Reduction of Nodular Growth Pattern of Metastatic Uveal Melanoma after Radioembolization of Hepatic Metastases

AIM

The aim of this study was to report a case of metastatic uveal melanoma in which radioembolized nodular liver metastases decreased in size while infiltrative sinusoidal metastases progressed, leading to jaundice without obstruction of the biliary ducts.

METHODS

The relevant clinical features, imaging, and histopathologic findings of this case are reviewed.

RESULTS

A 61-year-old Caucasian male with a history of uveal melanoma of the left eye status post plaque brachytherapy developed numerous liver metastases. After progression on systemic therapies, he underwent palliative radioembolization. Despite some radiographic improvement in the liver metastases, he developed hyperbilirubinemia without biliary tract obstruction or signs of liver failure. A biopsy of radiographically normal liver demonstrated extensive sinusoidal infiltration with melanoma.

CONCLUSIONS

Distinct angiographic and histopathologic growth patterns of metastatic uveal melanoma differ in their amenability to radioembolization. Sinusoidal infiltration may lead to hyperbilirubinemia in the absence of overt obstruction or liver failure.

Results of a Randomized Controlled Multicenter Phase III Trial of Percutaneous Hepatic Perfusion Compared with Best Available Care for Patients with Melanoma Liver Metastases

PURPOSE

There is no consensus for the treatment of melanoma metastatic to the liver. Percutaneous hepatic perfusion with melphalan (PHP-Mel) is a method of delivering regional chemotherapy selectively to the liver. In this study, we report the results of a multicenter, randomized controlled trial comparing PHP-Mel with best alternative care (BAC) for patients with ocular or cutaneous melanoma metastatic to the liver.

PATIENTS AND METHODS

A total of 93 patients were randomized to PHP-Mel (n = 44) or BAC (n = 49). On the PHP-Mel arm, melphalan was delivered via the hepatic artery, and the hepatic effluent captured and filtered extracorporeally prior to return to the systemic circulation via a venovenous bypass circuit. PHP-Mel was repeatable every 4-8 weeks. The primary endpoint was hepatic progression-free survival (hPFS), and secondary endpoints included overall PFS (oPFS), overall survival (OS), hepatic objective response (hOR), and safety.

RESULTS

hPFS was 7.0 months for PHP-Mel and 1.6 months for BAC (p < 0.0001), while oPFS was 5.4 months for PHP-Mel and 1.6 months for BAC (p < 0.0001). Median OS was not significantly different (PHP-Mel 10.6 months vs. BAC 10.0 months), likely due to crossover to PHP-Mel treatment (57.1 %) from the BAC arm, and the hOR was 36.4 % for PHP-Mel and 2.0 % for BAC (p < 0.001). The majority of adverse events were related to bone marrow suppression. Four deaths were attributed to PHP-Mel, three in the primary PHP-Mel group, and one post-crossover to PHP-Mel from BAC.

CONCLUSION

This randomized, phase III study demonstrated the efficacy of the PHP-Mel procedure. hPFS, oPFS, and hOR were significantly improved with PHP-Mel. PHP with melphalan should provide a new treatment option for unresectable metastatic melanoma in the liver.

Effects of Yttrium-90 selective internal radiation therapy on non-conventional liver tumors

The liver is a common site of metastasis, with essentially all metastatic malignancies having been known to spread to the liver. Nearly half of all patients with extrahepatic primary cancer have hepatic metastases. The severe prognostic implications of hepatic metastases have made surgical resection an important first line treatment in management. However, limitations such as the presence of extrahepatic spread or poor functional hepatic reserve exclude the majority of patients as surgical candidates, leaving chemotherapy and locoregional therapies as next best options. Selective internal radiation therapy (SIRT) is a form of catheter-based locoregional cancer treatment modality for unresectable tumors, involving trans-arterial injection of microspheres embedded with a radio-isotope Yttrium-90. The therapeutic radiation dose is selectively delivered as the microspheres permanently embed themselves within the tumor vascular bed. Use of SIRT has been conventionally aimed at treating primary hepatic tumors (hepatocellular carcinoma) or colorectal and neuroendocrine metastases. Numerous reviews are available for these tumor types. However, little is known or reviewed on non-colorectal or non-neuroendocrine primaries. Therefore, the aim of this paper is to systematically review the current literature to evaluate the effects of Yttrium-90 radioembolization on non-conventional liver tumors including those secondary to breast cancer, cholangiocarcinoma, ocular and percutaneous melanoma, pancreatic cancer, renal cell carcinoma, and lung cancer.

