What is the role of hemoadsorption in a patient with a history of colon cancer and progressive liver metastasis, who has previously been treated with oxaliplatin-based and irinotecan-based (chemotherapy) and is now experiencing liver dysfunction?

Hemoadsorption Has No Role in Managing Progressive Liver Metastasis from Colon Cancer

Hemoadsorption is not a validated treatment for chemotherapy-induced liver dysfunction or progressive liver metastases in colorectal cancer, and has no established role in this clinical scenario. 1

Immediate Management of Liver Dysfunction After Chemotherapy

Discontinue the current irinotecan-based regimen immediately, as irinotecan causes progressive steatohepatitis that worsens with continued exposure, particularly in the setting of existing liver dysfunction. 1

• Allow hepatic recovery before considering any alternative systemic therapy, as postoperative morbidity and chemotherapy tolerance are directly related to cumulative hepatotoxicity. 2, 1
• The pattern of liver injury differs by agent: oxaliplatin causes sinusoidal injury while irinotecan causes steatohepatitis, but both require treatment cessation when liver dysfunction develops. 2, 1

Next-Line Treatment Options After Hepatic Recovery

For RAS Wild-Type Tumors:

Consider targeted biologics (bevacizumab, cetuximab, or panitumumab) once liver function stabilizes, as these agents do not require hepatic metabolism and can provide disease control without additional hepatotoxicity. 2, 1

• Anti-EGFR antibodies (cetuximab or panitumumab) are confined to RAS wild-type tumors and should never be used in RAS-mutated disease. 2
• Bevacizumab can be combined with fluoropyrimidine monotherapy in patients with compromised liver function. 2

For RAS-Mutated Tumors:

Regorafenib or fruquintinib are appropriate third-line options for patients who have failed fluoropyrimidine, oxaliplatin, and irinotecan-based regimens, with regorafenib showing greater survival benefit in Asian populations. 2

• Use dose-escalation strategy for regorafenib: 80 mg/day week 1,120 mg/day week 2,160 mg/day week 3 to minimize toxicity. 2
• Trifluridine/tipiracil (TAS-102) combined with bevacizumab significantly prolonged overall survival compared to TAS-102 monotherapy in patients who failed standard treatment. 2

For BRAF V600E Mutated Tumors (RAS Wild-Type):

BRAF inhibitors plus cetuximab, or triple therapy with BRAF inhibitor, cetuximab, and MEK inhibitor should be considered for patients with extensive metastases and high tumor burden. 2

For HER-2 Amplified Tumors:

Conduct HER-2 IHC testing and NGS testing after failure of standard treatment, as trastuzumab-based combinations or trastuzumab deruxtecan show promising efficacy in HER-2 amplified colorectal cancer. 2

Safety Considerations for Chemotherapy in Hepatic Dysfunction

Oxaliplatin is well-tolerated at standard doses (130 mg/m² every 21 days) even in severe hepatic dysfunction, as pharmacokinetic studies demonstrate no apparent alteration in platinum clearance regardless of liver function abnormalities. 3

• However, limiting chemotherapy duration remains critical to prevent irreversible liver damage and maintain future treatment options. 1
• Irinotecan-based regimens carry higher risk in hepatic dysfunction and should be avoided or dose-reduced when liver function is compromised. 1
• Reduce irinotecan dose for patients with UGT1A1*28 and *6 homozygous or heterozygous variants. 2

Supportive Care and Monitoring

Optimize nutritional status when hypoalbuminemia is present, as albumin <2.6 g/dL significantly increases treatment-related morbidity. 1

• For patients with performance status 3-4 and severe organ dysfunction, best supportive care is the appropriate recommendation. 1
• Reevaluate every 2 months with history, physical examination, CEA (if initially elevated), and CT scan of involved regions. 2

Critical Clinical Pitfall

The consistent evidence from multiple guideline organizations demonstrates that hemoadsorption has no validated role in managing chemotherapy-induced liver injury or progressive liver metastases. 1 The appropriate strategy is limiting chemotherapy duration, allowing hepatic recovery, and transitioning to targeted biologics or alternative systemic agents based on molecular profiling once liver function stabilizes. 2, 1