201
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Padia SA, Lewandowski RJ, Johnson GE, Sze DY, Ward TJ, Gaba RC, Baerlocher MO, Gates VL, Riaz A, Brown DB, Siddiqi NH, Walker TG, Silberzweig JE, Mitchell JW, Nikolic B, Salem R. Radioembolization of Hepatic Malignancies: Background, Quality Improvement Guidelines, and Future Directions. J Vasc Interv Radiol 2017; 28:1-15. [DOI: 10.1016/j.jvir.2016.09.024] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Revised: 09/18/2016] [Accepted: 09/20/2016] [Indexed: 02/09/2023] Open
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202
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Kouri BE, Abrams RA, Al-Refaie WB, Azad N, Farrell J, Gaba RC, Gervais DA, Gipson MG, Kolbeck KJ, Marshalleck FE, Pinchot JW, Small W, Ray CE, Hohenwalter EJ. ACR Appropriateness Criteria Radiologic Management of Hepatic Malignancy. J Am Coll Radiol 2016; 13:265-73. [PMID: 26944037 DOI: 10.1016/j.jacr.2015.12.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 12/04/2015] [Indexed: 12/18/2022]
Abstract
Management of primary and secondary hepatic malignancy is a complex problem. Achieving optimal care for this challenging population often requires the involvement of multiple medical and surgical disciplines. Because of the wide variety of potential therapies, treatment protocols for various malignancies continue to evolve. Consequently, development of appropriate therapeutic algorithms necessitates consideration of medical options, such as systemic chemotherapy; surgical options, such as resection or transplantation; and loco-regional therapies, such as thermal ablation and transarterial embolization techniques. This article provides a review of treatment strategies for the three most common subtypes of hepatic malignancy treated with loco-regional therapies: hepatocellular carcinoma, neuroendocrine metastases, and colorectal metastases. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every three years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
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Affiliation(s)
- Brian E Kouri
- Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina.
| | | | - Waddah B Al-Refaie
- Georgetown University Hospital, Washington, District of Columbia, American College of Surgeons
| | - Nilofer Azad
- Sidney Kimmel Cancer Center at Johns Hopkins University, Baltimore, Maryland, American Society of Clinical Oncology
| | - James Farrell
- Interventional Endoscopy and Pancreatic Diseases, New Haven, Connecticut, American Gastroenterological Association
| | - Ron C Gaba
- University of Illinois Hospital, Chicago, Illinois
| | | | - Matthew G Gipson
- University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | | | | | | | - William Small
- Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois
| | - Charles E Ray
- University of Illinois Hospital and Health Science System, Chicago, Illinois
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203
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Efficacy of External Beam Radiation-Based Treatment plus Locoregional Therapy for Hepatocellular Carcinoma Associated with Portal Vein Tumor Thrombosis. BIOMED RESEARCH INTERNATIONAL 2016; 2016:6017406. [PMID: 27999803 PMCID: PMC5143704 DOI: 10.1155/2016/6017406] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 11/03/2016] [Accepted: 11/07/2016] [Indexed: 01/22/2023]
Abstract
Background. Portal vein tumor thrombosis (PVTT) is a common event in advanced hepatocellular carcinoma (HCC). The optimal treatment for these patients remains controversial. Methods. A retrospective review of 149 patients who had unresectable HCC associated with PVTT between January 2005 and December 2012 was performed. Outcomes related to external beam radiation-based treatment were measured, and clinicopathological features and parameters affecting prognosis were analyzed as well. Results. The radiotherapeutic response of PVTT was an important element that affected the overall treatment response of HCC. Serum α-fetoprotein < 400 ng/mL, the presence of a radiotherapeutic response on PVTT, and receiving additional locoregional therapy were significant prognostic factors affecting the survival of patients. Patients who had received additional locoregional therapy obtained a better outcome, and six of them were eventually able to undergo surgical management with curative intent. Conclusion. The outcome of HCC associated with PVTT remains pessimistic. In addition to the current recommended treatment using sorafenib, a combination of external beam radiotherapy targeting PVTT and locoregional therapy for intrahepatic HCC might be a promising strategy for patients who had unresectable HCC with PVTT. This approach could perhaps offer patients a favorable outcome as well as a possible cure with following surgical management.
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204
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Hsieh TC, Wu YC, Sun SS, Yen KY, Kao CH. Treating hepatocellular carcinoma with 90Y-bearing microspheres: a review. Biomedicine (Taipei) 2016; 6:19. [PMID: 27848114 PMCID: PMC5138159 DOI: 10.7603/s40681-016-0019-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Accepted: 08/06/2016] [Indexed: 12/21/2022] Open
Abstract
Hepatocellular carcinoma (HCC) is a disease usually diagnosed in its advanced-stage, and is frequently not amenable to curative surgical treatment. Also, HCC is resistant to chemotherapy and less vulnerable to radiation therapy compared to normal hepatic parenchyma. Both of these facts render the efficacy of adjuvant and palliative treatments problematic. Selective internal radiation therapy (SIRT) with 90Y-bearing microspheres is characterized by preferentially delivering substantially high doses of radiation to a liver tumor dose simultaneously limiting the damage to its non-tumorous cells, providing an opportunity for effective local tumor control and even tumor regression therapy. The current article reviews the specific characters, dosimetry, possible applications, and special considerations toward the pre-existing radiation therapy of 90Y microsphere SIRT in treating HCC.
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Affiliation(s)
- Te-Chun Hsieh
- Department of Nuclear Medicine and PET Center, China Medical University Hospital, No. 2, Yuh-Der Rd., North Dist., Taichung, 404, Taiwan.,Department of Biomedical Imaging and Radiological Science, China Medical University, 404, Taichung, Taiwan
| | - Yu-Chin Wu
- Department of Nuclear Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu Branch, No. 25, Ln. 442. Sec. 1, Jingguo Rd., East Dist.,, Hsinchu City, 300, Taiwan.
| | - Shung-Shung Sun
- Department of Nuclear Medicine and PET Center, China Medical University Hospital, No. 2, Yuh-Der Rd., North Dist., Taichung, 404, Taiwan.,Department of Biomedical Imaging and Radiological Science, China Medical University, 404, Taichung, Taiwan
| | - Kuo-Yang Yen
- Department of Nuclear Medicine and PET Center, China Medical University Hospital, No. 2, Yuh-Der Rd., North Dist., Taichung, 404, Taiwan.,Department of Biomedical Imaging and Radiological Science, China Medical University, 404, Taichung, Taiwan
| | - Chia-Hung Kao
- Department of Nuclear Medicine and PET Center, China Medical University Hospital, No. 2, Yuh-Der Rd., North Dist., Taichung, 404, Taiwan. .,School of Medicine, China Medical University, 404, Taichung, Taiwan.
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205
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Gandhi M, Choo SP, Thng CH, Tan SB, Low ASC, Cheow PC, Goh ASW, Tay KH, Lo RHG, Goh BKP, Wong JS, Ng DCE, Soo KC, Liew WM, Chow PKH. Single administration of Selective Internal Radiation Therapy versus continuous treatment with sorafeNIB in locally advanced hepatocellular carcinoma (SIRveNIB): study protocol for a phase iii randomized controlled trial. BMC Cancer 2016; 16:856. [PMID: 27821083 PMCID: PMC5100089 DOI: 10.1186/s12885-016-2868-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 10/13/2016] [Indexed: 02/08/2023] Open
Abstract
Background Approximately 20 % of hepatocellular carcinoma (HCC) patients diagnosed in the early stages may benefit from potentially curative ablative therapies such as surgical resection, transplantation or radiofrequency ablation. For patients not eligible for such options, prognosis is poor. Sorafenib and Selective Internal Radiation Therapy (SIRT) are clinically proven treatment options in patients with unresectable HCC, and this study aims to assess overall survival following either SIRT or Sorafenib therapy for locally advanced HCC patients. Methods This investigator-initiated, multi-centre, open-label, randomized, controlled trial will enrol 360 patients with locally advanced HCC, as defined by Barcelona Clinic Liver Cancer stage B or stage C, without distant metastases, and which is not amenable to immediate curative treatment. Exclusion criteria include previous systemic therapy, metastatic disease, complete occlusion of the main portal vein, or a Child-Pugh score of >7. Eligible patients will be randomised 1:1 and stratified by centre and presence or absence of portal vein thrombosis to receive either a single administration of SIRT using yttrium-90 resin microspheres (SIR-Spheres®, Sirtex Medical Limited, Sydney, Australia) targeted at HCC in the liver by the trans-arterial route or continuous oral Sorafenib (Nexavar®, Bayer Pharma AG, Berlin, Germany) at a dose of 400 mg twice daily until disease progression, no further response, complete regression or unacceptable toxicity. Patients for both the Sorafenib and SIRT arms will be followed-up every 4 weeks for the first 3 months and 12 weekly thereafter. Overall survival is the primary endpoint, assessed for the intention-to-treat population. Secondary endpoints are tumour response rate, time-to-tumour progression, progression free survival, quality of life and down-staging to receive potentially curative therapy. Discussion Definitive data comparing these two therapies will help to determine clinical practice in the large group of patients with locally advanced HCC and improve outcomes for such patients. Trial registration ClinicalTrials.gov identifier, NCT01135056, first received 24, May 2010.
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Affiliation(s)
- Mihir Gandhi
- Biostatistics, Singapore Clinical Research Institute, #02-01, Nanos, 31 Biopolis Way, Singapore, Singapore.,Centre for Quantitative Medicine, Duke-NUS Medical School, 8 College Road, Singapore, Singapore.,Tampere Center for Child Health Research, University of Tampere and Tampere University Hospital, Tempere, Finland
| | - Su Pin Choo
- Division of Medical Oncology, National Cancer Centre Singapore, 11 Hospital Drive, Singapore, Singapore
| | - Choon Hua Thng
- Division of Oncologic Imaging, National Cancer Centre Singapore, 11 Hospital Drive, Singapore, Singapore
| | - Say Beng Tan
- Office of Research, Singapore Health Services, 31 Third Hospital Avenue, #03-03 Bowyer Block C, Singapore, Singapore.,Clinical Sciences, Duke-NUS Medical School, 8 College Road, Singapore, Singapore
| | - Albert Su Chong Low
- Department of Diagnostic Radiology, Singapore General Hospital, Outram Road, Singapore, Singapore
| | - Peng Chung Cheow
- Department of Hepato-pancreato-biliary and Transplant Surgery, Singapore General Hospital, Outram Road, Singapore, Singapore
| | - Anthony Soon Whatt Goh
- Department of Nuclear Medicine and PET, Singapore General Hospital, Outram Road, Singapore, Singapore
| | - Kiang Hiong Tay
- Department of Diagnostic Radiology, Singapore General Hospital, Outram Road, Singapore, Singapore
| | - Richard Hoau Gong Lo
- Department of Diagnostic Radiology, Singapore General Hospital, Outram Road, Singapore, Singapore
| | - Brian Kim Poh Goh
- Department of Hepato-pancreato-biliary and Transplant Surgery, Singapore General Hospital, Outram Road, Singapore, Singapore
| | - Jen San Wong
- Department of Hepato-pancreato-biliary and Transplant Surgery, Singapore General Hospital, Outram Road, Singapore, Singapore
| | - David Chee Eng Ng
- Department of Nuclear Medicine and PET, Singapore General Hospital, Outram Road, Singapore, Singapore
| | - Khee Chee Soo
- Division of Surgical Oncology, National Cancer Centre Singapore, 11 Hospital Drive, Singapore, Singapore
| | - Wei Ming Liew
- Project Management, Singapore Clinical Research Institute, #02-01, Nanos, 31 Biopolis Way, Singapore, Singapore
| | - Pierce K H Chow
- Department of Hepato-pancreato-biliary and Transplant Surgery, Singapore General Hospital, Outram Road, Singapore, Singapore. .,Office of Clinical, Academic and Faculty Affairs, Duke-NUS Medical School, 8 College Road, Singapore, Singapore. .,Program in Translational and Clinical Liver Research, National Cancer Centre Singapore, Singapore, Singapore.
