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World Journal of Surgery

, Volume 19, Issue 2, pp 246–251 | Cite as

Intraportal chemotherapy for colorectal hepatic metastases

  • Urban Th. Laffer
  • Urs Metzger
Article

Abstract

One-third of colorectal cancer patients suffer from liver metastases on initial diagnosis. Overt liver metastases appear to be the first site of relapse for 40% to 50% of the patients with operable disease. The fact that tumor cells can be discovered in the mesenteric blood during surgery may indicate that circulating tumor cells give rise to metastases. Experimental investigations have shown that metastatic tumors reaching a diameter of 5 to 7 mm are predominantly perfused by the arterial route, which explains the unsuccessful attempts to treat established liver metastases through the portal vein. However, because metastases in the liver presumably arise via blood flow through the portal vein, adjuvant intraportal chemotherapy might permit ready access of the drug to small liver deposits in a way that systemic chemotherapy might not. The interest in portal adjuvant cytotoxic liver infusion in radically resected colorectal cancer patients is based on an early publication by Taylor, who in 1979 reported on a significant reduction of the incidence of liver metastases in a group of patients randomly assigned to perioperative adjuvant portal infusion with 5-fluorouracil. Based on these results, several groups initiated prospective randomized trials comparing intraportal infusion of various regimens to surgery alone. Results of most of these trials have been published during the last few years. All but one demonstrate improved overall survival and disease-free survival and a reduction of the incidence of liver recurrences in the adjuvant-treated patient group. Ongoing meta-analyses of the randomized trial data may confirm this tendency soon.

Keywords

Liver Metastasis Circulate Tumor Cell Colorectal Cancer Patient Resected Colorectal Cancer Colorectal Hepatic Metastasis 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Résumé

Un tiers des patients atteints d'un cancer colorectal ont également des métastases hépatiques lorsqu'ils sont vus pour la première fois. Quarante à 50% de patients traités pour cancer colorectal avec intention de guérison récidivent avec des métastases hépatiques. La détection des cellules tumorales dans le sang du système porte est peut-être annonciateur de leur pouvoir de métastaser au niveau du foie par la suite. Des investigations expérimentales ont démontré que les tumeurs métastatiques ayant déjà atteint un diamètre de 5 à 7 mm sont essentiellement perfusées par voie artérielle. Ceci explique les essais infructueux de traiter par voie portale des métastases hépatiques établies. Comme ces métastases se «greffent» au niveau du foie par voie porte, cependant, une chimiothérapie adjuvante par voie porte pourrait influencer l'évolution des petites métastases hépatiques plus efficacement que par voie systémique. L'intérêt d'un traitement cytotoxique par voie porte après chirurgie à visée curatrice pour cancer colorectal est basé sur une publication de Taylor qui, en 1979, rapportait une réduction significative de l'incidence des métastases hépatiques chez des patients ayant eu de façon randomisée du 5-FU par voie porte dans la période périopératoire. D'après ces résultats, plusieurs groupes ont commencé des études randomisées comparant l'infusion intraportale de différentes combinaisons de chimiothérapie à la chirurgie seule. Les résultats de la plupart de ces études ont été publiés pendant ces dernières années et toutes sauf une ont démontré une amélioration de la survie globale et sans maladie ainsi qu'une réduction de l'incidence des métastases hépatiques dans le groupe traités par chimiothérapie. Les méta-analyses actuellement en cours vont peur-être confirmer cette tendance.

Resumen

La tercera parte de los pacientes con cáncer colorrectal exhibe metástasis hepáticas en el momento del diagnóstico. Evidentes metástasis en el hígado son el primer lugar de recidiva en 40% a 50% de los pacientes con enfermedad operable. El hecho de que se puedan hallar células tumorales en la sangre mesentérica en el curso de la cirugía puede ser indicativo de que sean las células circulantes as que dan lugar a las metástasis. Estudios experimentales han demostrado que los tumores metastásicos que llegan a diámetros entre 5 y 7 mm son predominantemente perfundidos por la ruta arterial. Esto explica los intentos fallidos de tratar las metástasis hepáticas establecidas a través de la vena porta. Sin embargo, puesto que las metástasis en el hígado presumiblemente se inician por vía del flujo sanguíneo de la vena porta, la quimioterapia intraportal coadyuvante podría permitir el fácil acceso de la droga a los depósitos hepáticos más pequeños en forma no puede ser lograda por la quimioterapia sistémica. El interés en la infusión portal citotóxica coadyuvante en el cáncer colorrectal radicalmente resecado se fundamenta en una publicación de Taylor quien, en 1979, reportó una reducción significativa de la incidencia de metástasis hepáticas en un grupo de pacientes aleatoriamente asignados a infusión portal perioperatoria coadyuvante con 5-Fluorouracilo. Con case en estos resultados, varios grupos han iniciado ensayos prospectivos y randomizados para compara diversos regímenes de infusión intraportal con cirugía sola. Los resultados de la mayoría de estos ensayos han sido publicados en los últimos pocos años y todos, menos uno, demuestran una majoría tanto en la sobrevida global como en la sobrevida libre de enfermedad, así como reducción en la incidencia de recurrencias hepáticas en los pacientes tratodos con la modalidad coadyuvante. Los metaanálisis de la información de los ensayos clínicos randomizados actualmente en progreso pueden confirmar pronto tal tendencia.

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Copyright information

© Société Internationale de Chirurgie 1995

Authors and Affiliations

  • Urban Th. Laffer
    • 1
  • Urs Metzger
    • 1
  1. 1.Surgical ClinicRegionalspitalBielSwitzerland

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