Liver resection and ablation for metastatic melanoma: A single center experience

BACKGROUND

The median survival for patients with stage IV metastatic melanoma is usually limited to approximately 1 year. In the case of liver metastasis, resection and ablation can achieve long-term survival. This study aimed to describe the outcomes after liver resection or ablation for metastatic melanoma to the liver and identify preoperative prognostic factors.

METHODS

Forty eight patients who underwent liver resection (n = 32) or percutaneous ablation (n = 16) were identified from the 1,523 patients with melanoma liver metastases evaluated between January1993 and January 2013.

RESULTS

Median OS was 25.9 months. Median OS was not different after ablation (18 months) and resection (26 months; P > 0.2). Patients in the ablation group more often presented with extrahepatic disease (EHD) (P = 0.008) and received more frequently systemic therapy before ablation (P = 0.005). Patients without EHD tended to have longer OS (26.5 vs. 12 months; P = 0.076) and PFS (13 vs. 5 months; P = 0.11) in the whole cohort. EHD was significantly associated with a worse OS in the resection group (P = 0.034).

CONCLUSION

Liver resection is associated to prolonged survival over 24 months and should be considered only in selected patients with metastatic disease confined to the liver. In patients not candidate for surgery, tumor ablation can be considered.

Uveal Melanoma Metastatic to the Liver: Chemoembolization With 1,3-Bis-(2-Chloroethyl)-1-Nitrosourea

OBJECTIVE

The purpose of this study is to evaluate whether chemoembolization with 1,3-bis-(2-chloroethyl)-1-nitrosourea (BCNU) is a safe and effective treatment for bulky uveal melanoma liver metastasis.

MATERIALS AND METHODS

Over a 7-year period, 63 treatment-naïve patients presented with uveal melanoma metastasis replacing 50% or more of the normal liver parenchyma. Patients with Eastern Cooperative Oncology Group 0-2 performance status, no extensive extrahepatic metastases, and adequate liver and renal function were treated with BCNU (200 mg) chemoembolization. Pretreatment tumor burdens were classified by MRI as 50-75% and more than 75%. Lactate dehydrogenase (LDH) levels were divided into less than or equal to 500 and more than 500 IU/L (i.e., more than twice the normal level). Treatment toxicity was assessed using Common Terminology Criteria for Adverse Events (version 4.0). CT and MRI were used to determine best radiologic response (Response Evaluation Criteria in Solid Tumors). Overall survival (OS) and progression-free survival (PFS) were compared with tumor burden and LDH levels.

RESULTS

Fifty patients (31 men; mean age, 59.1 years; range, 30-88 years) met the inclusion criteria. A total of 271 chemoembolization procedures were performed. Grade 3 thrombocytopenia occurred in two patients, grade 3 hyperbilirubinemia (n = 2) was attributed to disease progression, and asymptomatic grade 4 transaminitis occurred after 16 treatments. Best radiologic response was as follows: partial response, n = 3; stable disease, n = 33; and disease progression, n = 12 (no follow-up imaging, n = 2). The median OS was 7.1 months (range, 1.2-32.3 months), and the median PFS was 5.0 months (range, 1.1-32.3 months). Eleven patients (22%) survived longer than 12 months (range, 12.2-32.3) with one patient alive at follow-up. Tumor burden and LDH levels showed no statistically significant effect on OS (p = 0.20 and p = 0.14, respectively) or PFS (p = 0.10 and p = 0.34, respectively).

CONCLUSION

BCNU chemoembolization should be considered as a treatment option for patients with bulky uveal melanoma hepatic metastases.