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206
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Ingraham C, Johnson G, Padia SA, Vaidya S. Interventional Radiology for Liver Lesions. Semin Roentgenol 2016; 51:367-377. [PMID: 27743571 DOI: 10.1053/j.ro.2016.05.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
| | - Guy Johnson
- Department of Interventional Radiology, University of Washington, Seattle, WA
| | - Siddharth A Padia
- Department of Interventional Radiology, University of Washington, Seattle, WA
| | - Sandeep Vaidya
- Department of Interventional Radiology, University of Washington, Seattle, WA.
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207
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Cucchetti A, Cappelli A, Ercolani G, Mosconi C, Cescon M, Golfieri R, Pinna AD. Selective Internal Radiation Therapy (SIRT) as Conversion Therapy for Unresectable Primary Liver Malignancies. Liver Cancer 2016; 5:303-311. [PMID: 27781202 PMCID: PMC5075901 DOI: 10.1159/000449341] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Many patients with primary liver cancers are not candidates for surgery, and systemic therapies are seldom effective. Selective internal radiation therapy (SIRT) has been shown to obtain partial and even complete response in unresectable primary tumors. As a "side effect", SIRT can induce contra-lateral liver hypertrophy. Tumor response to SIRT can be sufficient to allow disengagement from normal vital structures whose involvement is the cause of the initial unresectability. The contra-lateral hypertrophy can thereby increase the future liver remnant (FLR) volume to over the safe threshold so that extended hepatectomy can be performed. SUMMARY A review of the available literature was performed to assess the tumor response and liver hypertrophy that can be expected after SIRT, in order to delineate whether SIRTcan play a role in conversion therapy for resectability of primary liver malignancies. KEY MESSAGE Available data suggest that SIRT in unresectable hepatocellular and cholangiocellular carcinomas can provide a considerable down-sizing of the tumors to possibly allow resection. Hypertrophy of the contra-lateral lobe represents a favorable collateral effect that can help in achieving safer subsequent major hepatectomy. In patients whose FLR volume represents the only surgical concern, portal vein embolization remains the treatment of choice.
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Affiliation(s)
- Alessandro Cucchetti
- Department of Medical and Surgical Sciences–DIMEC, S.Orsola-Malpighi Hospital, Alma Mater Studiorum−University of Bologna, Bologna, Italy,*Alessandro Cucchetti, MD, Department of Medical and Surgical Sciences–DIMEC, S.Orsola-Malpighi, Hospital, Alma Mater Studiorum–University of Bologna, Via Massarenti 9, 40138 Bologna (Italy), Tel. +39 051 6363721, E-Mail
| | - Alberta Cappelli
- Radiology Unit, Department of Diagnostic and Preventive Medicine, S.Orsola-Malpighi Hospital, Bologna, Italy
| | - Giorgio Ercolani
- Department of Medical and Surgical Sciences–DIMEC, S.Orsola-Malpighi Hospital, Alma Mater Studiorum−University of Bologna, Bologna, Italy
| | - Cristina Mosconi
- Radiology Unit, Department of Diagnostic and Preventive Medicine, S.Orsola-Malpighi Hospital, Bologna, Italy
| | - Matteo Cescon
- Department of Medical and Surgical Sciences–DIMEC, S.Orsola-Malpighi Hospital, Alma Mater Studiorum−University of Bologna, Bologna, Italy
| | - Rita Golfieri
- Radiology Unit, Department of Diagnostic and Preventive Medicine, S.Orsola-Malpighi Hospital, Bologna, Italy
| | - Antonio Daniele Pinna
- Department of Medical and Surgical Sciences–DIMEC, S.Orsola-Malpighi Hospital, Alma Mater Studiorum−University of Bologna, Bologna, Italy
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208
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Best J, Schotten C, Theysohn JM, Wetter A, Müller S, Radünz S, Schulze M, Canbay A, Dechêne A, Gerken G. Novel implications in the treatment of hepatocellular carcinoma. Ann Gastroenterol 2016; 30:23-32. [PMID: 28042235 PMCID: PMC5198244 DOI: 10.20524/aog.2016.0092] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 08/29/2016] [Indexed: 02/06/2023] Open
Abstract
Worldwide hepatocellular carcinoma remains one of the leading causes of cancer-related death, associated with a poor prognosis due to late diagnosis in the majority of cases. Physicians at care are frequently confronted with patients who are ineligible for curative treatment such as liver resection, transplantation or radiofrequency ablation. Besides established palliative locoregional therapies, such as ablation or chemoembolization, new treatment options, such as microwave ablation, drug-eluting bead transarterial chemoembolization or selective internal radiation therapy, are emerging; however, data from randomized controlled trials are still lacking. In order to achieve optimal tumor control, patients should receive tailored treatment concepts, considering their tumor burden, liver function and performance status, instead of strictly assigning patients to treatment modalities following algorithms that may be partly very restrictive. Palliative locoregional pretreatment might facilitate downstaging to ensure later curative resection or transplantation. In addition, the combined utilization of different locoregional treatment options or systemic co-treatment has been the subject of several trials. In cases where local tumor control cannot be achieved, or in the scenario of extrahepatic spread, sorafenib remains the only approved systemic therapy option. Alternative targeted therapies, such as immune checkpoint inhibitors have shown encouraging preliminary results, while data from phase III studies are pending.
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Affiliation(s)
- Jan Best
- Department of Gastroenterology and Hepatology (Jan Best, Clemens Schotten, Ali Canbay, Alexander Dechêne, Guido Gerken)
| | - Clemens Schotten
- Department of Gastroenterology and Hepatology (Jan Best, Clemens Schotten, Ali Canbay, Alexander Dechêne, Guido Gerken)
| | - Jens M Theysohn
- Departments of Diagnostic and Interventional Radiology and Neuroradiology (Jens M. Theysohn, Axel Wetter)
| | - Axel Wetter
- Departments of Diagnostic and Interventional Radiology and Neuroradiology (Jens M. Theysohn, Axel Wetter)
| | | | - Sonia Radünz
- Departments of Transplant and General Surgery (Sonia Radünz, Maren Schulze), University Hospital Essen, Essen, Germany
| | - Maren Schulze
- Departments of Transplant and General Surgery (Sonia Radünz, Maren Schulze), University Hospital Essen, Essen, Germany
| | - Ali Canbay
- Department of Gastroenterology and Hepatology (Jan Best, Clemens Schotten, Ali Canbay, Alexander Dechêne, Guido Gerken)
| | - Alexander Dechêne
- Department of Gastroenterology and Hepatology (Jan Best, Clemens Schotten, Ali Canbay, Alexander Dechêne, Guido Gerken)
| | - Guido Gerken
- Department of Gastroenterology and Hepatology (Jan Best, Clemens Schotten, Ali Canbay, Alexander Dechêne, Guido Gerken)
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209
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Cai B, Altman MB, Garcia-Ramirez J, LaBrash J, Goddu SM, Mutic S, Parikh PJ, Olsen JR, Saad N, Zoberi JE. Process improvement for the safe delivery of multidisciplinary-executed treatments-A case in Y-90 microspheres therapy. Brachytherapy 2016; 16:236-244. [PMID: 27618420 DOI: 10.1016/j.brachy.2016.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 07/15/2016] [Accepted: 08/02/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE To develop a safe and robust workflow for yttrium-90 (Y-90) radioembolization procedures in a multidisciplinary team environment. METHODS AND MATERIALS A generalized Define-Measure-Analyze-Improve-Control (DMAIC)-based approach to process improvement was applied to a Y-90 radioembolization workflow. In the first DMAIC cycle, events with the Y-90 workflow were defined and analyzed. To improve the workflow, a web-based interactive electronic white board (EWB) system was adopted as the central communication platform and information processing hub. The EWB-based Y-90 workflow then underwent a second DMAIC cycle. Out of 245 treatments, three misses that went undetected until treatment initiation were recorded over a period of 21 months, and root-cause-analysis was performed to determine causes of each incident and opportunities for improvement. The EWB-based Y-90 process was further improved via new rules to define reliable sources of information as inputs into the planning process, as well as new check points to ensure this information was communicated correctly throughout the process flow. RESULTS After implementation of the revised EWB-based Y-90 workflow, after two DMAIC-like cycles, there were zero misses out of 153 patient treatments in 1 year. CONCLUSIONS The DMAIC-based approach adopted here allowed the iterative development of a robust workflow to achieve an adaptable, event-minimizing planning process despite a complex setting which requires the participation of multiple teams for Y-90 microspheres therapy. Implementation of such a workflow using the EWB or similar platform with a DMAIC-based process improvement approach could be expanded to other treatment procedures, especially those requiring multidisciplinary management.
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Affiliation(s)
- Bin Cai
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, MO
| | - Michael B Altman
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, MO
| | - Jose Garcia-Ramirez
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, MO
| | - Jason LaBrash
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, MO
| | - S Murty Goddu
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, MO
| | - Sasa Mutic
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, MO
| | - Parag J Parikh
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, MO
| | - Jeffrey R Olsen
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, MO
| | - Nael Saad
- Department of Radiology, Vascular and Interventional Radiology Section, Washington University School of Medicine, Saint Louis, MO
| | - Jacqueline E Zoberi
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, MO.
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210
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Zhang JF, Liu JM, Zhang N, Du C, Zheng Q. Trans-arterial Chemo-Embolization in Treating Elderly Patients with Hepatocellular Carcinoma. Asian Pac J Cancer Prev 2016; 16:7201-4. [PMID: 26514512 DOI: 10.7314/apjcp.2015.16.16.7201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This analysis was conducted to evaluate the efficacy and safety of Trans-arterial Chemo- Embolization (TACE) in treating Elderly patients with Hepatocellular Carcinoma (EHPC). METHODS Clinical studies evaluating the efficacy and safety of TACE on response and safety for patients with EHPC were identified by using a predefined search strategy. Pooled response rate of treatment were calculated. RESULTS In TACE based regimen, clinical studies which including patients with EHPC were considered eligible for the evaluation of response. And, in these TACE based treatments, pooled analysis suggested that, in all 288 patients whose response could be assessed, the pooled reponse rate was 29.5%(85/288) in TACE based treatment. The most commonly encountered TACE-related morbidity was liver function impairment. No grade III or IV renal or liver toxicity were observed. No treatment related death occurred in EHPC patients with TACE based treatments. CONCLUSION This evidence based analysis suggests that TACE based treatments are associated with mild response rate and accepted toxicities for treating patients with EHPC.
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Affiliation(s)
- Jian-Feng Zhang
- The Second People's Hospital of Nanjing, Nanjing, China E-mail :
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211
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Iodine-125 implantation plus transarterial chemoembolization for the treatment of hepatocellular carcinoma of 3-5cm: A propensity score matching study. Dig Liver Dis 2016; 48:1082-7. [PMID: 27365224 DOI: 10.1016/j.dld.2016.06.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Revised: 05/19/2016] [Accepted: 06/08/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Both iodine-125 implantation and transarterial chemoembolization (TACE) are feasible options for hepatocellular carcinoma (HCC). The aim of the research is to investigate whether iodine-125 implantation combined with TACE could improve the overall survival of patients with HCC of 3-5cm. METHODS 144 patients with HCC of 3-5cm who underwent iodine-125 implantation plus TACE and TACE alone were retrospectively enrolled in this study. To reduce the selection bias, 55 matched pairs of patients were generated by propensity score matching (PSM). Their overall survival was compared by the Kaplan-Meier method. Independent prognostic factors were identified by Cox proportional hazards regression model. RESULTS patients receiving iodine-125 implantation plus TACE have significantly better overall survival than patients receiving TACE alone (P<0.001). After PSM, treatment of iodine-125 plus TACE still provide better survival (1-year, 89.1% vs. 65.5%; 3-year, 51.0% vs. 7.4%; P<0.001). In multivariate analysis, BCLC stage, vascular invasion and treatment modality independently predicted the prognosis. No severe adverse events occurred in both groups. CONCLUSION for HCC patients of 3-5cm for whom surgical intervention is not an option, iodine-125 implantation combined with TACE might be an effective and viable alternative to provide better overall survival.
