A comparative analysis of transarterial downstaging for hepatocellular carcinoma: chemoembolization versus radioembolization

Radioembolization results in longer time-to-progression and reduced toxicity compared with chemoembolization in patients with hepatocellular carcinoma

BACKGROUND & AIMS

Chemoembolization is one of several standards of care treatment for hepatocellular carcinoma (HCC). Radioembolization with Yttrium-90 microspheres is a novel, transarterial approach to radiation therapy. We performed a comparative effectiveness analysis of these therapies in patients with HCC.

METHODS

We collected data from 463 patients who were treated with transarterial locoregional therapies (chemoembolization or radioembolization) over a 9-year period. We excluded patients who were not appropriate for comparison and analyzed data from 245 (122 who received chemoembolization and 123 who received radioembolization). Patients were followed for signs of toxicity; all underwent imaging analysis at baseline and follow-up time points. Overall survival was the primary outcome measure. Secondary outcomes included safety, response rate, and time-to-progression. Uni- and multivariate analyses were performed.

RESULTS

Abdominal pain and increased transaminase activity were more frequent following chemoembolization (P < .05). There was a trend that patients treated with radioembolization had a higher response rate than with chemoembolization (49% vs 36%, respectively, P = .104). Although time-to-progression was longer following radioembolization than chemoembolization (13.3 months vs 8.4 months, respectively, P = .046), median survival times were not statistically different (20.5 months vs 17.4 months, respectively, P = .232). Among patients with intermediate-stage disease, survival was similar between groups that received chemoembolization (17.5 months) and radioembolization (17.2 months, P = .42).

CONCLUSIONS

Patients with HCC treated by chemoembolization or radioembolization with Yttrium-90 microspheres had similar survival times. Radioembolization resulted in longer time-to-progression and less toxicity than chemoembolization. Post hoc analyses of sample size indicated that a randomized study with > 1000 patients would be required to establish equivalence of survival times between patients treated with these two therapies.

[Radioembolisation for hepatocellular carcinoma]

Hepatocellular carcinoma is now a major public health concern. In intermediate stages (one third of hepatocellular carcinoma patients), chemoembolization is the standard of care despite a poor tolerance and a moderate efficacy. Moreover, despite recent improvements, this technique seems in a dead end. Radioembolization could be an excellent tool for such patients. Currently (131)I-Lipiodol, (188)Re-Lipiodol, (90)Y-glass or resin microspheres are available. More recent and promising data come from microspheres, but phase II and III studies are needed before drawing any conclusion. In the future, the combination of radioembolization with systemic chemotherapy or targeted agents (particularly antiangiogenic drugs) seems very promising.

Radioembolization with yttrium-90 glass microspheres in hepatocellular carcinoma: European experience on safety and long-term survival

Radioembolization has been demonstrated to allow locoregional therapy of patients with hepatocellular carcinoma not eligible for transarterial chemoembolization or other local therapies. The aim of this study was to validate evidence of the safety and efficacy of this treatment in a European sample of patients with advanced hepatocellular carcinoma (HCC). Therefore, 108 consecutive patients with advanced HCC and liver cirrhosis were included. Yttrium-90 (Y-90) microspheres were administered in a lobar fashion over the right or left branch of the hepatic artery. The response to treatment was evaluated by computed tomography (CT) imaging applying Response Evaluation Criteria in Solid Tumors (RECIST) and World Health Organization (WHO) criteria with recent European Association for the Study of the Liver / National Cancer Institute (EASL/NCI) amendments. Time to progression (TTP) and overall survival were estimated by the Kaplan-Meier method. In all, 159 treatment sessions were performed ranging between one to three treatments per patient. The mean radiation dose per treatment was 120 (± 18) Gy. According to EASL criteria, complete responses were determined in 3% of patients, partial responses in 37%, stable disease 53%, and primary progression in 6% of patients. TTP was 10.0 months, whereas the median overall survival was 16.4 months. No lung or visceral toxicity was observed. The most frequently observed adverse events was a transient fatigue-syndrome.

CONCLUSION

Radioembolization with Y-90 glass microspheres for patients with advanced HCC is a safe and effective treatment which can be utilized even in patients with compromised liver function. Because TTP and survival appear to be comparable to systemic therapy in selected patients with advanced HCC, randomized controlled trials in combination with systemic therapy are warranted.

