s)
- Kyle J Napier
- From the Departments of Radiology (K.J.N., O.G.J., B.W.T.) and Surgery (M.E.L.), Duke University Medical Center, Box 3808, Durham, NC 27710
| | - Michael E Lidsky
- From the Departments of Radiology (K.J.N., O.G.J., B.W.T.) and Surgery (M.E.L.), Duke University Medical Center, Box 3808, Durham, NC 27710
| | - Olga G James
- From the Departments of Radiology (K.J.N., O.G.J., B.W.T.) and Surgery (M.E.L.), Duke University Medical Center, Box 3808, Durham, NC 27710
| | - Benjamin Wildman-Tobriner
- From the Departments of Radiology (K.J.N., O.G.J., B.W.T.) and Surgery (M.E.L.), Duke University Medical Center, Box 3808, Durham, NC 27710
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Pietge H, Sánchez-Velázquez P, Akhoundova D, Siebenhüner A, Winder T, Bachmann H, Nguyen-Kim TDL, Breitenstein S, Knuth A, Petrowsky H, Pestalozzi B, Clavien PA, Samaras P. Combination of HAI-FUDR and Systemic Gemcitabine and Cisplatin in Unresectable Cholangiocarcinoma: A Dose Finding Single Center Study. Oncology 2021; 99:300-309. [PMID: 33657549 DOI: 10.1159/000512967] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 09/21/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND Unresectable cholangiocarcinoma has a poor prognosis and treatment options are limited. Combined systemic and intrahepatic chemotherapy may improve local control and enable downsizing. The aim of this study was to determine the maximum tolerated dose (MTD) of intravenous gemcitabine combined with intravenous cisplatin and hepatic arterial infusion (HAI) with floxuridine (FUDR) in patients with unresectable intrahepatic or hilar cholangiocarcinoma. METHODS Twelve patients were treated within a 3 + 3 dose escalation algorithm with 600, 800, or 1,000 mg/m2 gemcitabine and predefined doses of cisplatin 25 mg/m2 on days 1 and 8, q21, for 4 cycles, and FUDR 0.2 mg/kg on days 1-14 as continuous HAI, q28, for 3 cycles. Safety and toxicity as well as resectability rates after 3 months and preliminary survival data are reported. RESULTS The determined MTD for gemcitabine was 800 mg/m2. Dose limiting toxicities were neutropenic fever and biliary tract infections. In total, 27% of the patients showed partial remission and 73% stable disease. Although none of the patients achieved resectability after 3 months, the 3-year overall survival rate was 33%, median overall survival 23.9 months (range 1-49), and median progression-free survival 10.1 months (range 2-40). CONCLUSIONS Intravenous gemcitabine/cisplatin plus HAI-FUDR is feasible and appears effective for disease control. Larger prospective studies evaluating this triplet combination are warranted.
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Affiliation(s)
- Heike Pietge
- Department of Medical Oncology and Hematology, Division of Medical Oncology, University Hospital Zurich, Zurich, Switzerland
| | | | - Dilara Akhoundova
- Department of Medical Oncology and Hematology, Division of Medical Oncology, University Hospital Zurich, Zurich, Switzerland
| | - Alexander Siebenhüner
- Department of Medical Oncology and Hematology, Division of Medical Oncology, University Hospital Zurich, Zurich, Switzerland
| | - Thomas Winder
- Department of Medical Oncology and Hematology, Division of Medical Oncology, University Hospital Zurich, Zurich, Switzerland
| | - Helga Bachmann
- Department of Medical Oncology and Hematology, Division of Medical Oncology, University Hospital Zurich, Zurich, Switzerland
| | | | | | - Alexander Knuth
- Department of Medical Oncology and Hematology, Division of Medical Oncology, University Hospital Zurich, Zurich, Switzerland
| | - Henrik Petrowsky
- Department of General Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Bernhard Pestalozzi
- Department of Medical Oncology and Hematology, Division of Medical Oncology, University Hospital Zurich, Zurich, Switzerland
| | - Pierre-Alain Clavien
- Department of General Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Panagiotis Samaras
- Department of Medical Oncology and Hematology, Division of Medical Oncology, University Hospital Zurich, Zurich, Switzerland,
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Abstract
BACKGROUND The hepatic arterial infusion (HAI) pump is a treatment-delivery method based on the principle of targeting the tumor site directly and can be used alone or in combination with systemic chemotherapy. OBJECTIVES The intent of this article is to serve as a resource for oncology nurses to safely identify and manage HAI pump complications. These complications include seroma, flipped HAI pump, infection, changes in pressure and temperature, challenging access, dry pump, high residual volume, chemical hepatitis, risk of ulcer, and radiologic imaging considerations. METHODS The authors performed a literature review to provide a foundation for nurses to be able to manage HAI pump infusions. FINDINGS The literature review revealed minimal nursing resources to manage complications with an HAI pump. Resources to manage complications are crucial for safely administering medications and properly maintaining the function of the pump. Attention to patient education should be incorporated in nursing practice.