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212
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Lobo L, Yakoub D, Picado O, Ripat C, Pendola F, Sharma R, ElTawil R, Kwon D, Venkat S, Portelance L, Yechieli R. Unresectable Hepatocellular Carcinoma: Radioembolization Versus Chemoembolization: A Systematic Review and Meta-analysis. Cardiovasc Intervent Radiol 2016; 39:1580-1588. [PMID: 27586657 DOI: 10.1007/s00270-016-1426-y] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 07/13/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Transarterial radioembolization (TARE) has emerged as a newer regional therapy to transarterial chemoembolization (TACE) for treatment of unresectable hepatocellular carcinoma (HCC). The aim of this study is to compare clinical outcomes of both the techniques. METHODS Online search for studies comparing TARE to TACE from 2005 to present was performed. Primary outcome was overall survival rate for up to 4 years. Secondary outcomes included post-treatment complications and treatment response. Quality of included studies was evaluated by STrengthening the Reporting of OBservational studies in Epidemiology criteria. Relative risk (RR) and 95 % confidence intervals (CI) were calculated from pooled data. RESULTS The search strategy yielded 172 studies, five met selection criteria and included 553 patients with unresectable HCC, 284 underwent TACE and 269 underwent TARE. Median ages were 63 and 64 years for TACE and TARE, respectively. Meta-analysis showed no statistically significant difference in survival for up to 4 years between the two groups (HR = 1.06; 95 % CI 0.81-1.46, p = 0.567). TACE required at least one day of hospital stay compared to TARE which was mostly an outpatient procedure. TACE had more post-treatment pain than TARE (RR = 0.51, 95 % CI 0.36-0.72, p < 0.01), but less subjective fatigue (RR = 1.68, 95 % CI 1.08-2.62, p < 0.01). There was no difference between the two groups in the incidence of post-treatment nausea, vomiting, fever, or other complications. In addition, there was no difference in partial or complete response rates between the two groups. CONCLUSION TARE appears to be a safe alternative treatment to TACE with comparable complication profile and survival rates. Larger prospective randomized trials, focusing on patient-reported outcomes and cost-benefit analysis are required to consolidate these results.
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Affiliation(s)
- Laila Lobo
- Division of Surgical Oncology at Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami - Miller School of Medicine, Miami, FL, USA
| | - Danny Yakoub
- Division of Surgical Oncology at Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami - Miller School of Medicine, Miami, FL, USA
| | - Omar Picado
- Division of Surgical Oncology at Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami - Miller School of Medicine, Miami, FL, USA
| | - Caroline Ripat
- Division of Surgical Oncology at Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami - Miller School of Medicine, Miami, FL, USA
| | - Fiorella Pendola
- Division of Surgical Oncology at Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami - Miller School of Medicine, Miami, FL, USA
| | - Rishika Sharma
- Division of Surgical Oncology at Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami - Miller School of Medicine, Miami, FL, USA
| | - Rana ElTawil
- Division of Surgical Oncology at Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami - Miller School of Medicine, Miami, FL, USA
| | - Deukwoo Kwon
- Department of Biostatistics and Bioinformatics, Sylvester Comprehensive Cancer Center, University of Miami - Miller School of Medicine, Miami, FL, USA
| | - Shree Venkat
- Department of Radiology, Sylvester Comprehensive Cancer Center, University of Miami - Miller School of Medicine, Miami, FL, USA
| | - Loraine Portelance
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami - Miller School of Medicine, Miami, FL, USA
| | - Raphael Yechieli
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami - Miller School of Medicine, Miami, FL, USA. .,Department of Radiation Oncology, Jackson Memorial Hospital/Sylvester Comprehensive Cancer Center, University of Miami - Miller School of Medicine, 1475 NW 12th Ave, Suite 1500, Miami, FL, 33136, USA.
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Bauschke A, Altendorf-Hofmann A, Freesmeyer M, Winkens T, Malessa C, Schierz JH, Teichgraeber U, Settmacher U. [Selective internal radioembolization in nonresectable hepatocellular carcinoma]. Chirurg 2016; 87:956-963. [PMID: 27460230 DOI: 10.1007/s00104-016-0259-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION The role of selective internal radioembolization (SIRT) in the treatment of hepatocellular carcinoma (HCC) is currently unclear. MATERIALS AND METHODS We investigated 52 patients with nonresectable HCC in cirrhosis who underwent SIRT at the Department of General, Visceral and Vascular Surgery in co-operation with the Department of Nuclear Medicine and the Institute of Diagnostic and Interventional Radiology between April 2011 and October 2015. RESULTS In five patients, SIRT was employed for bridging to liver transplantation. In patients who had undergone pre-treatment with SIRT, histological examination of the explanted livers showed extensive tumor necrosis in the targeted areas with only minor remnant vital tissue at the margins. Four of the patients who underwent SIRT as local bridging treatment are tumor-free after transplantation. In the 47 palliatively treated patients, a total of 76 radioembolizations were performed. The observed 1‑ and 2‑year survival rates in these patients were 58 and 29 %, respectively, after the first SIRT. In the multivariate analysis of the observed survival, AFP before the first SIRT >30ng/ml, time interval of <12 months between the initial diagnosis and the first SIRT, largest tumor diameter >5 cm and portal vein thrombosis were independent negative prognostic factors. In the multi-variate analysis, the time to progression was independently influenced only by the AFP level before the first SIRT. In addition to standard treatment with transarterial chemoembolization (TACE), SIRT is feasible in nonresectable HCC, in particular with portal vein thrombosis, with identical results, less interventions and few side effects.
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Affiliation(s)
- A Bauschke
- Klinik für Allgemein-,Visceral-und Gefäßchirurgie, Universitätsklinikum Jena, Erlanger Allee 101, 07740, Jena, Deutschland.
| | - A Altendorf-Hofmann
- Klinik für Allgemein-,Visceral-und Gefäßchirurgie, Universitätsklinikum Jena, Erlanger Allee 101, 07740, Jena, Deutschland
| | - M Freesmeyer
- Klinik für Nuklearmedizin, Universitätsklinikum Jena, Jena, Deutschland
| | - T Winkens
- Klinik für Nuklearmedizin, Universitätsklinikum Jena, Jena, Deutschland
| | - C Malessa
- Klinik für Allgemein-,Visceral-und Gefäßchirurgie, Universitätsklinikum Jena, Erlanger Allee 101, 07740, Jena, Deutschland
| | - J-H Schierz
- Institut für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Jena, Jena, Deutschland
| | - U Teichgraeber
- Institut für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Jena, Jena, Deutschland
| | - U Settmacher
- Klinik für Allgemein-,Visceral-und Gefäßchirurgie, Universitätsklinikum Jena, Erlanger Allee 101, 07740, Jena, Deutschland
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Sacco R, Conte C, Tumino E, Parisi G, Marceglia S, Metrangolo S, Eggenhoffner R, Bresci G, Cabibbo G, Giacomelli L. Transarterial radioembolization for hepatocellular carcinoma: a review. J Hepatocell Carcinoma 2016; 3:25-9. [PMID: 27574589 PMCID: PMC4994804 DOI: 10.2147/jhc.s50359] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Hepatocellular carcinoma (HCC) is the most common type of liver cancer and is the second cause of death due to malignancy in the world. The treatment of HCC is complex and includes potentially curative and palliative approaches. However, both curative and palliative treatments for HCC are often associated with a not-completely favorable safety/efficacy ratio. Therefore, other treatment options appear necessary in clinical practice. Transarterial radioembolization has shown a promising efficacy in terms of disease control and is associated with a good safety profile. This review discusses the use of transarterial radioembolization in HCC, with a focus on the clinical aspects of this therapeutic strategy.
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Affiliation(s)
- Rodolfo Sacco
- Department of Gastroenterology, Cisanello Hospital, Pisa
| | - Caterina Conte
- Endocrinology and Metabolic Diseases, Policlinico A. Gemelli, Università Cattolica del Sacro Cuore, Rome
| | | | | | - Sara Marceglia
- Department of Engineering and Architecture, University of Trieste, Trieste
| | | | - Roberto Eggenhoffner
- Department of Surgical Sciences and Integrated Diagnostics, School of Medicine, Genova University, Genoa
| | | | - Giuseppe Cabibbo
- Section of Gastroenterology, DIBIMIS, University of Palermo, Palermo, Italy
| | - Luca Giacomelli
- Department of Surgical Sciences and Integrated Diagnostics, School of Medicine, Genova University, Genoa
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Guarneri A, Franco P, Romagnoli R, Trino E, Mirabella S, Molinaro L, Rizza G, Filippi AR, Carucci P, Salizzoni M, Ricardi U. Stereotactic ablative radiation therapy prior to liver transplantation in hepatocellular carcinoma. Radiol Med 2016; 121:873-881. [DOI: 10.1007/s11547-016-0670-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 07/12/2016] [Indexed: 12/31/2022]
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216
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Park HC, Yu JI, Cheng JCH, Zeng ZC, Hong JH, Wang MLC, Kim MS, Chi KH, Liang PC, Lee RC, Lau WY, Han KH, Chow PKH, Seong J. Consensus for Radiotherapy in Hepatocellular Carcinoma from The 5th Asia-Pacific Primary Liver Cancer Expert Meeting (APPLE 2014): Current Practice and Future Clinical Trials. Liver Cancer 2016; 5:162-74. [PMID: 27493892 PMCID: PMC4960352 DOI: 10.1159/000367766] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
A consensus meeting to develop practice guidelines and to recommend future clinical trials for radiation therapy (RT), including external beam RT (EBRT), and selective internal RT (SIRT) in hepatocellular carcinoma (HCC) was held at the 5th annual meeting of the Asia-Pacific Primary Liver Cancer Expert consortium. Although there is no randomized phase III trial evidence, the efficacy and safety of RT in HCC has been shown by prospective and retrospective studies using modern RT techniques. Based on these results, the committee came to a consensus on the utility and efficacy of RT in the management of HCC according to each disease stage as follows: in early and intermediate stage HCC, if standard treatment is not compatible, RT, including EBRT and SIRT can be considered. In locally advanced stage HCC, combined EBRT with transarterial chemoembolization or hepatic arterial infusion chemotherapy, and SIRT can be considered. In terminal stage HCC, EBRT can be considered for palliation of symptoms and reduction of morbidity caused by the primary tumor or its metastases. Despite the currently reported benefits of RT in HCC, the committee agreed that there is a compelling need for large prospective studies, including randomized phase III trial evidence evaluating the role of RT. Specifically studies evaluating the efficacy and safety of sequential combination of EBRT and SIRT are strongly recommended.