A single-center experience in radioembolization as salvage therapy of hepatic metastases of uveal melanoma

BACKGROUND

Overall survival (OS) of patients with hepatic metastases of uveal melanoma is strongly linked with hepatic tumor control. Due to the lack of an effective systemic chemotherapy, locoregional therapies like radioembolization should play an increasingly important role.

PURPOSE

To report complications and response rates of radioembolization as salvage therapy for hepatic uveal melanoma metastases.

MATERIAL AND METHODS

Between October 2006 and January 2014, eight patients (age, 59.1 ± 15.3 years; 5 men) with histologically proven uveal melanoma and hepatic metastases received radioembolization with glass microspheres at a single center. All patients had been heavily pretreated with multiple systemic/locoregional therapies resulting in a long median interval between diagnosis of hepatic metastases and radioembolization (17.1 months; range, 6.4-23.2 months). Follow-up consisted of clinical assessment, laboratory tests and tri-phasic computed tomography (CT) before and 1, 3, 6, 9, and 12 months after radioembolization. Response to therapy was evaluated by CT using RECIST version 1.1 and by survival time. Safety (laboratory and clinical toxicity) was rated according to Common Terminology Criteria for Adverse Events 4.03. Using Kaplan-Meier analysis time to progression of hepatic metastases (hTTP) and OS were calculated.

RESULTS

One month after radioembolization 50% of patients presented with stable and 50% with progressive disease. Median hTTP and OS after radioembolization were 4.3 weeks (range, 3.4-28.6 weeks) and 12.3 weeks (range, 3.7-62.6 weeks), respectively. Median OS after diagnosis of hepatic metastases was 19.9 months (range, 7.3-31.4 months). Radioembolization was tolerated well in all patients without toxicity higher than grade 2.

CONCLUSION

Radioembolization is a safe salvage therapy even in heavily pretreated hepatic metastases of uveal melanoma.

Transarterial Chemoembolization of Liver Metastases from Uveal Melanoma Using Irinotecan-Loaded Beads: Treatment Response and Complications

PURPOSE

The purpose of this study was to evaluate treatment response and complications of transarterial chemoembolization using drug-eluting beads loaded with irinotecan (DEBIRI) in patients with liver metastases from uveal melanoma (UM).

MATERIALS AND METHODS

Patients treated with DEBIRI (n = 14) were retrospectively analyzed regarding overall survival, compared to patients (n = 14) treated with intravenous dacarbazine (DTIC). Median overall survival was calculated from time of diagnosis of metastatic disease (OS1) and start of treatment (OS2). Radiological response for DEBIRI was assessed according to RECIST 1.1 on contrast-enhanced computed tomography (CT), obtained 1.5 months (range 1.2-3.7) post treatment. Major complications of DEBIRI were defined according to the Society of Interventional Radiology classification for complications by outcome.

RESULTS

In the DEBIRI group, OS1 was 14.8 months (range 3.9-47.5), and OS2 was 9.4 months (range 1.7-39). Further, 11/13 (84.6%) of these patients had progressive disease on first follow-up CT and new lesions were seen in nine. There were 12 major complications in nine patients, possibly including one case of mortality due to disseminated intravascular coagulation (DIC).

CONCLUSION

For patients with liver metastases from UM, the effect on overall survival of DEBIRI alone is questionable. Compared to previous reports, the response rate of DEBIRI was poor, with new liver lesions observed in the majority of patients. Major complications possibly included one case of DIC.

Development and external validation of a prognostic nomogram for metastatic uveal melanoma

Background

Approximately 50% of patients with uveal melanoma (UM) will develop metastatic disease, usually involving the liver. The outcome of metastatic UM (mUM) is generally poor and no standard therapy has been established. Additionally, clinicians lack a validated prognostic tool to evaluate these patients. The aim of this work was to develop a reliable prognostic nomogram for clinicians.

Patients and Methods

Two cohorts of mUM patients, from Veneto Oncology Institute (IOV) (N=152) and Mayo Clinic (MC) (N=102), were analyzed to develop and externally validate, a prognostic nomogram.

