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Chemosaturation with Percutaneous Hepatic Perfusion in Unresectable Hepatic Metastases Evan S

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Chemosaturation with Percutaneous Hepatic Perfusion in Unresectable Hepatic Metastases Evan S Special Report Chemosaturation With Percutaneous Hepatic Perfusion in Unresectable Hepatic Metastases Evan S. Glazer, MD, PhD, and Jonathan S. Zager, MD Background: In patients with hepatic metastases from solid-organ malignancies, surgical resection may be a potentially curative option, but it is not possible in most cases. Chemosaturation with percutaneous hepatic perfusion was developed for the management of unresectable metastases to the liver. Methods: Relevant medical literature was summarized with regard to the outcomes and limitations of che- mosaturation with percutaneous hepatic perfusion. Results: Six articles were identified that contained data on 91 individuals who received chemosaturation with percutaneous hepatic perfusion. More than 60% of these study patients were diagnosed with ocular melanoma. The overall response rate was 48% and the rate of disease control was 90%. Chemosaturation with percutaneous hepatic perfusion improved the rates of overall and hepatic progression-free survival (PFS). The data are limited but suggest that the rate of PFS was improved in study patients with isolated melanoma hepatic metastases who received chemosaturation with percutaneous hepatic perfusion compared with those assigned to standard care. Conclusions: Our results suggest that chemosaturation with percutaneous hepatic perfusion produces favor- able tumor response rates in select individuals with unresectable hepatic metastases from multiple primary cancers, particularly ocular and cutaneous melanomas. Data from a single randomized clinical trial have also shown that chemosaturation with percutaneous hepatic perfusion can affect hepatic PFS in certain patients. Introduction primary cancer.4 The rate of median survival in per- Hepatic metastases from solid-organ malignancies sons with hepatic metastases from ocular melanoma portend a poor prognosis in most cases and are an im- is less than 9 months.5 Hepatic metastases will devel- portant determinant to survival.1-3 Complete surgical op in 20% to 40% of individuals with colorectal can- resection might represent a curative option in patients cer; the median survival rate in these cases is approxi- with isolated hepatic metastases, but resection is not mately 2 years.2,6 Neuroendocrine tumors metastasize possible in most patients because of the number, loca- to the liver in 25% to 90% of individuals, and the tion, or size of the hepatic metastases. Likewise, poor 5-year survival rate of those with liver metastases is hepatic functional reserve limits standard therapeutic 40% compared with a rate that exceeds 75% in those options such as resection. whose cancer does not metastasize to the liver.1 He- The liver is the predominant site of metastasis for patic metastases can also co-occur with many other ocular melanoma, colorectal cancer, and gastrointes- malignancies, such as breast cancer, renal cell cancer, tinal neuroendocrine tumors.1-3 In persons with ocu- cutaneous melanoma, and soft-tissue sarcoma.7,8 For lar melanoma, the sole site of metastatic disease in up patients with unresectable liver-dominant disease, to 50% of individuals is the liver after treatment of the multiple strategies for liver-directed therapy have been developed, including hepatic artery chemoem- bolization, radioactive bead embolization, hepatic ar- From the Department of Cutaneous Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida. terial infusion, isolated hepatic infusion, and chemo- 3 Submitted April 12, 2016; accepted June 24, 2016. saturation with percutaneous hepatic perfusion. Address correspondence to Jonathan S. Zager, MD, Department of In Europe, chemosaturation with percutaneous Cutaneous Oncology, Moffitt Cancer Center, 10920 North McKinley hepatic perfusion was commercially launched in 2012, Drive, Room 4123, Tampa, FL 33612. E-mail: Jonathan.Zager@Mof- and a second-generation, high-efficiency filter was ap- fitt.org proved for use in conjunction with a proprietary he- Dr Glazer is now affiliated with the Division of Surgical Oncology 3,9 in the Department of Surgery at the University of Tennessee Health patic delivery system that same year. However, the Sciences Center, Memphis, Tennessee. US Food and Drug Administration has not approved Dr Zager serves on the medical advisory board for Delcath. Dr Glaz- chemosaturation with percutaneous hepatic perfusion er reports no significant relationship with the companies/organiza- tions whose products or services may be referenced in this article. for use in the United States. This article describes therapy not approved by the US Food and Chemosaturation with percutaneous hepatic per- Drug