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Affiliation(s)
- Hee Chul Park
- Departments of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea,Medical Device Management and Research, SAIHST, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jeong Il Yu
- Departments of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jason Chia-Hsien Cheng
- Department of Oncology, National Taiwan University Hospital, National Taiwan University College of Medicine; Graduate Institute of Oncology, National Taiwan University College of Medicine, Taipei, Taiwan (ROC)
| | - Zhao Chong Zeng
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ji Hong Hong
- Department of Radiation Oncology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan (ROC)
| | | | - Mi Sook Kim
- Department of Radiation Oncology, Korea Institute of Radiological and Medical Sciences, Seoul, Republic of Korea
| | - Kwan Hwa Chi
- Department of Radiation Therapy and Oncology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan (ROC)
| | - Po-Ching Liang
- Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan (ROC)
| | - Rheun-Chuan Lee
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan (ROC)
| | - Wan-Yee Lau
- Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, SAR, China
| | - Kwang Hyub Han
- Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Pierce Kah-Hoe Chow
- Department of Surgical Oncology, National Cancer Center; Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital; Office of Clinical Sciences, Duke-NUS Graduate Medical School, Singapore,*Pierce K. H. Chow, MD, PhD, Department of Surgical Oncology, National Cancer, Center, Department of Hepatopancreatobiliary and, Transplant Surgery, Singapore General Hospital;, Office of Clinical Sciences, Duke-NUS Graduate, Medical School, Singapore (Singapore), Tel. +65 6326 6091, E-Mail
| | - Jinsil Seong
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea,*Jinsil Seong, MD, PhD, Department of Radiation Oncology, Yonsei Cancer, Center, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, (Republic of Korea), Tel. +82 2 2228 8111, E-Mail
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217
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Bozkurt MF, Salanci BV, Uğur Ö. Intra-Arterial Radionuclide Therapies for Liver Tumors. Semin Nucl Med 2016; 46:324-39. [DOI: 10.1053/j.semnuclmed.2016.01.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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218
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Cheng S, Yang J, Shen F, Zhou W, Wang Y, Cong W, Yang GS, Cheng H, Hu H, Gao C, Guo J, Li A, Meng Y, Jiang X, Yang Y, Qian G, Luo M, Hu B, Man X, Zhang B, Su C, Zhou F, Li N, Shi J, Wang M, Zheng Y, Guo W, Sun J, Wang H, Lau WY, Wu MC. Multidisciplinary management of hepatocellular carcinoma with portal vein tumor thrombus - Eastern Hepatobiliary Surgical Hospital consensus statement. Oncotarget 2016; 7:40816-40829. [PMID: 27027235 PMCID: PMC5130047 DOI: 10.18632/oncotarget.8386] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 03/18/2016] [Indexed: 02/07/2023] Open
Abstract
Hepatocellular carcinoma (HCC) complicated by portal vein tumor thrombus (PVTT) is associated with poor prognosis, early recurrence of HCC, and limited treatment options. Current guidelines do not have standardized diagnostic and treatment modalities, thus creating a need for a multidisciplinary treatment model for standardization of the treatment. Eastern Hepatobiliary Surgical Hospital (China) convened two working parties of experts from all the departments, to consolidate the current evidence, prevailing vision for the future, and experience of the practicing clinicians engaged in HCC management, so as to develop a consensus for PVTT diagnosis and treatment according to the GRADE system. Based on the quality of the existing evidence and the strength of recommendations, the consensus statements were categorized into 3 evidence levels (A/B/C) and 5 classes (I/II/IIa/IIb/III).The panel discussed and provided clarity on the management and research options in the field of HCC with PVTT. In addition, the panel also assessed the quality of the cited studies and assigned grades to the recommendation statements. Among the group of experts, there was excellent agreement with regard to effective diagnosis and treatment of HCC with PVTT. The recommendations of this consensus will provide guidance to physicians and clinical researchers on the effective management of HCC with PVTT.
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Affiliation(s)
- Shuqun Cheng
- Eastern Hepatobiliary Surgical Hospital, Second Military Medical University, Shanghai, China
| | - Jiamei Yang
- Eastern Hepatobiliary Surgical Hospital, Second Military Medical University, Shanghai, China
| | - Feng Shen
- Eastern Hepatobiliary Surgical Hospital, Second Military Medical University, Shanghai, China
| | - Weiping Zhou
- Eastern Hepatobiliary Surgical Hospital, Second Military Medical University, Shanghai, China
| | - Yi Wang
- Eastern Hepatobiliary Surgical Hospital, Second Military Medical University, Shanghai, China
| | - Wenming Cong
- Eastern Hepatobiliary Surgical Hospital, Second Military Medical University, Shanghai, China
| | - Guang shun Yang
- Eastern Hepatobiliary Surgical Hospital, Second Military Medical University, Shanghai, China
| | - Hongyan Cheng
- Eastern Hepatobiliary Surgical Hospital, Second Military Medical University, Shanghai, China
| | - Heping Hu
- Eastern Hepatobiliary Surgical Hospital, Second Military Medical University, Shanghai, China
| | - Chunfang Gao
- Eastern Hepatobiliary Surgical Hospital, Second Military Medical University, Shanghai, China
| | - Jia Guo
- Eastern Hepatobiliary Surgical Hospital, Second Military Medical University, Shanghai, China
| | - Aijun Li
- Eastern Hepatobiliary Surgical Hospital, Second Military Medical University, Shanghai, China
| | - Yan Meng
- Eastern Hepatobiliary Surgical Hospital, Second Military Medical University, Shanghai, China
| | - Xiaoqing Jiang
- Eastern Hepatobiliary Surgical Hospital, Second Military Medical University, Shanghai, China
| | - Yefa Yang
- Eastern Hepatobiliary Surgical Hospital, Second Military Medical University, Shanghai, China
| | - Guojun Qian
- Eastern Hepatobiliary Surgical Hospital, Second Military Medical University, Shanghai, China
| | - Ming Luo
- Eastern Hepatobiliary Surgical Hospital, Second Military Medical University, Shanghai, China
| | - Bing Hu
- Eastern Hepatobiliary Surgical Hospital, Second Military Medical University, Shanghai, China
| | - Xiaobo Man
- Eastern Hepatobiliary Surgical Hospital, Second Military Medical University, Shanghai, China
| | - Baohua Zhang
- Eastern Hepatobiliary Surgical Hospital, Second Military Medical University, Shanghai, China
| | - Changqing Su
- Eastern Hepatobiliary Surgical Hospital, Second Military Medical University, Shanghai, China
| | - Feiguo Zhou
- Eastern Hepatobiliary Surgical Hospital, Second Military Medical University, Shanghai, China
| | - Nan Li
- Eastern Hepatobiliary Surgical Hospital, Second Military Medical University, Shanghai, China
| | - Jie Shi
- Eastern Hepatobiliary Surgical Hospital, Second Military Medical University, Shanghai, China
| | - Meng Wang
- Eastern Hepatobiliary Surgical Hospital, Second Military Medical University, Shanghai, China
| | - Yaxin Zheng
- Eastern Hepatobiliary Surgical Hospital, Second Military Medical University, Shanghai, China
| | - Weixing Guo
- Eastern Hepatobiliary Surgical Hospital, Second Military Medical University, Shanghai, China
| | - Juxian Sun
- Eastern Hepatobiliary Surgical Hospital, Second Military Medical University, Shanghai, China
| | - Hongyang Wang
- Eastern Hepatobiliary Surgical Hospital, Second Military Medical University, Shanghai, China
| | - Wan-yee Lau
- Eastern Hepatobiliary Surgical Hospital, Second Military Medical University, Shanghai, China
| | - Meng-chao Wu
- Eastern Hepatobiliary Surgical Hospital, Second Military Medical University, Shanghai, China
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219
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Lee EW, Alanis L, Cho SK, Saab S. Yttrium-90 Selective Internal Radiation Therapy with Glass Microspheres for Hepatocellular Carcinoma: Current and Updated Literature Review. Korean J Radiol 2016; 17:472-88. [PMID: 27390539 PMCID: PMC4936170 DOI: 10.3348/kjr.2016.17.4.472] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 03/20/2016] [Indexed: 12/13/2022] Open
Abstract
Hepatocellular carcinoma is the most common primary liver cancer and it represents the majority of cancer-related deaths in the world. More than 70% of patients present at an advanced stage, beyond potentially curative options. Ytrrium-90 selective internal radiation therapy (Y90-SIRT) with glass microspheres is rapidly gaining acceptance as a potential therapy for intermediate and advanced stage primary hepatocellular carcinoma and liver metastases. The technique involves delivery of Y90 infused glass microspheres via the hepatic arterial blood flow to the appropriate tumor. The liver tumor receives a highly concentrated radiation dose while sparing the healthy liver parenchyma due to its preferential blood supply from portal venous blood. There are two commercially available devices: TheraSphere® and SIR-Spheres®. Although, Y90-SIRT with glass microspheres improves median survival in patients with intermediate and advanced hepatocellular carcinoma and has the potential to downstage hepatocellular carcinoma so that the selected candidates meet the transplantable criteria, it has not gained widespread acceptance due to the lack of large randomized controlled trials. Currently, there are various clinical trials investigating the use of Y90-SIRT with glass microspheres for treatment of hepatocellular carcinoma and the outcomes of these trials may result in the incorporation of Y90-SIRT with glass microspheres into the treatment guidelines as a standard therapy option for patients with intermediate and advanced stage hepatocellular carcinoma.
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Affiliation(s)
- Edward Wolfgang Lee
- Division of Interventional Radiology, Department of Radiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Lourdes Alanis
- Division of Interventional Radiology, Department of Radiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Sung-Ki Cho
- Division of Interventional Radiology, Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Sammy Saab
- Division of Hepatology, Department of Medicine, Pfleger Liver Institute, University of California at Los Angeles, Los Angeles, CA 90024, USA
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220
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Byrne TJ, Rakela J. Loco-regional therapies for patients with hepatocellular carcinoma awaiting liver transplantation: Selecting an optimal therapy. World J Transplant 2016; 6:306-313. [PMID: 27358775 PMCID: PMC4919734 DOI: 10.5500/wjt.v6.i2.306] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 02/02/2016] [Accepted: 03/23/2016] [Indexed: 02/05/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is a common, increasingly prevalent malignancy. For all but the smallest lesions, surgical removal of cancer via resection or liver transplantation (LT) is considered the most feasible pathway to cure. Resection - even with favorable survival - is associated with a fairly high rate of recurrence, perhaps since most HCCs occur in the setting of cirrhosis. LT offers the advantage of removing not only the cancer but the diseased liver from which the cancer has arisen, and LT outperforms resection for survival with selected patients. Since time waiting for LT is time during which HCC can progress, loco-regional therapy (LRT) is widely employed by transplant centers. The purpose of LRT is either to bridge patients to LT by preventing progression and waitlist dropout, or to downstage patients who slightly exceed standard eligibility criteria initially but can fall within it after treatment. Transarterial chemoembolization and radiofrequency ablation have been the most widely utilized LRTs to date, with favorable efficacy and safety as a bridge to LT (and for the former, as a downstaging modality). The list of potentially effective LRTs has expanded in recent years, and includes transarterial chemoembolization with drug-eluting beads, radioembolization and novel forms of extracorporal therapy. Herein we appraise the various LRT modalities for HCC, and their potential roles in specific clinical scenarios in patients awaiting LT.
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221
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Sanoff HK, Chang Y, Stavas JM, Stürmer T, Lund J. Effectiveness of Initial Transarterial Chemoembolization for Hepatocellular Carcinoma Among Medicare Beneficiaries. J Natl Compr Canc Netw 2016; 13:1102-10. [PMID: 26358794 DOI: 10.6004/jnccn.2015.0135] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Optimal administration of transarterial chemoembolization (TACE), the standard approach for intermediate-stage hepatocellular carcinoma (HCC), requires clinical and technical expertise. We sought to evaluate whether TACE retains its effectiveness when administered across a broad range of health care settings. Furthermore, as the use of yttrium(90) (Y(90)) radioembolization has been increasing, we explored the comparative effectiveness of Y(90) as an alternative to TACE. METHODS Patients with HCC diagnosed from 2004 through 2009 treated initially with TACE or Y(90) were identified from the SEER-Medicare linkage. Key covariates included prediagnosis α-fetoprotein (AFP) screening, complications of cirrhosis, and tumor extent. Effect of treatment, patient, and health care system factors on overall survival (OS) was evaluated using multivariable Cox proportional hazards. Stratified OS estimates are provided. Propensity score (PS) weighting was used to compare effectiveness of Y(90) with TACE. RESULTS Of 1528 patients who underwent intra-arterial embolization, 577 received concurrent chemotherapy (eg, TACE). Median OS was 21 months (95% CI, 18-23) following TACE and 9 months (95% CI, 1-41) following Y(90). Refined survival estimates stratified by stage, AFP screening, and liver comorbidity are presented. The 90-day mortality rate after TACE was 21% to 25% in patients with extrahepatic spread or vascular invasion. In the PS-weighted analysis, Y(90) was associated with inferior survival, with an adjusted hazard ratio of 1.39 (95% CI, 1.02-1.90). CONCLUSIONS The effectiveness of TACE is generalizable to Medicare patients receiving care in a variety of treatment settings. However, early posttreatment mortality is high in patients with advanced disease. We found no evidence of improved outcomes with Y(90) compared with TACE. Survival estimates from this large cohort can be used to provide prognostic information to patients considering palliative TACE.
