Radioembolization for unresectable neuroendocrine hepatic metastases using resin 90Y-microspheres: early results in 148 patients. Am J Clin Oncol. 2008;31:271-279. [PMID: 18525307 DOI: 10.1097/coc.0b013e31815e4557]

Neuroendocrine tumors of the small bowels are on the rise: Early aspects and management

Neuroendocrine tumors of the small bowel are on the rise. In the US they have increased by 300%-500% in the last 35 years. At the same time their prognosis is much improved. Today, most neuroendocrine tumors (NETs) of the duodenum are detected "incidentally" and therefore recognized at an early stage. Duodenal NETs which are well differentiated, not larger than 10 mm and limited to the mucosa/submucosa can be endoscopically resected. The management of duodenal NETs ranging between 10 and 20 mm needs an interdisciplinary discussion. Endoscopic ultrasound is the method of choice to determine tumor size and depth of infiltration. Surgery is recommended for well-differentiated duodenal NET tumors greater than 20 mm, for localized sporadic gastrinomas (of any size) and for localized poorly differentiated NE cancers. Surgery is recommended for any ileal NET. Advanced ileal NETs with a carcinoid syndrome are treated with long-acting somatostatin analogs. This treatment significantly improves (progression-free) survival in patients with metastatic NETs of the ileum. For optimal NET management, tumor biology, type, localization and stage of the neoplasm, as well as the patient's individual circumstances have to be taken into account.

NANETS consensus guideline for the diagnosis and management of neuroendocrine tumors: well-differentiated neuroendocrine tumors of the thorax (includes lung and thymus)

Neuroendocrine tumors (NETs) of the thorax, including bronchial and thymic neuroendocrine NETs, are often referred to as NETs of the foregut. The incidence and prevalence of NETs are increasing in the United States as demonstrated in the Surveillance, Epidemiology, and End Results from 1973 to 2004 (J Clin Oncol. 2008;26[18]:3063-3072). Although the majority of bronchial and thymic NETs are sporadic, approximately 5% to 10% can be associated with hereditary syndrome, multiple endocrine neoplasms type 1 (Nat Rev Cancer. 2005;5[5]:367-375). Diagnosis is made by tissue pathology, allowing for characterization and classification of the NET. Radiologic evaluation is performed to determine the extent of disease involvement. Clinical symptoms from hormonal overproduction or from paraneoplastic processes are medically managed to improve patients' quality of life. Locoregional disease can be curative with surgery; however, distant or metastatic disease is rarely curable. Therapeutic options for metastatic/advanced NETs of the thorax are mainly to palliate symptoms. Final treatment recommendations for patients with either bronchial or thymic NETs should be individualized, weighing the risks and benefits of therapy.

Radioembolization (yttrium-90 microspheres) for primary and metastatic hepatic malignancies

Radioembolization using radioactive yttrium-90-labeled microspheres is gaining a stronger foothold in the management of primary and metastatic hepatic cancers. The expanding literature reveals good and encouraging results in both retrospective and prospective reports as demonstrated by low acute or late toxicity and high response rates. This treatment modality, which is most beneficial in patients with good liver reserve and low Eastern Cooperative Oncology Group performance status, has led to improved time to liver progression and extended overall patient survival. Although the phase III trials of radioembolization are ongoing as a first-line treatment of patients with metastatic colorectal cancer, there are sufficient phase II and retrospective clinical data supporting its use in salvage therapy for most patients. Patients with hepatocellular cancer, neuroendocrine tumors, and other primary sites, including breast and lung, have also shown promising response and survival increases in multi-institutional experiences.

