hepatobiliary

Question 1

Successful resection generally requires:

Answer 1

preserving 2 contiguous functional liver segments

with adequate inflow, outflow, and biliary drainage

Question 2

unresectable mCRC

Answer 2

Cases that require resection of all 3 hepatic veins, both portal veins, or the retrohepatic vena cava to achieve negative margins

Question 3

Resect liver mets with unresectable diesease elsewhere?

Answer 3

No

Van Cutsem E, Cervantes A, Adam R, et al. ESMO consensus guidelines for the management of patients with metastatic colorectal cancer. Ann Oncol. 2016;27:1386-1422

Question 4

Is there an established benefit to chemo after complete resection of liver CRC mets?

Answer 4

No

Khoo E, O’Neill S, Brown E, et al. Systematic review of systemic adjuvant, neoadjuvant and perioperative chemotherapy for resectable colorectal-liver metastases. HPB (Oxford). 2016;18:485-493

Question 5

phase 2 CELIM trial

Answer 5

first-line cetuximab with FOLFOX or FOLFIRI in 111 patients with unresectable CRLM.

objective response rate (ORR) was 66%, and 36 patients (34%) were able to ultimately undergo complete resection of liver metastase

Question 6

The phase 2 OLIVIA trial

Answer 6

Overall tumor response rates were 81% and 62%, respectively, in the bevacizumab/FOLFOXIRI and bevacizumab/mFOLFOX-6 groups; complete resection rates were 49% and 23%, respectively. Toxicity was high, however, with 95% of patients in the bevacizumab/FOLFOXIRI group and 84% in the bevacizumab/mFOLFOX-6 group

Question 7

Collision trial

Answer 7

The ongoing prospective, randomized, phase 3 COLLISION trial is comparing surgery versus thermal ablation (RFA or MWA) in 618 patients with CRLM and at least 1 target lesion measuring 3 cm or less; the primary endpoint is OS

Question 8

Indications for radioembolization for liver CRC

Answer 8

Radioembolization is recommended for patients with bulky and/or bilobar liver metastases who are not candidates for resection or ablation

Question 9

outcomes for radioembolization for liver CRC

Answer 9

It is associated with improved hepatic response and prolonged PFS, but it does not appear to extend survival.

Question 10

toxicity for radioembolization for liver CRC

Answer 10

low

Question 11

Technical aspects of hepatic artery infusion

Answer 11

The HAI delivery system involves a pump implanted within the abdominal wall and a catheter introduced through the gastroduodenal artery.[21] The pump is tested to verify the absence of extrahepatic perfusion prior to treatment.[21]

Question 12

The phase 3 CALGB 9481 trial

Answer 12

only randomized head-to-head comparison to date of HAI chemotherapy (alone) versus systemic chemotherapy in unresectable CRLM.

Question 13

Outcomes in CALGB 9481

Answer 13

Compared with systemic chemotherapy, HAI-delivered chemotherapy significantly improved OS, ORR, and time to hepatic progression.

Question 14

Flaw, or problem with CALBG 9481

Answer 14

Time to extrahepatic progression, was significantly shorter following HAI. Now given concurrently with systemic chemo.

Question 15

Complications of hepatic artery infusion

Answer 15

MSKCC data: (22%) experienced 1 or more pump-related complications. Approximately one-half of complications involved the hepatic arterial system, most commonly arterial thrombosis (n = 33), extrahepatic perfusion (n = 16), and incomplete hepatic perfusion (n = 12). A significant fraction occur late and a significant fraction are salvageable.

Question 16

most clinically significant complication of hepatic artery infusion:

Answer 16

In the adjuvant HAI cohort, biliary sclerosis was associated with abnormal postoperative flow scans, postoperative infectious complications, and larger doses of FUDR per cycle. No cases of biliary sclerosis were directly fatal, and the complication did not adversely affect survival. The median survival for those without and with biliary sclerosis was 47.2 months and 61.0 months, respectively (P = .316)