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Affiliation(s)
- Hanna K Sanoff
- From UNC Lineberger Comprehensive Cancer Center and the Division of Hematology/Oncology, Division of Vascular-Interventional Radiology, and Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina. From UNC Lineberger Comprehensive Cancer Center and the Division of Hematology/Oncology, Division of Vascular-Interventional Radiology, and Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina
| | - YunKyung Chang
- From UNC Lineberger Comprehensive Cancer Center and the Division of Hematology/Oncology, Division of Vascular-Interventional Radiology, and Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina
| | - Joseph M Stavas
- From UNC Lineberger Comprehensive Cancer Center and the Division of Hematology/Oncology, Division of Vascular-Interventional Radiology, and Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina
| | - Til Stürmer
- From UNC Lineberger Comprehensive Cancer Center and the Division of Hematology/Oncology, Division of Vascular-Interventional Radiology, and Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina. From UNC Lineberger Comprehensive Cancer Center and the Division of Hematology/Oncology, Division of Vascular-Interventional Radiology, and Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina
| | - Jennifer Lund
- From UNC Lineberger Comprehensive Cancer Center and the Division of Hematology/Oncology, Division of Vascular-Interventional Radiology, and Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina. From UNC Lineberger Comprehensive Cancer Center and the Division of Hematology/Oncology, Division of Vascular-Interventional Radiology, and Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina
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Mahnken AH. Current status of transarterial radioembolization. World J Radiol 2016; 8:449-459. [PMID: 27247711 PMCID: PMC4882402 DOI: 10.4329/wjr.v8.i5.449] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Revised: 10/17/2015] [Accepted: 03/14/2016] [Indexed: 02/07/2023] Open
Abstract
Unresectable primary and secondary liver malignancies present a major problem in the treatment of solid tumors. Transarterial radioembolization (TARE) is an increasingly used technique for treating various types of malignant liver tumors. This approach is appealing, as the mechanism of action is independent from other loco-regional treatments and potentially complementary to systemic therapies. There are two commercially available products in use for TARE: 90Y-resin and 90Y-glass microspheres. Currently available data indicates TARE so be safe and effective in hepatocellular carcinoma (HCC) and metastatic liver disease. In HCC the results compare well with chemoembolization, while the role of TARE in combination with kinase inhibitors has yet to be established. Current data on TARE in metastatic liver disease is promising, but there is a strong need for prospective randomized trials comparing TARE and modern chemotherapeutic regimen to support the growing role of TARE in metastatic liver disease.
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Transarterial Radioembolization with Yttrium-90 for the Treatment of Hepatocellular Carcinoma. Adv Ther 2016; 33:699-714. [PMID: 27039186 PMCID: PMC4882351 DOI: 10.1007/s12325-016-0324-7] [Citation(s) in RCA: 106] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Indexed: 12/21/2022]
Abstract
Background Hepatocellular carcinoma (HCC) is a common cause of worldwide mortality. Transarterial radioembolization (TARE) with yttrium-90 (Y90), a transcatheter intra-arterial procedure performed by interventional radiology, has become widely utilized in managing HCC. Methods The following is a focused review of TARE covering its commercially available products, clinical considerations of treatment, salient clinical trial data establishing its utility, and the current and future roles of TARE in the management of HCC. Results TARE is indicated for patients with unresectable, intermediate stage HCC. The two available products are glass and resin microspheres. All patients undergoing TARE must be assessed with a history, physical examination, clinical laboratory tests, imaging, and arteriography with macroaggregated albumin. TARE is safe and effective in the treatment of unresectable HCC, as it has a safer toxicity profile than chemoembolization, longer time-to-progression, greater ability to downsize and/or bridge patients to liver transplant, and utility in tumor complicated by portal vein thrombosis. TARE can also serve as an alternative to ablation and chemotherapy. Conclusion TARE assumes an integral role in the management of unresectable HCC and has been validated by numerous studies.
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Liver transplantation for hepatobiliary malignancies: a new era of "Transplant Oncology" has begun. Surg Today 2016; 47:403-415. [PMID: 27130463 DOI: 10.1007/s00595-016-1337-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 04/06/2016] [Indexed: 01/10/2023]
Abstract
The indications of liver transplantation for hepatobiliary malignancies have been carefully expanded in a stepwise fashion, despite the fundamental limitations in oncological, immunological, and technical aspects. A new era of "Transplant Oncology," the fusion of transplant surgery and surgical oncology, has begun, and we stand at the dawn of a paradigm shift in multidisciplinary cancer treatment. For hepatocellular carcinoma, new strategies have been undertaken to select recipients based on biological and dynamic markers instead of conventional morphological and static parameters, opening the doors for a more deliberate expansion of the Milan criteria and locoregional therapies before liver transplantation. Neoadjuvant chemoradiation therapy followed by liver transplantation for unresectable perihilar cholangiocarcinoma developed by the Mayo Clinic provided excellent outcomes in a US multicenter study; however, the surgical indications are not necessarily universal and await international validation. Similarly, an aggressive multidisciplinary approach has been applied for other tumors, including intrahepatic cholangiocarcinoma, hepatoblastoma, liver metastases from colorectal and neuroendocrine primary and gastrointestinal stromal tumors as well as rare tumors, such as hepatic undifferentiated embryonal sarcoma and infantile choriocarcinoma. In conclusion, liver transplantation is an important option for hepatobiliary malignancies; however, prospective studies are urgently needed to ensure the appropriate patient selection, organ allocation and living donation policies, and administration of antineoplastic immunosuppression.
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The role of 90Y-radioembolization in downstaging primary and secondary hepatic malignancies: a systematic review. Clin Transl Imaging 2016; 4:283-295. [PMID: 27512689 PMCID: PMC4960274 DOI: 10.1007/s40336-016-0172-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 03/14/2016] [Indexed: 12/11/2022]
Abstract
Radioembolization (RE) is an emerging treatment strategy for patients with primary hepatic malignancies and metastatic liver disease. Though RE is primarily performed in the palliative setting, a shift toward the curative setting is seen. Currently, hepatic resection and in selected cases liver transplantation are the only curative options for patients with a hepatic malignancy. Unfortunately, at diagnosis most patients are not eligible for liver surgery due to the imbalance between the necessary liver resection and the remaining liver remnant. However, in borderline resectable cases, tumor volume reduction and/or increasing the future liver remnant can lead to a resectable situation. The combination of selective tumor treatment, the induction of hypertrophy of untreated liver segments, and its favourable toxicity profile make RE an appealing strategy for downstaging. The present review discusses the possibilities for RE in the preoperative setting as a downstaging tool or as a bridge to liver transplantation.
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226
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She WH, Cheung TT. Bridging and downstaging therapy in patients suffering from hepatocellular carcinoma waiting on the list of liver transplantation. Transl Gastroenterol Hepatol 2016; 1:34. [PMID: 28138601 DOI: 10.21037/tgh.2016.03.04] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 01/04/2016] [Indexed: 12/12/2022] Open
Abstract
Hepatocellular carcinoma (HCC) is a common primary malignancy worldwide especially in the patients with the background of chronic liver disease. Liver transplantation (LT) is the only curative treatment effective for both malignancy as well as the cirrhosis and portal hypertension. Unfortunately, living donor is not always possible and the deceased graft is scarce. Neoadjuvant therapies, therefore, have been developed as a downstaging treatment to try to downstage the tumor within the transplant criteria, or as a bridging therapy to control the tumor growth in patients while waiting in the transplant list. This paper reviewed the common modalities used as bridging and downstaging therapies for patients suffering from HCC before undergoing LT.
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Affiliation(s)
- Wong Hoi She
- Division of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Department of Surgery, the University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - Tan To Cheung
- Division of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Department of Surgery, the University of Hong Kong, Queen Mary Hospital, Hong Kong
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228
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Gabr A, Kallini JR, Desai K, Hickey R, Thornburg B, Kulik L, Lewandowski RJ, Salem R. Types of Research Bias Encountered in IR. J Vasc Interv Radiol 2016; 27:546-50. [DOI: 10.1016/j.jvir.2016.01.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 01/04/2016] [Accepted: 01/04/2016] [Indexed: 12/13/2022] Open
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229
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Lau WY, Teoh YL, Win KM, Lee RC, de Villa VH, Kim YHJ, Liang PC, Santos-Ocampo RS, Lo RHG, Lim KBL, Tai DWM, Ng DCE, Irani FG, Gogna A, Chow PKH. Current role of selective internal radiation with yttrium-90 in liver tumors. Future Oncol 2016; 12:1193-204. [PMID: 27007495 DOI: 10.2217/fon-2016-0035] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
An expert panel met to review the evidence for selective internal radiation therapy (SIRT) using yttrium-90 microspheres in hepatocellular carcinoma and metastases from colorectal cancer and neuroendocrine tumors. There is now convincing evidence for the safety and efficacy of SIRT in these situations albeit mostly from retrospective cohort studies. There are a number of ongoing prospective randomized controlled clinical trials investigating the role of SIRT in liver tumors; however, data from these trials are still several years away (although the SIRFLOX study has been recently published). In this evolving environment, published evidence and the authors' experience were used to summarize the current and potential role of SIRT in the management of hepatocellular carcinoma of intermediate or advanced stage and in liver-dominant metastatic colorectal cancer and metastatic neuroendocrine tumors.
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Affiliation(s)
- Wan Yee Lau
- Faculty of Medicine, Chinese University of Hong Kong, Shatin, New Territories, Hong Kong, China
| | | | - Khin Maung Win
- Department of Hepatology, University of Medicine 1, Yangon, Ministry of Health, Myanmar
| | - Rheun-Chuan Lee
- Department of Radiology, Taipei Veterans General Hospital & School of Medicine, National Yang-Ming University Taipei, Taiwan
| | - Vanessa H de Villa
- Department of Surgery, The Medical City, Pasig City, Metro Manila, Philippines.,Center for Liver Disease Management & Transplantation, The Medical City, Pasig City, Metro Manila, Philippines
| | | | - Po-Chin Liang
- Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan
| | | | | | - Kieron Boon Leng Lim
- Division of Gastroenterology & Hepatology, National University Centre for Organ Transplantation, National University Hospital, Singapore
| | | | - David Chee Eng Ng
- Department of Nuclear Medicine & PET, Singapore General Hospital, Singapore
| | - Farah Gillan Irani
- Department of Diagnostic Radiology, Singapore General Hospital, Singapore
| | - Apoorva Gogna
- Department of Diagnostic Radiology, Singapore General Hospital, Singapore
| | - Pierce Kah-Hoe Chow
- Department of Surgical Oncology, National Cancer Centre Singapore, 169610 Singapore.,Office of Clinical Sciences, Duke-NUS Graduate Medical School, Singapore
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Abstract
Hepatocellular carcinoma (HCC) is the second most common cause of cancer death worldwide. This cancer commonly arises against a background of chronic liver disease. As a result, a patient with HCC requires multidisciplinary care. Treatment options vary widely based on tumor burden and metastases. The most widely utilized staging system is the Barcelona Clinic Liver Cancer staging system, which recommends treatments based on tumor size and the underlying liver disease and functional status of the patient. Treatment options range from surgical resection or transplantation to locoregional therapies with modalities such as radiofrequency ablation and transarterial chemoembolization to systemic chemotherapies. Future care involves the development of combination therapies that afford the best tumor response, further clarification of the patients best suited for therapies and the development of new oral chemotherapeutic agents.
