The state of regional therapy in the management of metastatic colorectal cancer to the liver

ABSTRACT

Colorectal cancer (CRC) is one of the leading causes of cancer-related mortality in the United States. Most colorectal cancer patients die from advanced disease, and two-thirds of CRC deaths are due to liver metastases. Liver resection provides the best curative option for patients with colorectal liver metastases (CRLM), yet only 20% of those patients are eligible for liver metastases resection for curative intent. Loco-regional treatment of CRLM may provide additional benefits in terms of down-staging for resection and prolonged hepatic disease control. This review focusses on hepatic arterial infusion, radioembolization and chemoembolization.

KEYWORDS:

• Regional therapy
• liver metastases
• hepatic artery infusion
• radioembolization
• chemoembolization

Key issues

• The liver is the most common colorectal cancer (CRC) metastatic site with two-thirds of CRC deaths due to liver metastases.

• While liver resection provides the best curative chance for patients with colorectal liver metastases (CRLM), only 20% of those patients are eligible for liver metastases resection for curative intent.

• Hepatic arterial infusion (HAI), chemoembolization, and radioembolization can be used in addressing CRLM that are not amenable to curative intent resection or ablation; these hepatic directed strategies are not considered curative but are associated with a high rate of hepatic disease control that can translate into improved overall survival.

• HAI chemotherapy offers high RRs and a more established track record of downstaging to resection but requires a specialized team and is best suited to select centers with experience with this procedure.

• When the goal of regional therapy is disease control or systemic chemotherapy deintensification, we find radioembolization to be most suitable given its safety profile and ease of administration.

• Chemoembolization via drug-eluting bead with irinotecan in CRLM is another option in the palliative and/or refractory setting, but the evidence to support its use as a standard of care in CRLM, particularly in the first- or second-line setting, is not firmly established.

• Application of any of these therapies depends on the clinical presentation and requires a multidisciplinary discussion.

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.