May 2015 Webinar – Liver Metastases

Liver Metastases - when

CRC Spreads to the Liver

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Speaker:MARWAN G. FAKIH, MD received his Medical Doctorate from

the American University of Beirut in 1992. He subsequently

completed his residency in Internal Medicine at the Detroit

Medical Center (Wayne State University) and a fellowship in

Hematology and Oncology at the University of Pittsburgh. He

was recruited to City of Hope in November of 2012 to lead the

GI Oncology Section. In January 2015, he was appointed as the

Interim Chair of Medical Oncology at City of Hope.

Dr. Fakih’s research focuses on drug development, surveillance

and prevention of colorectal cancer. His current clinical research

is focusing on developing strategies to optimize biomarker

driven-targeted therapy in colorectal cancer and to overcome

anti-EGFR resistance. Dr. Fakih has published more than 100

peer-reviewed articles and serves on the editorial boards of

several scientific journals.

http://fightcolorectalcancer.org/wordpress/wp-content/uploads/2015/04/Dr-Fakih.jpg

http://fightcolorectalcancer.org/wordpress/wp-content/uploads/2015/04/Dr-Fakih.jpg

Current and Emerging Approaches to Unresectable Colorectal Liver Metastases

Marwan Fakih, MD

Professor

Section Head, Gastrointestinal oncology

City of Hope comprehensive cancer center

Disclosures

•Research support: Novartis, Amgen

•Consulting: Amgen, Sanofi, Taiho, SIRTEX

•Speaker: Genentech, Bayer, Sanofi, Amgen, SIRTEX

SEER Data: CRC in a Snapshot

seer.cancer.gov

Stage at Presentation and 5-Year Overall Survival

Colorectal Cancer and Liver Metastases

Colorectal Cancer

(~136,000)

20-25% Present with Metastatic Disease

>60% have liver involvement

>50% die of liver failure

70-75% Localized or Regional Disease

Another 20-25% Develop Metastatic Disease

1. Siegel R, et al. CA Cancer J Clin. 2014;64(2):104-117. 2. National Cancer Institute. SEER Stat Fact Sheets: Colon and Rectum Cancer. Surveillance, Epidemiology,

and End Results Program. Turning Cancer Data Into Discovery (Cancer of the Colon and Rectum). http://seer.cancer.gov/statfacts/html/colorect.html. 3. Raval M, et al.

Front Oncol. 2014;4:120. 4. Ye LC, et al. J Clin Oncol. 2013;31:1931-1938. 5. Foster JH, et al. Semin Liver Dis. 1984; 4:170-179.

Management of Isolated or Liver-Predominant Colorectal Liver Metastasis

Liver

Metastases

ResectabePotentially

Resection or Ablation Candidate

Non-Resectable

Society of Surgical Oncology Consensus for Resectability• A positive surgical margin should be avoided

• A margin < 1cm is not an exclusion criteria for resection

• Assessment of resctability should be based on the ability to obtain a complete resection (negative margin)

• Feasibility of resection should be based on• Ability to preserve 2 contiguous segments• Preservation of vascular inflow and outflow and

biliary drainage• Ability to preserve adequate liver remnant (>20%

healthy liver)

• Extrahepatic disease is no longer a contraindication for resection as long as complete resection of hepatic and extrahepatic disease is feasible

Charnsaagavej el al. Annals of Surgical Oncol 2006

Selected Series of Hepatectomy for MCRC to the Liver (N > 100)

N. of patients Operative Mortality 5-ys

Adson, 1984 141 2.8% 23%

Hughes, 1988 859 - 33%

Doci, 1991 100 5% 30%

Scheele, 1991 219 6% 39%

Rosen, 1992 280 4% 25%

Nordlinger, 1992 1818 2.4% 26%

Gayowski, 1994 204 0% 32%

Rees, 1997 114 1% 37%

Jamison, 1997 280 4% 27%

Fong, 1999 1001 2% 37%

Iwatsuki, 1999 305 1% 32%

Choti, 2002 226 - 40%

Abdalla, 2004 190 - 58%

Fernandez, 2004 100 1% 58%

Pawlic, 2005 557 - 58%

Long Term Disease Specific Survival of MCRC Hepatic Resection

• 612 patients with hepatic resection for MCRC at MSKCC with FU > 10 years

• DSS 10 year survival of 17% - (if Loss to FU included - 25%)