Results

The median survival of mUM was 17.2 months in the IOV cohort and 19.7 in the MC cohort. Percentage of liver involvement (HR 1.6), elevated levels of serum LDH (HR 1.6), and a WHO performance status=1 (HR 1.5) or 2–3 (HR 4.6) were associated with worse prognosis. Longer disease-free interval from diagnosis of UM to that of mUM conferred a survival advantage (HR 0.9). The nomogram had a concordance probability of 0.75 (SE .006) in the development dataset (IOV), and 0.80 (SE .009) in the external validation (MC). Nomogram predictions were well calibrated.

Conclusions

The nomogram, which includes percentage of liver involvement, LDH levels, WHO performance status and disease free-interval accurately predicts the prognosis of mUM and could be useful for decision-making and risk stratification for clinical trials.

Double-blinded, randomized phase II study using embolization with or without granulocyte-macrophage colony-stimulating factor in uveal melanoma with hepatic metastases

PURPOSE

To investigate the effects of immunoembolization with granulocyte-macrophage colony-stimulating factor (GM-CSF) in patients with uveal melanoma (UM) with liver-only metastasis.

MATERIALS AND METHODS

In this double-blind phase II clinical trial, patients were randomized to undergo immunoembolization or bland embolization (BE). Lobar treatment was performed with GM-CSF or normal saline solution mixed with ethiodized oil followed by embolization with gelatin sponge emulsified with iodinated contrast medium. Fifty-two patients (immunoembolization, n = 25; BE, n = 27) were enrolled. Response was assessed after every two treatments. The primary endpoint was overall response rate (ORR) of liver metastases. Progression-free survival (PFS), overall survival (OS), and immunologic responses were secondary endpoints.

RESULTS

There were five partial responses in the immunoembolization group (ORR, 21.2%; 90% confidence interval [CI], 10.3%-30.5%) and three in the BE group (ORR, 16.7%; 90% CI, 6.3%-26.9%). Stable disease was seen in 12 patients in the immunoembolization group and 19 in the BE group. OS times were 21.5 months (95% CI, 18.5-24.8 mo) with immunoembolization and 17.2 months (95% CI, 11.9-22.4 mo) with BE. The degree of proinflammatory cytokine production was more robust after immunoembolization and correlated with time to "systemic" extrahepatic progression. In the immunoembolization group, interleukin (IL)-6 levels at 1 hour (P = .001) and IL-8 levels at 18 hours after the procedure (P < .001) were significant predictors of longer systemic PFS. Moreover, a dose-response pattern was evident between posttreatment serum cytokine concentrations and systemic PFS.

CONCLUSIONS

Immunoembolization induced more robust inflammatory responses, which correlated with the delayed progression of extrahepatic systemic metastases.

Hepatic yttrium-90 radioembolization for metastatic melanoma: a single-center experience

The aim of the study was to analyze the safety and efficacy of yttrium-90 ((90)Y) radioembolization in the treatment of unresectable hepatic melanoma metastases refractory to previous systemic/locoregional therapy. Between February 2004 and April 2010, 16 patients with hepatic melanoma metastases (ocular=7, skin=4, other sites=5) were treated with (90)Y radioembolization at a single center. Toxicity was assessed using the National Cancer Institute Common Terminology Criteria, version 3.0. Response to therapy was assessed by size and necrosis criteria. Progression-free survival (hepatic) and overall survival were calculated using the Kaplan-Meier method. The median dose to the treatment site was 108.57 Gy. Grade 1 and 2 clinical toxicities included fatigue (44%), nausea (19%), and vomiting (12%). Grade 3 absolute lymphocyte toxicity and aspartate aminotransferase toxicity were noted in 2 (12%) and 1 (7%) patients, respectively. Grade 4 bilirubin toxicity was observed in 1 (7%) patient. Overall, 13 (81%) patients showed disease control (response+stable disease) according to WHO, European Association for the Study of the Liver, and Response Evaluation Criteria for Solid Tumors. Progressive disease was observed in 3 (19%) patients according to WHO, European Association for the Study of the Liver, and Response Evaluation Criteria for Solid Tumors. The median overall and hepatic progression-free survival times were 7.63 and 4.23 months. Patients with disease control (responders+stable disease) survived longer than those with progressive disease (9.97 vs. 2.13 months, P<0.0001). Results from this small and single-center experience show that radioembolization is a safe therapy and its potential for being an efficacious therapy for hepatic melanoma metastases should be explored further. Radioembolization should be considered for liver-dominant disease refractory to other forms of systemic therapies.

