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Yu SJ, Kim YJ. Effective treatment strategies other than sorafenib for the patients with advanced hepatocellular carcinoma invading portal vein. World J Hepatol 2015; 7:1553-1561. [PMID: 26085914 PMCID: PMC4462693 DOI: 10.4254/wjh.v7.i11.1553] [Citation(s) in RCA: 32] [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: 09/23/2014] [Revised: 02/12/2015] [Accepted: 04/14/2015] [Indexed: 02/06/2023] Open
Abstract
Patients with hepatocellular carcinoma (HCC) accompanying portal vein tumor thrombosis (PVTT) have relatively few therapeutic options and an extremely poor prognosis. These patients are classified into barcelona clinic liver cancer stage C and sorafenib is suggested as the standard therapy of care. However, overall survival (OS) gain from sorafenib is unsatisfactory and better treatment modalities are urgently required. Therefore, we critically appraised recent data for the various treatment strategies for patients with HCC accompanying PVTT. In suitable patients, even surgical resection can be considered a potentially curative strategy. Transarterial chemoembolization (TACE) can be performed effectively and safely in a carefully chosen population of patients with reserved liver function and sufficient collateral blood flow nearby the blocked portal vein. A recent meta-analysis demonstrated that TACE achieved a substantial improvement of OS in HCC patients accompanying PVTT compared with best supportive care. In addition, transarterial radioembolization (TARE) using yttrium-90 microspheres achieves quality-of-life advantages and is as effective as TACE. A large proportion of HCC patients accompanying PVTT are considered to be proper for TARE. Moreover, TACE or TARE achieved comparable outcomes to sorafenib in recent studies and it was also reported that the combination of radiotherapy with TACE achieved a survival gain compared to sorafenib in HCC patients accompanying PVTT. Surgical resection-based multimodal treatments, transarterial approaches including TACE and TARE, and TACE-based appropriate combination strategies may improve OS of HCC patients accompanying PVTT.
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252
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Chu KKW, Cheung TT. Update in management of hepatocellular carcinoma in Eastern population. World J Hepatol 2015; 7:1562-1571. [PMID: 26085915 PMCID: PMC4462694 DOI: 10.4254/wjh.v7.i11.1562] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Revised: 02/10/2015] [Accepted: 04/14/2015] [Indexed: 02/06/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is one of the commonest malignant tumours in the East. Although the management of HCC in the West is mainly based on the Barcelona Clinic for Liver Cancer staging, it is considered too conservative by Asian countries where the number of HCC patients is huge. Scientific and clinical advances were made in aspects of diagnosis, staging, and treatment of HCC. HCC is well known to be associated with cirrhosis and the treatment of HCC must take into account the presence and stage of chronic liver disease. The major treatment modalities of HCC include: (1) surgical resection; (2) liver transplantation; (3) local ablation therapy; (4) transarterial locoregional treatment; and (5) systemic treatment. Among these, resection, liver transplantation and ablation therapy for small HCC are considered as curative treatment. Portal vein embolisation and the associating liver partition with portal vein ligation for staged hepatectomy may reduce dropout in patients with marginally resectable disease but the midterm and long-term results are still to be confirmed. Patient selection for the best treatment modality is the key to success of treatment of HCC. The purpose of current review is to provide a description of the current advances in diagnosis, staging, pre-operative liver function assessment and treatment options for patients with HCC in the east.
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253
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Is radioembolization ((90)Y) better than doxorubicin drug eluting beads (DEBDOX) for hepatocellular carcinoma with portal vein thrombosis? A retrospective analysis. Surg Oncol 2015; 24:270-5. [PMID: 26133576 DOI: 10.1016/j.suronc.2015.06.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Revised: 03/14/2015] [Accepted: 06/08/2015] [Indexed: 02/07/2023]
Abstract
INTRODUCTION This study compares radioembolization ((90)Y) versus doxorubicin drug eluting beads (DEBDOX) in the treatment of unresectable hepatocellular carcinoma with portal vein thrombosis. METHODS Using our prospectively maintained, multi-center, non-controlled intra-arterial therapy registry, we identified 28 consecutive patients with hepatocellular carcinoma (HCC) and portal vein thrombosis (PVT) treated with DEBDOX and 20 with (90)Y. Follow-up protocol consisted of a 3-phase CT scan of the liver within 3 months post-treatment. Tumor response rates were measured according to modified Response Evaluation Criteria in Solid Tumors (mRECIST) criteria. RESULTS There were 65 and 29 treatments in the DEBDOX and (90)Y groups respectively. Median age of DEBDOX was 59.8 (35-81) and (90)Y was 66.5 (49-82) years. A defined number of lesions were seen in 78% DEBDOX and 50% (90)Y patients. Patients were similar in the remaining 8 baseline characteristics including performance status, Child Pugh and extent of PVT. There were fewer overall side effects in the DEBDOX group compared to the (90)Y group (11% vs 39%; P = 0.03). There was better disease control (mRECIST) in the DEBDOX group compared to the (90)Y group (67% vs 20%; P = 0.0014). Median survival times were 10 months in DEBDOX and 3 months in the (90)Y group respectively from first treatment (log-rank, P = 0.037). CONCLUSION DEBDOX is safe for patients with HCC and PVT and may have lower toxicity than (90)Y. It may also provide better disease control and survival benefit. Further studies are warranted to validate our observations and to determine if current clinical practice should be altered.
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Sacco R, Mismas V, Marceglia S, Romano A, Giacomelli L, Bertini M, Federici G, Metrangolo S, Parisi G, Tumino E, Bresci G, Corti A, Tredici M, Piccinno M, Giorgi L, Bartolozzi C, Bargellini I. Transarterial radioembolization for hepatocellular carcinoma: An update and perspectives. World J Gastroenterol 2015; 21:6518-25. [PMID: 26074690 PMCID: PMC4458762 DOI: 10.3748/wjg.v21.i21.6518] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 03/13/2015] [Accepted: 04/28/2015] [Indexed: 02/06/2023] Open
Abstract
In the last decade trans-arterial radioembolization has given promising results in the treatment of patients with intermediate or advanced stage hepatocellular carcinoma (HCC), both in terms of disease control and tolerability profile. This technique consists of the selective intra-arterial administration of microspheres loaded with a radioactive compound (usually Yttrium(90)), and exerts its therapeutic effect through the radiation carried by these microspheres. A careful and meticulous selection of patients is crucial before performing the radioembolization to correctly perform the procedure and reduce the incidence of complications. Radioembolization is a technically complex and expensive technique, which has only recently entered clinical practice and is supported by scant results from phase III clinical trials. Nevertheless, it may represent a valid alternative to transarterial chemoembolization (TACE) in the treatment of intermediate-stage HCC patients, as shown by a comparative retrospective assessment that reported a longer time to progression, but not of overall survival, and a more favorable safety profile for radioembolization. In addition, this treatment has reported a higher percentage of tumor shrinkage, if compared to TACE, for pre-transplant downsizing and it represents a promising therapeutic option in patients with large extent of disease and insufficient residual liver volume who are not immediately eligible for surgery. Radioembolization might also be a suitable companion to sorafenib in advanced HCC or it can be used as a potential alternative to this treatment in patients who are not responding or do not tolerate sorafenib.
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255
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Yao FY, Mehta N, Flemming J, Dodge J, Hameed B, Fix O, Hirose R, Fidelman N, Kerlan RK, Roberts JP. Downstaging of hepatocellular cancer before liver transplant: long-term outcome compared to tumors within Milan criteria. Hepatology 2015; 61:1968-77. [PMID: 25689978 PMCID: PMC4809192 DOI: 10.1002/hep.27752] [Citation(s) in RCA: 326] [Impact Index Per Article: 36.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2014] [Accepted: 02/13/2015] [Indexed: 12/07/2022]
Abstract
UNLABELLED We report on the long-term intention-to-treat (ITT) outcome of 118 patients with hepatocellular carcinoma (HCC) undergoing downstaging to within Milan/United Network for Organ Sharing T2 criteria before liver transplantation (LT) since 2002 and compare the results with 488 patients listed for LT with HCC meeting T2 criteria at listing in the same period. The downstaging subgroups include 1 lesion >5 and ≤8 cm (n = 43), 2 or 3 lesions at least one >3 and ≤5 cm with total tumor diameter ≤8 cm (n = 61), or 4-5 lesions each ≤3 cm with total tumor diameter ≤8 cm (n = 14). In the downstaging group, 64 patients (54.2%) had received LT and 5 (7.5%) developed HCC recurrence. Two of the five patients with HCC recurrence had 4-5 tumors at presentation. The 1- and 2-year cumulative probabilities for dropout (competing risk) were 24.1% and 34.2% in the downstaging group versus 20.3% and 25.6% in the T2 group (P = 0.04). Kaplan-Meier's 5-year post-transplant survival and recurrence-free probabilities were 77.8% and 90.8%, respectively, in the downstaging group versus 81% and 88%, respectively, in the T2 group (P = 0.69 and P = 0.66, respectively). The 5-year ITT survival was 56.1% in the downstaging group versus 63.3% in the T2 group (P = 0.29). Factors predicting dropout in the downstaging group included pretreatment alpha-fetoprotein ≥1,000 ng/mL (multivariate hazard ratio [HR]: 2.42; P = 0.02) and Child's B versus Child's A cirrhosis (multivariate HR: 2.19; P = 0.04). CONCLUSION Successful downstaging of HCC to within T2 criteria was associated with a low rate of HCC recurrence and excellent post-transplant survival, comparable to those meeting T2 criteria without downstaging. Owing to the small number of patients with 4-5 tumors, further investigations are needed to confirm the efficacy of downstaging in this subgroup.
