Pumped Up: Implanted Chemotherapy Device Improves Survival when Colorectal Cancer Spreads to the Liver

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Image of liver with tumors

This image shows a reconstructed CT scan of a liver. The yellow spots are metastases from a primary colorectal cancer.

The largest retrospective study ever done on a chemotherapy delivery approach called hepatic arterial infusion (HAI) has shown that this treatment extends survival by about two years when used in addition to systemic chemotherapy. Published in the Journal of Clinical Oncology (JCO), the study looked back at patients who were able to undergo surgical removal of colorectal cancer that had spread to the liver. It included patients treated at Memorial Sloan Kettering over a 20-year period.

“This is not a treatment that many other hospitals are using,” says study co-author Nancy Kemeny, an MSK medical oncologist who helped develop the current procedure for using HAI and who has been a proponent of the therapy for decades. “We get patients coming here from all over because they’ve heard about our expertise with this treatment.”

Colon and rectal cancers, which together affect more than 135,000 people in the United States every year, are often curable when caught early, but when they spread, they are much more difficult to treat.

Priming the Pump

HAI employs a pump about the size and shape of a hockey puck that’s surgically implanted in the abdomen and delivers chemotherapy directly to the liver. The pump is placed under the skin between the ribs and pelvis. It is then connected to the hepatic artery, which supplies blood to the liver, and especially to liver tumors. The pump is usually inserted at the same time a patient has surgery to remove tumors in the liver. HAI is called an adjuvant treatment, and it provides a way to offer extra cancer-fighting power and eliminate any residual disease.

We get patients coming here from all over because they've heard about our expertise with this treatment.
Nancy E. Kemeny medical oncologist

The pump also may be used to try to shrink large tumors or reduce the number of tumors, with the hope that they can then be surgically removed. Patients who receive chemotherapy through the pump also get systemic treatments, such as chemotherapy and targeted therapies, given by IV.

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Providing a Survival Advantage

VIDEO08:00
Medical oncologist Nancy Kemeny reviews evidence for HAI in extending survival and improving quality of life for patients with colorectal cancer and liver metastases.
Video Details

The JCO study looked at all the patients who underwent surgery at MSK between 1992 and 2012 to remove liver metastases from colorectal cancers — 2,368 people in total. Analysis showed that the median survival for patients who received the adjuvant HAI therapy was 67 months, versus 44 months for those who had standard systemic chemotherapy alone. Five-year survival was 53% in the pump group compared with 38% in those who got systemic chemotherapy alone. Ten-year survival rates were 38% and 23%, respectively.

“What’s especially noteworthy about this study is that the patients who got the HAI pump tended to be worse off before the treatment,” says MSK surgeon Michael D’Angelica, the senior author of the study. “They were sicker overall and had a greater number of metastases. Yet they still had a survival that was, on average, almost two years longer.”

The reported five-year survival in this study takes into account all the patients who underwent liver surgery for colorectal metastases during the 20-year period, but since 2003, there have been new systemic chemotherapy agents developed that have further improved survival. Another study conducted by Dr. Kemeny, which was recently published in the Journal of Surgical Oncology, reported an overall five-year survival of 78% for patients whose treatment plans included HAI plus the newer systemic chemotherapy agents after liver surgery.

Dr. D’Angelica adds that because the chemotherapy in the pump is completely taken up by the liver, there are no significant additional side effects. “The drugs from the pump are biochemically isolated in the liver, which allows us to give them in combination with other systemic drugs,” he says.

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Spreading the Word

Recently, medical and surgical oncologists from several institutions throughout the United States and Europe have visited MSK to learn about HAI pump therapy. They spent time with Dr. Kemeny and the hepatobiliary surgeons in the clinic and operating room to learn how to manage the pump. “These physicians from other centers are now starting pump programs at their own institutions,” Dr. Kemeny says.

One big caveat to the study’s findings, Dr. D’Angelica says, is that in order for the HAI pump to become part of the standard of care, it would need to be studied in a controlled, randomized trial comparing the two regimens. “The findings are exciting because the differences in outcome are not small, and they are not subtle,” he says. “The evidence is about as strong as you can get without doing a randomized trial.”

The HAI pump is also being studied in intrahepatic cholangiocarcinoma, a type of cancer originating in the liver that is becoming more common. “We see a doubling of response rate in patients with unresectable disease who also get the pump versus those who get systemic chemotherapy alone,” Dr. D’Angelica says. MSK is currently studying this treatment in a phase II trial.

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Comments

Dear MSK

Thank you for your article. Which chemo agent you are delivering through the pump? Thank you, Marilyn

Dear Marilyn, the chemotherapy drug used in the pump is FUDR (also called floxuridine). Thank you for your comment.

Would like further discussion on hai treatment for colon cancer with liver mets article by Nancy kemeny would like to send recent cat scan to you currently using irroctecan and f 5 u chemo need further info on where to send info

How does HAI compare with TACE ? What is the duration of treatment with the HAI pump?

Dear Dawn, with HAI, high doses of chemotherapy are delivered directly to the liver. TACE is an interventional radiology procedure in which blood flow to the liver is cut off by blocking the blood vessels. This restricts the tumor’s blood supply and makes it harder for the tumor to grow.

The HAI pump is often left in a for a few years, although chemotherapy is usually not used the whole time.

Thank you for your comment.