Radioembolization of liver tumors with yttrium-90 microspheres

Radioembolization (RE), also termed selective internal radiation therapy (SIRT), has been gradually introduced to the clinical arsenal of cytoreductive modalities in recent years. There is growing evidence for efficiency in liver tumors of various entities, with the most prominent ones being hepatocellular carcinoma, colorectal cancer, and neuroendocrine tumors. Hepatic metastases of numerous other tumor entities including breast cancer, cholangiocarcinoma, and pancreatic cancer are treatment-sensitive, even when being refractory to other treatment modalities such as bland-embolization, regional, or systemic chemotherapy. The antitumor effect of SIRT is related to radiation rather than embolization, with extraordinary high local radiation doses obtained selectively at the site of viable tumor and little affection of the surrounding normal liver tissue. Morphologic changes after RE may pose difficulties for interpretation in conventional restaging with regard to tumor viability and true response to treatment. Therefore, functional imaging, that is, metabolic imaging with (18)F fluorodeoxyglucose positron emission tomography (computed tomography) in the majority of treated tumors, is regarded the gold standard in this respect and should be included for pre- and post-SIRT assessment. To prevent serious toxicity to be associated with the potent antitumor efficacy, meticulous pretreatment evaluation is of particular importance. Improvements in predicting dosimetry will help optimize treatment and patient selection. Nuclear medicine procedures are essential for planning, performing, and monitoring of RE. However, the interdisciplinary aspect of patient management has to be emphasized for this particular treatment form. As SIRT is moving forward from the salvage setting indication to the use in earlier stages of hepatic tumor disease and with the advent of new treatment protocols and targeted therapies, embedding SIRT into a multidisciplinary approach will become even more important. This article focuses on procedural and technical aspects for selection, preparation, and performance of treatment as well as post-therapeutic monitoring and response assessment.

Locoregional management of hepatic metastasis from primary uveal melanoma

Uveal melanoma is the most common primary ocular malignancy in adults and has a significant predilection for metastasis to the liver. Despite successful treatment of the primary uveal melanoma, up to 50% of patients will subsequently develop a systemic metastasis, with the liver involved in up to 90% of these individuals. Metastatic uveal melanoma has proven to be resistant to currently available systemic chemotherapies. Recognition of the poor prognosis associated with liver metastasis has led to the evaluation of various locoregional treatment modalities primarily designed to control tumor progression in the liver, including surgical resection, hepatic arterial chemotherapy, transarterial chemoembolization (TACE), immunoembolization, radiosphere, drug-eluting beads, isolated hepatic perfusion (IHP), and percutaneous hepatic perfusion. This article reviews the efficacies, and morbidities of currently available locoregional therapies.

Yttrium-90 radioembolization in the management of liver malignancies

Primary and secondary liver tumors are common. Locoregional therapies are establishing a role in the management of liver tumors due to the limited roles of surgical and systemic therapies. Our review presents some general concepts associated with yttrium-90 radioembolization and its specific utilization in various primary and secondary liver malignancies.

Transarterial liver-directed therapies of neuroendocrine hepatic metastases

Neuroendocrine tumors (NETs) comprise a diverse group of slowly growing tumors with an indolent course, characterized by the capacity to synthesize and secrete polypeptide products that are hormonally active. Presence of liver metastases results in significant debilitating hormonal symptoms, and is associated with poor prognosis. Systemic chemotherapy has limited success in the management of patients with NET hepatic metastases. Although somatostatin analogs are effective in controlling symptoms in many of these patients, the disease can become refractory to treatment. For these reasons, interventional radiologic techniques for liver-directed therapy have become an important treatment option in patients with metastatic NETs. Transcatheter arterial procedures such as transarterial embolization (TAE), transarterial chemoembolization (TACE), and selective internal radiation therapy (SIRT) have been shown to reduce hormone levels, palliate symptoms, and reduce the tumor burden in many patients with unresectable and symptomatic NET hepatic metastases. This article summarizes the most recent information on arterial-based liver-directed therapies in the treatment of metastatic NETs.

Factors predicting response and survival after yttrium-90 radioembolization of unresectable neuroendocrine tumor liver metastases: a critical appraisal of 48 cases

BACKGROUND

Yttrium-90 (90Y) radioembolization is a promising treatment option for unresectable neuroendocrine tumor liver metastases (NETLM). This study is the first to evaluate the prognostic variables that influenced radiologic response and survival in patients with unresectable NETLM who were treated with 90Y radioembolization. As a secondary outcome, the impact of this treatment on serologic toxicity was assessed.

METHODS

Forty-eight patients underwent resin-based 90Y radioembolization for unresectable NETLM at a single institution between December 2003 and May 2009. Patients were assessed radiologically and serologically at 1 month and then at 3 month intervals after treatment. Prognostic variables that affected response and survival were determined. The impact of this treatment on serologic toxicity over a 6-month period was assessed.

DISCUSSION

No patient was lost to follow-up. The median follow-up for the patients who were alive was 41 months. The median survival was 35 months (range: 5-63). On imaging follow-up, 7 patients (15%) had a complete response and 19 patients (40%) had a partial response to treatment. Eleven patients (23%) had stable disease and 11 patients (23%) had progressive disease. Five prognostic factors were associated with an improved survival: complete/partial response (P=0.003), low hepatic tumor burden (P=0.022), female gender (P=0.022), well-differentiated tumor (P=0.001), and absence of extra-hepatic metastasis (P<0.001). Three factors were associated with a complete/partial response: female gender (P=0.040), well-differentiated tumor (P<0.001) and low hepatic tumor burden (P=0.041). There was a significant increase in the level of alkaline phosphatase over the 6-month period (P<0.001).