Patient selection and activity planning guide for selective internal radiotherapy with yttrium-90 resin microspheres

PURPOSE

Selective internal radiotherapy (SIRT) with yttrium-90 ((90)Y) resin microspheres can improve the clinical outcomes for selected patients with inoperable liver cancer. This technique involves intra-arterial delivery of β-emitting microspheres into hepatocellular carcinomas or liver metastases while sparing uninvolved structures. Its unique mode of action, including both (90)Y brachytherapy and embolization of neoplastic microvasculature, necessitates activity planning methods specific to SIRT.

METHODS AND MATERIALS

A panel of clinicians experienced in (90)Y resin microsphere SIRT was convened to integrate clinical experience with the published data to propose an activity planning pathway for radioembolization.

RESULTS

Accurate planning is essential to minimize potentially fatal sequelae such as radiation-induced liver disease while delivering tumoricidal (90)Y activity. Planning methods have included empiric dosing according to degree of tumor involvement, empiric dosing adjusted for the body surface area, and partition model calculations using Medical Internal Radiation Dose principles. It has been recommended that at least two of these methods be compared when calculating the microsphere activity for each patient.

CONCLUSIONS

Many factors inform (90)Y resin microsphere SIRT activity planning, including the therapeutic intent, tissue and vasculature imaging, tumor and uninvolved liver characteristics, previous therapies, and localization of the microsphere infusion. The influence of each of these factors has been discussed.

Current role of selective internal irradiation with yttrium-90 microspheres in the management of hepatocellular carcinoma: a systematic review

PURPOSE

This article reviews the role of selective internal irradiation (SIR) with yttrium-90 ((90)Y) microspheres for hepatocellular carcinoma (HCC).

METHODS AND MATERIALS

Studies were identified by searching Medline and PubMed databases for articles from 1990 to 2009 using the keywords "selective internal irradiation," "hepatocellular carcinoma," "therapeutic embolization," and "yttrium-90."

RESULTS

(90)Y microspheres are a safe and well-tolerated therapy for unresectable HCC (median survival range, 7 -21.6 months). The evidence was limited to cohort studies and comparative studies with historical control. (90)Y microspheres have been reported to downstage unresectable HCC to allow for salvage treatments with curative intent, act as a bridging therapy before liver transplantation, and treat HCC with curative intent for patients who are not surgical candidates because of comorbidities.

CONCLUSIONS

(90)Y microsphere is recommended as an option of palliative therapy for large or multifocal HCC without major portal vein invasion or extrahepatic spread. It can also be used for recurrent unresectable HCC, as a bridging therapy before liver transplantation, as a tumor downstaging treatment, and as a curative treatment for patients with associated comorbidities who are not candidates for surgery.

Transarterial Radioembolization with Yttrium-90 for Regional Management of Hepatocellular Cancer: The Early Results of a Nontransplant Center

Selective arterial radioembolization with Yttrium-90 (Y-90) microspheres has shown promise for regional management of hepatocellular cancer (HCC). Our objective was to report our early experience with this treatment modality from a nontransplant center. Treatment of patients with HCC was discussed in a multidisciplinary tumor board. Patients with unresectable disease resulting from high lesion number, ill location of the tumor, poor hepatic reserve, or medical comorbidities were offered Y-90 treatment. Liver treatment was either lobar or tumor-targeted. Response to therapy was assessed by CT scan obtained within 3 months using Response Evaluation Criteria in Solid Tumors criteria. During 2007 to 2009, 40 Y-90 radioembolizations were performed in 20 patients with age that ranged from 16 to 87 years; four patients were 80 years old or older. After the first therapy, CT assessment of the treated area showed stable disease (n = 15), partial response (n = 3), and progression (n = 2). Of the two patients who progressed, one was retreated with a subsequent complete response. The other patient died of progressive disease. The most common side effects were mild fatigue, anorexia, and nausea. In summary, our nontransplant center experience shows that Y-90 radioembolization is a well-tolerated treatment in select patients with unresectable HCC with an associated high rate of local tumor control.

Survival and cost-effectiveness analysis of competing strategies in the management of small hepatocellular carcinoma

The aim of the present study is to compare the survival rates and cost-effectiveness of different treatment strategies for small (<2 cm) hepatocellular carcinoma (HCC). Markov chains are developed to model different management strategies for patients with compensated cirrhosis and small HCC. Probabilities of progression and survival and the likelihood of orthotopic liver transplantation are taken from the literature and incorporated into the models. As a starting population, 1000 patients are followed over a period of 10 years. Patients treated immediately with transarterial chemoembolization (TACE) or radiofrequency ablation (RFA) live as long as or longer than patients who are monitored expectantly with the intention of liver transplantation once the HCC has grown larger than 2 cm and a higher transplant priority score becomes available. With TACE, immediate treatment results in an average survival time of 4.269 years versus 4.324 years with the monitoring strategy. With RFA, immediate treatment results in an average survival time of 5.273 years versus 5.236 years with the monitoring strategy. In addition, the cost analysis shows that immediate treatment with either TACE or RFA is less expensive than monitoring. The better cost-effectiveness of immediate therapy versus the monitoring strategy remains robust and unaffected by variations of the assumptions built into the model. In conclusion, in patients with compensated cirrhosis and small HCC, a strategy of immediate treatment with either TACE or RFA prevails over a strategy of expectant monitoring with the intention of transplantation.

