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Pang L, Xu LB, Wu WR. Downstaging of Hepatocellular Carcinoma Before Liver Transplantation: Current Advances in Selection Criteria and Therapeutic Options. Transplant Proc 2024:S0041-1345(24)00353-1. [PMID: 39089899 DOI: 10.1016/j.transproceed.2024.05.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Accepted: 05/07/2024] [Indexed: 08/04/2024]
Abstract
Liver transplantation (LT) is an ideal therapeutic option for selected patients with hepatocellular carcinoma (HCC). The selection criteria of HCC for LT have evolved in recent decades. Downstaging therapy is a promising strategy for patients with tumor burden beyond transplant criteria to increase the chance of receiving LT and improve posttransplant survival. Downstaging therapy is also a selection tool that refines the conventional selection criteria based on tumor morphology. Recently, the success of systemic treatment, including immune checkpoint inhibitors, antiangiogenic tyrosine kinase inhibitors, and VEGF inhibitors, in advanced HCC has prompted the discussion regarding the role of systemic therapies for HCC downstaging before transplantation. In this review, we aimed to summarize the current advances in selection criteria and therapeutic options of downstaging therapy for HCC before LT.
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Affiliation(s)
- Li Pang
- Liver Transplantation Center & Department of Biliary-Pancreatic Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Lei-Bo Xu
- Liver Transplantation Center & Department of Biliary-Pancreatic Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wen-Rui Wu
- Liver Transplantation Center & Department of Biliary-Pancreatic Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China.
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Jin S, Huang J, Dong Y, Hu D, Sun J, Li Z, Zhong BY, Liu Z, Zhu R, Wang G. Ultrastable PLGA-Coated 177Lu-Microspheres for Radioembolization Therapy of Hepatocellular Carcinoma. Mol Pharm 2024; 21:3407-3415. [PMID: 38822792 DOI: 10.1021/acs.molpharmaceut.4c00138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2024]
Abstract
Transarterial radioembolization (TARE) is a highly effective localized radionuclide therapy that has been successfully used to treat hepatocellular carcinoma (HCC). Extensive research has been conducted on the use of radioactive microspheres (MSs) in TARE, and the development of ideal radioactive MSs is crucial for clinical trials and patient treatment. This study presents the development of a radioactive MS for TARE of HCC. These MSs, referred to as 177Lu-MS@PLGA, consist of poly(lactic-co-glycolic acid) (PLGA) copolymer and radioactive silica MSs, labeled with 177Lu and then coated with PLGA. It has an extremely high level of radiostability. Cellular experiments have shown that it can cause DNA double-strand breaks, leading to cell death. In vivo radiostability of 177Lu-MS@PLGA is demonstrated by microSPECT/CT imaging. In addition, the antitumor study has shown that TARE of 177Lu-MS@PLGA can effectively restrain tumor growth without harmful side effects. Thus, 177Lu-MS@PLGA exhibits significant potential as a radioactive MS for the treatment of HCC.
