Nodular hepatocellular carcinoma. Treatment with subsegmental intraarterial injection of iodine 131-labeled iodized oil

An Overview of Clinical Trials in the Treatment of Resectable Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is one of the most common causes of cancer-related death worldwide. Partial hepatectomy, one of a few curative therapeutic modalities, is plagued by high recurrence rate of up to 70% at 5 years. Throughout the past 3 decades, many clinical trials have attempted to improve HCC recurrence rate following partial hepatectomy using adjuvant and neoadjuvant treatment modalities such as antiviral therapy, brachytherapy, systemic chemotherapy, immunotherapy, transarterial chemoembolization and radioembolization, and radiotherapy. The goal of this review is to discuss the clinical trials pertaining to resectable HCC including surgical technique considerations, adjuvant, and neoadjuvant treatment modalities.

Therapeutic Strategies in HCC: Radiation Modalities

Patients with hepatocellular carcinoma (HCC) comply with an advanced disease and are not eligible for radical therapy. In this distressed scenario new treatment options hold great promise; among them transarterial chemoembolization (TACE) and transarterial metabolic radiotherapy (TAMR) have shown efficacy in terms of both tumor shrinking and survival. External radiation therapy (RTx) by using novel three-dimensional conformal radiotherapy has also been used for HCC patients with encouraging results while its role had been limited in the past for the low tolerance of surrounding healthy liver. The rationale of TAMR derives from the idea of delivering exceptional radiation dose locally to the tumor, with cell killing intent, while preserving normal liver from undue exposition and minimizing systemic irradiation. Since the therapeutic efficacy of TACE is being continuously disputed, the TAMR with ¹³¹I Lipiodol or ⁹⁰Y microspheres has gained consideration providing adequate therapeutic responses regardless of few toxicities. The implementation of novel radioisotopes and technological innovations in the field of RTx constitutes an intriguing field of research with important translational aspects. Moreover, the combination of different therapeutic approaches including chemotherapy offers captivating perspectives. We present the role of the radiation-based therapies in hepatocellular carcinoma patients who are not entitled for radical treatment.

Transarterial chemoembolization versus transarterial radioembolization in hepatocellular carcinoma: optimization of selecting treatment modality

Hepatocellular carcinoma (HCC) of intermediate stage consists of diverse tumor and patient factors in terms of tumor number, size and liver function resulting in various outcomes given by transarterial chemoembolization (TACE). Transarterial radioembolization (TARE) using radioactive isotope, β-ray emitting Yttrium-90 with a short half-life and penetration depth, is an emerging intra-arterial brachytherapy characterized by potent anti-cancer effect given by radiation but minimal embolic effect. Although there is lack of study directly comparing the efficacy and safety between TACE and TARE in patients with unresectable HCC, several retrospective or small-scaled studies suggest that overall efficacy indicated by overall survival and time to progression is similar between two modalities and TARE has a superiority in the safety including postembolization syndrome, hospitalization days and outpatient-based therapy. In advanced HCC with portal vein (PV) invasion, TACE is not consistently recommended due to risk of hepatic decompensation or failure after procedure. On the contrary, available data suggest that TARE might be a promising treatment option in HCC with PV thrombosis if patient's liver function is preserved and the level of PV invasion is less than main trunk. Ongoing trials comparing TARE and sorafenib in advanced HCC would elucidate the role of this locoregional therapy. The need of a multidisciplinary team, complex steps of procedure and high cost of TARE are the hurdles to widespread recommendation of this therapy in intermediate or advanced HCC. The optimization of selection between TACE and TARE might be dependent on availability, experience, tumor factors and patient factors.