Administration. fusion is a minimally invasive, repeatable, regional 96 Cancer Control January 2017, Vol. 24, No. 1 therapy in which a high dose of melphalan is direct- flow from the proper hepatic artery. If the catheter is ly infused into the liver via the hepatic artery using a placed in the common hepatic artery, or there is back percutaneous approach.3,9,10 The liver is isolated from flow into the gastroduodenal artery, then the gastrodu- the systemic circulation by a double-balloon catheter odenal artery is embolized to avoid the systemic circu- inserted through the femoral vein. Chemotherapy-in- lation of chemotherapy. Likewise, unnamed collaterals fused blood is then diverted through the arterial cath- or other noncritical arteries are also embolized. Iden- eter via an extracorporeal pump circulation and is then tification of accessory or replaced hepatic arteries are filtered and returned to the patient via venovenous by- identified (if not done so already) and used for hepatic pass and the jugular vein. chemoperfusion if needed. Blood from the hepatic veins then exits the liver Methods through a channel in the multilumen catheter and is Authors reporting on the utility of percutaneous hepat- extracorporeally filtered before it is returned to the cir- ic perfusion for any malignancy met our inclusion crite- culation to limit systemic toxicity from chemotherapy. ria. Only literature written in English was reviewed. If The second-generation extracorporeal filtration system data were reported in combination with other hepatic- extracts greater than 90% of melphalan before return- directed therapies, only the data reported for chemo- ing the filtered blood back to the patient through the saturation with percutaneous hepatic perfusion were internal jugular vein to minimize systemic drug deliv- included. Exclusion criteria included 5 or fewer case pa- ery and the associated adverse effects.15 tients or data not evaluated in a peer-reviewed fashion. The procedure is described elsewhere in detail, For literature from the same institution, original but high-dose melphalan 3 mg/kg is administered deidentified data were requested to remove duplicate unless dose-limiting toxicities have been previously study patients from multiple reports. Once all study pa- demonstrated.7,10 All procedures are performed under tients were determined to be unique, we analyzed the general anesthesia with heparin-induced systemic an- response and disease control rates. The authors of each ticoagulation performed after catheterizations. Prior individual report determined the response rate. We de- to introducing chemotherapy, contrast angiography fined the disease control rate as the summation of com- is obtained of all the isolated sections to confirm the plete response, partial response, and stable disease. absence of leakage and to verify isolation from the systemic circulation. Melphalan is administered to Literature Review the liver in a split fashion by advancing the hepatic We identified 6 articles from the medical litera- artery catheter into the left and right hepatic arteries. ture.7,8,10-13 The report from Abbot et al11 is an update Unless anatomical variations exist, 60% of the drug is of the study results from Forster et al,7 so these data are given via the right hepatic artery and 40% is given via combined in our review. Likewise, some study patients the left hepatic artery. Treatment is administered for reported in Hughes et al10 were included in Abbot 30 minutes, followed by an additional 30 minutes of et al,11 so we also omitted those case patients from in- venovenous bypass to allow for melphalan washout. clusion in our review of the results from Abbot et al11 During the treatment, patients undergo clinically sig- and Forster et al.7 No data from Pingpank et al14 were nificant changes in pulse and blood pressure that re- utilized because this report included preliminary re- quire aggressive support with intravenous fluids and sults from a randomized control trial eventually pub- vasoactive drugs such as phenylephrine, norepineph- lished by Hughes et al.10 rine, and vasopressin. This is especially the case early on during the procedure when the filters are opened, Procedural Details and Management and vasoactive support is weaned off as the procedure Chemosaturation with percutaneous hepatic perfu- continues. After the procedure is completed, prot- sion is performed in an interventional radiology suite amine is used to reverse heparin. or operating room with imaging capability under gen- Catheters and intravascular sheaths are removed eral anesthesia (Fig). A catheter is first manipulated after baseline laboratory blood values (complete blood into the hepatic artery via the femoral artery followed count, platelet count, activated clotting time, prothrom- by catheterization of the internal jugular and femo- bin time, and partial thromboplastin
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