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Abstract
BACKGROUND Hepatic artery infusion pump (HAIP) use in chemotherapy started in the 1960s as a way to treat liver metastases that were not amendable to locoregional therapy or surgical resection. Because of complications and limited survival benefit, the use of HAIPs fell out of favor. A resurgence has occurred in the use of these pumps, but limited information is available in the literature guiding nursing care of these patients. OBJECTIVES The purpose of this study was to review the literature regarding the use, procedures, and nursing care of patients with HAIPs. METHODS A systematic literature review was conducted to obtain a comprehensive range of publications. FINDINGS Database searching resulted in 511 titles and abstracts. After eliminating duplicates and nonrelevant titles, 65 remained and were read in full. Of these, 20 were excluded because they did not fit the inclusion criteria.
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Affiliation(s)
- Lisa Parks
- Ohio State University Comprehensive Cancer Center-Arthur G. James Cancer Hospital and Richard J. Solove Research Institute in Columbus
| | - Meghan Routt
- Ohio State University Comprehensive Cancer Center-Arthur G. James Cancer Hospital and Richard J. Solove Research Institute in Columbus
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Subramanian M, Choti MA, Yopp AC. Hepatic Arterial Infusion Pump Chemotherapy for Colorectal Liver Metastases: Making a Comeback? Curr Colorectal Cancer Rep 2015. [DOI: 10.1007/s11888-015-0277-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Sahani DV, Bajwa MA, Andrabi Y, Bajpai S, Cusack JC. Current status of imaging and emerging techniques to evaluate liver metastases from colorectal carcinoma. Ann Surg. 2014;259:861-872. [PMID: 24509207 DOI: 10.1097/sla.0000000000000525] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Colorectal cancer is the third most common cancer diagnosed in both men and women in the United States. Liver is a common site of tumor spread and in approximately 30% of the cases; synchronous liver disease is present at the time of diagnosis. Early detection of liver metastases is crucial to appropriately select patients who may benefit from hepatic resection among those needing chemotherapy, to improve 5-year survival. Advances in imaging techniques have contributed greatly to the management of these patients. Multidetector computed tomography is the most useful test for initial staging and in posttreatment surveillance settings. Magnetic resonance imaging is considered superior to multidetector computed tomography and positron emission tomography for the detection and characterization of small lesions and for liver evaluation in the presence of background fatty liver changes. Positron emission tomography-computed tomography has a problem-solving role in the detection of distant metastasis and in posttreatment evaluation. The advanced imaging methods also serve a role in selecting appropriate patients for radiologically targeted therapies and in monitoring response to conventional and novel therapies.
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Abstract
INTRODUCTION Primary and secondary liver tumors resemble some of the most common causes of cancer and represent a major clinical problem owing to the poor prognosis. First-line therapeutic concepts are mainly based on surgical resection and/or systemic chemotherapy (SCT). However, many patients are not suitable for surgery or have failed SCT, although the total tumor load is still limited, which makes a regional therapy approach appealing. AREAS COVERED This review focuses on different types of transarterial instillation of chemotherapy, which encompasses conventional and drug-eluting transarterial chemoembolization (TACE), hepatic arterial infusion (HAI) chemotherapy and isolated hepatic perfusion (ILP). EXPERT OPINION TACE can be regarded as the treatment of choice in patients with multinodular hepatocellular carcinoma, but it should still be performed as a lipiodol-based regimen, while the value of doxorubicin-eluting beads needs to be exploited in further randomized controlled trials (RCTs). For patients with colorectal liver metastases, HAI chemotherapy has been challenged by the advent of more effective SCT, but encouraging results have been observed for the combination of the most recent, active drugs given by means of HAI with SCT. Nevertheless, data from RCTs comparing SCT with this transarterial regional therapy approach, as well as with TACE and ILP, are urgently needed.
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Affiliation(s)
- Oliver Dudeck
- Department of Radiology and Nuclear Medicine, University of Magdeburg, Magdeburg, Germany.
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