CONCLUSIONS

90Y radioembolization is a promising treatment option for unresectable NETLM. Patients with low hepatic tumor burden, well-differentiated tumor, female gender, and no extrahepatic disease benefit most from treatment.

State of the art: radiolabeled microspheres treatment for liver malignancies

IMPORTANCE OF THE FIELD

Metastatic tumours of the liver are responsible for significant morbidity and mortality, and only a small percentage is resectable with curative intent. Hepatic artery radioembolization (RE) with yttrium-90 ((90)Y)-loaded microspheres is an alternative treatment for patients with unresectable primary or secondary liver tumours, especially in cases of metastatic colorectal cancer (mCRC) and hepatocellular carcinoma (HCC).

AREAS COVERED IN THIS REVIEW

Data from recent relevant clinical trials with (90)Y-RE are discussed, focusing on response rate assessments and treatment outcome.

WHAT THE READER WILL GAIN

Current data show that (90)Y-RE combined with radiosensitizing chemotherapy is a safe and efficient modality that extends the time to progression in liver mCRC and unresectable HCC, although no survival benefits have been demonstrated. The treatment response after (90)Y-RE seems to be better assessed using metabolic response assessments with serial fluorodeoxyglucose positron emission tomography (FDG-PET) in cases of FDG-avid tumours than with morphological criteria measured on computed tomography or magnetic resonance imaging (RECIST or WHO trials). Predictive models using multimodality imaging approaches (PET-SPECT-CT image fusion algorithms) have been proposed to better select patients for (90)Y-RE. The optimal routine role of radioembolization remains to be defined; the complexity and wide availability of available therapeutic alternatives confuses the role of a locoregional treatment in a generalized disease.

TAKE HOME MESSAGE

(90)Y-RE is a safe and efficient treatment modality in salvage therapy of colorectal cancer metastatic to the liver and in unresectable HCC. However, it has still to find its place as a first- or second-line treatment of mCRC in combination with or as an alternative to available biological agents. The role of (90)Y-RE in other solid tumour types metastatic to the liver is much more uncertain and investigations in clinical situations in which disease is strictly limited to the liver are required. Pretherapeutic work-up, initially developed to explore hepatic vasculature and to assess lung shunting, might be able to predict treatment outcome, allowing a better patient selection.

Recent trends in the treatment of well-differentiated endocrine carcinoma of the small bowel

Well-differentiated endocrine carcinomas of the small bowel are fairly rare neoplasms that present many clinical challenges. They secrete peptides and neuroamines that may cause carcinoid syndrome. However, many are clinically silent until late presentation with major effects. Initial treatment aims to control carcinoid syndrome with somatostatin analogs. Even if there is metastatic spread, surgical resection of the primitive tumor should be discussed in cases of retractile mesenteritis, small bowel ischemia or subocclusive syndrome in order to avoid any acute complication, in particular at the beginning of somatostatin analog treatment. The choice of treatment depends on the symptoms, general health of the patient, tumor burden, degree of uptake of radionuclide, histological features of the tumor, and tumor growth. Management strategies include surgery for cure (which is rarely achieved) or for cytoreduction, radiological interventions (transarterial embolization or radiofrequency ablation), and chemotherapy (interferon and somatostatin analogs). New biological agent and radionuclide targeted therapies are under investigation. Diffuse and non-evolving lesions should also be simply monitored. Finally, it has to be emphasized that it is of the utmost importance to enroll these patients with a rare disease in prospective clinical trials assessing new therapeutic strategies.

Radioembolization with yttrium microspheres for neuroendocrine tumour liver metastases

Background

90Y microsphere radioembolization is performed by injecting the microspheres through a hepatic artery catheter placed percutaneously via the femoral or brachial artery. This study assessed the efficacy of 90Y microsphere therapy for patients with unresectable neuroendocrine tumour liver metastases (NETLMs). Potential prognostic factors were analysed for their impact on overall survival.

Methods

A prospectively collected database for patients with NETLMs treated by 90Y microspheres in two centres from 2003 to 2008 was examined retrospectively. Serial radiographic evidence was collected during follow-up to assess response.