• Only 1 patient of 102 patients with 10 year survival died of CRC

• 34% of 5-year survivors died of MCRC

Tomlinson JCO 2007

10 year survival = Cure

Management of Resectable Metastatic Colorectal Cancer

Resectable Metastatic Disease to the Liver

Surgery (Resection and/or ablation)

Chemotherapy x 6 months (FOLFOX in oxaliplatin naïve patients)

Resectable Metastatic Disease to the Liver

Chemotherapy x 3 months (FOLFOX)

Surgery

Addition Chemotherapy x 3 months (FOLFOX)

Nordlinger B. Lancet, 2008: 1007-1016

Resectable Metastatic Colorectal Cancer

74 year old female with sigmoid cancer and synchronous liver metastasis

3 m FOLFOX

Robotic segment 7 excision

1 year post-op

NED

Colorectal Cancer Liver Metastases Ablation (RFA)

Typically reserved for tumors < 5 cm. Risk of local relapse is minimal for tumors < 3 cm

http://www.colorectal-cancer.ca/en/treating-cancer/treatment-cancer/

Recurrence Free Survival and OS by Resection, Resection + RFA, or RFA

• 358 patients treated with a curative resection, or resection + RFA, or RFA• 190 resection only

• 101 RFA + resection

• 57 RFA only

• Liver only recurrence was 44% in RFA group vs. 11% surgery

• True local recurrence was 9% with RFA vs. 2% with resection

Abdallah, et al. Annals of Surgery; 2004


Liver

Metastases



Non-Resectable

Resectability of Liver Metastases

Nordlinger B. EJC 2007

Liver Metastases

85% Unresectable

10-30% potentially resectable

70- 90% never resectable

15% Resectable

Resection~30%

Chemotherapy

Paul Brousse Experience: 1988-99

Median chemotherapy = 10 cycles70% oxaliplatin-based

Adam R. Annals of Surgery 2004

138 pts

335 pts

Paul Brousse Experience: 1988-99

Adam R. Annals of Surgery 2004

Biological + Cytotoxic Results in Initially Non-Resectable CRC Liver Metastases

Study Design Treatment Arm Comparator Arm RR and

Resection Rate

PFS/ OS

Gruenberger

OLIVIA TRIAL

2015

Randomized Phase II

Clinical Trial

N = 80

Primary Endpoint:

overall resection rate

FOLFOX + BV FOLFOXIRI + BV Favors FOLFOXIRI

Arm

RR: 81% vs. 62%

Resection Rate:

61% vs. 49%

R0: 49% vs. 23%

Favors FOLFOXIRI

Arm

PFS 18.6 m vs.

11.5 m

Ye

2013

Randomized Phase III

Trial

N = 138 (KRAS-WT)

Primary Endpoint:

conversion rate to

radical resection

FOLFOX FOLFOX + Cmab Favors Cmab

Arm

Resection Rate:

29% vs. 13%

R0: 26% vs. 7%

Favors Cmab

Arm

PFS (HR = 0.6, p =

0.04)

OS (HR = 0.54, p

=0.013)

Venook

CALGB 80405

2014

Randomized phase III

clinical trial

Primary Endpoint:

OS

N = 1137 KRAS-WT

(exon 2)

Chemotherapy + BV Chemotherapy +

Cmab

130 patients

achieved surgical

remission (favors

Cmab Arm)

Cmab arm: 62%

vs. 38%

No difference in

OS between

arms.

OS for overall

patient

population with

surgical

remission

Metastatic CRC RAS/BRAF-WT

February 2014 November 2014

FOLFIRI + Panitumumab for MCRC

SURGERYJan 2015

+ Adjuvant FOLFOX

Metastatic CRC RAS/BRAF-WT: FOLFOXIRI/Bev – followed by FOLFIRI + Pmab

February 2014 November 2014

SURGERY DEC 2014

Kemeny N. JCO 2003Kemeny N. JCO 2011

Metastectomy in CRC (2000-2011)

Bartlett E. Cancer. 2014, Nov. Ahead of Print


Liver

Metastases



Non-Resectable

Regional Therapy for Unresectable Metastatic Colorectal Cancer

•DEBIRI (Drug eluting beads irinotecan)

•Hepatic arterial infusion with chemotherapy

•Radioembolization with Y90 microspheres

DEBIRI (Intra-arterial administration of drug eluting beads irinotecan)

http://www.hopkinscoloncancercenter.org/CMS/CMS_Page.aspx?CurrentUDV=59&CMS_Page_ID=F8D44AA8-C114-4C69-9A45-256284D9D0A9