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256
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Kolligs FT, Bilbao JI, Jakobs T, Iñarrairaegui M, Nagel JM, Rodriguez M, Haug A, D'Avola D, op den Winkel M, Martinez-Cuesta A, Trumm C, Benito A, Tatsch K, Zech CJ, Hoffmann RT, Sangro B. Pilot randomized trial of selective internal radiation therapy vs. chemoembolization in unresectable hepatocellular carcinoma. Liver Int 2015; 35:1715-21. [PMID: 25443863 DOI: 10.1111/liv.12750] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 11/19/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS To compare selective internal radiation therapy (SIRT) with transarterial chemoembolization (TACE), the standard-of-care for intermediate-stage unresectable, hepatocellular carcinoma (HCC), as first-line treatment. METHODS SIRTACE was an open-label multicenter randomized-controlled pilot study, which prospectively compared primarily safety and health-related quality of life (HRQoL) changes following TACE and SIRT. Patients with unresectable HCC, Child-Pugh ≤B7, ECOG performance status ≤2 and ≤5 liver lesions (≤20 cm total maximum diameter) without extrahepatic spread were randomized to receive either TACE (at 6-weekly intervals until tumour enhancement was not observed on MRI or disease progression) or single-session SIRT (yttrium-90 resin microspheres). RESULTS Twenty-eight patients with BCLC stage A (32.1%), B (46.4%) or C (21.4%) received either a mean of 3.4 (median 2) TACE interventions (N = 15) or single SIRT (N = 13). Both treatments were well tolerated. Despite SIRT patients having significantly worse physical functioning at baseline, at week-12, neither treatment had a significantly different impact on HRQoL as measured by Functional Assessment of Cancer Therapy-Hepatobiliary total or its subscales. Both TACE and SIRT were effective for the local control of liver tumours. Best overall response-rate (RECIST 1.0) of target lesions were 13.3% and 30.8%, disease control rates were 73.3% and 76.9% for TACE and SIRT, respectively. Two patients in each group were down-staged for liver transplantation (N = 3) or radiofrequency ablation (N = 1). CONCLUSIONS Single-session SIRT appeared to be as safe and had a similar impact on HRQoL as multiple sessions of TACE, suggesting that SIRT might be an alternative option for patients eligible for TACE.
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Affiliation(s)
- Frank T Kolligs
- Department of Internal Medicine II, University of Munich, Munich, Germany
| | - Jose I Bilbao
- Interventional Radiology, Clinica Universidad de Navarra and Instituto de Investigaciones Sanitarias de Navarra (IDISNA), Pamplona, Spain
| | - Tobias Jakobs
- Institute of Radiology, Krankenhaus der Barmherzigen Brüder, Munich, Germany
| | | | - Jutta M Nagel
- Department of Internal Medicine II, University of Munich, Munich, Germany
| | | | - Alexander Haug
- Department of Nuclear Medicine, University of Munich, Munich, Germany
| | - Delia D'Avola
- Liver Unit, Clinica Universidad de Navarra, Instituto de Investigaciones Sanitarias de Navarra (IDISNA) and Centro de Investigacion Biomedica en Red de Enfermedades Hepaticas y Digestivas (CIBEREHD), Pamplona, Spain
| | - Mark op den Winkel
- Department of Internal Medicine II, University of Munich, Munich, Germany
| | | | - Christoph Trumm
- Institute of Radiology, University of Munich, Munich, Germany
| | - Alberto Benito
- Department of Radiology, Clinica Universidad de Navarra, Pamplona, Spain
| | - Klaus Tatsch
- Department of Nuclear Medicine, Municipal Hospital Karlsruhe Inc., Karlsruhe, Germany
| | - Christoph J Zech
- Clinic of Radiology and Nuclear Medicine, University of Basel, Basel, Switzerland
| | - Ralf-Thorsten Hoffmann
- Institute and Policlinic of Radiology, University Hospital at the Technische Universitaet Dresden, Dresden, Germany
| | - Bruno Sangro
- Liver Unit, Clinica Universidad de Navarra, Instituto de Investigaciones Sanitarias de Navarra (IDISNA) and Centro de Investigacion Biomedica en Red de Enfermedades Hepaticas y Digestivas (CIBEREHD), Pamplona, Spain
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257
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2014 KLCSG-NCC Korea Practice Guideline for the Management of Hepatocellular Carcinoma. Gut Liver 2015; 9:267-317. [PMID: 25918260 PMCID: PMC4413964 DOI: 10.5009/gnl14460] [Citation(s) in RCA: 101] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 03/09/2015] [Indexed: 12/23/2022] Open
Abstract
The guideline for the management of hepatocellular carcinoma (HCC) was first developed in 2003 and revised in 2009 by the Korean Liver Cancer Study Group and the National Cancer Center, Korea. Since then, many studies on HCC have been carried out in Korea and other countries. In particular, a substantial body of knowledge has been accumulated on diagnosis, staging, and treatment specific to Asian characteristics, especially Koreans, prompting the proposal of new strategies. Accordingly, the new guideline presented herein was developed on the basis of recent evidence and expert opinions. The primary targets of this guideline are patients with suspicious or newly diagnosed HCC. This guideline provides recommendations for the initial treatment of patients with newly diagnosed HCC.
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258
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Waghray A, Murali AR, Menon KVN. Hepatocellular carcinoma: From diagnosis to treatment. World J Hepatol 2015; 7:1020-1029. [PMID: 26052391 PMCID: PMC4450179 DOI: 10.4254/wjh.v7.i8.1020] [Citation(s) in RCA: 105] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Revised: 01/15/2015] [Accepted: 02/12/2015] [Indexed: 02/06/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is the sixth most prevalent malignancy worldwide and is a rising cause of cancer related mortality. Risk factors for HCC are well documented and effective surveillance and early diagnosis allow for curative therapies. The majority of HCC appears to be caused by cirrhosis from chronic hepatitis B and hepatitis C virus. Preventive strategies include vaccination programs and anti-viral treatments. Surveillance with ultrasonography detects early stage disease and improves survival rates. Many treatment options exist for individuals with HCC and are determined by stage of presentation. Liver transplantation is offered to patients who are within the Milan criteria and are not candidates for hepatic resection. In patients with advanced stage disease, sorafenib shows some survival benefit.
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259
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Hayano K, Lee SH, Sahani DV. Imaging for assessment of treatment response in hepatocellular carcinoma: Current update. Indian J Radiol Imaging 2015; 25:121-8. [PMID: 25969635 PMCID: PMC4419421 DOI: 10.4103/0971-3026.155835] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Morphologic methods such as the Response Evaluation Criteria in Solid Tumors (RECIST) are considered as the gold standard for response assessment in the management of cancer. However, with the increasing clinical use of antineoplastic cytostatic agents and locoregional interventional therapies in hepatocellular carcinoma (HCC), conventional morphologic methods are confronting limitations in response assessment. Thus, there is an increasing interest in new imaging methods for response assessment, which can evaluate tumor biology such as vascular physiology, fibrosis, necrosis, and metabolism. In this review, we discuss various novel imaging methods for response assessment and compare them with the conventional ones in HCC.
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Affiliation(s)
- Koichi Hayano
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sang Ho Lee
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Dushyant V Sahani
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
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260
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Abstract
Unresectable liver cancer presents a major problem in the treatment of solid tumors. Transarterial radioembolization is a modern approach toward primary and secondary liver malignancies. The mechanism of action is independent from other therapies that are based on ischemia or chemotoxicity. (90)Y-resin and (90)Y-glass microspheres are commercially available for transarterial radioembolization. Available data on the use of (90)Y-glass microspheres in hepatocellular carcinoma and metastatic disease indicate that this treatment is safe and effective. In hepatocellular carcinoma the results compare well with chemoembolization and might be considered more often. Current data in metastatic disease are promising, but there is a strong need for prospective randomized trials to identify the role of transarterial radioembolization with (90)Y-glass microspheres in metastatic liver disease.
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261
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Hepatocellular carcinoma: Consensus, controversies and future directions. A report from the Canadian Association for the Study of the Liver Hepatocellular Carcinoma Meeting. Can J Gastroenterol Hepatol 2015; 29:178-84. [PMID: 25965437 PMCID: PMC4444026 DOI: 10.1155/2015/824263] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality worldwide and its incidence has rapidly increased in North America in recent years. Although there are many published guidelines to assist the clinician, there remain gaps in knowledge and areas of controversy surrounding the diagnosis and management of HCC. In February 2014, the Canadian Association for the Study of the Liver organized a one-day single-topic consensus conference on HCC. Herein, the authors present a summary of the topics covered and the result of voting on consensus statements presented at this meeting.
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262
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Shaw CM, Eisenbrey JR, Lyshchik A, O'Kane PL, Merton DA, Machado P, Pino L, Brown DB, Forsberg F. Contrast-enhanced ultrasound evaluation of residual blood flow to hepatocellular carcinoma after treatment with transarterial chemoembolization using drug-eluting beads: a prospective study. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2015; 34:859-867. [PMID: 25911704 DOI: 10.7863/ultra.34.5.859] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVES To evaluate the accuracy and change over time of contrast-enhanced ultrasound (US) imaging for assessing residual blood flow after transarterial chemoembolization of hepatocellular carcinoma with drug-eluting beads at 2 different follow-up intervals. METHODS Data from 16 tumors treated by transarterial chemoembolization with drug-eluting beads were successfully obtained. As part of the study, patients provided consent to undergo contrast-enhanced US examinations the morning before embolization, 1 to 2 weeks after embolization, and the morning before follow-up contrast-enhanced magnetic resonance imaging (MRI) or computed tomography (CT) (1 month after embolization). Blinded review of contrast-enhanced US and MRI/CT studies were performed by 2 radiologists who evaluated residual flow as no change, partial change, or no residual flow. Inter- and intra-reader variability rates were calculated before discordant individual reads were settled by consensus. RESULTS The only adverse event reported during the contrast-enhanced US examinations was a single episode of transient back pain. Contrast-enhanced US at 1 to 2 weeks after embolization (n = 14) resulted in 100% sensitivity, specificity, positive predictive value, negative predictive value, and accuracy. Contrast-enhanced US 1 month after embolization (n = 15) resulted in 75% sensitivity, 100% specificity, 100% positive predictive value, 92% negative predictive value, and 93% accuracy. Inter-reader agreement was 86% for contrast-enhanced US at 1 to 2 weeks, 93% for contrast-enhanced US at 1 month, and 100% for contrast-enhanced MRI/CT at 1 month, whereas intra-reader agreement was 71% for contrast-enhanced US at 1 to 2 weeks, 87% for contrast-enhanced US at 1 month, and 91% for MRI/CT. CONCLUSIONS Contrast-enhanced US imaging at 1 to 2 weeks after the procedure may be a viable alternative to MRI/CT for evaluating residual blood flow after transarterial chemoembolization with drug-eluting beads, albeit with a higher degree of reader variability.