Results

Fifty-eight patients were included, 51 of whom had evaluable disease at most recent follow-up. Six patients achieved a complete response, 14 a partial response, 14 had stable disease and 17 had disease progression. Overall survival rates at 1, 2 and 3 years were 86, 58 and 47 per cent respectively; median survival was 36 (range 1–61) months. Extent of tumour involvement, radiographic response to treatment, extrahepatic disease and tumour grade were significant prognostic factors for overall survival.

Conclusion

90Y microsphere radioembolization achieved a radiographic response in a significant proportion of patients with NETLMs.

Liver radioembolization using 90Y resin microspheres in elderly patients: tolerance and outcome

PURPOSE

Yttrium 90 (90Y) microsphere radioembolization (90Y-RE) is an emerging locoregional treatment for liver cancer. The most common complications of 90Y-RE arise from excessive irradiation of nontarget organs (eg, gastrointestinal tract, lung, and nontumoral liver). Patients with advanced age may have substantial comorbidities that can affect their life expectancy, and tolerance to radiation in elderly patients may be altered. The purpose of this study is to evaluate the safety and survival of elderly patients treated with 90Y-RE.

MATERIALS AND METHODS

We analyzed 255 patients with liver tumors (primary or metastatic) who were treated with 90Y-RE in our institution from September 2003 to February 2010. We categorized patients as "elderly" if aged ≥ 70 years and "younger" if aged < 70 years.

RESULTS

Seventy-three patients (29%) were aged ≥ 70 years. The most frequent liver tumor among elderly patients was hepatocellular carcinoma. Complication rates were similar in both groups: 10.4% of elderly patients and 9.9% of younger patients developed radioembolization-induced liver disease (P = 1.000). Only 1.5% of elderly patients developed gastrointestinal ulceration and no patient in the elderly group developed pneumonitis. The median overall survival of patients with hepatocellular carcinoma was similar in elderly and younger groups (13 months, 95% confidence interval [CI], 10.4-15.5 and 12 months, 95% CI, 4.2-15.7; P = 0.4). In patients with colorectal carcinoma metastatic to the liver, the median overall survival was 10 months (95% CI, 5.2-14.7) for elderly patients and 13 months (95% CI, 7.0-18.9) for younger patients (P = 0.3). The median overall survival of patients with other histologies was 9 months (95% CI, 3.5-14.4) for younger patients and 4 months (95% CI, 2.7-5.2) for elderly patients (P = 0.9).

CONCLUSION

Elderly patients did not have more toxicity than younger patients treated with 90Y-RE, and survival was similar for each histology. Elderly patients should be considered for 90Y-RE if they otherwise meet the inclusion criteria applicable to younger patients.

Management of advanced neuroendocrine tumors with hepatic metastasis

Neuroendocrine tumors (NETs) in general and specifically these gastroenteropancreatic-neuroendocrine tumors often present a considerable diagnostic and therapeutic challenge, especially those that behave in an aggressive fashion. The majority of tumors are diagnosed at a stage that the only curative treatment, radical surgical intervention, is no longer an option and thus long-term therapy with somatostatin analogs is focused on symptom amelioration and in the improvement of quality of life. Although biotherapy is currently the most efficient treatment to achieve palliation, conventional chemotherapy may have some utility in undifferentiated or highly proliferating neuroendocrine carcinomas and pancreatic NETs. Hepatic metastases, depending on size, location, and number may be amenable to surgical resection or radiofrequency ablation. If surgery is not feasible, embolization either alone (bland), in combination with chemotherapeutic agents, or using radioactive microspheres can be used. Peptide receptor targeted radiotherapy using radiolabeled octapeptide analogs (Yttrium or Lutetium-octreotide) may lead to reduction in tumor size, but in most circumstances has a tumor stabilizing effect. A variety of antiangiogenesis and growth factor-targeted agents have been evaluated, but to date, the results have failed to meet our expectations.

Complications following radioembolization with yttrium-90 microspheres: a comprehensive literature review

The past decade has seen significant advancement in the locoregional management of liver tumors; novel and promising therapies such as transarterial chemoembolization, radioembolization, and radiofrequency ablation are now available. The development of new techniques and devices has led to the improved safety and efficacy profiles of external-beam radiation. Radioembolization with yttrium-90 ((90)Y) microspheres has emerged as a safe and efficacious treatment modality for liver malignancies. The purpose of this article is to present a comprehensive evidence-based review of the complications and adverse events that may be associated with radioembolization with (90)Y microspheres. Strategies to mitigate these adverse events are also discussed.