Rationale of transcatheter intra-arterial therapies of hepatic cancers

Transcatheter, intra-arterial therapies for primary and metastatic hepatic malignancies comprise angiographically guided procedures that provide for the administration of tumoricidal agents directly to liver tumors. These locoregional therapies have demonstrated encouraging clinical outcomes for liver tumors that are otherwise not amenable or not responsive to standard surgical or systemic treatments. This article provides a review of transcatheter therapies for hepatic cancers and reported clinical outcomes.

SIR-Spheres yttrium-90 radioembolization for the treatment of unresectable liver cancers

Transarterial radioembolization with yttrium-90 resin microspheres (SIR-Spheres; Sirtex Medical Limited, Sydney, Australia) is a liver-directed therapy that is gaining recognition as a treatment option for liver-dominant primary and metastatic cancers. The incidence of complications is low and can be further reduced by patient selection and rigorous pretreatment assessment. Ideal candidates for radioembolization have preserved liver function without ascites or encephalopathy, Child-Pugh score <7 and limited lung shunting. Phase III randomized controlled trials (RCTs) against other liver-directed therapies are lacking for intermediate-stage hepatocellular carcinoma. However, preliminary data from a recent RCT has suggested that radioembolization has a similar time-to-progression and comparable toxicity to selective chemoembolization. Phase II/III RCTs are now ongoing to evaluate the combination of radioembolization with systemic therapies in advanced-stage hepatocellular carcinoma and metastatic liver-dominant colorectal cancer in order to expand the treatment opportunities for patients with cancers in the liver.

Transhepatic therapies for metastatic uveal melanoma

Despite successful treatment of the primary tumor, uveal melanoma has a propensity to metastasize to the liver. Prognosis is poor due to the very aggressive nature of these tumors. Because systemic therapies are relatively ineffective and patient survival correlates to disease control in the liver, locoregional therapies provide a means of prolonging survival. We review various techniques including chemoembolization, immunoembolization, radioembolization, arterial fotemustine infusion, and hepatic perfusion for the treatment of liver metastases from uveal melanoma.

Beyond hepatocellular carcinoma and colorectal metastasis: the expanding applications of radioembolization

As a relatively safe outpatient procedure, radioembolization can potentially be used to treat any type of tumor within the liver, primary or metastatic. The safety and effectiveness of radioembolization in the treatment of hepatocellular carcinoma (HCC) and metastatic colorectal cancer (mCRC) has led many groups to explore its application in other malignancies. Moreover, other organs, such as the lungs and kidneys, have been explored as targets for therapy. Although the most data for radioembolization is related to HCC and mCRC, there is increasing experience and data regarding metastatic disease to the liver for other primary tumors. We review the current state of liver-directed therapy with radioembolization outside of HCC and mCRC, including metastatic neuroendocrine, breast, and melanoma, as well as limited experiences with other primary malignancies. Applications of radioembolization related to these other cancers and new trends and future directions will be discussed. With increasing use and availability of radioembolization, it promises to serve an expanding role in the repertoire of tools available for treating and managing oncologic disease.