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Affiliation(s)
- Colette M Shaw
- Department of Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania USA
| | - John R Eisenbrey
- Department of Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania USA
| | - Andrej Lyshchik
- Department of Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania USA
| | - Patrick L O'Kane
- Department of Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania USA
| | - Daniel A Merton
- Department of Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania USA
| | - Priscilla Machado
- Department of Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania USA
| | - Laura Pino
- Department of Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania USA
| | - Daniel B Brown
- Department of Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania USA
| | - Flemming Forsberg
- Department of Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania USA
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263
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2014 Korean Liver Cancer Study Group-National Cancer Center Korea practice guideline for the management of hepatocellular carcinoma. Korean J Radiol 2015; 16:465-522. [PMID: 25995680 PMCID: PMC4435981 DOI: 10.3348/kjr.2015.16.3.465] [Citation(s) in RCA: 143] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2015] [Accepted: 04/02/2015] [Indexed: 02/07/2023] Open
Abstract
The guideline for the management of hepatocellular carcinoma (HCC) was first developed in 2003 and revised in 2009 by the Korean Liver Cancer Study Group and the National Cancer Center, Korea. Since then, many studies on HCC have been carried out in Korea and other countries. In particular, a substantial body of knowledge has been accumulated on diagnosis, staging, and treatment specific to Asian characteristics, especially Koreans, prompting the proposal of new strategies. Accordingly, the new guideline presented herein was developed on the basis of recent evidence and expert opinions. The primary targets of this guideline are patients with suspicious or newly diagnosed HCC. This guideline provides recommendations for the initial treatment of patients with newly diagnosed HCC.
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264
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Radioembolization with Yttrium-90 microspheres in hepatocellular carcinoma: Role and perspectives. World J Hepatol 2015. [PMID: 25914774 DOI: 10.4254/wjh.v7.i5.738].] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Transarterial radioembolization (TARE) is a form of brachytherapy in which intra-arterially injected yttrium-90-loaded microspheres serve as a source for internal radiation purposes. On the average, it produces disease control rates exceeding 80% and it is a consolidated therapy for hepatocellular carcinoma (HCC); however, current data are all based on retrospective series or non-controlled prospective studies since randomized controlled trials comparing it with the other liver-directed therapies for intermediate and locally advanced stage HCC are still underway. The data available show that TARE provides similar or even better survival rates when compared to transarterial chemoembolization (TACE). First-line TARE is best indicated for both intermediate-stage patients (staged according to the barcelona clinic liver cancer staging classification) who have lesions which respond poorly to TACE due to multiple tumors or a large tumor burden, and for locally advanced-stage patients with solitary tumors, and segmental or lobar portal vein tumor thrombosis. In addition, emerging data have suggested the use of TARE in patients who are classified slightly beyond the Milan criteria regarding radical treatment for downstaging purposes. As a second-line treatment, TARE can also be applied in patients progressing to TACE or sorafenib; a large number of phase II/III trials are ongoing with the purpose of evaluating the best association with systemic therapies. Transarterial radioembolization is very well tolerated and has a low rate of complications which are mainly related to unintended non-target tissue irradiation, including the surrounding liver parenchyma. The complications can be additionally reduced by accurate patient selection and a strict pre-treatment evaluation including dosimetry and assessment of the vascular anatomy. Since a correct treatment algorithm for potential TARE candidates is not clear and standardized, this comprehensive review analyzes the best selection criteria for patients who really benefit from TARE and also the new advances of this therapy, which can be a very important weapon against HCC.
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265
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Rodríguez-Fraile M, Iñarrairaegui M. [Radioembolization with (90)Y-microspheres for liver tumors]. Rev Esp Med Nucl Imagen Mol 2015; 34:244-57. [PMID: 25911062 DOI: 10.1016/j.remn.2015.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 03/12/2015] [Accepted: 03/13/2015] [Indexed: 12/16/2022]
Affiliation(s)
- M Rodríguez-Fraile
- Servicio de Medicina Nuclear, Clínica Universidad de Navarra, Pamplona, Navarra; Área de Oncología Hepatobiliopancreática, Clínica Universidad de Navarra, Pamplona, Navarra, España; Instituto de Investigaciones Sanitarias de Navarra (IDISNA), España.
| | - M Iñarrairaegui
- Unidad de Hepatología, Clínica Universidad de Navarra, Pamplona, Navarra, España; Área de Oncología Hepatobiliopancreática, Clínica Universidad de Navarra, Pamplona, Navarra, España; Instituto de Investigaciones Sanitarias de Navarra (IDISNA), España; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Pamplona, España
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266
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Mosconi C, Cappelli A, Pettinato C, Golfieri R. Radioembolization with Yttrium-90 microspheres in hepatocellular carcinoma: Role and perspectives. World J Hepatol 2015; 7:738-52. [PMID: 25914774 PMCID: PMC4404379 DOI: 10.4254/wjh.v7.i5.738] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Revised: 12/09/2014] [Accepted: 01/15/2015] [Indexed: 02/06/2023] Open
Abstract
Transarterial radioembolization (TARE) is a form of brachytherapy in which intra-arterially injected yttrium-90-loaded microspheres serve as a source for internal radiation purposes. On the average, it produces disease control rates exceeding 80% and it is a consolidated therapy for hepatocellular carcinoma (HCC); however, current data are all based on retrospective series or non-controlled prospective studies since randomized controlled trials comparing it with the other liver-directed therapies for intermediate and locally advanced stage HCC are still underway. The data available show that TARE provides similar or even better survival rates when compared to transarterial chemoembolization (TACE). First-line TARE is best indicated for both intermediate-stage patients (staged according to the barcelona clinic liver cancer staging classification) who have lesions which respond poorly to TACE due to multiple tumors or a large tumor burden, and for locally advanced-stage patients with solitary tumors, and segmental or lobar portal vein tumor thrombosis. In addition, emerging data have suggested the use of TARE in patients who are classified slightly beyond the Milan criteria regarding radical treatment for downstaging purposes. As a second-line treatment, TARE can also be applied in patients progressing to TACE or sorafenib; a large number of phase II/III trials are ongoing with the purpose of evaluating the best association with systemic therapies. Transarterial radioembolization is very well tolerated and has a low rate of complications which are mainly related to unintended non-target tissue irradiation, including the surrounding liver parenchyma. The complications can be additionally reduced by accurate patient selection and a strict pre-treatment evaluation including dosimetry and assessment of the vascular anatomy. Since a correct treatment algorithm for potential TARE candidates is not clear and standardized, this comprehensive review analyzes the best selection criteria for patients who really benefit from TARE and also the new advances of this therapy, which can be a very important weapon against HCC.
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Affiliation(s)
- Cristina Mosconi
- Cristina Mosconi, Alberta Cappelli, Rita Golfieri, Radiology Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, 40138 Bologna, Italy
| | - Alberta Cappelli
- Cristina Mosconi, Alberta Cappelli, Rita Golfieri, Radiology Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, 40138 Bologna, Italy
| | - Cinzia Pettinato
- Cristina Mosconi, Alberta Cappelli, Rita Golfieri, Radiology Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, 40138 Bologna, Italy
| | - Rita Golfieri
- Cristina Mosconi, Alberta Cappelli, Rita Golfieri, Radiology Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, 40138 Bologna, Italy
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267
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Mosconi C, Cappelli A, Pettinato C, Golfieri R. Radioembolization with Yttrium-90 microspheres in hepatocellular carcinoma: Role and perspectives. World J Hepatol 2015. [PMID: 25914774 DOI: 10.4254/wjh.v7.i5.738]] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Transarterial radioembolization (TARE) is a form of brachytherapy in which intra-arterially injected yttrium-90-loaded microspheres serve as a source for internal radiation purposes. On the average, it produces disease control rates exceeding 80% and it is a consolidated therapy for hepatocellular carcinoma (HCC); however, current data are all based on retrospective series or non-controlled prospective studies since randomized controlled trials comparing it with the other liver-directed therapies for intermediate and locally advanced stage HCC are still underway. The data available show that TARE provides similar or even better survival rates when compared to transarterial chemoembolization (TACE). First-line TARE is best indicated for both intermediate-stage patients (staged according to the barcelona clinic liver cancer staging classification) who have lesions which respond poorly to TACE due to multiple tumors or a large tumor burden, and for locally advanced-stage patients with solitary tumors, and segmental or lobar portal vein tumor thrombosis. In addition, emerging data have suggested the use of TARE in patients who are classified slightly beyond the Milan criteria regarding radical treatment for downstaging purposes. As a second-line treatment, TARE can also be applied in patients progressing to TACE or sorafenib; a large number of phase II/III trials are ongoing with the purpose of evaluating the best association with systemic therapies. Transarterial radioembolization is very well tolerated and has a low rate of complications which are mainly related to unintended non-target tissue irradiation, including the surrounding liver parenchyma. The complications can be additionally reduced by accurate patient selection and a strict pre-treatment evaluation including dosimetry and assessment of the vascular anatomy. Since a correct treatment algorithm for potential TARE candidates is not clear and standardized, this comprehensive review analyzes the best selection criteria for patients who really benefit from TARE and also the new advances of this therapy, which can be a very important weapon against HCC.
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Affiliation(s)
- Cristina Mosconi
- Cristina Mosconi, Alberta Cappelli, Rita Golfieri, Radiology Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, 40138 Bologna, Italy
| | - Alberta Cappelli
- Cristina Mosconi, Alberta Cappelli, Rita Golfieri, Radiology Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, 40138 Bologna, Italy
| | - Cinzia Pettinato
- Cristina Mosconi, Alberta Cappelli, Rita Golfieri, Radiology Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, 40138 Bologna, Italy
| | - Rita Golfieri
- Cristina Mosconi, Alberta Cappelli, Rita Golfieri, Radiology Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, 40138 Bologna, Italy
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Abstract
CLINICAL/METHODICAL ISSUE Due to late diagnosis and a lack of organs only about 30 % of patients suffering from hepatocellular carcinoma (HCC) undergo curative treatment. STANDARD RADIOLOGICAL METHODS Transarterial chemoembolization (TACE) is a routine procedure in intermediate stage HCC. In addition transarterial embolization (TAE) and transarterial radioembolization (TARE) are available for these patients. PERFORMANCE For inoperable patients with HCC, TACE is superior to best supportive care in terms of survival. Combined with percutaneous ablation TACE achieves results similar to resection. ACHIEVEMENTS Current developments, such as drug-eluting beads, TARE and multimodal treatment are well suited to further improve outcome in patients with intermediate stage HCC. PRACTICAL RECOMMENDATIONS Transarterial therapies in HCC should be applied in accordance with the Barcelona Clinic Liver Cancer (BCLC) criteria. Due to a better safety profile and potentially improved disease-free survival the use of drug-eluting beads should be liberally considered.