Population-based risk factors and resource utilization for HCC: US perspective

OBJECTIVE

Hepatocellular carcinoma (HCC) is a deadly cancer with limited treatment options. HCC cases in the United States (US) were identified from a claims database to analyze the risk factors, the health care provider referral patterns, and treatment options in actual (real-world) clinical settings.

METHODS

MarketScan, a health care claims database from Thomas Reuters covering 18 million lives yearly and all US census regions from 2002 to 2008, was used to identify HCC patients and obtain data on patient characteristics, health care providers, and treatment utilization (i.e., medications, interventions).

RESULTS

HCC cases (n = 4406) were identified with an annual incidence of 0.4 per 1000 covered lives (i.e., those currently enrolled in a health care plan) from 2002 to 2008. Nonalcoholic fatty liver disease (NAFLD)/nonalcoholic steatohepatitis (NASH) was the most common underlying etiologic risk factor (59%), followed by diabetes (36%) and hepatitis C virus infection (22%). Primary care/internal medicine providers managed the majority of cases (55%); a minority were seen by an oncologist (24%). Only 22% of cases known to have cirrhosis were undergoing HCC screening prior to diagnosis. Type of provider did not change significantly after the diagnosis was made. Systemic chemotherapy was the most commonly used treatment (32.8%); however, only 6% received sorafenib, the only approved drug for HCC. Limitations include lack of patient records and potential for physician coding variances.

CONCLUSION

The incidence of HCC in the database was 0.4 per 1000 persons. NAFLD/NASH and type 2 diabetes mellitus, along with hepatitis C virus infection, were the major etiologic risk factors associated with HCC. This claims database analysis suggests a gap exists between screening and treatment guidelines and practice patterns, implying a need for greater health care provider awareness and education.

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

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

Future perspectives in hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the most common and lethal malignancies worldwide. Due to late diagnosis and advanced underlying liver cirrhosis, only limited treatment options with marginal clinical benefits have been available in up to 70% of patients. However, major progress has been achieved with regard to surveillance, early diagnosis, and multimodal treatment approaches during the last years leading to an improvement in prognosis. Particularly, the increasing knowledge of molecular hepatocarcinogenesis today provides the opportunity for targeted therapy. The multikinase inhibitor sorafenib has broadened the therapeutic horizon for patients with advanced disease and is currently under investigation for patients in early and intermediate stages as adjuvant therapy after resection/local ablation or in combination with transcatheter arterial chemoembolization. Future research will continue to unravel the key signaling cascades in different subclasses of HCC patients according to their genomic and proteomic profiling. These approaches bear the potential to individualize anticancer therapy, in the end allowing treatment of those benefiting most and excluding those who do not. This article shortly reviews the current knowledge in the management of HCC and provides insights into future perspectives with a special focus on recent progress in multidisciplinary treatment modalities.

Yttrium-90 radioembolization in the management of liver malignancies

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

Current approach to hepatocellular carcinoma

Hepatocellular carcinoma (HCC) accounts for 80% of all primary liver cancers and ranks globally as the fourth leading cause of cancer-related death. Partial hepatectomy remains the best treatment option for select patients with HCC without cirrhosis. Liver transplantation is well established as the gold standard for patients with HCC and cirrhosis in the absence of extrahepatic spread and macrovascular invasion. Local regional therapy is indicated in select patients who are not surgical candidates, and its role as adjuvant therapy remains to be clarified by prospective studies.