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Affiliation(s)
- Jennifer S Au
- Division of Gastroenterology and Hepatology, Scripps Clinic
| | - Catherine T Frenette
- Liver Transplantation, Center for Organ and Cell Transplantation, Scripps Clinic, La Jolla, CA, USA
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231
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Hickey RM, Lewandowski RJ, Salem R. Yttrium-90 Radioembolization for Hepatocellular Carcinoma. Semin Nucl Med 2016; 46:105-8. [DOI: 10.1053/j.semnuclmed.2015.10.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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232
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Conventional Ethiodized Oil Transarterial Chemoembolization for Treatment of Hepatocellular Carcinoma: Contemporary Single-Center Review of Clinical Outcomes. AJR Am J Roentgenol 2016; 206:645-54. [PMID: 26901023 DOI: 10.2214/ajr.15.14758] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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233
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Yao FY, Fidelman N, Sibille C, Najimi M, Sokal EM. Reassessing the boundaries of liver transplantation for hepatocellular carcinoma: Where do we stand with tumor down-staging? Hepatology 2016; 63:1014-25. [PMID: 26560491 DOI: 10.1002/hep.28139] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Accepted: 08/21/2015] [Indexed: 01/06/2023]
Abstract
UNLABELLED Down-staging of hepatocellular carcinoma prior to liver transplantation (LT) has generated a lot of interest in recent years and has been identified in two recent national conferences on hepatocellular carcinoma as one of the priorities for research. Down-staging is defined as reduction in the tumor burden using local regional therapy specifically to meet acceptable criteria for LT. The rationale behind down-staging of tumors initially exceeding conventional criteria for LT is to select a subgroup of tumors with favorable biology and prognosis for LT as assessed by their response to local regional therapy. The expectation is to achieve comparable posttransplant survival between patients who achieve successful tumor down-staging before LT and those whose tumors meet LT criteria at the outset without needing down-staging. The application of tumor down-staging requires a highly structured approach using a treatment protocol that includes five essential components: eligibility criteria, down-staging endpoints, selection of the type of local regional therapy, minimal observation period from successful tumor down-staging to LT, and criteria for treatment failure and exclusion from LT. This review article summarizes published data on down-staging and addresses key questions related to each of the components of the down-staging protocol as well as treatment efficacy. CONCLUSION Based on a review of published data and recommendations from recent national and international conferences on hepatocellular carcinoma and LT, a standardized down-staging protocol is proposed to further evaluate the feasibility and efficacy of applying tumor down-staging on a broader scale.
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Affiliation(s)
- Francis Y Yao
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, CA
| | - Nicholas Fidelman
- Division of Interventional Radiology, Department of Radiology, University of California, San Francisco, CA
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234
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Abdel-Rahman OM, Elsayed Z. Yttrium-90 microsphere radioembolisation for unresectable hepatocellular carcinoma. Cochrane Database Syst Rev 2016; 2:CD011313. [PMID: 26905230 DOI: 10.1002/14651858.cd011313.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Hepatocellular carcinoma is the most common liver neoplasm and the fifth most common cancer worldwide. Moreover, its incidence has increased dramatically since the mid-2000s. While surgical resection and liver transplantation are the main curative treatments, only around 20% of people with early hepatocellular carcinoma may benefit from these therapies. Current treatment options for unresectable hepatocellular carcinoma include various ablative and trans-arterial therapies in addition to the drug sorafenib. OBJECTIVES To determine the benefits and harms of yttrium-90 microsphere trans-arterial radioembolisation either as a monotherapy or in combination with other systemic or locoregional therapies versus placebo, no treatment, or other similar systemic or locoregional therapies for people with unresectable hepatocellular carcinoma. SEARCH METHODS We reviewed data from the Cochrane Hepato-Biliary Controlled Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and Science Citation Index Expanded. We also checked reference lists of primary original studies and review articles manually for further related articles (cross-references) up to December 2015. SELECTION CRITERIA Eligible studies included all randomised clinical trials comparing yttrium-90-90 microsphere radioembolisation either as a monotherapy or in combination with other systemic or locoregional therapies versus placebo, no treatment, or other systemic or locoregional therapies for unresectable hepatocellular carcinoma. DATA COLLECTION AND ANALYSIS The two review authors independently extracted the relevant information on participant characteristics, interventions, study outcomes, and data on the outcomes for this review, as well as information on the design and methodology of the studies. The two review authors assessed risk of bias of the included trials using pre-defined risk of bias domains. We used Trial Sequential Analysis to control the risk of random errors. We assessed the methodological quality with GRADE. MAIN RESULTS Two randomised clinical trials with 68 participants fulfilled our inclusion criteria. Both trials were at high risk of bias, and we rated the evidence as very low quality. One of the included trials compared radioembolisation versus chemoembolization for intermediate stage hepatocellular carcinoma as classified by the Barcelona Clinic Liver Cancer (BCLC) staging system, while the other included trial was an interim analysis of a randomised trial assessing radioembolisation combined with sorafenib versus sorafenib monotherapy in participants with BCLC-advanced stage hepatocellular carcinoma. The available data were insufficient to perform the planned analyses. Neither of the two trials reported data on all-cause mortality, cancer-related mortality, or time to progression of the tumour. The trial comparing radioembolisation with chemoembolization reported quality of life and serious adverse events, and there were no statistically significant differences between the trial groups with regard to these outcomes at week 12. On the basis of the two included randomised clinical trials, single-session radioembolisation appeared to be as safe as multiple sessions of chemoembolization for intermediate stage hepatocellular carcinoma and had a similar impact on quality of life, but data were too sparse to exclude even major differences. Radioembolisation followed by sorafenib appeared to be as well tolerated as sorafenib alone for advanced stage hepatocellular carcinoma, but data were too sparse to exclude even major differences. We also identified five ongoing studies evaluating the topic of our review. AUTHORS' CONCLUSIONS There was insufficient evidence to assess the beneficial and harmful effects of yttrium-90 microsphere radioembolisation for people with unresectable hepatocellular carcinoma. Further randomised clinical trials are mandatory to better assess the potential beneficial and harmful outcomes of yttrium-90 microsphere trans-arterial radioembolisation either as a monotherapy or in combination with other systemic or locoregional therapies versus placebo, no treatment, or other systemic or locoregional therapies for people with unresectable hepatocellular carcinoma.
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Affiliation(s)
- Omar M Abdel-Rahman
- Clinical Oncology, Faculty of Medicine, Ain Shams University, Lofty Elsayed Street, Cairo, Egypt, 11335
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235
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Riaz A, Lewandowski RJ, Salem R. Locoregional Therapies for Primary and Secondary Hepatic Malignancies. Cancer Treat Res 2016; 168:233-256. [PMID: 29206376 DOI: 10.1007/978-3-319-34244-3_12] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Management of hepatic malignancies is a multidisciplinary task with the involvement of hepatologists, medical/surgical oncologists, transplant surgeons, and interventional radiologists. The patients should be selected for a specific targeted therapy after multidisciplinary consensus. Interventional oncology has established its role in the management of hepatic malignancies. Image-guided locoregional therapies decrease the rate of systemic toxicity without compromising tumoricidal effect.
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236
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Mohamed M, Katz AW, Tejani MA, Sharma AK, Kashyap R, Noel MS, Qiu H, Hezel AF, Ramaraju GA, Dokus MK, Orloff MS. Comparison of outcomes between SBRT, yttrium-90 radioembolization, transarterial chemoembolization, and radiofrequency ablation as bridge to transplant for hepatocellular carcinoma. Adv Radiat Oncol 2016; 1:35-42. [PMID: 28799575 PMCID: PMC5506745 DOI: 10.1016/j.adro.2015.12.003] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 12/18/2015] [Accepted: 12/20/2015] [Indexed: 12/25/2022] Open
Abstract
PURPOSE To evaluate and compare outcome of stereotactic body radiation therapy (SBRT), yttrium-90 radioembolization, radiofrequency ablation (RFA), or transarterial chemoembolization (TACE) as bridge to liver transplant (LT) in patients with hepatocellular carcinoma. METHODS AND MATERIALS We retrospectively reviewed patients treated at our institution with SBRT, TACE, RFA, or yttrium-90 as bridge to LT between 2006 and 2013. We analyzed radiologic and pathologic response and rate of failure after bridge therapy. Toxicities were reported using Common Terminology Criteria for Adverse Events, 4.0. Kaplan-Meier method was used to calculate disease-free survival (DFS) and overall survival after LT. RESULTS Sixty patients with a median age 57.5 years (range, 44-70) met inclusion criteria. Thirty-one patients (50.7%) had hepatitis C cirrhosis, 14 (23%) alcoholic cirrhosis, and 8 (13%) nonalcoholic steatohepatitis cirrhosis. Patients received a total of 79 bridge therapies: SBRT (n = 24), TACE (n = 37), RFA (n = 9), and Y90 (n = 9). Complete response (CR) was 25% for TACE, 8.6% for SBRT, 22% for RFA, and 33% for Y90. Grade 3 or 4 acute toxicity occurred following TACE (n = 4) and RFA (n = 2). Transplant occurred at a median of 7.4 months after bridge therapy. Pathological response among 57 patients was 100% necrosis (n = 23, 40%), >50% necrosis (n = 20, 35%), <50% necrosis (n = 9, 16%), and no necrosis (n = 5, 9%). Pathologic complete response was as follows: SBRT (28.5%), TACE (41%), RFA (60%), Y90 (75%), and multiple modalities (33%). At a median follow-up of 35 months, 7 patients had recurrence after LT. DFS was 85.8% and overall survival was 79% at 5 years. CONCLUSION All bridge therapies demonstrated good pathological response and DFS after LT. SBRT and Y90 demonstrated significantly less grade ≥3 acute toxicity. Choice of optimal modality depends on tumor size, pretreatment bilirubin level, Child-Pugh status, and patient preference. Such a decision is best made at a multidisciplinary tumor board as is done at our institution.
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Affiliation(s)
- Mostafa Mohamed
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York
| | - Alan W. Katz
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York
| | - Mohamedtaki A. Tejani
- Department of Medicine, Division of Hematology and Oncology, University of Rochester Medical Center, Rochester, New York
| | - Ashwani K. Sharma
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, New York
| | - Randeep Kashyap
- Department of Surgery, Division of Solid Organ Transplantation and Hepatobiliary Surgery, University of Rochester Medical Center, Rochester, New York
| | - Marcus S. Noel
- Department of Medicine, Division of Hematology and Oncology, University of Rochester Medical Center, Rochester, New York
| | - Haoming Qiu
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York
| | - Aram F. Hezel
- Department of Medicine, Division of Hematology and Oncology, University of Rochester Medical Center, Rochester, New York
| | - Gopal A. Ramaraju
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Rochester Medical Center, Rochester, New York
| | - M. Katherine Dokus
- Department of Surgery, Division of Solid Organ Transplantation and Hepatobiliary Surgery, University of Rochester Medical Center, Rochester, New York
| | - Mark S. Orloff
- Department of Surgery, Division of Solid Organ Transplantation and Hepatobiliary Surgery, University of Rochester Medical Center, Rochester, New York
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237
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Transarterial Chemoembolization and (90)Y Radioembolization for Hepatocellular Carcinoma: Review of Current Applications Beyond Intermediate-Stage Disease. AJR Am J Roentgenol 2015; 205:742-52. [PMID: 26397322 DOI: 10.2214/ajr.15.14802] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The practice guideline of the American Association for the Study of Liver Diseases currently recommends transarterial chemoembolization (TACE) for the treatment of intermediate-stage hepatocellular carcinoma (HCC). The use of transarterial radioembolization (TARE) using (90)Y microspheres is not formally recommended. This article discusses the current clinical applications of TACE and TARE and compares the clinical utility of these techniques for various subpopulations of patients with HCC. CONCLUSION For most clinical scenarios, the efficacy and safety of TACE and TARE are probably equivalent. However, TARE appears to have an advantage over TACE in the facilitation of surgical resection by resulting in compensatory hypertrophy of the future liver remnant and possibly in the treatment of patients with portal vein tumor thrombus. On the contrary, TACE is the transarterial treatment of choice for patients with marginal hepatic reserve (i.e., hyperbilirubinemia, ascites) who may be candidates for transplant.