I am currently Stage 3b colorectal cancer victim, they have found spots on my liver (4) very tiny but seem to be growing .. I am currently at UNC Chapel Hill but have been told that MSK is cutting edge and we called for Appt and we are waiting for Biopsy done on Friday .. i live in North Carolina , if I am accepted will you coordinate with my Drs: Here ? And how does this work logistically ? Do I come up there once a month or stay there ?Just trying to prepare and hopefully you can answer some questions Thank you so much

Dear Gray, we’re sorry to hear you’re going through this. The experts with our Patient Access Service should be able to answer your questions. They can be reached at 800-525-2225. Thank you for your comment, and best wishes to you.

Hi.
I have stage four colon cancer. Would this treatment work for someone with my diagnosis? Or have you found this to be more effective before it spreads to lymph nodes?
Thank you

Dear Kay, we’re sorry to hear about your diagnosis. This procedure was developed to treat stage 4 colorectal cancer that has spread to the liver. If you would like to make an appointment to learn more, you can call 800-525-2225 or go to https://www.mskcc.org/experience/become-patient/appointment for more information or to make an appointment online. Thank you for your comment, and best wishes to you.

If HAI would help me, is it possible to start after already getting FOLFOX plus Avastin for 11 treatments? I just saw an oral surgeon who won't pull teeth due to possible necropsy from Avastin/Fusilev side effects. Would that also apply here?

Dear Karen, we are not able to answer individual medical questions or make treatment recommendations on MSK’s blog. If you would like to arrange a consultation with one of our experts to discuss this, you can call 800-525-2225 or go to https://www.mskcc.org/experience/become-patient/appointment to schedule online or find more information about making an appointment. Thank you for your comment, and best wishes to you.

My sister, age 65, has rectosigmoid cancer with widespread liver mets. Not a candidate for liver resection. What are the results with hepatic artery infusion without liver resection? Thank you

Dear Charles, we’re sorry to hear about your sister’s disease. We do offer hepatic artery infusion for people who do not qualify for liver resection. The outcomes vary depending on a number of factors. If your sister would like to come to MSK for a consultation, she can call 800-525-2225 or go to https://www.mskcc.org/experience/become-patient/appointment for more information on making an appointment. Thank you for your comment and best wishes to both of you.

Can you do the hai pump if you also have 2 lung mets?

Dear Isabel, this treatment would not be offered to someone who has metastases in their lungs. If you are interested in speaking with an MSK expert about what other treatment options may be available, you can call 800-525-2225 or go to https://www.mskcc.org/experience/become-patient/appointment for more information on making an appointment. Thank you for your comment, and best wishes to you.

I have read these HAI pumps have been discontinued. Is the accurate?

Dear Kyle, due to changes in the plans for manufacture of both pumps and catheters (the tube that attaches the pump to the liver), we have an investigational protocol where we are investigating a new pump and catheter combination that still provides access to pumps for appropriate patients. Some pumps using catheter combinations that have been evaluated previously are still available for placement as well. These options can be discussed with the patient’s treating physician. We continue to provide pumps to patients in which this treatment is recommended as the best option.

Hi, I was diagnosed with stage IV colon cancer with Mets to the liver. I was told that I have innumerable tumors( too many to count) on my liver. I am currently doing chemo just finished my 6th round.
Would I be eligible for the pump?

Dear Daryllyn, we’re sorry to hear about your diagnosis. if you are interested in arranging a consultation with an expert at MSK to learn about your treatment options for liver metastases, you can make an appointment online or call 800-525-2225. Thank you for your comment and best wishes to you.

Just found out I have colon cancer which has spread to my liver. Had at least 4 masses. Biopsy was done. Said metastic adenocarcinoma of probable gastrointestinal origin. Stains for CDX2, CK20 and villin are positive. While CK7 is negative.Not sure what I should do. I am on medicare/medicaid with very little income. Would I be accepted at your hospital? Thanks so much

Dear Deborah, we’re sorry to hear about your diagnosis. if you are interested in arranging a consultation with an expert at MSK to learn about your treatment options , you can make an appointment online or call 800-525-2225.

Hospital and physician services at Memorial Sloan Kettering are covered by standard Medicare insurance. 

You can learn more here:

https://www.mskcc.org/insurance-assistance/insurance-information/medicare-medicaid

In addition, MSK does offer financial assistance in certain cases. Thank you for your comment and best wishes to you.

My husband is in the diagnostic process for primary liver cancer that has not spread. The MRI was not clear. They were looking for HCC but instead it looks like ICCA. There is one 10cm tumor and one 1.7 cm satelite tumor. So a biopsy has been scheduled for next week. He is adamantly against systemic but will consider Y90 or HAI if eligible. Prominent and borderline enlarged periportal nodes are indeterminate. So possible stage IVa. He is 69, good health considering.

Hello,
I am currently a stage 4 colon cancer patient on neo-adjuvent FULFOX + cetuxizumab for evaluation after 6 cycles and resolution of the eccentric thickening of the sigmoid colon.
I have multiple metastatic liver lesions for example the lesion in segment 6 of the liver measures 2x1.8cm previously measuring 5x4cm, the lesion at the liver dome has also decreased in size now measuring 2x1.7cm previously measuring 4.5x4.4cm.
I live in Lebanon and in the hospital that I am treated in (American university of the Beirut -AUB) the tumor board took decision to do a liver operation to remove the lesions in the liver on 1 AUGUST 2019.
Would this treatment (HAI) work for someone with my diagnosis ?
and do you support the decision they took to do the surgery?
Please I really need your opinion
THANK YOU !