Randomized Phase III Clinical Trial of DEBIRI vs. FOLFIRI

Previously Treated MCRC to Liver

DEBIRI

FOLFIRI

22 vs. 15mP < 0.05

7 vs. 4 mP < 0.05

Most patients had 2-3 lines of treatmentAbout 1/3 of patients had prior irinotecan

Fiorentini, G. Anticancer Res. 2012

Chemotherapy Intensification: Randomized Phase II Trial of FOLFOX +/-DEBIRI

MCRC with Liver Metastases

FOLFOX +/- Bevacizumab

(n = 30)

FOLFOX +/- Bevacizumab + DEBIRI

(n = 40)

DEBIRI + Chemo vs. Chemo p

DEBIRI + Chemo vs. Chemo p

Martin, R. GI ASCO 2014

Increase in RR in liverIncreased resection rate in liverSystemic effect of irinotecan suspected (increased BM suppression)

DEBIRI in MCRC to the Liver

• Clinical activity noted but in small studies

• Requires repeated treatments

• Associated with a high rate of abdominal pain, nausea and vomiting

• Often requires 24-48 hour admission

• Systemic impact of chemotherapy (irinotecan) is likely a contributing factor to activity

Hepatic Arterial Infusion Pumps

• FUDR (5-FU pro-drug) is metabolized in the liver with 95-99% first-pass hepatic clearance

• Allows the administration of higher regional concentrations of chemotherapy without systemic toxicity

• Placement requires surgery and cholecystectomy• Risk of biliary sclerosis

CALGB 9481: Systemic vs. HAI Fluoropyrimidines

Metastatic CRC to Liver

Mayo Clinic FU/LV

(67 pts)

HAI FUDR

(68 pts)

Kemeny N. et al. J Clin Oncol 2006: 1395

Time to Liver progression Overall survival

Median: 9.8 vs. 7.3 m Median: 24.4 vs. 20 m

HAI (FUDR) FU/LV

THF 9.8 m 7.3 m

TEHF 7.7 m 14.8 m

OS 24.4 m 20 m

THF = time to hepatic failure; TEHF: time to extra-hepatic failure

HAI in Chemotherapy Refractory MCRC Limited to the Liver

Hepatic Arterial Infusion and MCRC to Liver

• Limited applicability in the first-line (untreated) metastatic colorectal cancer

• Potential benefits in subsequent lines of treatment are based on single institute studies and do not include a control arm

• May be associated with morbidity and toxicity

• Have to be performed in a high volume center

• May be most promising in the adjuvant setting in patients with high risk for recurrence post hepatectomy

FDA Indication: SIR-Spheres microspheres

40

SIR-Spheres microspheres are indicated for the treatment of unresectable metastatic liver

tumors from primary colorectal cancer with adjuvant intra-

hepatic artery chemotherapy (IHAC) of FUDR (Floxuridine)

SIR-Spheres® microspheres (Yttrium-90 Microspheres) [prescribing information]. Woburn, MA: Sirtex Medical, Inc.; October 2011.

SIR-Spheres microspheres

• Biocompatible resin microspheres

• Adsorbed Yttrium-90

• Mean diameter of 32.5μm (95%: 24μm to 36μm )

• lnjected into the right or left hepatic artery

Cell death through apoptotic mechanisms including double-strand DNA breaks

SIR-Spheres® microspheres (Yttrium-90 Microspheres) [Prescribing Information]. Woburn, MA: Sirtex Medical, Inc.; October 2011

Common Adverse Events Associated with SIR-Spheres Microspheres

42

Side EffectIncidence, %

Grade 2 Grade 3

Weight loss 3 0

Fatigue 37 1

Fever 2 0

Nausea 9 1

Emesis 6 1

Pain 11 2

Gastric ulceration5 (median)

(0-20)

Radiation-induced liver disease (RILD)<1 (median)

(0-4)

Most Common Acute (0-30 Days) and Delayed (31+ Days) Grade 2/3 Toxicities*

*CTCAE 3.0.Sirtex Clinical Safety and Tolerability. http://www.sirtex.com/ap/clinicians/safety/. Accessed October 16, 2014.