Metastatic melanoma to the liver: a contemporary and comprehensive review of surgical, systemic, and regional therapeutic options

Effective management of hepatic metastases from ocular and cutaneous melanoma remains a major therapeutic challenge. Treatment options include hepatic resection, hepatic intra-arterial (HIA) chemotherapy, chemoembolization, and hepatic perfusions. Evaluating the efficacy of these interventions is limited by the retrospective nature of most of the data, although controlled phase 3 studies are starting to emerge. Studies of hepatic resection are strongly suggestive of a survival benefit following surgery in selected patients. Effective systemic agents for metastatic cutaneous melanoma are available and supported by randomized controlled phase 3 trials. In contrast, no active systemic treatment has yet been identified for metastatic ocular melanoma. HIA and intravenous delivery of fotemustine have been compared in a randomized phase 3 trial in patients with unresectable metastases from melanoma, but no differences between the 2 approaches were observed. Hepatic arterial chemoembolization appears only to be moderately effective according to uncontrolled studies; targeting patients with less liver involvement may improve outcomes. A recent phase 3 study showed a significant improvement in hepatic progression-free survival with percutaneous hepatic perfusion compared with best alternative care in patients with metastatic melanoma; however, the overall survival analysis was confounded by crossover of control patients to active treatment. In conclusion, hepatic resection offers the possibility of long-term survival in carefully selected patients with liver-limited metastases from melanoma. In patients with unresectable cutaneous melanoma, effective systemic therapy is the best treatment option. For patients with unresectable ocular melanoma, regional treatments are likely to assume a greater role until effective systemic treatments are identified.

MR-guided laser-induced thermotherapy (LITT) in patients with liver metastases of uveal melanoma

PURPOSE

Evaluation of the local tumour control rate and survival data for magnetic resonance (MR) imaging-guided laser ablation of uveal malignant melanoma liver metastases by using laser-induced interstitial thermotherapy (LITT).

MATERIALS AND METHODS

The LITT was performed in 18 patients with liver metastases (n = 44) from uveal malignant melanoma. All patients tolerated this intervention well. With the Kaplan-Meier method, the survival rates were calculated. Indications for the procedure were defined for patients with no more than five metastases, none of which were larger than 5 cm in diameter: The Indication for LITT treatment were recurrent liver metastases after partial liver resection (22%), locally non-resectable tumours (17%) or metastases in both liver lobes (61%).

RESULTS

The mean survival rate for all treated patients was 3.6 years (95% CI: 2.19, 5.06). We started the calculation on the date of diagnosis of the metastases treated with LITT. The median survival was 1.83 years; 1-year survival, 88%; 3-year survival 47%, 5-year survival 17%. Calculated after the first LITT treatment the median survival was 2.8 years (95% CI: 1.0, 5.0). 10 patients were treated by transarterial chemoembolization before LITT.

CONCLUSION

MR-guided LITT treatment shows a high local tumour control and survival rates in patients with liver metastases of uveal malignant melanoma.

Intra-arterial infusion and chemo-embolization for melanoma liver metastases

This article will review the rationale for hepatic arterial administration of agents to treat melanoma liver metastases, the techniques and practical considerations pertinent to hepatic arterial therapy, the variety of agents that have been used and the reported outcomes. Recent and emerging developments will be highlighted and the potential role of liver-directed therapies in the context of molecular advances and improved systemic therapy will be discussed.

Treatment of liver metastases from uveal melanoma: a retrospective single-center analysis

BACKGROUND

Metastatic liver melanoma is a rare event in the Chinese population with extremely poor prognosis. Any treatment that controls a metastatic hepatic lesion potentially prolongs survival. This study aimed to evaluate the survival of patients with isolated liver metastases from uveal melanoma treated with partial hepatectomy or non-surgical management and to find the best therapeutic modality for these patients.

METHODS

From January 1996 to September 2008, eight patients with liver metastases secondary to uveal melanoma were admitted to our hospital. Five patients underwent partial hepatectomy and 3 received other treatments (TACE, RFA, PEI). Their medical records were reviewed and overall survival was analyzed.

RESULTS

The patients comprised 3 men and 5 women, with a median age of 44 years. Six patients presented with liver metastases at the time the primary tumor was diagnosed. The interval from the diagnosis of uveal melanoma to liver metastasis in the remaining 2 patients was 9.5 and 32.5 months, respectively. The median survival after the treatment of liver metastasis was 11.5 and 7.5 months in the surgical and non-surgical groups, respectively. There was no procedure-related mortality in the whole study cohort.

