Transarterial Chemoembolization Using DEBIRI for Treatment of Hepatic Metastases from Colorectal Cancer

Background/Aim: Dismal survival rates of metastatic colorectal cancer (mCRC) to the liver have been recorded. Transarterial chemoembolization (TACE) with irinotecan eluting beads (DEBIRI) may be a safe palliative treatment with fewer serious adverse effects (SAEs). We aimed to establish the safety and efficacy of DEBIRI TACE in the treatment of hepatic metastases from colorectal cancer (CRC). Patients and Methods: A retrospective analysis of DEBIRI TACE was performed. Response was assessed using the m-RECIST criteria. The Common Terminology Criteria for Adverse Events (CTCAE v3.0) were used to record toxicity. Survival was estimated using Kaplan Meier analysis. Results: Twenty-eight patients treated with 47 DEBIRI TACE procedures were followed from September 2008 until February 2012. Twenty-two had metastases from colonic cancer and six metastases from rectal cancer; three patients (15%) had complete response, six (30%) partial response, four (20%) stable disease and disease progression was recorded in seven (35%); computer tomography (CT) scans were unavailable for eight patients. AEs included gastrointestinal and acid-base disturbances, hypertension, fever, insomnia, chest pain, pruritus, and neutropenia; five patients did not present AEs. The median time from diagnosis of liver metastases to initial DEBIRI treatment was 19.6 months. The median follow-up was 6.9 months. The median overall survival from first treatment was 13.3 months (95% confidence interval=6.8-19.8 months). Conclusion: DEBIRI is a well-tolerated treatment option that can be used safely in the palliative treatment of hepatic metastases from CRC. Worldwide incidence of colorectal cancer (CRC) is approximately 400,000 patients. Sixty percent of these patients will develop liver metastases, with the liver being the second most common site of disease after lymph nodes and the most common site of refractory progression (1, 2). In approximately 35% of patients with CRC, metastases are confined to the liver (3). The survival rates for patients with liver metastases from CRC are improving, but 5-year survival is still only approximately 19.2% (4). Surgical resection of the affected portion of the liver offers the best chance for disease-free and overall survival (5, 6). Unfortunately, most patients present with disease that is not amenable to resection or have other contraindications to surgery. It is estimated that only 15-30% of patients are surgical candidates at initial disease presentation (7), the vast majority being treated with systemic chemotherapy and other locoregional therapies, including transarterial chemotherapy, radioembolisation, radiofrequency ablation, and microwave ablation(2). The recent availability of active chemotherapeutic agents has doubled the median overall survival for patients with metastatic colorectal cancer from 10 to 20 months (8). The conventional first-line systemic chemotherapy for colorectal cancer usually includes FOLFOX (oxaliplatin, 5- fluorouracil and leucovorin) with or without bevacizumab, and can be interchanged with FOLFIRI (irinotecan, 5- fluorouracil and leucovorin), with or without bevacizumab, as second-line therapy. In patients without K-RAS mutations, third-line therapy typically involves the introduction of biological agents such as cetuximab to irinotecan-based regimens (9). Irinotecan belongs to a class of chemotherapy drugs known as topoisomerase inhibitors. It is derived from naturally-occurring plant alkaloids and is an active drug in the second-and third-line treatment of advanced CRC with systemic chemotherapy. These inhibitors are drugs that interfere with the action of topoisomerase enzymes controlling the structure of DNA necessary for replication. Transarterial chemoembolization has been shown to deliver high-dose chemotherapy directly to target lesions within the liver with minimal systemic side-effects. This