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Affiliation(s)
- Shuo Jin
- State Key Laboratory of Radiation Medicine and Protection, School of Radiation Medicine and Protection, Collaborative Innovation Center of Radiation Medicine of Jiangsu Higher Education Institutions, Soochow University, Suzhou 215123, China
| | - Jintao Huang
- Department of Interventional Radiology, the First Affiliated Hospital of Soochow University, Suzhou 215006, China
| | - Yi Dong
- State Key Laboratory of Radiation Medicine and Protection, School of Radiation Medicine and Protection, Collaborative Innovation Center of Radiation Medicine of Jiangsu Higher Education Institutions, Soochow University, Suzhou 215123, China
| | - Di Hu
- Department of Interventional Radiology, the First Affiliated Hospital of Soochow University, Suzhou 215006, China
| | - Jing Sun
- State Key Laboratory of Radiation Medicine and Protection, School of Radiation Medicine and Protection, Collaborative Innovation Center of Radiation Medicine of Jiangsu Higher Education Institutions, Soochow University, Suzhou 215123, China
| | - Zhihao Li
- State Key Laboratory of Radiation Medicine and Protection, School of Radiation Medicine and Protection, Collaborative Innovation Center of Radiation Medicine of Jiangsu Higher Education Institutions, Soochow University, Suzhou 215123, China
| | - Bin-Yan Zhong
- Department of Interventional Radiology, the First Affiliated Hospital of Soochow University, Suzhou 215006, China
| | - Zhiyong Liu
- State Key Laboratory of Radiation Medicine and Protection, School of Radiation Medicine and Protection, Collaborative Innovation Center of Radiation Medicine of Jiangsu Higher Education Institutions, Soochow University, Suzhou 215123, China
| | - Ran Zhu
- State Key Laboratory of Radiation Medicine and Protection, School of Radiation Medicine and Protection, Collaborative Innovation Center of Radiation Medicine of Jiangsu Higher Education Institutions, Soochow University, Suzhou 215123, China
| | - Guanglin Wang
- State Key Laboratory of Radiation Medicine and Protection, School of Radiation Medicine and Protection, Collaborative Innovation Center of Radiation Medicine of Jiangsu Higher Education Institutions, Soochow University, Suzhou 215123, China
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Regnault H, Chalaye J, Galetto-Pregliasco A, Perrin C, Derbel H, Amaddeo G, Mulé S, Lequoy M, Kobeiter H, Reizine E, Itti E, Duvoux C, Laurent A, Leroy V, Sommacale D, Rasolonirina D, Luciani A, Calderaro J, Tacher V, Brustia R. Selective internal radiation therapy for unresectable HCC: The SIRT downstaging study. Hepatol Commun 2024; 8:e0475. [PMID: 38934702 PMCID: PMC11213600 DOI: 10.1097/hc9.0000000000000475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 05/02/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND Selective internal radiation therapy (SIRT) is recommended as a downstaging (DS) strategy for solitary unresectable HCC <8 cm. The aim of this study was to report the results of acquired experience in a tertiary center for all unresectable HCCs. METHODS We conducted a retrospective, observational study using data collected from consecutive patients undergoing SIRT between October 2013 and June 2020. DS was considered achieved when a curative treatment could be proposed 6 months after SIRT. RESULTS One hundred twenty-seven patients were included (male = 90%, 64 ± 11 y), of whom 112 (n = 88%) had cirrhosis. HCC was classified as BCLC stage C in 64 patients (50%), with a median diameter of 61 mm, an infiltrative pattern in 51 patients (40%), and portal vein invasion in 62 (49%) patients. Fifty patients (39%) achieved DS 6 months following SIRT, with 29 of them (23%) undergoing curative treatment in a median time of 4.3 months: 17 (13%) were transplanted, 11 (85%) had liver resection, and 1 patient had a radiofrequency ablation. The median overall survival of patients with or without DS was 51 versus 10 months, respectively (p < 0.001). In patients who achieved DS, progression-free survival was higher in patients who underwent surgery: 47 versus 11 months (p < 0.001). Four variables were independently associated with DS: age (OR: 0.96, 95% CI: [0.92, 0.99]; p = 0.032), baseline α-fetoprotein (OR: 1.00, 95% CI: [1.00, 1.00]; p = 0.034), HCC distribution (OR: 0.3, 95% CI: [0.11, 0.75]; p = 0.012), and ALBI grade (OR: 0.34. 95% CI: [0.14, 0.80]; p = 0.014). CONCLUSIONS These results suggest that SIRT in patients with unresectable HCC could be an effective treatment: DS was achieved for around 39% of the patients and more than half of these then underwent curative treatment.
