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What's Old Is New Again: Patients Receiving Hepatic Arterial Infusion Chemotherapy

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Fedricker D. Barber at University of Texas MD Anderson Cancer Center
Fedricker D. Barber
Lou Ellen Fabugais-Nazario
Lou Ellen Fabugais-Nazario
Lou Ellen Fabugais-Nazario
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Abstract

Hepatocellular carcinoma (HCC) ranks as the eighth most common cancer in the world. Although uncommon in North America, the incidence of HCC in the United States has increased by 70% since the 1980s (Yu, Yuan, Govindarajan, & Ross, 2000). The most frequent causes of malignant hepatic disease in the United States are metastases from melanoma and primary tumors of the gastrointestinal tract, breast, and lung. Surgical resection and systemic chemotherapy are the standard treatments for this disease. However, surgery is not an option for patients with advanced disease, and the response rate from systemic chemotherapy remains low. An alternative therapy for patients with HCC or cancers with liver metastases is hepatic arterial infusion of chemotherapy directly into the liver. This method allows a high total body clearance and hepatic extraction to generate high hepatic and low systemic exposures. Nursing care of patients receiving hepatic arterial infusion of chemotherapy includes patient education and monitoring for complications.
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CLINICAL JOURNAL OF ONCOLOGY NURSING • VOLUME 7, NUMBER 6 • HEPATIC ARTERIAL INFUSION CHEMOTHERAPY 647
F
EATURE
A
RTICLE
What’s Old Is New Again:
Patients Receiving
Hepatic Arterial Infusion Chemotherapy
Fedricker Diane Barber, RN, MSN, ANP, AOCN®, and Lou Ellen Fabugais-Nazario, RN, BSN
Hepatocellular carcinoma (HCC) ranks as the eighth most
common cancer in the world. Although uncommon in
North America, the incidence of HCC in the United States
has increased by 70% since the 1980s (Yu, Yuan, Govin-
darajan, & Ross, 2000). The most frequent causes of ma-
lignant hepatic disease in the United States are me-
tastases from melanoma and primary tumors of the gas-
trointestinal tract, breast, and lung. Surgical resection
and systemic chemotherapy are the standard treatments
for this disease. However, surgery is not an option for pa-
tients with advanced disease, and the response rate from
systemic chemotherapy remains low. An alternative
therapy for patients with HCC or cancers with liver me-
tastases is hepatic arterial infusion of chemotherapy di-
rectly into the liver. This method allows a high total body
clearance and hepatic extraction to generate high hepatic
and low systemic exposures. Nursing care of patients re-
ceiving hepatic arterial infusion of chemotherapy includes
patient education and monitoring for complications.
Key Words: carcinoma, hepatocellular; neoplasm metas-
tasis; infusions, intra-arterial
Submitted May 2003. Accepted for publica-
tion June 17, 2003. (Mention of specific
products and opinions related to those prod-
ucts do not indicate or imply endorsement by
the
Clinical Journal of Oncology Nursing
or
the Oncology Nursing Society.)
Digital Object Identifier: 10.1188/03.CJON.647-652
Hepatocellular carcinoma
(HCC) ranks as the
eighth most common
cancer in the world. Although
uncommon in North America,
the incidence of HCC in the
United States has increased by
70% since the 1980s (Yu, Yuan,
Govindarajan, & Ross, 2000).
Estimates suggest that approxi-
mately 17,300 people in the
United States will develop HCC
in 2003 (Jemal et al., 2003). Gen-
erally, the most frequent causes
of malignant hepatic disease in
the United States are metastases
from melanoma and primary tu-
mors of the gastrointestinal tract,
breast, and lung. Approximately
30% of patients with colorectal
cancer present with liver involve-
ment, and an additional 60% de-
velop liver metastases (Kemeny,
Kemeny, & Lawerence, 2000).