Adjuvant Iodine (131) Lipiodol after Resection of Hepatocellular Carcinoma

Background. Survival after liver resection for HCC is compromised by a high rate of intrahepatic recurrence. Adjuvant treatment with a single, postoperative dose of intra-arterial I(131) lipiodol has shown promise, as a means of prolonging disease-free survival (DFS). Methodology. DFS and overall survival (OS) after a single dose of postoperative I(131) lipiodol were compared to liver resection alone, for treatment of hepatocellular carcinoma (HCC). Data were collected retrospectively for patients who had a curative resection for HCC between December 1993 and September 2011. Seventy-two patients were given I(131) lipiodol after surgery and 70 patients had surgery alone. Results. The DFS at 1, 3, and 5 years was 72%, 43%, and 26% in the surgery group and 70%, 39%, and 29% in the adjuvant I(131) lipiodol group (p = 0.75). The 1-, 3-, and 5-year OS was 83%, 64%, and 52% in the surgery group and 96%, 72%, and 61% in the adjuvant I(131) lipiodol group (p = 0.16). Conclusion. This retrospective study has found no significant benefit to survival, after adjuvant treatment with I(131) lipiodol.

Adjuvant Intrahepatic Injection Iodine-131-Lipiodol Improves Prognosis of Patients with Hepatocellular Carcinoma After Resection: a Meta-Analysis

High incidence of intrahepatic recurrence is a major surgical limitation following hepatectomy of hepatocellular carcinoma (HCC). This study was intended to investigate the effects of adjuvant intrahepatic injection of iodine-131-lipiodol on disease recurrence and survival in patients with HCC who underwent resection. A computerized literature search was performed to identify relevant articles. Data synthesis was performed using Review Manager 5.0 software, and results are presented as odds ratio (OR) with 95 % confidence intervals. Two randomized controlled trials and three case-control studies with a total of 334 participants were analyzed. Iodine-131-lipiodol treatment achieved significantly lower rates of intrahepatic recurrence (OR = 0.48, 95 % confidence interval (95 % CI) = 0.30-0.74; P = 0.001) and early recurrence (<2 year) (OR = 0.45, 95 % CI = 0.23-0.89; P = 0.02). Likewise, iodine-131-lipiodol treatment improved both the 5-year disease-free survival and overall survival significantly (OR = 1.85, 95 % CI = 1.13-3.03; P = 0.01; OR = 2.00, 95 % CI = 0.99-4.04; P = 0.05, respectively). Adjuvant intrahepatic injection of iodine-131-lipiodol resulted in a preventive effect on recurrence and improved survival after resection of HCC. Further larger, multi-centred, randomized prospective trial is warranted.

Survival after 131I-labeled lipiodol therapy for hepatocellular carcinoma

This study investigated the efficacy of 131iod- ine-labeled lipiodol (1311-lipiodol) as a palliative therapy, evaluated overall survival (OS) across Barcelona Clinic Liver Cancer (BCLC) stages, and determined the main prognostic factors influencing OS in patients with hepatocellular carcinoma (HCC). Patients, methods: We retrospectively analyzed 57 (44 men; mean age, 65.7 years; mean activity per session, 1.6 GBq; mean cumulative activity in patients with >1 sessions, 3.9 GBq) HCC patients who underwent 1311-lipiodol therapy. A majority of patients exhibited Child-Pugh class B (53.6%) disease and a good Eastern Cooperative Oncology Group performance status (0-1; 72%). Multinodular disease was observed in 87.7% patients, bilobar disease in 73%, and portal vein occlusion (PVO) in 54%. Furthermore, 21.1% patients were staged as BCLC B and 59.6 % as BCLC C. All patients were followed until death. Results: The median OS was 6.4 months, which varied significantly with disease stage (median OS for BCLC A, B, C, and D was 29.4, 12.0, 4.6, and 2.7 months, respectively; p = 0.009); Child-Pugh score and class; presence of ascites, PVO, or extrahepatic disease; largest lesion size; favourable treatment response; international normalized ratio, baseline albumin and alpha-fetopro- tein levels. Patients with a Child-Pugh A liver disease had a longer OS. Conclusion: Currently, different treatment modalities for HCC include radioembolization, transarterial chemoemboliz- ation, and systemic therapy with sorafenib; however, 1311-lipiodol therapy remains a feasible alternative for patients without a favourable response to other therapies, particularly for patients with Child-Pugh A liver cirrhosis.