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Affiliation(s)
- A H Mahnken
- Klinik für Diagnostische und Interventionelle Radiologie, Klinikum der Philipps-Universität Marburg, Baldingerstraße, 35043, Marburg, Deutschland,
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269
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Gibbs P, Tie J, Bester L. Radioembolization for hepatocellular carcinoma: current role and future directions – the medical oncologist's perspective. Hepat Oncol 2015; 2:117-132. [DOI: 10.2217/hep.14.39] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY The incidence and impact of hepatocelluar carcinoma (HCC) continues to increase worldwide. While radical therapies such as resection, radiofrequency ablation or transplantation are potentially curative for patients with early-stage HCC, the majority of patients in routine practice present with more advanced tumors, where treatment goals are palliation and extending survival. With multiple new and promising treatment options emerging for these patients, the challenge for the medical oncologist is how best to integrate these therapies into routine clinical practice. Here we review the most recent data on the efficacy and safety of yttrium-90 radioembolization in HCC, the considerations involved in patient selection, and the optimal assessment and management of patients receiving treatment. We also examine the potential impact of several ongoing clinical trials.
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Affiliation(s)
- Peter Gibbs
- Department of Medical Oncology, Royal Melbourne Hospital, Parkville, Melbourne, Australia
| | - Jeanne Tie
- Department of Medical Oncology, Royal Melbourne Hospital, Parkville, Melbourne, Australia
| | - Lourens Bester
- Interventional Radiology, Department of Medical Imaging, St Vincent's Hospital, Sydney, Australia
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270
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271
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Edeline J, Gilabert M, Garin E, Boucher E, Raoul JL. Yttrium-90 microsphere radioembolization for hepatocellular carcinoma. Liver Cancer 2015; 4:16-25. [PMID: 26020026 PMCID: PMC4439788 DOI: 10.1159/000343878] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Yttrium-90 (Y90) radioembolization is an emerging strategy to treat liver malignancies, and clinical data supporting its use have accumulated in recent years. Y90-radioembolization has shown clinical effectiveness in intermediate and advanced hepatocellular carcinoma, with a favorable safety profile. Retrospective data show similar levels of effectiveness to transarterial chemoembolization in intermediate hepatocellular carcinoma, with some evidence of better tolerance. While phase 3 studies comparing Y90-radioembolization to chemoembolization in intermediate hepatocellular carcinoma would be difficult to conduct, studies comparing or combining Y90-radioembolization with sorafenib are under way. Questions also remain about the most suitable modalities for defining the dose to administer. Phase 3 studies are under way to clarify the place of Y90-radioembolization in the algorithm of HCC treatment.
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Affiliation(s)
- Julien Edeline
- Medical Oncology, Eugene Marquis Comprehensive Cancer Center, Rennes, France
| | - Marine Gilabert
- Medical Oncology, Paoli Calmette Institute, Marseille, France
| | - Etienne Garin
- Nuclear Medicine, Eugene Marquis Comprehensive Cancer Center, Rennes, France
| | - Eveline Boucher
- Medical Oncology, Eugene Marquis Comprehensive Cancer Center, Rennes, France
| | - Jean-Luc Raoul
- Medical Oncology, Paoli Calmette Institute, Marseille, France,*Jean-Luc Raoul, MD, PhD, Institut Paoli Calmette, 232, boulevard Sainte Marguerite, BP 156, 13273 Marseille cedex9 (France), Tel. +33 4 9122 3679, E-Mail
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272
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Gramenzi A, Golfieri R, Mosconi C, Cappelli A, Granito A, Cucchetti A, Marinelli S, Pettinato C, Erroi V, Fiumana S, Bolondi L, Bernardi M, Trevisani F. Yttrium-90 radioembolization vs sorafenib for intermediate-locally advanced hepatocellular carcinoma: a cohort study with propensity score analysis. Liver Int 2015; 35:1036-47. [PMID: 24750853 DOI: 10.1111/liv.12574] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Accepted: 04/17/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Sorafenib and transarterial (90) Y-radioembolization (TARE) are possible treatments for Barcelona Clinic Liver Cancer (BCLC) intermediate-advanced stage hepatocellular carcinoma (HCC). No study directly comparing sorafenib and TARE is currently available. This single-centre retrospective study compares the outcomes achieved with sorafenib and TARE in HCC patients potentially amenable to either therapy. METHODS Seventy-four sorafenib (71 ± 10 years, male 87%, BCLC B/C 53%/47%) and 63 TARE HCC patients (66 ± 9 years, male 79%, BCLC B/C 41%/59%) were included based on the following criteria: Child-Pugh class A/B, performance status ≤1, HCC unfit for other effective therapies, no metastases and no previous systemic chemotherapy. RESULTS Median overall survivals of the two groups were comparable, being 14.4 months (95% CI: 4.3-24.5) in sorafenib and 13.2 months (95% CI: 6.1-20.2) in TARE patients, with 1-, 2- and 3-year survival rates of 52.1%, 29.3% and 14.7% vs 51.8%, 27.8% and 21.6% respectively. Two TARE patients underwent liver transplantation after successful down-staging. To minimize the impact of confounding factors on survival analysis, propensity model matched 32 patients of each group for median age, tumour gross pathology and the independent prognostic factors (portal vein thrombosis, performance status, Model for End Liver Disease). Even after matching, the median survival did not differ between sorafenib (13.1 months; 95% CI: 1.2-25.9) and TARE patients (11.2 months; 95% CI: 6.7-15.7), with comparable 1-, 2- and 3-year survival rates. CONCLUSIONS In cirrhotic patients with intermediate-advanced or not-otherwise-treatable HCC, sorafenib and TARE provide similar survivals. Down-staging allowing liver transplantation only occurred after TARE.
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Affiliation(s)
- Annagiulia Gramenzi
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy
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273
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El Fouly A, Ertle J, El Dorry A, Shaker MK, Dechêne A, Abdella H, Mueller S, Barakat E, Lauenstein T, Bockisch A, Gerken G, Schlaak JF. In intermediate stage hepatocellular carcinoma: radioembolization with yttrium 90 or chemoembolization? Liver Int 2015; 35:627-35. [PMID: 25040497 DOI: 10.1111/liv.12637] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Accepted: 07/01/2014] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Transarterial chemoembolization (TACE) is one of the standard treatments recommended for intermediate stage hepatocellular carcinoma (HCC). At the same time, only little is known about the use of radioembolization with Yttrium-90 microspheres (TARE Y-90) for this subset of patients. To perform comparative analysis between both locoregional therapies in intermediate HCCs. Primary endpoint was overall survival (OS), while safety, response rate and time-to-progression (TTP) were considered as secondary endpoints. METHODS We collected data of 86 HCC patients in two university hospitals at which conventional TACE with doxorubicin or TARE Y-90 using glass microspheres were performed. The median observation period was 10 months. Patients were followed up for signs of toxicity and response. They underwent imaging analysis at baseline and follow-up at regular time intervals. RESULTS Eighty-six HCC patients with intermediate stage B (BCLC) were treated with either TACE (n = 42) or TARE Y-90 (n = 44). Despite a higher tumour burden in the TARE Y-90 group, the median OS (TACE: 18 months vs. TARE Y-90: 16.4 months) and the median TTP (TACE: 6.8 months vs. TARE Y-90: 13.3 months) were not statistically different. The number of treatment sessions, the average rate of treatment sessions per patient, total hospitalization time and rate of adverse events were significantly higher in the TACE cohort. CONCLUSION In intermediate HCC stage patients, both treatments resulted in similar survival probabilities despite more advanced disease in the TARE Y-90 group. Still, TARE Y-90 was better tolerated and associated with less hospitalization and treatment sessions.
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Affiliation(s)
- Amr El Fouly
- Department of Hepatology and Gastroenterology, University Hospital of Essen, Essen, Germany; Tropical Medicine Dep., Ain Shams University Hospital, Cairo, Egypt; Egyptian Atomic Energy Authority, Cairo, Egypt
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274
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Abstract
The burden of hepatocellular carcinoma is rising and anticipated to escalate and while the best chance for long term cure remains transplantation, however the shortage of available organs remains a limitation. Liver directed therapy can serve the role of bridge/downstaging to transplant or as palliative care. Despite an improved overall survival among patients with HCC, due to advancements in surgical techniques, liver directed and systemic therapy, the 5 year overall survival remains low at 18% high-lightening the need for novel therapies. Surveillance for HCC is key to detect disease at an early stage to increase the chances for a potentially curative option.
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Affiliation(s)
- Laura M Kulik
- Kovler Organ Transplantation Center, NMH, Arkes Family Pavilion, Suite 1900, 676 North Saint Clair, Chicago, IL 60611, USA.
| | - Attasit Chokechanachaisakul
- Kovler Organ Transplantation Center, NMH, Arkes Family Pavilion, Suite 1900, 676 North Saint Clair, Chicago, IL 60611, USA
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275
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Usefulness of radioembolization in identifying patients with favorable tumor biology before living donor liver transplantation. Transplantation 2014; 98:e47-50. [PMID: 25171535 DOI: 10.1097/tp.0000000000000317] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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276
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Ni JY, Xu LF, Wang WD, Sun HL, Chen YT. Conventional transarterial chemoembolization vs microsphere embolization in hepatocellular carcinoma: A meta-analysis. World J Gastroenterol 2014; 20:17206-17217. [PMID: 25493037 PMCID: PMC4258593 DOI: 10.3748/wjg.v20.i45.17206] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Revised: 04/19/2014] [Accepted: 07/22/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare conventional transarterial chemoembolization (c-TACE) with microsphere embolization in hepatocellular carcinoma (HCC).
METHODS: We searched PubMed, Medline, Embase and the Cochrane Library for trials assessing the efficacy and safety of c-TACE in comparison with those of yttrium-90 microsphere or drug-eluting bead embolization from January 2004 to December 2013. Overall survival rate (OSR), tumor response [complete response, partial response (PR), stable disease (SD), progressive disease (PD)], α-fetoprotein (AFP) response, progression rate and complications were compared and analyzed. Pooled ORs with 95%CI were calculated using either the fixed-effects model or random-effects model. All statistical analyses were conducted using the Review Manager (version 5.1.) from the Cochrane collaboration.