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238
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Wedd JP, Nordstrom E, Nydam T, Durham J, Zimmerman M, Johnson T, Thomas Purcell W, Biggins SW. Hepatocellular carcinoma in patients listed for liver transplantation: Current and future allocation policy and management strategies for the individual patient. Liver Transpl 2015; 21:1543-52. [PMID: 26457885 DOI: 10.1002/lt.24356] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 09/10/2015] [Accepted: 09/14/2015] [Indexed: 12/12/2022]
Abstract
Liver transplantation can provide definitive cure for patients with cirrhosis and hepatocellular carcinoma (HCC) when used appropriately. Advances in the management of HCC have allowed improved control of HCC while waiting for liver transplantation and new approaches to candidate selection particularly with regard to tumor burden and downstaging protocols. Additionally, there have been recent changes in allocation policy related to HCC in the U.S. that cap the HCC MELD exception at 34 points and implement a 6-month delay in a HCC MELD exception. This review examines the U.S. liver transplant allocation policy related to HCC, comprehensively details locoregional therapy options in HCC patients awaiting liver transplantation, and considers the impact of an increasing burden of HCC on future liver graft allocation policy.
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Affiliation(s)
- Joel P Wedd
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Eric Nordstrom
- Division of Gastroenterology and Hepatology, University of Colorado, Aurora, CO
| | - Trevor Nydam
- Department of Surgery, University of Colorado, Aurora, CO
| | - Janette Durham
- Department of Interventional Radiology, Anschutz Medical Campus, University of Colorado, Aurora, CO
| | | | - Thor Johnson
- Department of Interventional Radiology, Anschutz Medical Campus, University of Colorado, Aurora, CO
| | - W Thomas Purcell
- Division of Medical Oncology, University of Colorado, Aurora, CO
| | - Scott W Biggins
- Division of Gastroenterology and Hepatology, University of Colorado, Aurora, CO
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239
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Molvar C, Lewandowski R. Yttrium-90 Radioembolization of Hepatocellular Carcinoma-Performance, Technical Advances, and Future Concepts. Semin Intervent Radiol 2015; 32:388-97. [PMID: 26622103 DOI: 10.1055/s-0035-1564704] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Hepatocellular carcinoma (HCC) is a lethal tumor, claiming over half a million lives per year. Treatment of HCC is commonly performed without curative intent, and palliative options dominate, including catheter-based therapies, namely, transarterial chemoembolization and yttrium-90 ((90)Y) radioembolization. This review will showcase the performance of (90)Y radioembolization for the treatment of HCC, focusing on recent seminal data and technical advances. In particular, novel radioembolization treatment concepts are discussed and compared with conventional HCC therapy.
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Affiliation(s)
- Christopher Molvar
- Section of Vascular and Interventional Radiology, Department of Radiology, Loyola University Medical Center, Maywood, Illinois
| | - Robert Lewandowski
- Division of Interventional Oncology, Section of Interventional Radiology, Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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240
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Zhang Y, Li Y, Ji H, Zhao X, Lu H. Transarterial Y90 radioembolization versus chemoembolization for patients with hepatocellular carcinoma: A meta-analysis. Biosci Trends 2015; 9:289-98. [PMID: 26559021 DOI: 10.5582/bst.2015.01089] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Transarterial chemoembolization (TACE) is one of the standard locoregional treatments for intermediate stage hepatocellular carcinoma (HCC). Transarterial radioembolization (TARE) using β-emitting yttrium-90 (90Y) integral to the glass matrix of the microspheres has been developed as an alternative to TACE in recent years. Thus, we conducted a meta analysis to evaluate the safety and efficacy of TARE versus TACE for unresectable HCC. We searched PubMed, EMBASE, Web of science and the Cochrane Library for clinical trials comparing TARE with TACE for unresectable HCC. Response rate, overall survival (OS), time to progression (TTP), hospitalization time days and clinical complications were analyzed and compared. Eight studies published from 2009 to 2014, with a total of 1,499 patients, were included in this meta-analysis. The pooled results showed that TARE (90Y) is significantly better in OS (HR = 0.74; 95% CI: 0.61-0.90), 3-year OS rates (RR = 1.75; 95% CI = 1.01-3.03, p = 0.05), TTP (HR = 0.61; 95% CI: 0.41-0.89), hospitalization time days (mean difference = -2.66; 95% CI: -4.08 - -1.24) and some complications (abdominal pain [RR = 0.30, 95% CI: 0.11-0.83, p = 0.02]) for patients with HCC, but did not affect tumor response (CR [RR = 1.06; 95% CI = 0.51-2.22], PR [RR = 1.24; 95% CI = 0.79-1.94], SD [RR = 1.13; 95% CI = 0.92-1.39], PD[RR = 0.75; 95% CI = 0.37-1.51], over-all tumor control [RR = 1.16; 95 % CI = 0.94-1.44]). The current meta-analysis suggests that TARE (Y90) is significantly better in OS, 3-year OS rates, TTP, hospitalization time days and some complications for patients with HCC.
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Affiliation(s)
- Yafei Zhang
- Department of General Surgery, Second Affiliated Hospital, School of Medicine, Xi'an Jiaotong University
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241
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Iñarrairaegui M, Sangro B. Radioembolization as an adjunct therapy to the resection of liver tumors. Hepat Oncol 2015; 2:335-338. [PMID: 30191014 PMCID: PMC6095312 DOI: 10.2217/hep.15.23] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Mercedes Iñarrairaegui
- Liver Unit at Clinica Universidad de Navarra, CIBEREHD, & Navarra Institute for Health Research, Avda. Pio XII 36, 31008 Pamplona, Spain
| | - Bruno Sangro
- Liver Unit at Clinica Universidad de Navarra, CIBEREHD, & Navarra Institute for Health Research, Avda. Pio XII 36, 31008 Pamplona, Spain
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242
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Faltermeier C, Busuttil RW, Zarrinpar A. A Surgical Perspective on Targeted Therapy of Hepatocellular Carcinoma. Diseases 2015; 3:221-252. [PMID: 28943622 PMCID: PMC5548262 DOI: 10.3390/diseases3040221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 09/15/2015] [Accepted: 09/21/2015] [Indexed: 12/12/2022] Open
Abstract
Hepatocellular carcinoma (HCC), the second leading cause of cancer deaths worldwide, is difficult to treat and highly lethal. Since HCC is predominantly diagnosed in patients with cirrhosis, treatment planning must consider both the severity of liver disease and tumor burden. To minimize the impact to the patient while treating the tumor, techniques have been developed to target HCC. Anatomical targeting by surgical resection or locoregional therapies is generally reserved for patients with preserved liver function and minimal to moderate tumor burden. Patients with decompensated cirrhosis and small tumors are optimal candidates for liver transplantation, which offers the best chance of long-term survival. Yet, only 20%-30% of patients have disease amenable to anatomical targeting. For the majority of patients with advanced HCC, chemotherapy is used to target the tumor biology. Despite these treatment options, the five-year survival of patients in the United States with HCC is only 16%. In this review we provide a comprehensive overview of current approaches to target HCC. We also discuss emerging diagnostic and prognostic biomarkers, novel therapeutic targets identified by recent genomic profiling studies, and potential applications of immunotherapy in the treatment of HCC.
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Affiliation(s)
- Claire Faltermeier
- Dumont-UCLA Transplant Center, Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA 90095, USA.
| | - Ronald W Busuttil
- Dumont-UCLA Transplant Center, Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA 90095, USA.
| | - Ali Zarrinpar
- Dumont-UCLA Transplant Center, Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA 90095, USA.
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Abdelfattah MR, Al-Sebayel M, Broering D, Alsuhaibani H. Radioembolization using yttrium-90 microspheres as bridging and downstaging treatment for unresectable hepatocellular carcinoma before liver transplantation: initial single-center experience. Transplant Proc 2015; 47:408-11. [PMID: 25769582 DOI: 10.1016/j.transproceed.2014.11.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Accepted: 11/17/2014] [Indexed: 02/08/2023]
Abstract
INTRODUCTION HCC is the sixth most common malignancy worldwide and is the third most common cause of cancer related mortality. Moreover, the incidence of HCC is increasing. Surgical treatments for HCC including resection and/or transplantation provide the best curative outcomes in early stages. Unfortunately, many patients present at an advanced stage. Currently, locoregional therapies have an emerging role in the management of HCC for bridging to liver transplantation and for downstaging the disease to within transplant criteria. Radioembolization is among commonly used locoregional therapies. OBJECTIVE To describe our initial experience with the use of Therasphere® as bridging or downstaging modality before liver transplantation, including our institutional indications, technique and outcome. MATERIALS AND METHODS We retrospectively examined our database for liver transplantation after the use of Therasphere®. Nine patients were identified and reported. RESULTS They were 5 females and 4 males. Their current age range is 40-72 years with a mean of 53.8 ± 9.5 years. Three patients had Therasphere® as downstaging treatment to our institutional transplantation criteria. Our institution is using UCSF criteria as a cut off limit for liver transplantation as primary treatment modality. The other 6 patients had Therasphere® as bridging for liver transplantation especially when other modalities are not possible. None of these lesions were treated by any other locoregional treatment before or after Therasphere®. Follow-up after liver transplantation ranged between 3.7 and 60.1 months (mean of 15.8 ± 17.7 months). All patients are still living, no retransplantation was done and none of them showed evidence of disease recurrence (100% graft, patient and disease free survival). CONCLUSION Our initial experience showed that Therasphere® is a promising therapeutic tool for both downstaging and bridging of HCC before liver transplant.
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Affiliation(s)
- M R Abdelfattah
- Department of Liver Transplantation and Hepatobiliary Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia; Department of Surgery, Faculty of Medicine, University of Alexandria, Egypt.
| | - M Al-Sebayel
- Department of Liver Transplantation and Hepatobiliary Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - D Broering
- Department of Liver Transplantation and Hepatobiliary Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - H Alsuhaibani
- Department of Radiology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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244
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Galun D, Basaric D, Zuvela M, Bulajic P, Bogdanovic A, Bidzic N, Milicevic M. Hepatocellular carcinoma: From clinical practice to evidence-based treatment protocols. World J Hepatol 2015; 7:2274-91. [PMID: 26380652 PMCID: PMC4568488 DOI: 10.4254/wjh.v7.i20.2274] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Revised: 07/06/2015] [Accepted: 08/30/2015] [Indexed: 02/06/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is one of the major malignant diseases in many healthcare systems. The growing number of new cases diagnosed each year is nearly equal to the number of deaths from this cancer. Worldwide, HCC is a leading cause of cancer-related deaths, as it is the fifth most common cancer and the third most important cause of cancer related death in men. Among various risk factors the two are prevailing: viral hepatitis, namely chronic hepatitis C virus is a well-established risk factor contributing to the rising incidence of HCC. The epidemic of obesity and the metabolic syndrome, not only in the United States but also in Asia, tend to become the leading cause of the long-term rise in the HCC incidence. Today, the diagnosis of HCC is established within the national surveillance programs in developed countries while the diagnosis of symptomatic, advanced stage disease still remains the characteristic of underdeveloped countries. Although many different staging systems have been developed and evaluated the Barcelona-Clinic Liver Cancer staging system has emerged as the most useful to guide HCC treatment. Treatment allocation should be decided by a multidisciplinary board involving hepatologists, pathologists, radiologists, liver surgeons and oncologists guided by personalized -based medicine. This approach is important not only to balance between different oncologic treatments strategies but also due to the complexity of the disease (chronic liver disease and the cancer) and due to the large number of potentially efficient therapies. Careful patient selection and a tailored treatment modality for every patient, either potentially curative (surgical treatment and tumor ablation) or palliative (transarterial therapy, radioembolization and medical treatment, i.e., sorafenib) is mandatory to achieve the best treatment outcome.