Meta-analysis of interstitial pneumonia in studies evaluating iodine-131-labeled lipiodol for hepatocellular carcinoma using exact likelihood approach

PURPOSE

Iodine-131-labeled lipiodol is currently licensed for unresectable hepatocellular carcinoma with portal thrombosis. It is thought to be well tolerated. Cases of interstitial pneumonia have been reported, but their frequency (≈2%) has not been well estimated. Quantifying adverse drug event frequency requires an appropriate statistical approach because standard methods are biased.

METHODS

To estimate the frequency of interstitial pneumonia in patients with hepatocellular carcinoma receiving iodine-131-labeled lipiodol, we conducted a systematic review of English articles using MEDLINE and EMBASE. All types of articles were considered except case reports. Primary outcome measure was symptomatic interstitial pneumonia based on investigators' judgment. All pooled analyses were based on a random effects meta-analysis model using an exact likelihood approach based on the binomial within-study distribution.

RESULTS

Ten studies, including 142 patients, used low activity per dose, ranging from 0.3 to 1.1 GBq. No respiratory adverse event was noticed in these studies. Eighteen studies, including 542 patients, evaluated higher activity per dose, around 2.2 GBq; 24 cases of interstitial pneumonia were reported in these studies. Estimated frequency of interstitial pneumonia was 1.6% (95%CI, 0.4-6.4%) after one high dose and 4.1% (95%CI, 1.0-16.0%) after two or more high doses.

CONCLUSIONS

The frequency of interstitial pneumonia appears higher and more precise than previously estimated. The risk appears to be related to the number of injections and the dose level per injection. Generalized linear mixed models using the exact binomial within-study distribution initially described to summarize data on diagnostic evaluation could be relevant for drug-related adverse reaction frequency assessment.

Iodine-131-lipiodol therapy in hepatic tumours

The incidence of hepatocellular carcinoma (HCC) is worldwide sharply on the rise and patients with advanced disease carry a poor prognosis. HCC is the sixth most common cancer and the third leading cause of cancer associated deaths in the world. Intra-arterially administered (131)I-Lipiodol is selectively retained by hepatocellular carcinomas, and has been used as a vehicle for delivery of therapeutic agents to these tumours. In this review we focus on the therapeutic indications, usefulness and methods of treatment with 131-Iodine Lipiodol. The effectiveness of (131)I-Lipiodol treatment is proven both in the treatment of HCC with portal thrombosis and also as an adjuvant to surgery after the resection of HCCs. It is at least as effective as chemoembolization and is tolerated much better. Severe liver dysfunction represents theoretic contraindication for radioembolization as well as for TACE. In such cases (131)I-Lipiodol is an alternative therapy option especially in tumours smaller than 6cm.

Adjuvant intra-arterial iodine-131-labeled lipiodol for resectable hepatocellular carcinoma: a prospective randomized trial-update on 5-year and 10-year survival

OBJECTIVE

In this prospective randomized trial, we attempted to find out if 1 dose of postoperative adjuvant intra-arterial iodine-131-labeled lipiodol could reduce the rate of local recurrence, and increase disease-free and overall survival for patients with hepatocellular carcinoma (HCC). This study evaluated the long-term outcome.

BACKGROUND

Resection of HCC is potentially curative, but local recurrence is common. However, there is currently no effective adjuvant therapy. Early results after closing the trial (Lau et al. Lancet 1999;353:797-801) showed that 1 dose of intra-arterial I-lipiodol given after curative resection significantly decreased the rate of recurrence, and increased disease-free and overall survival.

METHODS

Patients who underwent curative resection for HCC and recovered within 6 weeks were randomly assigned one 1850 MBq dose of I-lipiodol or no further treatment (controls). We compared rates of recurrence, and long-term disease-free and overall survival (the primary endpoints) between the 2 groups by intention-to-treat.