The liver is the initial site of me-
tastasis in 4% of breast cancers,
15% of lung cancers, and 24% of
melanomas (Kemeny et al.,
2000). Reviews of autopsy series
revealed that the prevalence of liver me-
tastases was 70% in patients with melanoma,
45%–60% in those with breast carcinoma,
and 30%–50% in those with lung carcinoma
(Gilbert & Kagan, 1976; Weiss, Grunder-
mann, & Torhorst, 1986).
The increased frequency of the liver as the
initial site of metastasis is thought to be caused
by the liver’s large blood supply, which origi-
nates from the portal and systemic systems.
Researchers have suggested that humoral fac-
tors that promote cell growth and cellular
factors such as adhesion molecules favor
metastatic spread to the liver (Kemperman,
Driessens, La Riviere, Meijne, & Roos, 1995;
Long, Nip, & Brodt, 1994). Others speculate
that the liver’s geographic proximity to other
intra-abdominal organs may facilitate malig-
nant infiltration by direct extension (Bhat-
tacharya, Rao, & Kowdley, 2002).
Surgical resection and systemic chemo-
therapy are standard treatments for hepatic
disease. However, surgery is not an option
for patients with advanced disease, and the
response rate from systemic chemotherapy
remains low (10%–30%) (Kemeny & Fata,
2001; Nagorney, van Heerden, Ilstrup, &
Adson, 1989). An alternative therapy for pa-
tients with HCC or metastatic liver cancer is
hepatic arterial infusion (HAI) chemother-
apy. HAI chemotherapy is the
infusion of a chemotherapeutic
drug through the hepatic artery
directly into the liver.
HAI chemotherapy has been
performed for more than 40
years as treatment for HCC and
hepatic metastases. In the early
1970s and 1980s, approximately
375 patients were enrolled in
randomized clinical trials com-
paring HAI therapy with sys-
temic chemotherapy in the treat-
ment of unresectable liver
metastases from colorectal can-
cer (Venook & Warren, 2001).
Researchers conducting early
trials found response rates of
more than 50% when compared
to systemic therapy. However,
HAI chemotherapy failed to
show a survival advantage
(Allen-Mersh, Earlam, Fordy, &
Houghton, 1994; Chang et al.,
1987; Hohn et al., 1989; Martin
et al., 1990; Rougier et al.,
1992). For example, Chang et al.
randomized 64 patients to HAI
of floxuridine (FUDR) versus
systemic FUDR and observed response rates
of 62% in the HAI group and 17% in the
systemic group. Two-year survivals were
not statistically significant (22% and 15%,
respectively). Another randomized trial con-
ducted by Martin et al. reported a response
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Article
  • Nov 1996
A number of articles have appeared in the medical literature regarding regional infusion chemotherapy for the treatment of metastatic colorectal carcinoma confined to the liver. The results and conclusions have been varied. A meta-analysis of the literature was undertaken to determine if regional infusion chemotherapy using either 5-fluorouracil or floxuridine (FUDR) confers a survival advantage over systemic chemotherapy for the treatment of this disease. A MEDLINE search was conducted encompassing the period from January 1976 to May 1995. The search was narrowed to include only articles that referenced prospective randomized clinical trials. A total of 149 articles or abstracts were reviewed for potential eligibility in this meta-analysis. Six articles met the current study inclusion criteria. One and 2-year survival rates for each treatment modality were directly retrieved from each study or calculated from the Kaplan-Meier survival curves that were presented. Prior to pooling the estimates of the treatment survival differences, a test was conducted for homogeneity of the treatment effect using the test statistic proposed by DerSimonian and Laird 1986. The fixed effect model was then used to obtain summary estimates of the survival differences from the group of studies. Regional infusion chemotherapy with FUDR produced a 10% (P = 0.041) and 6% (P = 0.124) increased survival at 1 and 2 years, respectively. Based on this meta-analysis, it appears that hepatic artery infusion chemotherapy confers a modest survival benefit over systemic chemotherapy. Whether this is clinically relevant depends on the quality rather than just the duration of survival.
View