Hepatic arterial infusion pump chemotherapy for colorectal liver metastases: an old technology in a new era

Aggressive treatment of colorectal cancer (CRC) liver metastases can yield long-term survival and cure. Unfortunately, most patients present with technically unresectable metastases; conventional therapy in such patients consists of systemic therapy. Despite advances in the effectiveness of systemic therapy in the first-line setting, the tumour response rate and median survival remain low in the second-line setting. The preferential blood supply from the hepatic artery to CRC liver metastases allows for excellent regional delivery of chemotherapy. Here, we review efficacy and safety data for hepatic artery infusion (HAI) pump chemotherapy in patients with metastatic CRC from the 5-fluorouracil era and from the era of modern chemotherapy. In selected patients with liver-only or liver-dominant disease who have progressed on first-line chemotherapy, HAI combined with systemic agents is a viable therapeutic option when performed at experienced centres. Furthermore, significantly improved survival has been demonstrated with adjuvant HAI therapy after liver resection in the phase III setting. The complication rates and local toxicities associated with HAI pump therapy are infrequent at experienced centres and can be managed with careful follow-up and early intervention. The major obstacles to the wide adoption of HAI therapy include technical expertise for pump insertion and maintenance, and for floxuridine dose modification. The creation of formal preceptor-focused education and training in HAI therapy for interdisciplinary medical professionals might encourage the creation and expansion of this liver-directed approach.