RESULTS

Between April 1992 and August 1997, we recruited 43 patients: 21 were randomized to receive intra-arterial I-lipiodol and 22 to receive no adjuvant treatment. I-lipiodol had no significant toxic effects. During a median follow-up of 66 (range, 3-198) months, there were 10 (47.6%) recurrences among the 21 patients in the adjuvant treatment group, compared with 14 (63.6%) in the control group (P = 0.29). The actuarial 5-year disease-free survival in the treatment and control groups was 61.9% and 31.8%, respectively (P = 0.0397). The actuarial 5-year overall survival in the treatment and control groups was 66.7% and 36.4%, respectively (P = 0.0433). The actuarial 7-year disease-free survival in the treatment and control groups was 52.4% and 31.8%, respectively (P = 0.0224). The actuarial 7-year overall survival in the treatment and control groups was 66.7% and 31.8%, respectively (P = 0.0243). The actuarial 10-year disease-free survival in the treatment and control groups was 47.6% and 27.3%, respectively (P = 0.0892). The actuarial 10-year overall survival in the treatment and control groups was 52.4% and 27.3%, respectively (P = 0.0905).

CONCLUSIONS

In patients with HCC, adjuvant intra-arterial I-lipiodol after curative liver resection provided survival benefit on the disease-free survival and overall survival, although the difference became statistically insignificant at 8 years after randomization.

Effect of a 188Re-SSS lipiodol/131I-lipiodol mixture, 188Re-SSS lipiodol alone or 131I-lipiodol alone on the survival of rats with hepatocellular carcinoma

BACKGROUND AND AIM

It has been shown that the use of a cocktail of isotopes of different ranges of action leads to an increase in the effectiveness of metabolic radiotherapy. The purpose of the present study was to compare with a control group the effectiveness of three different treatments in rats bearing hepatocellular carcinoma (HCC), using (1) a mixture of lipiodol labelled with both I and Re, (2) lipiodol labelled with I alone and (3) lipiodol labelled with Re alone.

MATERIAL AND METHODS

Four groups were made up, each containing 14 rats with the N1-S1 tumour cell line. Group 1 received a mixture composed of 22 MBq of Re-SSS lipiodol and 7 MBq I-lipiodol. Group 2 received 14 MBq I-lipiodol. Group 3 received 44 MBq of Re-SSS lipiodol and group 4 acted as the control. The survival of the various groups was compared by a non-parametric test of log-rank, after a follow-up of 60, 180 and 273 days.

RESULTS

Compared with the controls, the rats treated with a mixture of Re-SSS lipiodol and I-lipiodol show an increase in survival, but only from day 60 onwards (P=0.05 at day 60 and 0.13 at days 180 and 273). For the rats treated with I-lipiodol, there was a highly significant increase in survival compared with the controls at day 60, day 180 and day 273 (P=0.03, 0.04 and 0.04, respectively). There is no significant increase in survival for the rats treated with Re-SSS lipiodol, irrespective of the follow-up duration (P=0.53 at day 60, 0.48 at day 180, and 0.59 at day 273).

CONCLUSIONS

In this study, I-lipiodol is the most effective treatment in HCC-bearing rats, because this is the only method that leads to a prolonged improvement of survival. These results cannot necessarily be extrapolated to humans because of the relatively small size and unifocal nature of the lesions in this study. It appears necessary to carry out a study in humans with larger tumours in order to compare these three treatments, particularly with a view to replacing I-labelled lipiodol by Re-labelled lipiodol. However, this study clearly demonstrated that, for small tumours, as in an adjuvant setting for example, I-labelled lipiodol should be a better option than Re-labelled lipiodol.

188Re-SSS lipiodol: radiolabelling and biodistribution following injection into the hepatic artery of rats bearing hepatoma

BACKGROUND

Although intra-arterial radiation therapy with 131I-lipiodol is a useful therapeutic approach to the treatment of hepatocellular carcinoma, various disadvantages limit its use.

AIM

To describe the development of a method for the labelling of lipiodol with 188Re-SSS (188Re (S2CPh)(S3CPh)2 complex) and to investigate its biodistribution after injection into the hepatic artery of rats with hepatoma.