The place of downstaging for hepatocellular carcinoma

In the treatment of hepatocellular carcinomas, therapies such as trans-arterial chemo-embolisation, trans-arterial radioembolisation, percutaneous ethanol injection and radio-frequency ablation can decrease the size (and overall viability) of the tumours, thus potentially increasing the proportion of patients qualifying for resection and transplantation. While the use of such downstaging therapies is straightforward when resection is the aim, in a similar way to other neo-adjuvant treatments in the surgery of tumours that are too large or awkwardly placed to be primarily resected the issues related to transplantation are more complex. In the context of transplantation the word "downstaging" designates not only a neo-adjuvant treatment, but also a selection strategy to allow patients who are initially outside accepted listing criteria to benefit from transplantation should the neo-adjuvant therapy be successful in reducing tumour burden. The effectiveness of downstaging as a selection strategy, at first questioned because of methodological bias in the studies that described it, has been recently demonstrated by more solid prospective investigations. Several issues however remain open, such as inclusion criteria before the strategy is implemented (size/number, surrogate markers of differentiation/vascular invasion such as alpha-fetoprotein), the choice of which downstaging therapy, the end-points of treatment, and the need and duration of a period of observation proving disease response or stabilisation before the patient can be listed. The present review discusses which treatments and strategies are available for downstaging HCC on the basis of the published literature.

Nonoperative therapies for combined modality treatment of hepatocellular cancer: expert consensus statement

Although surgical resection and liver transplantation are the only treatment modalities that enable prolonged survival in patients with hepatocellular carcinoma (HCC), the majority of HCC patients presents with advanced disease and do not undergo resective or ablative therapy. Transarterial chemoembolization (TACE) is indicated in intermediate/advanced stage unresectable HCC even in the setting of portal vein involvement (excluding main portal vein). Sorafenib has been shown to improve survival of patients with advanced HCC in two controlled randomized trials. Yttrium 90 is a safe microembolization treatment that can be used as an alternative to TACE in patients with advanced liver only disease or in case of portal vein thrombosis. External beam radiation can be helpful to provide local control in selected unresectable HCC. These different treatment modalities may be combined in the treatment strategy of HCC and also used as a bridge to resection or liver transplantation. Patients should undergo formal multidisciplinary evaluation prior to initiating any such treatment in order to individualize the best available options.

The challenges of liver transplantation for hepatocellular carcinoma on cirrhosis

Hepatocellular carcinoma (HCC) is a major cause of cancer mortality worldwide and liver transplantation (LT) has potentials to improve survival for patients with HCC. However, expansion of indications beyond Milan Criteria (MC) and use of bridging/downstaging procedures to convert intermediate-advanced stages of HCC within MC limits are counterbalanced by graft shortage and increasing use of marginal donors, partially limited by the use of donor-division protocols applied to the cadaveric and living-donor settings. Several challenges in technique, indications, pre-LT treatments and prioritization policies of patients on the waiting list have to be precised through prospective investigations that have to include individualization of prognosis, biological variables and pathology surrogates as stratification criteria. Also, liver resection has to be rejuvenated in the general algorithm of HCC treatment in the light of salvage transplantation strategies, while benefit of LT for HCC should be determined through newly designed composite scores that are able to capture both efficiency and equity endpoints. Innovative treatments such as radioembolization for HCC associated with portal vein thrombosis and molecular targeted compounds are likely to influence future strategies. Accepting this challenge has been part of the history of LT and will endure so also for the future.

State of the art: radiolabeled microspheres treatment for liver malignancies

IMPORTANCE OF THE FIELD

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

AREAS COVERED IN THIS REVIEW

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

WHAT THE READER WILL GAIN

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

TAKE HOME MESSAGE

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

Imaging response in the primary index lesion and clinical outcomes following transarterial locoregional therapy for hepatocellular carcinoma

CONTEXT

Response Evaluation Criteria in Solid Tumors (RECIST) (unidimensional), World Health Organization (WHO) (bidimensional), and European Association for Study of the Liver (EASL) (necrosis) guidelines are commonly used to assess response following therapy for hepatocellular carcinoma (HCC). No universally accepted standard exists.

OBJECTIVES

To evaluate intermethod agreement between these 3 imaging guidelines and to introduce the concept of the "primary index lesion" as a biomarker for response.

DESIGN, SETTING, AND PARTICIPANTS

Single-center comprehensive imaging analysis including 245 consecutive patients with HCC who were treated with chemoembolization or radioembolization between January 2000 and December 2008. Computed tomography and magnetic resonance imaging scans (N = 1065) were reviewed to assess response in the "primary index lesion," defined as the largest tumor targeted during first treatment.

MAIN OUTCOME MEASURES

Intermethod agreement (kappa statistics) between RECIST, WHO, and EASL guidelines response; correlation of WHO and EASL response in the primary index lesion with time to progression and survival.

