Improving SUrgery of Liver Metastases: a Trial of the Arterial Chemotherapy Network

1. Histologically confirmed colorectal cancer (CRC), and radiologic or histologic proof of CRLM not amenable to a curative intent-treatment.
2. At least two months of prior induction systemic CT with oxaliplatin and/or irinotecan combined with a fluoropyrimidine combined or not to a targeted therapy (e.g., anti-EGFR or antiangiogenic antibody) for metastatic disease (patients ending their adjuvant chemotherapy after primary tumor resection since more than 6 months should also have received first-line chemotherapy for metastatic disease). Further systemic chemotherapy lines are allowed.

3. Unresectability of the CRLM will be confirmed by a centralized multidisciplinary expert panel (composed of surgeons, radiologists, interventional radiologists and medical oncologists). The panel will review the CT scan and MRI of the patients (weekly web conference). Non-resectability criteria (one of the following criteria):

   • Upfront R0/R1 resection of all CRLM (that leaves at least two adequately perfused and drained segments) is not possible
   • and/or metastases in contact with major vessels of the remnant liver which would require resection of the vessel for an R0 resection (i.e., tumor involvement of main portal right and left portal veins, of the three main hepatic veins, or of the retrohepatic vena cava)
   • and/or documented progressive disease on imaging (according to the RECIST v1.1) or doubling of serum levels of carcinoembryonic antigen (CEA) or carbohydrate antigen 19-9 (CA 19-9) following ≥2 months of induction CT
4. At least one measurable liver metastasis according to the RECIST v1.1
5. Age ≥18 years
6. Eastern Cooperative Oncology Group (ECOG) performance status 0-1
7. Normal liver function, i.e. bilirubin \<1.5 times the upper limit of normal values (ULN), aminotransferases \<5 ULN, alkaline phosphatase \<5 ULN
8. International normalized ratio (INR) \<1.5 ULN
9. Neutrophils >1500/mm³, platelets >100 000/mm³, hemoglobin >9 g/dL (transfusion allowed)
10. Calculated creatinine clearance >50 mL/min (Cockcroft and Gault formula)
11. Informed consent signed by the patient or his/her legal representative
12. Patient affiliated to a social security regimen
13. Potentially reproductive patients must agree to use an effective contraceptive method or practice adequate methods of birth control or practice complete abstinence while on treatment, and for at least 6 months after the last dose of study drug.
14. Uracilemia \<16 ng/ml

Exclusion Criteria:

1. Patient eligible for curative-intent treatment of CRLM (i.e. resection and/or thermoablation), according to the local multidisciplinary team and/or the central review.

2. Definitive anatomical contraindication to complete surgical resection (any of the following criteria):

   • More than two lesions in all liver segments
   • Bilobar liver metastasis and more than three lesions >3 cm in the hepatic lobe the least affected (i.e. the future remnant liver)
   • Bilobar liver metastasis and disease liver extend >50%
3. Extrahepatic tumor disease (except ≤3 lung nodules \<10 mm deemed amenable to curative-intent resection/thermoablation and non-resected primary tumor with no or mild symptoms)
4. Patient with contraindication for trial drugs (investigators have to refer to drugs SmPC); contraindication limited to targeted therapy (e.g., anti-EGFR or antiangiogenic antibody) is not an exclusion criteria
5. Disease progression after FOLFOXIRI/FOLFIRINOX
6. Sensory neuropathy ≥ grade 2 (National Cancer Institute - Common Terminology Criteria for Adverse Events (NCI-CTCAE) v.4.0)

7. If patients received bevacizumab, following non-inclusion criteria must be respected:

   • Proteinuria >1 g,
   • Gastro-intestinal fistulae or perforation,
   • Hypersensitivity to Chinese hamster ovary cell products or other human recombinant antibody,
   • Major surgery in the last 28 days.

8. If patients received panitumumab, following non-inclusion criteria must be respected:

   • Interstitial lung disease,
   • Pulmonary fibrosis.
9. Significant chronic liver disease (resulting in portal hypertension and/or liver insufficiency)
10. Allergy to contrast media that cannot be managed with standard care
11. Previous organ transplantation, HIV or other immunodeficiency syndromes
12. Concomitant or past history of cancer within 5 years prior to entry into the trial other than adequately treated basal-cell skin cancer or in situ carcinoma of the cervix
13. Patients with clinically significant active heart disease or myocardial infarction in the last 6 months
14. Concomitant medications/comorbidities that may prevent the patient from receiving study treatments as uncontrolled intercurrent illness (for instance: active infection, active inflammatory disorders, inflammatory bowel disease, intestinal obstruction, uncontrolled hypertension systolic >15 and diastolic >9, symptomatic congestive heart failure...)

15. Ionic disorders as:

    • Kalemia ≥1 x ULN
    • Magnesemia \<0.5 mmol/L
    • Calcemia \<2 mmol/L
16. Patient with a dihydropyrimidine dehydrogenase (DPD) deficiency; Uracilemia ≥16 ng/ml, the test should be done for all patients before first 5-FU administration, according to "agence nationale de sécurité du médicament" (ANSM) communication regarding recommendation about high risk of no testing DPD in patient before 5-FU administration
17. QT/QTc >450 msec for men and > 470 msec for women
18. Concomitant intake of St. John's wort
19. Patient already included in another clinical trial with an experimental treatment
20. Pregnancy or lactation
21. Patients deprived of liberty or under guardianship
22. Patients unable to undergo medical monitoring test for geographical, social or psychological reasons