SIR-Spheres Microspheres:Clinical Data

43

Gray, et al (2001)1 van Hazel, et al (2004)2 Sharma, et al (2007)3

SIR-Spheresmicrospheres +

FUDR HAC(n=36)

FUDR HAC(n=34)

SIR-Spheres microspheres +

5-FU/LV(n=11)

5-FU/LV(n=10)

SIR-Spheres microspheres + FOLFOX4

(n=20)

Cohort Liver-only Liver-onlyLiver-

dominantLiver-

dominantLiver-

dominantLiver-only

ORR, %44 18 72.7 0

90P=0.01 P<0.001

CEA response, %72 47

– –0.004

Median TTP, months

NR18.6 3.6

9.3P<0.0005

Median TTLP, months15.9 9.7

NR 12.3P=0.001

Median survival, months

23.5 18.4 29.4 12.8

NRHR=1.14P=0.18

HR=0.33P=0.025

First Line: SIR-Spheres Microspheres withChemotherapy Are Associated with Improved Outcome

5-FU/LV=5-fluorouracil/leucovorin; FOLFOX=5-FU/LV + oxaliplatin; HAC=hepatic arterial chemotherapy; NR=not reported; TTP= Time to progression, TTLP=time to liver progression.

1. Gray B, et al. Ann Oncol. 2001;12:1711-1720. 2. van Hazel G, et al. J Surg Oncol. 2004;88:78-85. 3. Sharma RA, et al. J Clin Oncol. 2007;25:1099-1106.

44

Second Line

SIR-Spheres microspheres + Irinotecan (n=25)

Cohort Liver-dominant

ORR, % 48

Median TTP†, months 6.0

Median TTLP‡, months NR

Median survival, months 12.2

Second Line: Efficacy of SIR-Spheres Microspheres with Chemotherapy

van Hazel G, et al. J Clin Oncol. 2009;27:4089-4095.

45

† Time to Progression

‡Time to Liver Progression

Refractory Setting: SIR-Spheres microspheres With Chemotherapy Are Associated With Improved Outcome (Level 1 Evidence)

SIR-Spheresmicrospheres + 5-FU

(n=21)

5-FU(n=23)

Cohort Liver-only Liver-only

ORR, %10 0

P=0.22

Median TTP, months4.5 2.1

HR=0.51; P=0.03

Median TTLP, months5.5 2.1

HR=0.38; P=0.003

Median OS,* months10.0 7.3

HR=0.92; P=0.8

*Crossover was allowed, which may have impacted P value.Hendlisz A, et al. J Clin Oncol. 2010;28:3687-3694.

46

Integrating SIR-Spheres microspheres in the Management of mCRC: A Case Study–Based Approach

47

RefractorySecond LineFirst Line

Potential Applications of SIRT in mCRC

48

First-line SettingChemotherapy Tolerant

Chemotherapy Intolerant

49

Male, 74 years

Clinical history• Diagnosed with predominant liver metastatic colon cancer (unresected primary, low-

volume lung disease)• KRAS mutation

Treatment• FOLFOX + Bev induction chemotherapy × 4 months with

stable disease • Followed by maintenance 5-FU/LV + Bev with PD in

liver only

Case Study 1

Presentation

50

• SIR-Spheres microspheres administered concurrently with one cycle of FOLFOX

• Patient was remaintained on 5-FU/LV + bevacizumab

• 14 months from initiation of chemotherapy until progression on maintenance treatment and switch to a second-line treatment

Case Study 1: Treatment and Outcome

Fakih. Colorectal Cancer. 2014;3:331-343.

51

SIR-Spheresmicrospheres

7/2013 9/2013

Male, 72 years

Clinical history• NHL with mediastinal involvement and malignant pleural effusion (lymphoma)• 5/2013 PET/CT: right colon mass and multiple hepatic metastases

– Colon adenocarcinoma• RAS mutation

Treatment• FOLFOX + Bev for 3-4 months between 6/2013 and 9/2013

– Minor response with normalization in CEA; grade 3 neuropathy and severe fatigue

– 10/2013-12/2013: FU/LV + Bev• Rising CEA• Minor progression in 12/2014• Primary tumor stable to mildly improved

• Options: FOLFIRI + Bev or SIR-Spheres microspheres?

Presentation

Case Study 2: Rising CEA With Minimal Progression in First-line Treatment

52

FOLFIRI=5-FU/LV + irinotecan.

Case Study 2: Rising CEA With Minimal Progression in First-line Treatment (Cont.)

