APP understanding of hepatic arterial infusion pump function crucial for treatment success
Hepatic arterial infusion pump (HAIP) chemotherapy, developed in the 1980s, has shown efficacy as an advanced treatment option for primary and secondary hepatic malignancies.
However, due to limited expertise in the placement and management of HAIPs, few institutions utilize this cancer therapy.
As research continues to show benefits of HAIP chemotherapy and its use increases, it is important for APPs to understand how HAIP functions, its application in patients with colorectal liver metastases and complications related to the pump.
How HAIP functions
The HAIP is a programmable device that delivers chemotherapy via an implantable catheter. Chemotherapy enters the pump through the reservoir fill port and passes through the reservoir valve into the pump reservoir. At normal body temperatures, pressurized gas stored below the reservoir expands, exerting pressure on the reservoir. This allows the chemotherapy to flow through the catheter into the liver.
The HAIP can be placed in the operating room through an open approach or robotically. During surgery, the surgeon creates a subcutaneous pocket in the abdomen, often called a pump pocket. The surgeon places the pump in the pump pocket and sutures it to the abdominal fascia, then identifies the gastroduodenal artery and ligates all branches to prevent extrahepatic perfusion. Finally, the surgeon inserts a hepatic catheter into the gastroduodenal artery.
Taking the patient’s size and anatomy into account, the surgeon can place the pump in an upper or lower quadrant, or on the right or left, with the goal of making the pump easy to access. A cholecystectomy completed during placement can prevent cholecystitis when chemotherapy is instilled into the HAIP. A radionucleotide scan verifies placement to confirm there is no extrahepatic perfusion.
Floxuridine, a pyrimidine antimetabolite converted to 5-flurodeoxyuridine in the liver, has a high rate of hepatic extraction and low systemic exposures. Administration involves a 14-day infusion with heparin and normal saline to prevent catheter clotting. The treating medical oncologist determines the drug dose based on the patient’s weight, liver enzyme trends and individualized flow rate calculation.
Impact on outcomes
Oncologists use adjuvant HAIP and systemic chemotherapy to reduce recurrences after resection of colorectal cancer.
More than one-third of patients with colorectal cancer develop liver metastases. After resection of colon cancer, about 70% of patients experience recurrence, most within 2 years of resection.
Both systemic chemotherapy and adjuvant HAIP have resulted in median OS of 3 years, and half of these patients will convert from an unresectable to a resectable status. Results of clinical trials at Memorial Sloan Kettering Cancer Center showed median OS of 10 years with use of HAIP chemotherapy after surgical resection of colon cancer.
Intrahepatic cholangiocarcinoma (ICC) is the second most common primary malignancy of the liver, and 85% of patients present with unresectable disease. Low response rates to systemic chemotherapy (25%) and median survival of less than 1 year have led to early phase 2 trials that have shown a potential benefit to treatment with HAIP.
The liver receives 75% of its blood supply from the portal vein and only 25% from the hepatic artery. Hepatic metastases receive their blood supply from the hepatic artery. Intra-arterial administration of chemotherapy allows for high intrahepatic concentrations while limiting systemic adverse events.
Candidates for HAIP insertion undergo imaging to confirm the absence of extrahepatic disease and an arteriogram to identify any aberrant hepatic vessels prior to surgery. Replaced or accessory arteries occur in 30% to 40% of cases. Primary contraindications for HAIP include poor hepatic function due to liver disease, prolonged systemic chemotherapy, and extensive hepatic replacement of liver with tumor (> 70%), portal hypertension, portal vein thrombus or hepatic artery occlusion.
Potential complications
APPs should be aware of complications related to the HAIP, including pump pocket seroma, hematoma or infection, wound dehiscence or infection, and device malpositioning. Pump pocket seromas can be aspirated if they affect access to the pump for instillation of chemotherapy. Infection of the overlying skin may be treated with antibiotics. Infection of the pocket itself may require removal of the HAIP. Patients with obesity most commonly experience pump malpositioning. If the pump cannot be manually repositioned, it may require repositioning in the operating room.
HAIP catheters can occlude, become malpositioned or dislodged, or erode through the hepatic artery. Catheter occlusion occurs less than 30 days after the initial insertion due to a clot formation of fibrin sheath. Initial flow declines are treated with fibrinolytic agents.
Intrahepatic biliary ducts obtain their blood supply from the hepatic artery. This leads to increased exposure to chemotherapeutic agents and a higher risk for biliary injury. Chemical hepatitis, biliary sclerosis or cholangitis may occur. An elevated aspartate transaminase level is the first indicator of biliary toxicity. Dexamethasone combined with the chemotherapy may decrease the biliary toxic effects.
The HAIP can stay in place for many years to treat disease recurrence. Good responses to the HAIP can lead to hepatic resection.
It is important as APPs to understand the concept of the HAIP in treatment of metastatic colorectal cancer, as early intervention of complications of the HAIP result in pump retention for prolonged treatment. Patients should be screened for compliance, as these devices require drainage and reinstallation with chemotherapy every 2 weeks. Travel may need to be arranged around refill dates. Advise patients to avoid hot tubs, saunas and heating pads positioned over the HAIP that speed up delivery of the chemotherapy. Pressurization in an airplane cabin may also alter drug delivery.
The knowledge of the APP regarding the function and potential issues of the HAIP is essential for treatment success.
References:
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For more information:
Lisa Parks, MS, APRN-CNP, ANP-BC, is an inpatient nurse practitioner in hepatobiliary surgery in the division of surgical oncology at James Cancer Hospital and Solove Research Institute of The Ohio State University. She can be reached at lisa.parks@osumc.edu.
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