CIO 2021-7 Recent Advances and Future Directions in Locoregional Therapy for Colorectal Cancer with Liver Metastasis

Purpose: Colon cancer is the third most common cancer worldwide, and half of patients with colon cancer will develop liver metastasis. In the past decade, a number of locoregional approaches, including transarterial chemoembolization (TACE), transarterial radioembolization (TARE), and ablation have demonstrated high rates of disease control and superior survival compared to systemic chemotherapy in patients with unresectable, chemorefractory colorectal cancer with liver metastasis. We provide a review of the indications and contraindications for locoregional therapy, preprocedural considerations, technical aspects, and postprocedural care in these patients, paired with outcome data from the latest clinical trials, recent advances, and future directions.

Material and Methods: A literature review of clinical trials of TACE, TARE, and ablation in colorectal cancer with liver metastasis was performed. Progression-free survival and overall survival data from these trials are presented, accompanied by an overview of procedure details. Recent advances and future directions are highlighted.

Results: Locoregional therapies are indicated in colorectal cancer with liver metastasis after failure of resection and systemic chemotherapy. Interest in TACE was spurred by the results of a 2012 study by Fiorentini et al. demonstrating the superiority of irinotecan drug-eluting beads (DEBIRI) versus FOLFIRI (systemic irinotecan, fluorouracil, and leucovorin) in terms of overall survival (OS) and progression free survival (PFS). Regarding TARE, recent studies show improved OS, PFS, and downstaging when TARE is combined with systemic chemotherapy. Recent trials using ablation demonstrate similar outcomes to resection in tumors <3cm with adequate margins (>5mm). Compared to systemic chemotherapy alone, ablation plus chemotherapy is associated with increased OS and PFS. Finally, future directions for locoregional therapy in colorectal cancer with liver metastasis, including irreversible electroporation and microwave ablation, show promise moving forward.

Conclusions: Recent trial data suggests that locoregional approaches including TACE, TARE, and ablation can offer a survival benefit to patients with colorectal cancer with liver metastasis. In particular, DEBIRI has emerged as a promising option for unresectable patients who have failed chemotherapy. Further, emerging data highlight the benefits of combining TARE and ablation with systemic chemotherapy.