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Affiliation(s)
- Danijel Galun
- Danijel Galun, Dragan Basaric, Marinko Zuvela, Predrag Bulajic, Aleksandar Bogdanovic, Nemanja Bidzic, Miroslav Milicevic, Clinic of Digestive Surgery, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Dragan Basaric
- Danijel Galun, Dragan Basaric, Marinko Zuvela, Predrag Bulajic, Aleksandar Bogdanovic, Nemanja Bidzic, Miroslav Milicevic, Clinic of Digestive Surgery, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Marinko Zuvela
- Danijel Galun, Dragan Basaric, Marinko Zuvela, Predrag Bulajic, Aleksandar Bogdanovic, Nemanja Bidzic, Miroslav Milicevic, Clinic of Digestive Surgery, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Predrag Bulajic
- Danijel Galun, Dragan Basaric, Marinko Zuvela, Predrag Bulajic, Aleksandar Bogdanovic, Nemanja Bidzic, Miroslav Milicevic, Clinic of Digestive Surgery, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Aleksandar Bogdanovic
- Danijel Galun, Dragan Basaric, Marinko Zuvela, Predrag Bulajic, Aleksandar Bogdanovic, Nemanja Bidzic, Miroslav Milicevic, Clinic of Digestive Surgery, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Nemanja Bidzic
- Danijel Galun, Dragan Basaric, Marinko Zuvela, Predrag Bulajic, Aleksandar Bogdanovic, Nemanja Bidzic, Miroslav Milicevic, Clinic of Digestive Surgery, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Miroslav Milicevic
- Danijel Galun, Dragan Basaric, Marinko Zuvela, Predrag Bulajic, Aleksandar Bogdanovic, Nemanja Bidzic, Miroslav Milicevic, Clinic of Digestive Surgery, University Clinical Center of Serbia, 11000 Belgrade, Serbia
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245
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Moir JAG, Burns J, Barnes J, Colgan F, White SA, Littler P, Manas DM, French JJ. Selective internal radiation therapy for liver malignancies. Br J Surg 2015; 102:1533-40. [PMID: 26364826 DOI: 10.1002/bjs.9924] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 07/06/2015] [Accepted: 07/24/2015] [Indexed: 01/11/2023]
Abstract
BACKGROUND Selective internal radiation therapy (SIRT) is a non-ablative technique for the treatment of liver primaries and metastases, with the intention of reducing tumour bulk. This study aimed to determine optimal patient selection, and elucidate its role as a downsizing modality. METHODS Data were collected retrospectively on patients who underwent SIRT between 2011 and 2014. The procedure was performed percutaneously by an expert radiologist. Response was analysed in two categories, based on radiological (CT/MRI according to Response Evaluation Criteria In Solid Tumours (RECIST)) and biological (α-fetoprotein, carcinoembryonic antigen, carbohydrate antigen 19-9, chromogranin A) parameters. RESULTS Forty-four patients were included. Liver metastases from colorectal cancer (22 patients) and hepatocellular carcinoma (HCC) (9) were the most common pathologies. Radiological response data were collected from 31 patients. A reduction in sum of diameters (SOD) was observed in patients with HCC (median -24.1 (95 per cent c.i. -43.4 to -3.8) per cent) and neuroendocrine tumours (-30.0 (-45.6 to -7.7) per cent), whereas a slight increase in SOD was seen in patients with colorectal cancer (4.9 (-10.6 to 55.3) per cent). Biological response was assessed in 17 patients, with a reduction in 12, a mixed response in two and no improvement in three. Six- and 12-month overall survival rates were 71 and 41 per cent respectively. There was no difference in overall survival between the RECIST response groups (median survival 375, 290 and 214 days for patients with a partial response, stable disease and progressive disease respectively; P = 0.130), or according to primary pathology (P = 0.063). Seven patients underwent liver resection with variable responses after SIRT. CONCLUSION SIRT may be used to downsize tumours and may be used as a bridge to surgery in patients with tumours deemed borderline for resection.
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Affiliation(s)
- J A G Moir
- Departments of Hepatopancreatobiliary and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - J Burns
- Departments of Hepatopancreatobiliary and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - J Barnes
- Departments of Hepatopancreatobiliary and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - F Colgan
- Departments of Interventional Radiology, Freeman Hospital, Newcastle upon Tyne, UK
| | - S A White
- Departments of Hepatopancreatobiliary and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - P Littler
- Departments of Interventional Radiology, Freeman Hospital, Newcastle upon Tyne, UK
| | - D M Manas
- Departments of Hepatopancreatobiliary and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - J J French
- Departments of Hepatopancreatobiliary and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK
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246
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Sacco R, Giorgi L, Fornaro L, Bargellini I. Trans-Arterial Radioembolization for Hepatocellular Carcinoma. Dig Dis 2015; 33:661-7. [PMID: 26398498 DOI: 10.1159/000438476] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
This article offers an overview of a new therapeutic option in hepatocellular carcinoma using trans-arterial radioembolization. In particular, it covers practical aspects of the technique and the currently available preliminary data in terms of disease control. We explore the potentials of radioembolization both in early and advanced stages of the disease, as single treatment and as companion to targeted agents such as sorafenib.
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Affiliation(s)
- Rodolfo Sacco
- Department of Gastroenterology, Pisa University Hospital, Pisa, Italy
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247
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Parikh ND, Waljee AK, Singal AG. Downstaging hepatocellular carcinoma: A systematic review and pooled analysis. Liver Transpl 2015; 21:1142-52. [PMID: 25981135 DOI: 10.1002/lt.24169] [Citation(s) in RCA: 168] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 04/30/2015] [Accepted: 05/03/2015] [Indexed: 12/17/2022]
Abstract
Downstaging can facilitate liver transplantation (LT) for patients outside of Milan criteria with hepatocellular carcinoma (HCC); however, the optimal protocol and downstaging outcomes are poorly defined. We aimed to characterize rates of successful downstaging to within Milan criteria and post-LT recurrence and survival among patients who underwent downstaging. We performed a systematic literature review using the MEDLINE and Embase databases from January 1996 through March 2015 and a search of national meeting abstracts from 2010 to 2014. Rates of downstaging success (defined as a decrease of tumor burden to within Milan) and post-LT recurrence with 95% confidence intervals (CIs) were calculated. Prespecified subgroup analyses were conducted by treatment modality, study design, and patient characteristics. Thirteen studies (n = 950 patients) evaluating downstaging success had a pooled success rate of 0.48 (95% CI, 0.39-0.58%). In subgroup analyses, there was no significant difference comparing transarterial chemoembolization (TACE) versus transarterial radioembolization (TARE; P = 0.51), but there were higher success rates in prospective versus retrospective studies (0.68 versus 0.44; P < 0.001). The 12 studies (n = 320 patients) evaluating post-LT HCC recurrence had a pooled recurrence rate of 0.16 (95% CI, 0.11-0.23). There was no significant difference in recurrence rates between TACE and TARE (P = 0.33). Post-LT survival could not be aggregated because of heterogeneity in survival data reporting. Current data have heterogeneity in baseline tumor burden, waiting time, downstaging protocols, and treatment response assessments. There are also notable limitations including inconsistent reporting of inclusion criteria, downstaging protocols, and outcome assessment criteria. In conclusion, the success rate of downstaging HCC to within Milan criteria exceeds 40%; however, posttransplant HCC recurrence rates are high at 16%. Downstaging protocols for HCC should be systematically studied and optimized to minimize the risk of post-LT HCC recurrence.
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Affiliation(s)
- Neehar D Parikh
- Division of Gastroenterology, University of Michigan Health System, University of Michigan, Ann Arbor, MI.,Division of Digestive and Liver Diseases, University of Texas South Western Medical Center, Dallas, TX
| | - Akbar K Waljee
- Division of Gastroenterology, University of Michigan Health System, University of Michigan, Ann Arbor, MI.,Division of Digestive and Liver Diseases, University of Texas South Western Medical Center, Dallas, TX
| | - Amit G Singal
- VA Ann Arbor Health Services Research and Development Center of Clinical Management Research, Ann Arbor, MI.,Division of Digestive and Liver Diseases, University of Texas South Western Medical Center, Dallas, TX
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248
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Kulik L, Salem R. Downstaging: Looking for answers, generating more questions? Liver Transpl 2015; 21:1117-9. [PMID: 26147566 DOI: 10.1002/lt.24209] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 06/28/2015] [Indexed: 12/05/2022]
Affiliation(s)
- Laura Kulik
- Department of Medicine, Northwestern University, Chicago, IL
| | - Riad Salem
- Department of Medicine, Northwestern University, Chicago, IL
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249
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Bouazza F, Poncelet A, Garcia CA, Delatte P, Engelhom JL, Galdon MG, Deleporte A, Hendlisz A, Vanderlinden B, Flamen P, Donckier V. Radioembolisation and portal vein embolization before resection of large hepatocellular carcinoma. World J Gastroenterol 2015; 21:9666-9670. [PMID: 26327775 PMCID: PMC4548128 DOI: 10.3748/wjg.v21.i32.9666] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 02/20/2015] [Accepted: 04/09/2015] [Indexed: 02/06/2023] Open
Abstract
Resectability of hepatocellular carcinoma in patients with chronic liver disease is dramatically limited by the need to preserve sufficient remnant liver in order to avoid postoperative liver insufficiency. Preoperative treatments aimed at downsizing the tumor and promoting hypertrophy of the future remnant liver may improve resectability and reduce operative morbidity. Here we report the case of a patient with a large hepatocellular carcinoma arising from chronic liver disease. Preoperative treatment, including tumor downsizing with transarterial radioembolization and induction of future remnant liver hypertrophy with right portal vein embolization, resulted in a 53% reduction in tumor volume and compensatory hypertrophy in the contralateral liver. The patient subsequently underwent extended right hepatectomy with no postoperative signs of liver decompensation. Pathological examination demonstrated a margin-free resection and major tumor response. This new therapeutic sequence, combining efficient tumor targeting and subsequent portal vein embolization, could improve the feasibility and safety of major liver resection for hepatocellular carcinoma in patients with liver injury.
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250
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Facciorusso A, Licinio R, Muscatiello N, Di Leo A, Barone M. Transarterial chemoembolization: Evidences from the literature and applications in hepatocellular carcinoma patients. World J Hepatol 2015; 7:2009-2019. [PMID: 26261690 PMCID: PMC4528274 DOI: 10.4254/wjh.v7.i16.2009] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2015] [Revised: 06/26/2015] [Accepted: 07/27/2015] [Indexed: 02/06/2023] Open
Abstract
Transarterial chemoembolization (TACE) is the current standard of care for patients with large or multinodular hepatocellular carcinoma (HCC), preserved liver function, absence of cancer-related symptoms and no evidence of vascular invasion or extrahepatic spread (i.e., those classified as intermediate stage according to the Barcelona Clinic Liver Cancer staging system). The rationale for TACE is that the intra-arterial injection of a chemotherapeutic drug such as doxorubicin or cisplatin followed by embolization of the blood vessel will result in a strong cytotoxic effect enhanced by ischemia. However, TACE is a very heterogeneous operative technique and varies in terms of chemotherapeutic agents, treatment devices and schedule. In order to overcome the major drawbacks of conventional TACE (cTACE), non-resorbable drug-eluting beads (DEBs) loaded with cytotoxic drugs have been developed. DEBs are able to slowly release the drug upon injection and increase the intensity and duration of ischemia while enhancing the drug delivery to the tumor. Unfortunately, despite the theoretical advantages of this new device and the promising results of the pivotal studies, definitive data in favor of its superiority over cTACE are still lacking. The recommendation for TACE as the standard-of-care for intermediate-stage HCC is based on the demonstration of improved survival compared with best supportive care or suboptimal therapies in a meta-analysis of six randomized controlled trials, but other therapeutic options (namely, surgery and radioembolization) proved competitive in selected subsets of intermediate HCC patients. Other potential fields of application of TACE in hepato-oncology are the pre-transplant setting (as downstaging/bridging treatment) and the early stage (in patients unsuitable to curative therapy). The potential of TACE in selected advanced patients with segmental portal vein thrombosis and preserved liver function deserves further reports.
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