Dr. Nancy E. Kemeny
Journal: Journal of Clinical Oncology
Purpose: To investigate whether perioperative hepatic arterial infusion (HAI) pump chemotherapy was associated with overall survival (OS) in patients who had a complete resection of colorectal liver metastases (CLM).
Methods: Patients who underwent a complete resection of CLM between 1992 and 2012 were included from a single-center prospectively maintained database. All patients who received HAI pump chemotherapy also received perioperative systemic chemotherapy. Propensity score analysis was used to match patients for seven known prognostic factors.
Results: A total of 2,368 consecutive patients underwent a complete resection of CLM, with a median follow-up of 55 months. The median OS for patients with HAI pump chemotherapy (n = 785) was 67 months versus 44 months without (n = 1,583; p < 0.001), despite more advanced disease in the HAI pump chemotherapy group. OS at 10 years was 38.0% versus 23.8% without HAI pump chemotherapy. For patients who received modern systemic chemotherapy (n = 1,442), the median OS was 67 months with HAI pump chemotherapy and 47 months without (p < 0.001). The hazard ratio adjusted by propensity score demonstrated longer OS with HAI pump chemotherapy: 0.67 (95% CI, 0.59 to 0.76; p < 0.001). A pronounced difference in median OS was found for patients with node-negative colorectal cancer (129 months with HAI pump chemotherapy vs. 51 months without; p < 0.001) and a low clinical risk score of 0 to 2 points (89 months with HAI pump chemotherapy vs. 53 months without; p < 0.001).
Dr. Bas Groot Koerkamp
Bas Groot Koerkamp, MD, PhD, and Nancy E. Kemeny, MD, FASCO, Memorial Sloan Kettering Cancer Center
Q: Were the results of your study surprising?
Dr. Groot Koerkamp: Many assumed that mostly patients with more advanced disease (e.g., > 10 lesions or node-positive colorectal cancer) benefit from adjuvant HAI pump chemotherapy. The surprising result was that particularly patients with less advanced disease appeared to benefit from adjuvant HAI pump chemotherapy. This was most striking in 908 patients with node-negative colorectal cancer with a median OS of 51 months without and 129 months with adjuvant HAI pump chemotherapy.
Q: How does your study serve to improve treatment going forward?
Dr. Kemeny: Given the greatly improved survival outcomes possible today, we recommend that patients with resectable disease should undergo resection and see a multidisciplinary team of cancer care experts to consider HAI pump chemotherapy. It is a complex treatment protocol that requires skill and experience. Surgical pump placement after resection requires learning about 25 procedures; avoiding biliary toxicity requires intensive management by a medical oncologist; and nuclear medicine specialists, interventional radiologists, and gastroenterologists should also be involved to manage potential complications such as bleeding or ulcer disease.
Dr. Groot Koerkamp: Many considered HAI pump chemotherapy obsolete with the introduction of more effective modern systemic chemotherapy (i.e., irinotecan and oxaliplatin). We found that patients who received both modern systemic and HAI pump chemotherapy had a median OS of 67 months versus 47 months with systemic chemotherapy alone. Going forward, we recommend that patients should be considered to receive both adjuvant systemic and HAI pump chemotherapy. A randomized controlled trial is set up in the Netherlands.
Q: Have you seen any significant changes in treatment decisions in the wake of your study?
Dr. Groot Koerkamp: It is too early to determine how this study will influence guidelines. However, several centers in the United States and the European Union have started or will start treating patients with adjuvant HAI pump chemotherapy based on our study.