CONCLUSIONS

Partial hepatectomy or other therapies were safe and feasible for isolated liver metastases from uveal melanoma. Aggressive treatment with multidisciplinary modalities may result in prolonged survival.

Current and emerging treatment options for uveal melanoma

Uveal melanoma (UM) is the most common primary malignant intraocular tumor in adults, with a 10-year cumulative metastatic rate of 34%. The most common site of metastasis is the liver (95%). Unfortunately, the current treatment of metastatic UM is limited by the lack of effective systemic therapy. Options for the management of the primary intraocular tumor include radical surgery as well as conservative treatments in order to preserve visual acuity. For metastatic disease, several approaches have been described with no standard method. Nevertheless, median survival after liver metastasis is poor, being around 4–6 months, with a 1-year survival of 10%–15%. In this review, the authors summarize current and promising new treatments for UM.

Interventional oncologic approaches to liver metastases

Metastatic liver disease is the most common cause of death in cancer patients. Complete surgical resection is currently considered the only curative treatment, with only about 25% of patients being amenable to surgery. Therefore, a variety of interventional oncologic techniques have been developed for treating secondary liver malignancies. The aim of these therapies is either to allow patients with unresectable tumors to become surgical candidates, provide curative treatment options in nonsurgical candidates, or improve survival in a palliative or even curative approach. Among these interventional therapies are transcatheter therapies such as portal vein embolization, hepatic artery infusion chemotherapy, transarterial chemoembolization, and radioembolization, as well as interstitial techniques, particularly radiofrequency ablation as the most commonly applied technique. The rationale, application and clinical results of each of these techniques are reviewed on the basis of the current literature. Future prospects such as gene therapy and immunotherapy are introduced.

Fotemustine chemoembolization of hepatic metastases from uveal melanoma: a retrospective single-center analysis

OBJECTIVE

The purpose of the current study was to retrospectively evaluate response and survival in patients with hepatic metastasis from uveal melanoma treated by palliative transarterial chemoembolization (TACE) with fotemustine.

MATERIALS AND METHODS

During the study period, 21 patients with hepatic metastases from uveal melanoma were treated by TACE. A series of TACE interventions (mean number per patient, 3.29 interventions; range, 1-6 interventions) was performed on each patient with an emulsion of fotemustine dissolved in 10 mL of saline mixed with 10 mL of an oily contrast agent. Tumor response based on the Response Evaluation Criteria in Solid Tumors was evaluated using contrast-enhanced CT scans obtained 6-10 weeks after embolization.

RESULTS

CT showed partial regression after TACE in three patients (14%). Six patients (29%) presented with stable disease but no significant change in tumor size after TACE, and 12 patients (57%) presented with progressive disease after TACE treatment. The overall response rate was 43%. The mean survival after diagnosis of hepatic metastasis was 28.7 months.

CONCLUSION

TACE of hepatic metastasis from uveal melanoma with fotemustine is well tolerated, and the survival rates in this study (mean, 28.7 months) are among the longest reported.

Tumor burden analysis on computed tomography by automated liver and tumor segmentation

The paper presents the automated computation of hepatic tumor burden from abdominal computed tomography (CT) images of diseased populations with images with inconsistent enhancement. The automated segmentation of livers is addressed first. A novel 3-D affine invariant shape parameterization is employed to compare local shape across organs. By generating a regular sampling of the organ's surface, this parameterization can be effectively used to compare features of a set of closed 3-D surfaces point-to-point, while avoiding common problems with the parameterization of concave surfaces. From an initial segmentation of the livers, the areas of atypical local shape are determined using training sets. A geodesic active contour corrects locally the segmentations of the livers in abnormal images. Graph cuts segment the hepatic tumors using shape and enhancement constraints. Liver segmentation errors are reduced significantly and all tumors are detected. Finally, support vector machines and feature selection are employed to reduce the number of false tumor detections. The tumor detection true position fraction of 100% is achieved at 2.3 false positives/case and the tumor burden is estimated with 0.9% error. Results from the test data demonstrate the method's robustness to analyze livers from difficult clinical cases to allow the temporal monitoring of patients with hepatic cancer.