2/201412/2013

53


• SIR-Spheres microspheres concurrent with 1 cycle of FOLFOX

• Resumed 5-FU/Bev

• Patient without PD and normal CEA

54

Case Study 2: Rising CEA With Minimal Progression in First-line Treatment (Cont.)

2/2014 7/2014

PFS >15 months before second-line chemotherapy


Case Study 3: Patient Intolerant to Chemotherapy in the First Line Setting

55

Female, 81 years

Clinical history• Transanal excision of rectal cancer at 77 years of age• 2/2013: recurrent perirectal pelvic mass with unresectable hepatic metastases

Treatment• 3/2013-1/2014: treated with 5-FU/LV + Bev

– Worsening hand-foot syndrome despite reduction in 5-FU infusion to 1800 mg/m2

– Increasing fatigue despite dose reduction– Improvement in metastatic disease but still PET/CT positive

• 1/2014-2/2014: radiation + low-dose capecitabine to the pelvis to control pelvic recurrence

Presentation

• Right hepatic lobe SIR-Spheres microspheres + infusional 5-FU on 4/2014• Right hepatic liver metastases with a CR by PET/CT. Left lobe of the liver has progressive disease

56

Case Study 3: Treatment and Outcome From SIR-Spheres microspheres in a Patient With Chemotherapy Intolerance

5/20143/2014

7/2014

Patient is 18 months from initiation of chemotherapy without a need to switch to second-line therapy

• SIRT with SIR-Spheres microspheres

• PET/CT repeated 7/2014 with a complete PET/CT response in the liver

57

Case Study 3: Treatment and Outcome (Cont.)

5/2014

Case 4: 64 year-old intolerant to chemotherapy with CRC liver metastases

June 2014 March 2015

June 2014 March 2015

Patient is 9 months from SIRT with SIR-Spheres x 1 (July 2014) with ongoing regression of hepatic metastases

Second-line Setting

59

Male, 53 years

Clinical history• Diagnosed with sigmoid colon cancer with metastatic disease to the liver• Status post sigmoid resection for colon cancer with synchronous hepatic lesions: No

extrahepatic disease• >10 lesions scattered in both lobes• KRAS mutation

Treatment• FOLFIRI + Bev in the first-line setting

– Myocardial infarction with first dose of FOLFIRI + Bev

• Subsequently treated with 5 cycles of IROX with stable disease, associated with severe neuropathy

Case Study 5: Application in a Patient with Inadequate Response in the 2nd Line-Setting

60

IROX=irinotecan + oxaliplatin.

Presentation

• SIR-Spheres microspheres in 7/2013 in combination with irinotecan

• PD 6 months later

Case 5: Integration in the Second-line Setting

7/2013 11/2013

Irinotecan + SIR-Spheres microspheres

61

Refractory Setting

62

Case Study 6: Refractory Case

63

Male, 52 years

Clinical history

• Progressive liver-dominant disease with low-volume lung metastases

• Failed all systemic treatments

• RAS WT

Presentation

7/2013 9/2013 11/2013

Rechallenge FOLFIRI +

cetuximab

• Infusional 5-FU + SIR-Spheres microspheres 8/2013

• Systemic chemotherapy rechallenge with FOLFIRI + cetuximab started on 10/2013

Case 6: Integrating SIR-Spheres Microspheres in Refractory Settings

64


Case 6: Repeat SIRT Performed 8 Months Later

65

Increasingliver metastases

Post SIR-Spheresmicrospheres

SIR-Spheres microspheres

4/2014


3/2014 7/2014

Case Study 6: Advanced Refractory Disease

66

FOLFOXIRI=5-FU/LV + oxaliplatin + irinotecan.

Male, 45 years

Clinical history• Presented with rectal bleeding, change in bowel habits, increasing abdominal pain• Colonoscopy showed an anorectal junction tumor and biopsy confirmed an adenocarcinoma• KRAS mutation• Staging showed widespread metastatic disease

– Extensive liver disease– Low volume lung disease– Pelvic adenopathy– Large rectal primary

Treatment• Patient was treated with 9 cycles of FOLFOXIRI followed by FOLFIRI + Bev as maintenance

therapy

Presentation

Case Study 7: Baseline PET Scan Imaging, 12/2012

67

Case Study 7: Best Response Achieved at 10 Months of Treatment

12/2012 9/2013

12/2012 2/2013 3/2013 4/2013 5/2013 5/2013 6/2013 7/2013 8/2013 9/2013

CEA 7160.9 851.7 85.7 40.8 18.5 15.9 10.8 8.4 5.8 5.4

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Case Study 6: Post 1/2014 – SIR-Spheres microspheres