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Affiliation(s)
- Hélène Regnault
- Hepatology Department, Henri Mondor Hospital (AP-HP), Créteil, France
- Team “Viruses, Hepatology, Cancer”, Institut Mondor de Recherche Biomédicale, INSERM U955, Hôpital Henri Mondor (AP-HP), Université Paris-Est, Créteil, France
| | - Julia Chalaye
- Nuclear Medicine Department, Henri Mondor Hospital (AP-HP), Créteil, France
| | | | - Clara Perrin
- Hepatology Department, Henri Mondor Hospital (AP-HP), Créteil, France
| | - Haytham Derbel
- Radiology Department, Henri Mondor Hospital (AP-HP), Créteil, France
| | - Giuliana Amaddeo
- Hepatology Department, Henri Mondor Hospital (AP-HP), Créteil, France
- Team “Viruses, Hepatology, Cancer”, Institut Mondor de Recherche Biomédicale, INSERM U955, Hôpital Henri Mondor (AP-HP), Université Paris-Est, Créteil, France
| | - Sébastien Mulé
- Team “Viruses, Hepatology, Cancer”, Institut Mondor de Recherche Biomédicale, INSERM U955, Hôpital Henri Mondor (AP-HP), Université Paris-Est, Créteil, France
- Radiology Department, Henri Mondor Hospital (AP-HP), Créteil, France
| | - Marie Lequoy
- Hepatology Department, Saint Antoine Hospital (AP-HP), Paris, France
| | - Hicham Kobeiter
- Radiology Department, Henri Mondor Hospital (AP-HP), Créteil, France
| | - Edouard Reizine
- Radiology Department, Henri Mondor Hospital (AP-HP), Créteil, France
| | - Emmanuel Itti
- Nuclear Medicine Department, Henri Mondor Hospital (AP-HP), Créteil, France
| | - Christophe Duvoux
- Hepatology Department, Henri Mondor Hospital (AP-HP), Créteil, France
| | - Alexis Laurent
- Hepatobiliary Surgery, Henri Mondor Hospital (AP-HP), Créteil, France
| | - Vincent Leroy
- Hepatology Department, Henri Mondor Hospital (AP-HP), Créteil, France
- Team “Viruses, Hepatology, Cancer”, Institut Mondor de Recherche Biomédicale, INSERM U955, Hôpital Henri Mondor (AP-HP), Université Paris-Est, Créteil, France
| | - Daniele Sommacale
- Hepatobiliary Surgery, Henri Mondor Hospital (AP-HP), Créteil, France
| | - Diana Rasolonirina
- Nuclear Medicine Department, Henri Mondor Hospital (AP-HP), Créteil, France
| | - Alain Luciani
- Team “Viruses, Hepatology, Cancer”, Institut Mondor de Recherche Biomédicale, INSERM U955, Hôpital Henri Mondor (AP-HP), Université Paris-Est, Créteil, France
- Radiology Department, Henri Mondor Hospital (AP-HP), Créteil, France
| | - Julien Calderaro
- Team “Viruses, Hepatology, Cancer”, Institut Mondor de Recherche Biomédicale, INSERM U955, Hôpital Henri Mondor (AP-HP), Université Paris-Est, Créteil, France
- Department of Pathology, Henri Mondor Hospital (AP-HP), Créteil, France
| | - Vania Tacher
- Team “Viruses, Hepatology, Cancer”, Institut Mondor de Recherche Biomédicale, INSERM U955, Hôpital Henri Mondor (AP-HP), Université Paris-Est, Créteil, France
- Radiology Department, Henri Mondor Hospital (AP-HP), Créteil, France
| | - Raffaele Brustia
- Team “Viruses, Hepatology, Cancer”, Institut Mondor de Recherche Biomédicale, INSERM U955, Hôpital Henri Mondor (AP-HP), Université Paris-Est, Créteil, France
- Hepatobiliary Surgery, Henri Mondor Hospital (AP-HP), Créteil, France
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Pianka KT, Barahman M, Minocha J, Redmond JW, Schnickel GT, Rose SC, Fowler KJ, Berman ZT. Voxel-based tumor dose correlates to complete pathologic necrosis after transarterial radioembolization for hepatocellular carcinoma. Eur J Nucl Med Mol Imaging 2024:10.1007/s00259-024-06813-8. [PMID: 38913189 DOI: 10.1007/s00259-024-06813-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 06/16/2024] [Indexed: 06/25/2024]
