Hepatic Arterial Infusion

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Hepatic arterial infusion

Definition

Hepatic arterial infusion (HAI) therapy, delivers chemotherapeutic agents directly to the liver through a catheter placed in the hepatic artery. The hepatic artery is the main route of blood supply to liver tumors. HAI is also known as regional chemotherapy .

Purpose

Approximately 160, 000 patients are diagnosed with colon cancer in the U.S. each year. The cancer spreads to the liver in about 70 percent of those patients. For patients with colorectal liver metastases, tumor progression within the liver is typically the primary cause of death.

Systemic chemotherapy using various agents has some efficacy, but the side effects can have a profound negative impact on the patient's quality of life during treatment. HAI therapy may be an effective option because it delivers chemotherapy medication directly to the site of the tumor, making it appropriate as an alternative or adjuvant treatment to systemic chemotherapy. When metastases is limited to the liver, HAI with floxuridine (FUDR) or radioactive microspheres through an implantable pump under the skin or an external pump worn on the belt may be a better option than systemic chemotherapy.

HAI may extend life expectancy and reduce the chance that more liver tumors will develop.

Precautions

Strict aseptic techniques should be used to prevent infection during all procedures.
Pump flow rate will vary depending on factors such as body temperature, altitude, arterial pressure at the catheter tip, and solution viscosity.
Patients should not attempt to resterilize the pump.
The manufacturer's instructions should be followed regarding drug preparation, dosage, and administration.
FUDR should be used with added caution in patients with impaired liver or kidney function.

Systemic therapy should be considered for patients with disease known to extend beyond the area capable of being infused.

Description

HAI enhances cancer therapy by increasing drug delivery directly to the site of the tumor (the liver) while minimizing systemic drug exposure and side effects. Development of fully implanted infusion systems have allowed for long-term delivery of hepatic regional chemotherapy.

Benefits of HAI therapy:

yields higher tumor response rates and delays cancer progression
trend toward increased survival rates
enhances quality of life
reduced systemic side effects

Preparation

Patient selection criteria

Successful results depend on careful patient selection.

Candidates for HAI therapy should:

have primary liver cancer or liver metastases from primary colorectal cancer
show an absence of tumors outside the liver
have demonstrated portal vein patency
be a suitable surgical candidate
show no evidence of infection
be willing to participate in frequent pump refill appointments

Studies have demonstrated that patients with metastatic colorectal cancer who had liver disease only, had less than 70% of their liver involved with metastases, and had a good performance status responded best to HAI. When metastases are also located outside of the liver, HAI does not offer an advantage over systemic chemotherapy.

Aftercare

During the course of treatment, pump pocket infections occur rarely. At the first sign of infection at the pump pocket, systemic antibiotics need to be started. The pump needs to be moved to a new location in a newly created pocket if the infection does not resolve itself. The old pocket should be opened and drained.

Risks

The major problems with HAI are not surgical. They include gastritis, duodenitis, and biliary sclerosis.

Drug toxicity and medication side effects may occur. The most commonly reported side effects for FUDR are nausea and vomiting , diarrhea , and intestinal inflammation.

Other possible complications include:

arterial thromboses
catheter dislodgement
the catheter may erode through the wall of the duodenum when the pump has been in place for more than a year.
overdose or underdose of medication if certain conditions affect the rate at which the pump delivers medication, i.e. pump damage due to strenuous activity, high heat, or a change in air pressure.
disruption in therapy if the pump is damaged by improper handling or filling.

Normal results

Morbidity or mortality occurring as a result of this procedure should be close to zero. Appropriate selection of patients and new combinations of chemotherapy should provide at least a 70% response rate from HAI for the treatment of hepatic metastases from colorectal primary tumors. This response rate is at least twice that of current systemic chemotherapies.

When used in conjunction with traditional chemo-therapy, HAI therapy has been shown to extend life expectancy and reduce recurrence of liver tumors after two years for certain patients.

Abnormal results

Complications that can occur with surgery:

infection
fluid build up around the implant site
skin erosion over the site of the implant
incision breakdown
drugs may be delivered to organs other than the liver

Resources

PERIODICALS

Henderson, C.W. "Combined Criteria Predict Response to Hepatic Arterial Infusion Chemotherapy." Cancer Weekly (1 August 2000).

Venook, Alan, Betsy Althaus, et al. " Hepatic Arterial Infusion of Chemotherapy for Metastatic Colorectal Cancer." New England Journal of Medicine 342 no. 20 (18 May 2000): 1524.

Link, Karl H., Marko Kornmann, et al. " Thymidylate Synthase Quantitation and In Vitro Chemosensitivity Testing Predicts Responses and Survival of Patients with Isolated Nonresectable Liver Tumors Receiving Hepatic Arterial Infusion Chemotherapy." Cancer 89, no 12 (15 July 2000): 288-9.

Crystal Heather Kaczkowski, M.S.

KEY TERMS

Adjuvant treatment

—A treatment that is added to increase effectiveness of the first treatment.

Cancer

—A term for diseases in which abnormal cells divide without control. Cancer cells can invade nearby tissues and can spread through the bloodstream and lymphatic system to other parts of the body.

Catheter

—A flexible tube used to administer or withdraw fluids. During a course of chemotherapy, an indwelling catheter can be placed in a vein to administer intravenous fluids and chemotherapy. Catheters can stay in place for several weeks or months with proper care.