RESULTS: Thirteen trials were identified, including a total of 1834 patients; 1233 were treated with c-TACE, 377 underwent yttrium-90 microsphere embolization and 224 underwent drug-eluting bead embolization. The meta-analysis with either the random-effects model or fixed-effects model indicated that microsphere embolization was associated with significantly higher OSRs compared with those of c-TACE (OR1-year = 1.38, 95%CI1-year: 1.05-1.82; OR2-year = 2.88, 95%CI2-year: 1.18-7.05; OR3-year = 2.15, 95%CI3-year: 1.18-3.91). The complete tumor response rates of patients who underwent microspheres embolization were significantly higher than those of patients treated with c-TACE (OR = 2.19, 95%CI: 1.31-3.64). The tumor progression rate after microsphere embolization was markedly lower than that after c-TACE (OR = 0.56, 95%CI: 0.39-0.81). There was no significant difference between microsphere embolization and c-TACE in PR (OR = 0.73, 95%CI: 0.47-1.15), SD (OR = 1.07, 95%CI: 0.79-1.44), PD (OR = 0.75, 95%CI: 0.33-1.68), AFP response (OR = 1.38, 95%CI: 0.64-2.94) and complications (OR = 0.68, 95%CI: 0.46-1.00).
CONCLUSION: Our analysis indicated that microsphere embolization was associated with superior survival and treatment response in comparison with c-TACE in the treatment of patients with HCC.
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277
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Bargellini I. How does selective internal radiation therapy compare with and/or complement other liver-directed therapies. Future Oncol 2014; 10:105-9. [PMID: 25478780 DOI: 10.2217/fon.14.236] [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: 11/21/2022] Open
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278
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Garlipp B, Bruns CJ. The evidence for resection post-selective internal radiation therapy. Future Oncol 2014; 10:49-52. [PMID: 25478767 DOI: 10.2217/fon.14.223] [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: 01/03/2023] Open
Affiliation(s)
- Benjamin Garlipp
- Department of Surgery, University Hospital Magdeburg, Otto von Guericke University, Leipziger Str. 44, 39120 Magdeburg, Germany
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279
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Liver Transplantation for Hepatocellular Carcinoma. CURRENT TRANSPLANTATION REPORTS 2014. [DOI: 10.1007/s40472-014-0028-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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280
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Boas FE, Do B, Louie JD, Kothary N, Hwang GL, Kuo WT, Hovsepian DM, Kantrowitz M, Sze DY. Optimal imaging surveillance schedules after liver-directed therapy for hepatocellular carcinoma. J Vasc Interv Radiol 2014; 26:69-73. [PMID: 25446423 DOI: 10.1016/j.jvir.2014.09.013] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2014] [Revised: 09/08/2014] [Accepted: 09/18/2014] [Indexed: 10/24/2022] Open
Abstract
PURPOSE To optimize surveillance schedules for the detection of recurrent hepatocellular carcinoma (HCC) after liver-directed therapy. MATERIALS AND METHODS New methods have emerged that allow quantitative analysis and optimization of surveillance schedules for diseases with substantial rates of recurrence such as HCC. These methods were applied to 1,766 consecutive chemoembolization, radioembolization, and radiofrequency ablation procedures performed on 910 patients between 2006 and 2011. Computed tomography or magnetic resonance imaging performed just before repeat therapy was set as the time of "recurrence," which included residual and locally recurrent tumor as well as new liver tumors. Time-to-recurrence distribution was estimated by Kaplan-Meier method. Average diagnostic delay (time between recurrence and detection) was calculated for each proposed surveillance schedule using the time-to-recurrence distribution. An optimized surveillance schedule could then be derived to minimize the average diagnostic delay. RESULTS Recurrence is 6.5 times more likely in the first year after treatment than in the second. Therefore, screening should be much more frequent in the first year. For eight time points in the first 2 years of follow-up, the optimal schedule is 2, 4, 6, 8, 11, 14, 18, and 24 months. This schedule reduces diagnostic delay compared with published schedules and is cost-effective. CONCLUSIONS The calculated optimal surveillance schedules include shorter-interval follow-up when there is a higher probability of recurrence and longer-interval follow-up when there is a lower probability. Cost can be optimized for a specified acceptable diagnostic delay or diagnostic delay can be optimized within a specified acceptable cost.
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Affiliation(s)
- F Edward Boas
- Interventional Radiology Service, Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY 10065.
| | - Bao Do
- Veterans Affairs Palo Alto Health Care System, Palo Alto
| | - John D Louie
- Department of Radiology, Stanford University Medical Center, Stanford, California
| | - Nishita Kothary
- Department of Radiology, Stanford University Medical Center, Stanford, California
| | - Gloria L Hwang
- Department of Radiology, Stanford University Medical Center, Stanford, California
| | - William T Kuo
- Department of Radiology, Stanford University Medical Center, Stanford, California
| | - David M Hovsepian
- Department of Radiology, Stanford University Medical Center, Stanford, California
| | | | - Daniel Y Sze
- Department of Radiology, Stanford University Medical Center, Stanford, California
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281
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Cappelli A, Pettinato C, Golfieri R. Transarterial radioembolization using yttrium-90 microspheres in the treatment of hepatocellular carcinoma: a review on clinical utility and developments. J Hepatocell Carcinoma 2014; 1:163-82. [PMID: 27508185 PMCID: PMC4918277 DOI: 10.2147/jhc.s50472] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
A selective intra-arterial liver injection using yttrium-90-loaded microspheres as sources for internal radiation therapy is a form of transarterial radioembolization (TARE). Current data from the literature suggest that TARE is effective in hepatocellular carcinoma (HCC) and is associated with a low rate of adverse events; however, they are all based on retrospective series or non-controlled prospective studies, since randomized controlled trials comparing the other liver-directed therapies for intermediate and locally advanced stages HCC are still ongoing. The available data show that TARE provides similar or even better survival rates. TARE is very well tolerated and has a low rate of complications; these complications do not result from the embolic effects but mainly from the unintended irradiation to non-target tissue, including the liver parenchyma. The complications can be further reduced by accurate patient selection and a strict pre-treatment evaluation, including dosimetry and assessment of the vascular anatomy. First-line TARE is best indicated for intermediate-stage patients (according to the Barcelona Clinic Liver Cancer [BCLC] staging classification) who are poor candidates for transarterial chemoembolization or patients having locally advanced disease with segmental or lobar branch portal vein thrombosis. Moreover, data are emerging regarding the use of TARE in patients classified slightly above the criteria for liver transplantation with the purpose of downstaging them. TARE can also be applied as a second-line treatment in patients progressing to transarterial chemoembolization or sorafenib; a large number of Phase II/III trials are in progress in order to evaluate the best association with systemic therapies. Given the complexity of a correct treatment algorithm for potential TARE candidates and the need for clinical guidance, a comprehensive review was carried out analyzing both the best selection criteria of patients who really benefit from TARE and the new advances of this therapy which add significant value to the therapeutic weaponry against HCC.
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Affiliation(s)
| | - Cinzia Pettinato
- Medical Physics Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, S Orsola-Malpighi Hospital, Bologna, Italy
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282
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Abstract
Over the last decade, transarterial therapies have gained worldwide acceptance as standard of care for inoperable primary liver cancer. Survival times after transarterial chemoembolization (TACE) continue to improve as the technique and selection criteria are refined. Transarterial treatments, frequently provided in an outpatient setting, are now safely and effectively being applied to patients with even advanced malignancy or partially decompensated cirrhosis. In the coming years, newer transarterial therapies such as radiation segmentectomy, boosted-transarterial radioembolzation, combined TACE-ablation, TACE-portal vein embolization, and transarterial infusion of cancer-specific metabolic inhibitors promise to continue improving survival and quality of life.
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283
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Schlaak JF. Radioembolization with yttrium-90 glass microspheres for patients with hepatocellular carcinoma: a review. Hepat Oncol 2014; 1:387-393. [DOI: 10.2217/hep.14.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY Clinical studies have evaluated the safety and efficacy of radioembolization with yttrium-90 in patients with unresectable hepatocellular carcinoma (HCC). Citing literature published within the last 5 years, we review the clinical evidence of survival outcomes and safety of yttrium-90 treatment in patients with unresectable HCC. This paper is primarily focused on survival rates following the typical application of yttrium-90 in HCC treatment, and also includes time to progression and safety data. Also discussed are special indications and new developments related to yttrium-90 therapy in HCC, as well as patient selection and its correlation with successful treatment outcomes.
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284
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Sangro B. Chemoembolization and radioembolization. Best Pract Res Clin Gastroenterol 2014; 28:909-19. [PMID: 25260317 DOI: 10.1016/j.bpg.2014.08.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Accepted: 08/15/2014] [Indexed: 01/31/2023]
Abstract
Chemoembolization and radioembolization are at the core of the treatment of patients with hepatocellular carcinoma who cannot receive potentially curative therapies such as transplantation, resection or percutaneous ablation. They differ in the mechanism of action (ischaemia and increase cytotoxic drug exposure for chemoembolization, internal irradiation for radioembolization) and may target different patient populations. Chemoembolization with cytotoxic drug-eluting beads is a more standardized although not necessarily more effective way of performing chemoembolization. Cytoreduction is achieved in most patients but complete tumor ablation may be achieved and lead to extended survival. Grade 1 level of evidence support the use of chemoembolization for the treatment of patients in the early and intermediate stages while grade 2 evidence supports the use of radioembolization for the treatment of patients in intermediate to advanced stages. Selecting the best candidates for both techniques is still a work in progress that ongoing clinical trials are trying to address.
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Affiliation(s)
- Bruno Sangro
- Clinica Universidad de Navarra, and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Avda, Pio XII 36, 31008 Pamplona, Spain.
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285
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Abstract
The most common non-surgical approaches for the treatment of localized hepatocellular carcinoma remain hepatic artery-delivered particles laden with chemotherapy (TACE), or radioactive microparticles (TARE). External beam radiotherapy has been an effective option in many parts of the world for selected HCC patients, but now has an expanded role with stereotactic and proton beam technologies. This review focuses on existing evidence and current guidance for utilizing these modalities for localized, but unresectable, non-transplantable HCC patients.x.