Abstract
PURPOSE The transarterial radioembolization (TARE) dose is traditionally calculated using the single-compartment Medical Internal Radiation Dose (MIRD) formula. This study utilized voxel-based dosimetry to correlate tumor dose with explant pathology in order to identify dose thresholds that predicted response. METHODS All patients with HCC treated with TARE using yttrium-90 [90Y] glass microspheres at a single institution between January 2015 - June 2023 who underwent liver transplantation were eligible. The [90Y] distribution and dose-volume histograms were determined using Simplicity90 (Mirada Medical, Oxford UK) with a Bremsstrahlung SPECT/CT. A complete response was assigned if explant pathology showed complete necrosis and the patient had not undergone additional treatments to the same tumor after TARE. Logistic regression and receiver operator characteristic (ROC) curves were constructed to evaluate dose thresholds correlated with response. RESULTS Forty-one patients were included. Twenty-six (63%) met criteria for complete response. Dose to 95% (D95), 70% (D70), and 50% (D50) of the tumor volume were associated with likelihood of complete response by logistic regression (all p < 0.05). For lesions with complete response versus without, the median D95 was 813 versus 232 Gy, D70 was 1052 versus 315 Gy, and D50 was 1181 versus 369 Gy (all p < 0.01). A D95 > 719 Gy had the highest accuracy at 68% (58% sensitivity, 87% specificity) for predicting complete response. Median percent of tumor volume receiving at least 100 Gy (V100), 200 Gy (V200), 300 Gy (V300), and 400 Gy (V400) also differed by pathologic response: the median V100, V200, V300, and V400 was 100% versus 99%, 100% versus 97%, 100% versus 74%, and 100% versus 43% in the complete response versus non-complete response groups, respectively (all p < 0.05). CONCLUSION Voxel-based dosimetry was well-correlated with explant pathology. The D95 threshold had the highest accuracy, suggesting the D95 may be a relevant target for multi-compartment dosimetry.
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Affiliation(s)
- Kurt T Pianka
- School of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Mark Barahman
- Department of Radiology, University of California San Diego, 200 West Arbor Drive, Mail Code 8756, San Diego, CA, USA
| | - Jeet Minocha
- Department of Radiology, University of California San Diego, 200 West Arbor Drive, Mail Code 8756, San Diego, CA, USA
| | - Jonas W Redmond
- Department of Radiology, University of California San Diego, 200 West Arbor Drive, Mail Code 8756, San Diego, CA, USA
| | - Gabriel T Schnickel
- Department of Surgery, University of California San Diego, La Jolla, CA, 92103, USA
| | - Steven C Rose
- Department of Radiology, University of California San Diego, 200 West Arbor Drive, Mail Code 8756, San Diego, CA, USA
| | - Kathryn J Fowler
- Department of Radiology, University of California San Diego, 200 West Arbor Drive, Mail Code 8756, San Diego, CA, USA
| | - Zachary T Berman
- Department of Radiology, University of California San Diego, 200 West Arbor Drive, Mail Code 8756, San Diego, CA, USA.