METHODS

188Re-SSS lipiodol was obtained after dissolving a chelating agent, previously labelled with 188Re, in cold lipiodol. The radiochemical purity (RCP) of labelling was checked immediately. The 188Re-SSS lipiodol was injected into the hepatic artery of nine rats with a Novikoff hepatoma. They were sacrificed 1, 24 and 48 h after injection, and used for ex vivo counting.

RESULTS

Labelling of 188Re-SSS lipiodol was achieved with a yield of 97.3+/-2.1%. The immediate RCP was 94.1+/-1.7%. Ex vivo counting confirmed a predominantly hepatic uptake, with a good tumoral retention of 188Re-SSS lipiodol, a weak pulmonary uptake and a very faint digestive uptake. The 'tumour/non-tumoral liver' ratio was high at 1, 24 and 48 h after injection (2.9+/-1.5, 4.1+/-/4.1 and 4.1+/-0.7, respectively).

CONCLUSIONS

Using the method described here, 188Re-SSS lipiodol can be obtained with a very high yield and a satisfactory RCP. The biodistribution in rats with hepatoma indicates a good tumoral retention of 188Re-SSS lipiodol associated with a predominant hepatic uptake, a weak pulmonary uptake and a very faint digestive uptake. This product should be considered for intra-arterial radiation therapy in human hepatoma.

Transcatheter Arterial Embolization with 188Rhenium-HDD–labeled Iodized Oil in Rabbit VX2 Liver Tumor

PURPOSE

To evaluate the antitumor effect of transcatheter arterial embolization (TAE) with use of rhenium 188 HDD (4-hexadecyl 2,2,9,9-tetramethyl-4,7-diaza-1,10-decanethiol)-labeled iodized oil and to compare it with that of transcatheter arterial chemoembolization (TACE) with use of an established chemotherapeutic agent and iodized oil in experimentally induced liver tumor.

MATERIALS AND METHODS

VX2 carcinoma was grown in the livers of 57 rabbits. TAE was performed with (188)Re-HDD-labeled iodized oil (Re-Lp group; n = 21), doxorubicin/iodized oil emulsion (Dx-Lp group; n = 21), and iodized oil alone (n = 15). Sequential conjugated planar imaging was performed for dosimetry of the radioisotope in the Re-Lp group (n = 15). Growth ratio and percentage of viable tumor were estimated by computed tomography and histopathologic examination. Hepatic and hematologic toxicities were evaluated by biochemical analysis.

RESULTS

On conjugated planar imaging, radioactivity was concentrated on the tumor (effective half-life, 16.2 hours), and mean radiation dose to the tumor was 147.7 Gy. The mean growth ratios 1, 2, and 3 weeks after TAE and the percentage of viable tumor in the Re-Lp group (-3.4, -7.6, -11.1, and 0.3%) and the Dx-Lp group (-3.2, -5.3, 29.0, and 2.6%) were significantly lower than the respective values in the iodized oil group (45.5, 145.4, 283.0, and 30.1%; P < .001). However, the differences between the values in the Re-Lp group and those in the Dx-Lp group were not significant (P values of .165-0.497 for growth ratios; P = .134 for percentage of viable tumor). There was similar transient hepatotoxicity in all three groups.

CONCLUSIONS

TAE with (188)Re-HDD-labeled iodized oil has potent antitumor effect in VX2 liver tumor that is comparable with that of TACE with an established chemotherapeutic agent.

Safe radiation exposure of medical personnel by using simple methods of radioprotection while administering 131I-lipiodol therapy for hepatocellular carcinoma