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Affiliation(s)
- Andrew S Kennedy
- Radiation Oncology Research, Sarah Cannon Research Institute, 3322 West End Avenue, Suite 800, Nashville, TN, 37203, USA,
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286
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Abdel-Rahman OM, Elsayed Z. Yttrium-90 microsphere radioembolisation for unresectable hepatocellular carcinoma. Cochrane Database Syst Rev 2014. [DOI: 10.1002/14651858.cd011313] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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287
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Hickey RM, Lewandowski RJ, Salem R. Rationale of transcatheter intra-arterial therapies of hepatic cancers. Hepat Oncol 2014; 1:285-291. [PMID: 30190963 DOI: 10.2217/hep.14.11] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Transcatheter, intra-arterial therapies for primary and metastatic hepatic malignancies comprise angiographically guided procedures that provide for the administration of tumoricidal agents directly to liver tumors. These locoregional therapies have demonstrated encouraging clinical outcomes for liver tumors that are otherwise not amenable or not responsive to standard surgical or systemic treatments. This article provides a review of transcatheter therapies for hepatic cancers and reported clinical outcomes.
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Affiliation(s)
- Ryan M Hickey
- Northwestern University, Department of Radiology, Division of Vascular & Interventional Radiology, Chicago, IL 60611, USA
| | - Robert J Lewandowski
- Northwestern University, Department of Radiology, Division of Vascular & Interventional Radiology, Chicago, IL 60611, USA
| | - Riad Salem
- Northwestern University, Department of Radiology, Division of Vascular & Interventional Radiology, Chicago, IL 60611, USA
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288
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She WH, Cheung TT, Yau TCC, Chan ACY, Chok KSH, Chu FSK, Liu RKY, Poon RTP, Chan SC, Fan ST, Lo CM. Survival analysis of transarterial radioembolization with yttrium-90 for hepatocellular carcinoma patients with HBV infection. Hepatobiliary Surg Nutr 2014; 3:185-93. [PMID: 25202695 DOI: 10.3978/j.issn.2304-3881.2014.07.09] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Accepted: 07/22/2014] [Indexed: 12/13/2022]
Abstract
INTRODUCTION For patients with resectable hepatocellular carcinoma (HCC), hepatectomy remains one of the best treatment options to provide long-term survival. However, more than 50% of the patients have unresectable disease upon diagnosis even though there are no distant metastases. Transarterial chemoembolization (TACE) is a well-established treatment option that offers a palliative survival benefit for this group of patients. A better treatment for unresectable HCC has been sought after. There is some evidence that transarterial radioembolization (TARE) with the agent yttrium-90 produces encouraging outcomes, especially in patients with portal vein tumor thrombus. This study aims to analyze the outcomes of TARE at our center. METHODS From August 2009 to April 2013, 16 patients underwent TARE at our center. Sixteen patients with similar tumor characteristics were selected to undergo TACE alone for comparison. A retrospective analysis of the prospectively collected data of the patients was conducted. Only patients with newly diagnosed primary tumors were included in this study. RESULTS The median survival for patients having TARE was 19.9 versus 14.0 months in the TACE group (P=0.615). There was no difference in terms of tumor response according to the modified Response Evaluation Criteria in Solid Tumors (mRECIST) (P=0.632). The 1-, 2- and 3-year survival rates in the TARE group were 80.0%, 30.5% and 20.3% respectively. The 1-year survival in the TACE group was 58.3% (P=0.615). For patients who had major vascular invasion (eight in each group), the 1- and 2-year survival rates in the TARE group were 62.5% and 15.6% respectively, while the 1-year survival in the TACE group was 35.0% (P=0.664). CONCLUSIONS The two groups showed similar results in terms of tumor response and overall survival benefit. TARE might provide a survival benefit for patients with major vessel invasion.
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Affiliation(s)
- Wong Hoi She
- 1 Department of Surgery, 2 Department of Diagnostic Radiology, 3 Department of Clinical Oncology, The University of Hong Kong, Hong Kong, China
| | - Tan To Cheung
- 1 Department of Surgery, 2 Department of Diagnostic Radiology, 3 Department of Clinical Oncology, The University of Hong Kong, Hong Kong, China
| | - Thomas C C Yau
- 1 Department of Surgery, 2 Department of Diagnostic Radiology, 3 Department of Clinical Oncology, The University of Hong Kong, Hong Kong, China
| | - Albert C Y Chan
- 1 Department of Surgery, 2 Department of Diagnostic Radiology, 3 Department of Clinical Oncology, The University of Hong Kong, Hong Kong, China
| | - Kenneth S H Chok
- 1 Department of Surgery, 2 Department of Diagnostic Radiology, 3 Department of Clinical Oncology, The University of Hong Kong, Hong Kong, China
| | - Ferdinand S K Chu
- 1 Department of Surgery, 2 Department of Diagnostic Radiology, 3 Department of Clinical Oncology, The University of Hong Kong, Hong Kong, China
| | - Rico K Y Liu
- 1 Department of Surgery, 2 Department of Diagnostic Radiology, 3 Department of Clinical Oncology, The University of Hong Kong, Hong Kong, China
| | - Ronnie T P Poon
- 1 Department of Surgery, 2 Department of Diagnostic Radiology, 3 Department of Clinical Oncology, The University of Hong Kong, Hong Kong, China
| | - See Ching Chan
- 1 Department of Surgery, 2 Department of Diagnostic Radiology, 3 Department of Clinical Oncology, The University of Hong Kong, Hong Kong, China
| | - Sheung Tat Fan
- 1 Department of Surgery, 2 Department of Diagnostic Radiology, 3 Department of Clinical Oncology, The University of Hong Kong, Hong Kong, China
| | - Chung Mau Lo
- 1 Department of Surgery, 2 Department of Diagnostic Radiology, 3 Department of Clinical Oncology, The University of Hong Kong, Hong Kong, China
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289
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Golfieri R. SIR-Spheres yttrium-90 radioembolization for the treatment of unresectable liver cancers. Hepat Oncol 2014; 1:265-283. [PMID: 30190962 DOI: 10.2217/hep.14.6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Transarterial radioembolization with yttrium-90 resin microspheres (SIR-Spheres; Sirtex Medical Limited, Sydney, Australia) is a liver-directed therapy that is gaining recognition as a treatment option for liver-dominant primary and metastatic cancers. The incidence of complications is low and can be further reduced by patient selection and rigorous pretreatment assessment. Ideal candidates for radioembolization have preserved liver function without ascites or encephalopathy, Child-Pugh score <7 and limited lung shunting. Phase III randomized controlled trials (RCTs) against other liver-directed therapies are lacking for intermediate-stage hepatocellular carcinoma. However, preliminary data from a recent RCT has suggested that radioembolization has a similar time-to-progression and comparable toxicity to selective chemoembolization. Phase II/III RCTs are now ongoing to evaluate the combination of radioembolization with systemic therapies in advanced-stage hepatocellular carcinoma and metastatic liver-dominant colorectal cancer in order to expand the treatment opportunities for patients with cancers in the liver.
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Affiliation(s)
- Rita Golfieri
- Radiology Unit, Department of Digestive Diseases & Internal Medicine, Azienda Ospedaliero-Universitaria, Policlinico S. Orsola-Malpighi, Via Massarenti 9, Bologna, Italy
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290
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Henry LR, Hostetter RB, Ressler B, Bowser I, Yan M, Vaghefi H, Abad J, Gulec S, Schwarz RE. Liver resection for metastatic disease after y90 radioembolization: a case series with long-term follow-up. Ann Surg Oncol 2014; 22:467-74. [PMID: 25190114 DOI: 10.1245/s10434-014-4012-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Indexed: 12/25/2022]
Abstract
INTRODUCTION There are only few reports of liver resections for metastatic disease in patients previously treated with Y-90 radioembolization (RE), and long-term outcome data are sparse. We reviewed our center's experience in patients undergoing hepatectomy after hepatic RE. METHODS A retrospective chart review of patients undergoing RE from 2004 to 2011 was performed. Demographic, clinicopathologic, operative, and long-term outcomes variables were collected. Independent pathologic review of tumor necrosis and normal liver tissue grading of fibrosis and inflammation after resection was performed. Data are expressed as medians and ranges. RESULTS RE was delivered to 106 patients with primary and metastatic disease of the liver, of whom 9 patients (6 males, 3 females, median age 54 (47-76) years) with metastatic disease ultimately underwent resection. RE was previously administered to the right liver in five, the left liver in one, and to the whole liver in three. Two patients had a second RE performed before resection. Six of the nine patients had previously received several infusions of cytotoxic therapy. The operations occurred at a median of 115 (56-245) days after RE and included right lobectomy (n = 5), left lobectomy (n = 1), left-lateral sectionectomy (n = 1), and bilobar wedge resections (n = 2). Extrahepatic sites were resected in three patients. Median blood loss was 900 (range 250-3600) ml. Grade 3 or higher complications occurred in seven cases (78 %). Follow-up was complete all nine patients. Three patients (33 %) died within 30 days of resection. All those surviving the operative period had disease recurrence (time to recurrence: 202 [range 54-315] days), and all have since died (overall survival: 584 [range 127-1230] days). Review of resected specimens demonstrated median tumor necrosis of 70 % (range 20-90 %). In nontumor-bearing liver, fibrosis grade (0-4) and inflammation score (0-4) was 2 or less in all specimens. CONCLUSIONS In this small cohort of highly selected and heavily pretreated patients, long-term survival in patients undergoing resection after RE appears possible, but the operations may carry substantial risks-highlighting the importance of careful patient selection for these resections. The etiology of morbidity and mortality is likely multifactorial and additional reports that include long-term outcomes will be necessary to identify more clearly the impact of RE on postoperative complications and death.
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Affiliation(s)
- Leonard R Henry
- Division of Surgical Oncology, Indiana University Health, Goshen Center for Cancer Care, Goshen, IN, USA,
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291
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Surgical resection of a malignant liver lesion: what the surgeon wants the radiologist to know. AJR Am J Roentgenol 2014; 203:W21-33. [PMID: 24951226 DOI: 10.2214/ajr.13.11701] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Hepatic malignancy is a common and lethal disease, whether due to a primary tumor or metastasis. There are numerous treatment options available depending on the stage of the disease and medical condition of the patient, including systemic chemotherapy, transcatheter embolization, thermal ablation, and surgical resection. In a subset of patients with liver malignancy, surgical resection can offer the best chance of long-term survival and potentially even cure. This article reviews the major indications and contraindications for resection, basic surgical techniques and terminology, key clinical and imaging preoperative workup, and pertinent interventional oncology procedures in the management of hepatic malignancy. CONCLUSION Diagnostic and interventional radiology plays an important role in the assessment and treatment of malignant hepatic lesions. Radiologists should be familiar with how surgeons select, work up, and treat candidates for liver resection to provide the most clinically valuable service.