12/2013 1/2014

69


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Case Study 7: PET/CT (4/2014) Post SIR-Spheres microspheres

Chemotherapy Regimens in Combination With SIRT

Chemotherapy Regimen SIRT Administration

FOLFOX1

mFOLFOX6 regimen with oxaliplatin reduced to 60 mg/m2, maintained for 2 cycles following SIRT

mFOLFOX6 ± bevacizumab (SIRFLOX)

Day 3 or 4 of first cycle

5-FU/LV bolus2 5-FU at 425 mg/m2 and LV at 20 mg/m2 daily × 5 (4-week cycle)

Day 3 or 4 of second cycle

5-FU protracted infusion3

5-FU at 225 mg/m2/day for 14 days then300 mg/m2/day for 14 days thereafter

(3-week cycle)Day 1 of cycle

Capecitabine4 Capecitabine 1000 mg/m2 po bid for 14 days(3-week cycle)

Day 2 of cycle

Irinotecan5 Irinotecan at 100 mg/m2 on days 1 and 8 (3-week cycle)

Day 2 or 3 of cycle

1. Sharma RA, et al. J Clin Oncol. 2007;25:1099-1106. 2. van Hazel G, et al. J Surg Oncol. 2004;88:78-85. 3. Hendlisz A, et al. J Clin Oncol. 2010;28:3687-3694.

4. Cohen SJ, et al. Br J Cancer. 2014;111:265-271. 5. van Hazel G, et al. J Clin Oncol. 2009;27:4089-4095.

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• SIR-Spheres microspheres can be integrated safely with multiple chemotherapy backbones

• First-line, second-line, and refractory settings

• Associated with down-staging

• Prospective studies support efficacy across different lines of treatment and a favorable safety profile

• The procedure is an outpatient procedure (no hospitalization) with a favorable toxicity profile

• SIR-Spheres microspheres constitute an effective tool in the control of mCRC to the liver

Case Studies: Summary

72

SIRFLOX Study Design

• Multicenter, international study:• US, Israel, Australia,

New Zealand, Europe

• Eligible patients:• Unresectable liver-only or

liver-prominent colorectal cancer metastases

• No prior chemotherapy for advanced disease

• Fit for combination therapy and SIRT

• Primary endpoint:• Progression-free survival

SIR-Spheresmicrospheres*

+mFOLFOX6† ±

bevacizumabC4

mFOLFOX6†

±bevacizumabC1

Stratify

• Presence of extrahepatic metastases

• Degree of liver involvement

• Institution

• Use of bevacizumab

R1:1

(n=532)‡

*SIR-Spheres microspheres administered day 3/4 of cycle 1. †Oxaliplatin administered at 60 mg/m2 (for cycles 1-3 in the SIR-Spheres

microspheres + FOLFOX arm). ‡Enrollment completed 4/2013. C4/C1At the investigator’s discretion, bevacizumab may commence at cycle 4 in the

test arm and at cycle 1 (or per institutional protocol) in the control arm.

http://clinicaltrials.gov/ct2/show/NCT00724503?term=nct00724503&rank=1. Accessed October 16, 2014.

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SIRFLOX Preliminary Results

•Primary Endpoint• No difference in PFS

• Chemo PFS = 10.2 m vs. Chemo + SIR-Spheres PFS = 10.7 m (HR = 0.93)

•Secondary Endpoints• Significant delay in liver progression in favor of the

SIR-Spheres arm• Liver PFS 20.5 vs. 12.6 m (HR = 0.69)

• Hepatic response rate was better on the SIR-Spheres arm

• Liver RR = 78.7% vs. 68.6%

• OS data is not mature

Liver Directed Therapies

•Liver directed therapies should be focused on curative intent strategies when feasible• Surgery or RFA or combination

•Non-resectable liver metastases can benefit from regional strategies• Radioembolization (SIR-Spheres)• DEBIRI• Hepatic arterial infusion

•Radioembolization is the favored strategy in non-resectable, chemo-resistant, liver limited disease

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May 2015 Webinar – Liver Metastases

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Transcript of May 2015 Webinar – Liver Metastases