The intra-arterial administration of 131I-lipiodol is a therapeutic approach increasingly used for the treatment of inoperable hepatocellular carcinomas. This technique has even become the reference treatment for hepatocellular carcinomas with portal thrombosis and is the only effective treatment to reduce the risk of recurrence among patients who could benefit from surgical operation. Currently, few data have been published concerning the levels of exposure for personnel carrying out this type of treatment. We undertook a dosimetric study targeted mainly on the exposure of the person performing the injection of 131I-lipiodol to show that this treatment can be carried out with an exposure at the extremities distinctly lower than the regulatory annual threshold by using simple means of radioprotection. The point of puncture was carried out at the level of left femoral artery, the preparation and injection of the therapeutic dose was carried out extemporaneously by the nuclear medicine specialist using a 10 ml syringe (for an injected volume of 4 ml) fitted with an adapted syringe protector. The injection was carried out as rapidly as possible under scopic control while avoiding reflux, with compression carried out by the radiologist. This study comprises 52 intra-arterial injections of 131I-lipiodol (2016+/-92 MBq). For the nuclear medicine specialists, 52 measurements were carried out at the level of the thorax and 41 on the fingers. For the radiologists, 22 measurements were carried out at the level of the thorax and six on their index fingers; nine measurements were carried out at the level of the thorax for the technologist and four at the level of the thorax for the stretcher bearer. For the nuclear medicine specialists, the average dose received at the level of the fingers varies between 140 and 443 microSv (according to the fingers) and the average dose at the thorax is 17 microSv. For the radiologists, the average dose received is 215 microSv at the level of the fingers and 15 microSv at the thorax. These results show that the administration of high therapeutic activities of 131I-lipiodol can be carried out for the exposed personnel with a dose at the level of the fingers much lower than the European regulatory limit of 500 mSv.

Intra-arterial radionuclide therapy for liver tumours: effect of selectivity of catheterization and 131I-Lipiodol delivery on tumour uptake and response

Several authors have demonstrated the good tolerance of hepatic intra-arterial 131I-Lipiodol therapy and report survival rates of 21-25% after 1 year in inoperable patients. This study explored the possibility that more selective hepatic arterial instillation could be a strategy for increasing tumoural uptake and response of 131I-Lipiodol. Between June 1999 and September 2001 we selected 24 patients: 14 received a selective instillation of 131I-Lipiodol to the proper hepatic artery (SEL group); and 10 received a hyperselective instillation in the right or left hepatic artery (HYP-SEL group). The individual 131I-Lipiodol activity as a per cent of the injected activity per millilitre of tumour (%IA/ml tumour) was correlated with the selectivity of instillation in 28 tumours and with tumour response in 24 tumours. Differences in tumour response or tumour uptake between the SEL and HYP-SEL groups were not significant. In general, we observed a %IA/ml tumour of 0.05-2.6% for the uptake of 131I-Lipiodol. The uptake was significantly higher in responsive disease than in stable or progressive disease (P=0.002). A large tumour volume was invariably related to low uptake of 131I-Lipiodol and progressive disease (P=0.008). In conclusion, our study does not support the general use of hyper-selective or super-selective intra-arterial administration of 131I-Lipiodol. This result may be extrapolated to similar types of intra-arterial, loco-regional hepatic radionuclide therapy.

131I lipiodol therapy for unresectable hepatocellular carcinoma

BACKGROUND

More than 80% of hepatocellular carcinoma tumours (HCC) are unresectable at presentation because of the multicentric nature of the disease or the severity of liver disease. Arterially administered lipiodol is preferentially retained by HCC and has been used as a vehicle for delivery of therapeutic agents to the tumour. The aim of this phase I study is to present the experience with 131I-labelled lipiodol in the treatment of unresectable HCC.

METHODS

131Iodine lipiodol treatment was administered to 12 patients with unresectable HCC between 1994 and 1999. The outcome of treatment in these patients was evaluated for survival, clinical tolerance, liver function tests, alpha-fetoprotein (AFP) levels and changes in tumour size on computed tomography (CT) scans.

RESULTS

Ten of the 12 patients received more than one 131I treatment. Five patients had treatment for post-resection recurrence. Serum AFP levels dropped initially in five of the seven patients with elevated values. Tumour size, evaluated by CT scans at 3 months, decreased in six patients and remained stable in the rest, except one patient in whom both the AFP level and tumour size had increased. Using life table analysis, the 50% survival was 19 months.

CONCLUSIONS

Intra-arterial 131I treatment was very well tolerated. A reduction in AFP levels and tumour size occurred in half of the patients and resulted in a 50% probability of survival of 19 months. Further examination of the value of this treatment in phase II and III studies is required.