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292
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Shouval D. The emerging questionable benefit of sorafenib as a neo-adjuvant in HCC patients treated with Y-90 radioembolization pending liver transplantation. J Hepatol 2014; 61:190-2. [PMID: 24845608 DOI: 10.1016/j.jhep.2014.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Accepted: 05/08/2014] [Indexed: 12/04/2022]
Affiliation(s)
- Daniel Shouval
- Liver Unit, Hadassah-Hebrew University Hospital, Jerusalem, Israel.
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293
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Paul SB, Sharma H. Role of Transcatheter Intra-arterial Therapies for Hepatocellular Carcinoma. J Clin Exp Hepatol 2014; 4:S112-21. [PMID: 25755602 PMCID: PMC4284218 DOI: 10.1016/j.jceh.2014.03.048] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Accepted: 03/03/2014] [Indexed: 02/07/2023] Open
Abstract
Transcatheter intra-arterial therapies play a vital role in treatment of HCC due to the unique tumor vasculature. Evolution of techniques and newer efficacious modalities of tumor destruction have made these techniques popular. Various types of intra-arterial therapeutic options are currently available. These constitute: bland embolization, trans-arterial chemotherapy, trans-arterial chemo embolization with or without drug-eluting beads and trans-arterial radio embolization, which are elaborated in this review.
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Key Words
- AFP, alpha feto protein
- CR, complete response
- HAIC, hepatic artery infusion chemotherapy
- HCC, hepatocellular carcinoma
- LA, laser ablation
- OLT, orthotopic liver transplant
- PD, progressive disease
- PEI, percutaneous ethanol injection
- PR, partial response
- PVT, portal vein thrombosis
- RFA, ablation
- SD, stable disease
- TACE, trans-arterial chemoembolization
- TAE, Trans-arterial embolization
- TART, trans-arterial radiotherapy
- drug eluting bead (DEB)
- hepatocellular carcinoma (HCC)
- trans-arterial chemoembolization (TACE)
- trans-arterial embolization (TAE)
- trans-arterial radiotherapy (TART)
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Affiliation(s)
- Shashi B. Paul
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Hanish Sharma
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi 110029, India
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294
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Kumar A, Acharya SK, Singh SP, Saraswat VA, Arora A, Duseja A, Goenka MK, Jain D, Kar P, Kumar M, Kumaran V, Mohandas KM, Panda D, Paul SB, Ramachandran J, Ramesh H, Rao PN, Shah SR, Sharma H, Thandassery RB. The Indian National Association for Study of the Liver (INASL) Consensus on Prevention, Diagnosis and Management of Hepatocellular Carcinoma in India: The Puri Recommendations. J Clin Exp Hepatol 2014; 4:S3-S26. [PMID: 25755608 PMCID: PMC4284289 DOI: 10.1016/j.jceh.2014.04.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Accepted: 04/08/2014] [Indexed: 02/08/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is one of the major causes of morbidity, mortality and healthcare expenditure in patients with chronic liver disease. There are no consensus guidelines on diagnosis and management of HCC in India. The Indian National Association for Study of the Liver (INASL) set up a Task-Force on HCC in 2011, with a mandate to develop consensus guidelines for diagnosis and management of HCC, relevant to disease patterns and clinical practices in India. The Task-Force first identified various contentious issues on various aspects of HCC and these issues were allotted to individual members of the Task-Force who reviewed them in detail. The Task-Force used the Oxford Center for Evidence Based Medicine-Levels of Evidence of 2009 for developing an evidence-based approach. A 2-day round table discussion was held on 9th and 10th February, 2013 at Puri, Odisha, to discuss, debate, and finalize the consensus statements. The members of the Task-Force reviewed and discussed the existing literature at this meeting and formulated the INASL consensus statements for each of the issues. We present here the INASL consensus guidelines (The Puri Recommendations) on prevention, diagnosis and management of HCC in India.
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Key Words
- AFP, alpha-fetoprotein
- AIIMS, All India Institute of Medical Sciences
- ASMR, age standardized mortality rate
- BCLC, Barcelona-Clinic Liver Cancer
- CEUS, contrast enhanced ultrasound
- CT, computed tomography
- DCP, des-gamma-carboxy prothrombin
- DDLT, deceased donor liver transplantation
- DE, drug eluting
- FNAC, fine needle aspiration cytology
- GPC-3, glypican-3
- GS, glutamine synthase
- Gd-EOB-DTPA, gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid
- HBV, Hepatitis B virus
- HCC, hepatocellular carcinoma
- HCV, Hepatitis C virus
- HSP-70, heat shock protein-70
- HVPG, hepatic venous pressure gradient
- ICG, indocyanine green
- ICMR, Indian Council of Medical Research
- INASL, Indian National Association for Study of the Liver
- LDLT, living donor liver transplantation
- MRI, magnetic resonance imaging
- Mabs, monoclonal antibodies
- NAFLD, non-alcoholic fatty liver disease
- OLT, orthotopic liver transplantation
- PAI, percutaneous acetic acid injection
- PEI, percutaneous ethanol injection
- PET, positron emission tomography
- PVT, portal vein thrombosis
- RECIST, Response Evaluation Criteria in Solid Tumors
- RFA
- RFA, radio frequency ablation
- SVR, sustained viral response
- TACE
- TACE, transarterial chemoembolization
- TART, trans-arterial radioisotope therapy
- UCSF, University of California San Francisco
- liver cancer
- targeted therapy
- transplant
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Affiliation(s)
- Ashish Kumar
- Department of Gastroenterology & Hepatology, Sir Ganga Ram Hospital, New Delhi, India
| | - Subrat K. Acharya
- Department of Gastroenterology, All India Institute of Medical Sciences, Ansari Road, New Delhi 110 029, India
| | - Shivaram P. Singh
- Department of Gastroenterology, SCB Medical College, Cuttack, Odisha, India
| | - Vivek A. Saraswat
- Department of Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Anil Arora
- Department of Gastroenterology & Hepatology, Sir Ganga Ram Hospital, New Delhi, India
| | - Ajay Duseja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Mahesh K. Goenka
- Department of Gastroenterology, Apollo Gleneagles Hospital, 58, Canal Circular Road, Kolkata, West Bengal 700 054, India
| | - Deepali Jain
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Premashish Kar
- Department of Medicine, Maulana Azad Medical College, University of Delhi, New Delhi, India
| | - Manoj Kumar
- Department of Hepatology, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Vinay Kumaran
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, India
| | - Kunisshery M. Mohandas
- Department of Digestive Diseases, Tata Medical Center, Kolkata, West Bengal 700156, India
| | - Dipanjan Panda
- Department of Oncology, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Shashi B. Paul
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Jeyamani Ramachandran
- Department of Hepatology, Christian Medical College, Vellore, Tamil Nadu 632 004, India
| | - Hariharan Ramesh
- Department of Surgical Gastroenterology, Lakeshore Hospital and Research Center, Cochin, Kerala, India
| | - Padaki N. Rao
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Somajiguda, Hyderabad, India
| | - Samir R. Shah
- Department of Gastroenterology, Jaslok Hospital and Research Centre, Peddar Road, Mumbai, Maharashtra 400 026, India
| | - Hanish Sharma
- Department of Gastroenterology, All India Institute of Medical Sciences, Ansari Road, New Delhi 110 029, India
| | - Ragesh B. Thandassery
- Department of Gastroenterology, Apollo Gleneagles Hospital, 58, Canal Circular Road, Kolkata, West Bengal 700 054, India
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295
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Prospective randomized pilot study of Y90+/-sorafenib as bridge to transplantation in hepatocellular carcinoma. J Hepatol 2014; 61:309-17. [PMID: 24681342 DOI: 10.1016/j.jhep.2014.03.023] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Revised: 03/07/2014] [Accepted: 03/19/2014] [Indexed: 01/19/2023]
Abstract
BACKGROUND & AIMS To investigate the safety and adverse event profile of sorafenib plus radioembolization (Y90) compared to Y90 alone in patients awaiting liver transplantation. METHODS 20 patients with HCC were randomized to Y90 alone (Group A) or Y90+sorafenib (Group B). Adverse events, dose reductions, and peri-transplant complications were assessed. RESULTS All patients in the sorafenib group necessitated dose reductions. Seventeen of 20 patients underwent liver transplantation; median time-to-transplant was 7.8 months (range: 4.2-20.3) and similar between groups (p = 0.35). In the sorafenib group, there were 4/8 peri-transplant (<30 days) biliary complications (p = 0.029) and 3/8 acute rejections (p = 0.082); there were none in the Y90-only group. Survival rates were 70% (Group A) and 72% (Group B) at 3 years (p = 0.57). CONCLUSIONS The addition of sorafenib to Y90 necessitated dose reductions in all patients awaiting transplantation. Preliminary data suggest that the combination was associated with more peri-transplant biliary complications and potentially trended towards more acute rejections. Caution should be exercised when considering sorafenib in the transplant setting. Further investigation is warranted.