RESULTS

Kappa coefficients were 0.86 (95% confidence interval [CI], 0.80-0.92) between the WHO and RECIST guidelines, 0.24 (95% CI, 0.16-0.33) between RECIST and EASL, and 0.28 (95% CI, 0.19-0.36) between WHO and EASL. Disease progressed in 96 patients; 113 died. The hazard ratio for time to progression in responders compared with nonresponders was 0.36 (95% CI, 0.23-0.57) for WHO, 0.38 (95% CI, 0.24-0.58) for RECIST, and 0.38 (95% CI, 0.22-0.64) for EASL. Hazard ratios for survival in responders compared with nonresponders in univariate and multivariate analyses were 0.46 (95% CI, 0.32-0.67) and 0.55 (95% CI, 0.35-0.84) for WHO and 0.36 (95% CI, 0.22-0.57) and 0.54 (95% CI, 0.34-0.85) for EASL. Hazard ratios for survival in responders vs nonresponders in patients with solitary and multifocal HCC were 0.39 (95% CI, 0.19-0.77) and 0.51 (95% CI, 0.32-0.82) for WHO and 0.26 (95% CI, 0.10-0.67) and 0.47 (95% CI, 0.28-0.79) for EASL.

CONCLUSIONS

Among a group of patients with HCC, agreement for classification of therapeutic response was high between the RECIST and WHO guidelines but low between each of these and EASL. Application of these methods to measure response in a primary index lesion resulted in statistically significant correlations with disease progression and survival.

Treatment of hepatocellular carcinoma with intra-arterial injection of radionuclides

Hepatocellular carcinoma (HCC) is becoming an important public health concern. Current therapeutic options are limited and new treatments are therefore being developed. The intra-arterial treatment chemoembolization has limited efficacy and few prospects for further progress. One particularly promising, though little used, alternative to chemoembolization is radioembolization with iodine-131 ((131)I) or rhenium-188 labeled lipiodol or yttrium-90 labeled microspheres (glass or resin beads). Three randomized studies have proven the effectiveness of (131)I-lipiodol in patients with HCC-as adjuvant therapy after surgery, compared with chemoembolization, and also in patients who have portal vein thrombosis. Microspheres enable the delivery of high-dose radiation (>200 Gy) to the tumor while sparing the neighboring hepatic tissue from overexposure. Overall, the efficacy of radioembolization has been good and toxic effects have been low. These results are comparable to those obtained with chemoembolization but further improvement can be expected by combining radioembolization with standard chemotherapy or with targeted therapies, such as anti-angiogenic drugs.

Yttrium-90 radioembolization for liver malignancies: prognostic factors associated with survival

PURPOSE

To identify key prognostic clinical and imaging variables in patients undergoing yttrium-90 radioembolization ((90)Y) for liver malignancies.

MATERIALS AND METHODS

Patients with liver malignancies that progressed despite standard-of-care therapy were treated with (90)Y from 2002 to 2006. Baseline functional status, laboratory values, and diagnostic imaging were assessed before therapy. Imaging follow-up was performed 1 month after treatment and subsequently at 3-month intervals. Patients were followed for survival from the time of their first (90)Y treatment.

RESULTS

Patients with follow-up imaging after radioembolization (N = 130) were included in this analysis. Primary malignancies included colon, neuroendocrine, and others. The following clinical variables had a significant effect on survival on multivariate analysis: Eastern Cooperative Oncology Group (ECOG) performance status (PS) greater than 0 (hazard ratio [HR], 7.98; 95% CI, 3.98-16), hepatic tumor burden of 51%-75% (HR, 2.46; 95% CI, 1.01-6.02), bilirubin level greater than 1.3 mg/dL (HR, 2.60; 95% CI, 1.27-5.34), hepatic metastases from breast cancer (HR, 2.51; 95% CI, 1.13-5.61), response on imaging based on World Health Organization (WHO) criteria (HR, 0.48; 95% CI, 0.24-0.94), and lymphocyte depression (HR, 0.56; 95% CI, 0.31-0.96). Among patients with colorectal cancer metastases to the liver, the HR for survival on univariate analysis for responders compared with nonresponders (per WHO criteria) was 0.26 (95% CI, 0.10-0.69).

CONCLUSIONS

Cancer-related symptoms (ie, ECOG PS > 0), hepatic tumor burden greater than 50%, increased bilirubin levels, and hepatic metastases from breast cancer were found to be negative prognostic factors. Tumor response to therapy and lymphocyte depression were associated with favorable prognosis. Additionally, WHO response was identified to be a favorable prognostic factor in patients with colorectal cancer metastases. These findings may be useful when counseling patients regarding prognosis of their hepatic disease.