A first report of radioembolization for hepatic metastases from ocular melanoma

BACKGROUND

Ocular melanoma (OM) metastasizes to the liver and is rapidly fatal despite aggressive therapy. Yttrium-90 microspheres (radioembolization) delivered via the hepatic artery is an established and effective approach for primary and metastatic hepatic tumors, although (90)Y use in OM has not been reported previously.

METHODS

A retrospective review was performed for all patients with OM who received radioembolization at 5 centers.

RESULTS

11 patients received 12 treatments with a median activity of 1.55 GBq delivered per treatment. Toxicity was minimal, with PET/CT at 3 months posttreatment showing a response in all patients; 1 patient had a complete response.

CONCLUSIONS

Radioembolization can control hepatic metastases of OM with very few side effects.

[Arterial embolization of hepatic metastases from neuroendocrine tumors]

Neuroendocrine tumors are slowly growing neoplasms and 75% of patients already present with hepatic metastases at the time of diagnosis. Size and growth of liver metastases is of prognostic value. Due to arterial vascularization of metastases, transarterial embolization (TAE) is a suitable procedure, which can also be combined with chemotherapeutic agents. Indications for embolization or chemoembolization (TACE) are growth of liver metastases or inadequate symptom control. The majority of patients show clinical improvement and partial remission can be achieved in 50% of cases with 5-year survival rates of 50-60%. Response rates, survival or complications are not dependent on the embolization technique (TAE or TACE). Embolization is usually performed in several sessions depending on individual tumor stage and disease progression. Embolization is a cost-effective procedure and is included in the treatment algorithm of international guidelines. Therefore, evaluation of new embolization therapies must be evaluated in randomized controlled studies.

Review article: future therapies for management of metastatic gastroenteropancreatic neuroendocrine tumours

BACKGROUND

Gastroenteropancreatic neuroendocrine tumours (GEP NETs) are relatively uncommon tumours that occur anywhere within the gastrointestinal tract. The prevalence of GEP NETs is estimated to be 35 per 100 000 population. Patients often present with metastatic disease and consequently, palliative treatments form the mainstay of therapy.

AIM

To review the current and novel therapeutic options for management of GEP NETs.

METHODS

Searches for all studies related to GEP NETs, NETs and carcinoid tumours in Medline and abstracts from international meetings.

RESULTS

Somatostatin analogues remain the first line therapy for management of symptoms of GEP NETs and may have anti-proliferative action. New somatostatin analogues with different somatostatin receptor affinity have been developed. Radionuclide peptide receptor therapy is established in patients with positive somatostatin scintigraphy. A number of new agents and targeted therapies are currently being evaluated in a phase I and II studies and these include angiogenic inhibitors, mammalian target of rapamycin inhibitors and immune therapies.

CONCLUSIONS

A number of nonsurgical therapies are available for management of gastroenteropancreatic neuroendocrine tumours. It is hoped, the development of some of these promising novel therapies will expand the therapeutic armamentarium.

Treatment parameters and outcome in 680 treatments of internal radiation with resin 90Y-microspheres for unresectable hepatic tumors

PURPOSE

Radioembolization (RE) using (90)Y-microspheres is an effective and safe treatment for patients with unresectable liver malignancies. Radiation-induced liver disease (RILD) is rare after RE; however, greater understanding of radiation-related factors leading to serious liver toxicity is needed.

METHODS AND MATERIALS

Retrospective review of radiation parameters was performed. All data pertaining to demographics, tumor, radiation, and outcomes were analyzed for significance and dependencies to develop a predictive model for RILD. Toxicity was scored using the National Cancer Institute Common Toxicity Criteria Adverse Events Version 3.0 scale.

RESULTS

A total of 515 patients (287 men; 228 women) from 14 US and 2 EU centers underwent 680 separate RE treatments with resin (90)Y-microspheres in 2003-2006. Multifactorial analyses identified factors related to toxicity, including activity (GBq) Selective Internal Radiation Therapy delivered (p < 0.0001), prescribed (GBq) activity (p < 0.0001), percentage of empiric activity (GBq) delivered (p < 0.0001), number of prior liver treatments (p < 0.0008), and medical center (p < 0.0001). The RILD was diagnosed in 28 of 680 treatments (4%), with 21 of 28 cases (75%) from one center, which used the empiric method.

CONCLUSIONS

There was an association between the empiric method, percentage of calculated activity delivered to the patient, and the most severe toxicity, RILD. A predictive model for RILD is not yet possible given the large variance in these data.