Intraarterial HCC therapy with I-131-Lipiodol

We report on our 2-year experience with intraarterial liver therapy with I-131-Lipiodol in patients with hepatocellular carcinoma in Germany. 30 therapies with intraarterial delivery of I-131-labeled Lipiodol were performed in 14 patients with hepatocellular carcinoma (HCC) with or without portal vein thrombosis during hepatic angiography. The patients were monitored for 1) distribution of Lipiodol by CT, 2) distribution of applied activity by planar scintigraphy and SPECT, and 3) tumor response by CT, MRT and 18-FDG-PET. In 5 patients the tumor size was reduced after the first treatment (responder). Eight patients, primarily with big tumors (> 7 cm), had stable (4) or progressive disease (4), and 1 patient died because of renal failure. CT and SPECT showed pronounced I-131-lipiodol accumulation in the tumor tissue in all patients with variable distribution patterns. One patient had an acute pancreatitis like syndrome together with elevation of liver enzymes, probably due to arterial spasm. 9 patients had transient and mild symptoms in the upper abdomen, fever to 40 degrees C, and a leukocytosis. Two patients had a transient mild elevation of pancreatic enzymes. All patients had a transient rise in liver enzymes. In conclusion, therapeutic efficacy was dependent on the tumor mass. Side effects due to the radiopharmaceutical were tolerable, and other side effects may result from the angiography procedure related manipulations. These results are encouraging for tumors up to a moderate mass.

I-131-Lipiodol therapy in liver neoplasms

Twelve patients with liver neoplasms [10 HCC, 1 CCC, 1 multiple breast cancer metastases (BCM)] were treated by transarterial I-131-Lipiodol. Computed tomography (CT) and single photon emission CT (SPECT) showed pronounced I-131-Lipiodol accumulation in the tumor tissue in all cases. In three patients with HCC a reduction of tumor size was achieved after the first treatment. The remaining patients had big tumor masses; 5 of these (4 HCC, 1 CCC) had stable disease after the first treatment, and 2 HCC were progressive. One patient died immediately after therapy due to other reasons. The BCM proved significant reduction in number and size. Eighteen-FDG-PET (positron emission tomography with fluor-18-deoxy-glucose) and CT controls showed in part different results with pretherapeutic PET proving high interindividual variability in tumor activity. Side effects were tolerable. In summary, the therapy procedure with transarterial I-131-Lipiodol is safe and effective in tumors with moderate tumor mass.

Etiology, screening, and treatment of hepatocellular carcinoma

The prognosis with large hepatocellular carcinomas is poor, and only palliative treatment is available. Small tumors are amenable to several modes of treatment, including liver transplantation, resection, or alcohol injection, with acceptable 5-year survival rates. Although the value of screening for hepatocellular carcinoma has yet to be shown, these data, coupled with the recognition of at-risk groups and useful diagnostic techniques, might encourage the clinician to screen at-risk patients in the clinic. New imaging techniques such as ultrasonographic angiography enhanced with CO2 microbubbles, or color Doppler ultrasound, may clarify the intratumoral blood flow of small tumors.

Limitations of hyperselective intraarterial injections for the treatment of hepatocellular carcinoma

The authors report the case of a cirrhotic patient with a multinodular hepatocellular carcinoma. Two nodules were located in the right liver lobe and a minute nodule was in the left lobe. Because of poor liver function, two injections of iodine-131-labeled Lipiodol were delivered in the right hepatic artery to protect the left lobe. The efficacy was obvious in the treated areas, but the minute lesion enlarged dramatically and was responsible for the patient's death.