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296
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Saxena A, Meteling B, Kapoor J, Golani S, Danta M, Morris DL, Bester L. Yttrium-90 radioembolization is a safe and effective treatment for unresectable hepatocellular carcinoma: a single centre experience of 45 consecutive patients. Int J Surg 2014; 12:1403-8. [PMID: 25091398 DOI: 10.1016/j.ijsu.2014.07.269] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Revised: 06/23/2014] [Accepted: 07/25/2014] [Indexed: 02/08/2023]
Abstract
INTRODUCTION There is controversy regarding the role of yttrium-90 (90Y) radioembolization in the management of advanced, unresectable hepatocellular carcinoma (HCC). METHODS Forty-five consecutive patients underwent resin-based 90Y radioembolization for unresectable, HCC between 2006 and 2013 in Sydney, Australia. All patients were followed up with imaging studies at regular intervals until death. Radiologic response was evaluated with the Response Criteria in Solid Tumors (RECIST) criteria. Clinical toxicities were prospectively recorded. Survival was calculated by the Kaplan-Meier method and potential prognostic variables were identified on univariate and multivariate analysis. RESULTS Follow-up in the complete cohort was 7.8 (range, 0.1-41.8) months. The median survival after 90Y radioembolization was 27.7 months with a 36-month survival of 26%. By RECIST criteria of the 40 patients followed-up beyond 2 months, a complete response (CR) to treatment was observed in 1 patients (3%), partial response (PR) in 18 (45%), stable disease (SD) in 11 (22%) and progressive disease (PD) in 10 (25%). On multivariate analysis only radiological response to treatment was independently associated with improved survival: CR/PR to treatment vs. SD vs. PD; p < 0.001. Thirteen patients (29%) developed clinical toxicity after treatment; all complications were minor (grade I/II) and resolved without active intervention. CONCLUSION Radioembolization with 90Y is a safe and effective treatment for unresectable HCC.
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Affiliation(s)
- Akshat Saxena
- Department of Interventional Radiology, St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia; UNSW Department of Surgery, St George Hospital, Kogarah, New South Wales, Australia.
| | - Baerbel Meteling
- Department of Interventional Radiology, St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
| | - Jada Kapoor
- UNSW Department of Surgery, St George Hospital, Kogarah, New South Wales, Australia
| | - Sanjeev Golani
- UNSW Department of Surgery, St George Hospital, Kogarah, New South Wales, Australia
| | - Mark Danta
- UNSW Faculty of Medicine, St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
| | - David L Morris
- UNSW Department of Surgery, St George Hospital, Kogarah, New South Wales, Australia
| | - Lourens Bester
- Department of Interventional Radiology, St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
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297
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Braat AJAT, Huijbregts JE, Molenaar IQ, Borel Rinkes IHM, van den Bosch MAAJ, Lam MGEH. Hepatic radioembolization as a bridge to liver surgery. Front Oncol 2014; 4:199. [PMID: 25126539 PMCID: PMC4115667 DOI: 10.3389/fonc.2014.00199] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Accepted: 07/15/2014] [Indexed: 12/11/2022] Open
Abstract
Treatment of oncologic disease has improved significantly in the last decades and in the future a vast majority of cancer types will continue to increase worldwide. As a result, many patients are confronted with primary liver cancers or metastatic liver disease. Surgery in liver malignancies has steeply improved and curative resections are applicable in wider settings, leading to a prolonged survival. Simultaneously, radiofrequency ablation (RFA) and liver transplantation (LTx) have been applied more commonly in oncologic settings with improving results. To minimize adverse events in treatments of liver malignancies, locoregional minimal invasive treatments have made their appearance in this field, in which radioembolization (RE) has shown promising results in recent years with few adverse events and high response rates. We discuss several other applications of RE for oncologic patients, other than its use in the palliative setting, whether or not combined with other treatments. This review is focused on the role of RE in acquiring patient eligibility for radical treatments, like surgery, RFA, and LTx. Inducing significant tumor reduction can downstage patients for resection or, through attaining stable disease, patients can stay on the LTx waiting list. Hereby, RE could make a difference between curative of palliative intent in oncologic patient management. Prior to surgery, the future remnant liver volume might be inadequate in some patients. In these patients, forming an adequate liver reserve through RE leads to prolonged survival without risking post-operative liver failure and minimizing tumor progression while inducing hypertrophy. In order to optimize results, developments in procedures surrounding RE are equally important. Predicting the remaining liver function after radical treatment and finding the right balance between maximum tumor irradiation and minimizing the chance of inducing radiation-related complications are still challenges.
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Affiliation(s)
- Arthur J A T Braat
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht , Utrecht , Netherlands
| | - Julia E Huijbregts
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht , Utrecht , Netherlands
| | - I Quintus Molenaar
- Department of Surgery, University Medical Center Utrecht , Utrecht , Netherlands
| | | | | | - Marnix G E H Lam
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht , Utrecht , Netherlands
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298
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Vouche M, Habib A, Ward TJ, Kim E, Kulik L, Ganger D, Mulcahy M, Baker T, Abecassis M, Sato KT, Caicedo JC, Fryer J, Hickey R, Hohlastos E, Lewandowski RJ, Salem R. Unresectable solitary hepatocellular carcinoma not amenable to radiofrequency ablation: multicenter radiology-pathology correlation and survival of radiation segmentectomy. Hepatology 2014; 60:192-201. [PMID: 24691943 DOI: 10.1002/hep.27057] [Citation(s) in RCA: 210] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Accepted: 02/01/2014] [Indexed: 12/17/2022]
Abstract
UNLABELLED Resection and radiofrequency ablation (RFA) are treatment options for hepatocellular carcinoma (HCC) <3 cm; there is interest in expanding the role of ablation to 3-5 cm. RFA is considered high-risk when the lesion is in close proximity to critical structures. Combining microcatheter technology and the localized emission properties of Y90, highly selective radioembolization is a possible alternative to RFA in such cases. We assessed the efficacy (response, radiology-pathology correlation, survival) of radiation segmentectomy in solitary HCC not amenable to RFA or resection. Patients with treatment-naïve, unresectable, solitary HCC ≤ 5 cm not amenable to RFA were included in this multicenter study. Administered dose, response rate, time-to-progression (modified Response Evaluation Criteria in Solid Tumors [mRECIST]), radiology-pathology correlation and long-term survival were assessed. In all, 102 patients were included in this study. mRECIST complete response (CR), partial response (PR), and stable disease (SD) were 47/99 (47%), 39/99 (39%), and 12/99 (12%), respectively. Median time-to-disease-progression was 33.1 months. In all, 33/102 (32%) patients were transplanted with a median (interquartile range [IQR]) time-to-transplantation of 6.3 months (3.6-9.7). Pathology revealed 100% and 50-99% necrosis in 17/33 (52%) and 16/33 (48%), respectively. Median overall survival was 53.4 months. Univariate analysis demonstrated a survival benefit for Eastern Cooperative Oncology Group (ECOG) 0 patients. In the multivariate model, age <65, ECOG 0, and Child-Pugh A were characteristics associated with longer survival. CONCLUSION Radiation segmentectomy is an effective technique with a favorable risk profile and radiology-pathology outcomes for solitary HCC ≤ 5 cm. This approach may allow for treatment of HCC in difficult locations. Since RFA and resection are not options given tumor location, there appears to be a strong rationale for this technique as second choice.
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Affiliation(s)
- Michael Vouche
- Department of Radiology, Section of Interventional Radiology and Division of Interventional Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL
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Section 3. Current status of downstaging of hepatocellular carcinoma before liver transplantation. Transplantation 2014; 97 Suppl 8:S10-7. [PMID: 24849822 DOI: 10.1097/01.tp.0000446267.19148.21] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Liver transplantation (LT) is a well-established option of cure for hepatocellular carcinoma (HCC). Milan criteria is recognized as standard for selection of patients and set the baseline of survival to be achieved. It has been shown that tumor biology including differentiation, vascular invasion, and serum α-fetoprotein (AFP) predict posttransplant recurrence and survival better than morphology. Downstaging by locoregional therapies of HCC before LT, with the response to treatments and progression within observation period, serves as a selection tool rather than modulation of tumor biology. It selects those patients outside standard criteria at presentation but good tumor biology and high chance of good outcome to receive transplantation. The definition of downstaging should be differentiated from neo-adjuvant therapy, and the objectives in surgical and pretransplant candidates also differ.Published studies in this area showed variation in inclusion criteria, downstaging protocol and assessment of successful downstaging. Tumor biology predownstaging and postdownstaging was not incorporated. Posttransplant outcome were not clearly stated with regard to intention-to-treat survival, disease-free survival, and comparison against those originally within criteria. Meta-analysis of these results was impossible. Nevertheless, majority had reasonable protocol and were able to select patients whom likely to have good outcome. At present, there is no evidence that downstaged patients have a poorer prognosis than those presenting within the Milan criteria. Patients with tumors outside Milan criteria should be offered downstaging therapies. Those who are successfully downstaged to within Milan criteria should be eligible to liver transplant as same as those initially fit the criteria. In the last decade, various extended criteria of HCC for LT have been proposed and reported satisfactory survival. That makes downstaging technically unnecessary.To refine and validate the role of downstaging, it needs collaborative and prospective study with significant sample size, adequate preoperative staging, standardized protocol of selection of patients, and approaches to downstaging. Selection criteria should include histopathological data on tumor biology and serum AFP. There should be standardized definition of successful downstaging. Posttransplant disease-free survival should be reported in detail and compared with those who fit the standard criteria initially. A consistent immunosuppressant protocol is important to avoid bias.
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Xing M, Kokabi N, Camacho JC, Kooby DA, El-Rayes BF, Kim HS. 90Y radioembolization versus chemoembolization in the treatment of hepatocellular carcinoma: an analysis of comparative effectiveness. J Comp Eff Res 2014; 2:435-44. [PMID: 24236684 DOI: 10.2217/cer.13.37] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Locoregional catheter-based therapies for unresectable hepatocellular carcinoma (HCC) include conventional transarterial chemoembolization (cTACE), drug-eluting bead chemoembolization and yttrium-90 ((90)Y) radioembolization. Although current guidelines recommend cTACE for inoperable HCC, comparative effectiveness of drug-eluting bead chemoembolization and (90)Y radioembolization in the management of HCC remains undefined due to the lack of data evaluating safety and effectiveness among these therapies. A comprehensive search of the literature was carried out for studies examining comparative effectiveness of cTACE and (90)Y based on objective tumor response and overall patient survival. Further data on efficacy, safety, toxicity and cost-effectiveness was also examined. The National Cancer Institute Levels of Evidence for Cancer Treatment Studies provided a useful framework for the critical understanding and stratification of current evidence on locoregional therapy for unresectable HCC. Based on current retrospective cohort studies, evidence for similar efficacy and safety between cTACE and (90)Y radioembolization was demonstrated. Further prospective, randomized studies are required to validate these observations and to analyze cost-effectiveness of these interventions in unresectable HCC patients for definitive recommendations to be made.
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Affiliation(s)
- Minzhi Xing
- Division of Interventional Radiology & Image Guided Medicine, Department of Radiology & Imaging Sciences, Emory University School of Medicine, GA, USA
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