Superselective intra-arterial radiometabolic therapy with I-131 lipiodol in hepatocellular carcinoma

Superselective transcatheter arterial radioembolization with radioiodinated lipiodol and gelatin sponges was evaluated in 11 patients with nodular hepatocellular carcinoma. Thirteen tumor nodules were treated using 3-5 ml of lipiodol labeled with 259 to 2220 MBq of I-131 followed by gelatin sponge with the following results: 1) there was elevated uptake in 12 tumor nodules with high tumor-to-background ratios: 2) there was excellent clinical tolerance to the treatment (stable cirrhosis in 5 patients and cirrhosis progression in 2 cases); 3) there was good disease control with size reduction in five tumor lesions (41%) and no increase in seven lesions (59%) followed for 2 years; 4) there was a 2-year survival rate of 70%; and 5) three deaths due to hepatic failure at 2, 3, and 20 months after therapy. Superselective arterial radioembolization with I-131 lipiodol is a useful palliative approach to inoperable hepatocarcinoma, providing long-term local control without severe complications in the progression of cirrhosis.

Iodized oil in the treatment of hepatocellular carcinoma

When injected into the hepatic artery the contrast agent Lipiodol (iodized poppy seed oil) is selectively retained by hepatocellular carcinoma (HCC) for a prolonged period of time. Liver computed tomography (CT) performed after Lipiodol angiography is more sensitive than ordinary CT at imaging HCC. Arterial administration of cytotoxic drugs and radioisotopes conjugated to Lipiodol has been shown to be reasonably safe in patients with irresectable HCC. These therapies, often combined with embolization, provide effective palliation, better tumour response and improved survival compared with other available treatments. Their use as a preoperative adjunct to surgical resection of HCC is controversial.

A new, effective, and safe therapeutic option using proton irradiation for hepatocellular carcinoma

BACKGROUND/AIMS

Conventional radiation is almost useless for hepatocellular carcinoma (HCC) because of the severe adverse effects of the irradiation to the accompanying liver cirrhosis. In contrast, the proton beam has Bragg peak, which limits distribution of the beam. The aim of this study was to prove the usefulness of proton irradiation for HCC.

METHODS

The proton irradiation was performed in 32 nodular lesions in 24 patients with HCC who had unresectable tumors or serious complications; the proton irradiation was performed either as monotherapy (15 lesions) or as combination therapy to insufficient Lipiodol-targeted chemotherapy (Kodama Co. Ltd., Tokyo, Japan) (17 lesions). The energy was 250 MeV, and 50-87 Gy (76.5 +/- 9.5, mean +/- SD) in total was irradiated for a time period of 17-69 days.

RESULTS

After 1 year, size reduction was seen in 12 out of 13 lesions (92%) in the monotherapy group and 9 out of 9 lesions (100%) in the combination therapy group; after 2 years, size reduction was seen 4 out of 5 lesions (80%) in the monotherapy group and 5 out of 5 lesions (100%) in the combination therapy group. Local tumor control has being assured for 2 years of the observation, which is continuing for another 2 years. None of the patients have experienced any serious adverse effects.

CONCLUSIONS

These results show that proton irradiation is a new, safe, and effective therapeutic option in cases of HCC, even in patients with unresectable tumors or those with serious complications.

Small hepatocellular carcinoma: high dose internal radiation therapy with superselective intra-arterial injection of I-131-labeled Lipiodol

The aim of the present study was to deliver a high internal radiation dose to small hepatocellular carcinoma (HCC) lesions in an attempt to treat this disease. A total of 18 patients with HCC lesions measuring less than 4.5 cm in diameter (25 lesions) were treated with superselective intra-arterial injection of I-131-labeled Lipiodol (370-1,100 MBq in 3-5 ml) using a 5-F or coaxial catheter. All the lesions were nodular, multinodular, or hypervascular on pretreatment angiography. In all, 15 lesions that received over 180 Gy of cumulative radiation decreased in size in proportion to the Lipiodol retention on CT, and no pericapsular recurrence was found on angiography after 14-54 months of follow-up. In five patients who subsequently underwent surgery, 65% to 100% tumor necrosis was detected. No abnormal change in liver function tests or untoward clinical symptom of the lung, thyroid, or bone marrow was detected in patients who survived for more than 3 years after the treatment. Superselective high-dose internal radiation therapy of small HCC offers hope of treatment and long-term local control without complications.