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Makary MS, Bozer J, Miller ED, Diaz DA, Rikabi A. Long-term Clinical Outcomes of Yttrium-90 Transarterial Radioembolization for Hepatocellular Carcinoma: A 5-Year Institutional Experience. Acad Radiol 2024; 31:1828-1835. [PMID: 37537129 DOI: 10.1016/j.acra.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 07/08/2023] [Accepted: 07/09/2023] [Indexed: 08/05/2023]
Abstract
RATIONALE AND OBJECTIVES To examine the clinical outcomes of yttrium-90 (Y90) transarterial radioembolization (TARE) for primary hepatocellular carcinoma (HCC) through the evaluation of a 5-year institutional experience. MATERIALS AND METHODS This retrospective study evaluated 88 consecutive patients with primary HCC receiving Y90 TARE treatment at an academic medical center from 2017 to 2021. Disease distribution was bilobar in 60.2% of patients with an average lesion diameter of 5.0 ± 3.4 cm and Barcelona Clinic Liver Cancer stage B or C in 77% of the participants. Clinical outcomes were elucidated by examination of complications, liver function tests, biochemical response, and radiographic response. Objective response ratio (ORR) and progression-free survival (PFS) were also calculated. RESULTS The mean administered Y90 radiation dose was 127.8 ± 20.2 Gy. No significant complications or LFT elevations occurred post-therapy. Of the 73.9% of patients with α-fetoprotein-producing tumors, 67.8% experienced a complete or partial biochemical response 1 month post-treatment. The ORR was 83.3% on 6-month imaging and PFS was 9.6 ± 8.5 months. Functional outcomes (Eastern Cooperative Oncology Group) were maintained or improved in 79.6% and 76.1% of patients by 6 months and 1 year post-treatment, respectively. The mean survival was 14.7 ± 12.1 months. At 6 months post-treatment, 77.3% of patients were downstaged to or maintained Milan criteria, which was sustained for 74.4% and 70.0% of patients 1 year and 2 years after treatment, respectively. CONCLUSION Y90-TARE is a safe and effective therapy for primary HCC. Enduring outcomes further act as a realistic bridge to liver transplantation, with a majority of patients maintaining Milan criteria and preserving their functional status long term.
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Affiliation(s)
- Mina S Makary
- Division of Vascular and Interventional Radiology, Department of Radiology, The Ohio State University Wexner Medical Center, 395 W 12th Avenue, 4th Floor, Columbus, OH 43210 (M.S.M., J.B., A.R.).
| | - Jordan Bozer
- Division of Vascular and Interventional Radiology, Department of Radiology, The Ohio State University Wexner Medical Center, 395 W 12th Avenue, 4th Floor, Columbus, OH 43210 (M.S.M., J.B., A.R.)
| | - Eric D Miller
- Department of Radiation Oncology, The Ohio State University Medical Center, Columbus, Ohio (E.D.M., D.A.D.)
| | - Dayssy A Diaz
- Department of Radiation Oncology, The Ohio State University Medical Center, Columbus, Ohio (E.D.M., D.A.D.)
| | - Ali Rikabi
- Division of Vascular and Interventional Radiology, Department of Radiology, The Ohio State University Wexner Medical Center, 395 W 12th Avenue, 4th Floor, Columbus, OH 43210 (M.S.M., J.B., A.R.)
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Mosenthal M, Adams W, Cotler S, Ding X, Borge M, Malamis A, Lee D, Thomas T, Jawahar A, Amin P, Molvar C. Locoregional Therapies for Hepatocellular Carcinoma prior to Liver Transplant: Comparative Pathologic Necrosis, Radiologic Response, and Recurrence. J Vasc Interv Radiol 2024; 35:506-514. [PMID: 38123127 DOI: 10.1016/j.jvir.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 11/30/2023] [Accepted: 12/08/2023] [Indexed: 12/23/2023] Open
Abstract
PURPOSE To compare pathologic tumor necrosis rates after locoregional therapies (LRTs) for hepatocellular carcinoma (HCC) prior to liver transplantation and evaluate radiologic-pathologic correlation along with posttransplant HCC recurrence. MATERIALS AND METHODS Consecutive patients with solitary HCC bridged or downstaged with LRT from 2010 to 2022 were included. LRTs were transarterial chemoembolization (TACE), radioembolization (yttrium-90 [90Y]), ablation, and stereotactic body radiotherapy (SBRT). Upfront combination therapy options were TACE/ablation and TACE/SBRT. Subsequent therapy crossover due to local recurrence was allowed. Posttreatment imaging closest to the time of transplant, explant histopathologic necrosis, and tumor recurrence after transplant were reviewed. RESULTS Seventy-three patients met inclusion criteria, of whom 5 (7%) required downstaging. 90Y alone (n = 36) and multimodal therapy (pooled upfront combination and crossover therapy, n = 23) resulted in significantly greater pathologic necrosis compared with TACE alone (n = 14; P = .01). High dose 90Y radiation segmentectomy (≥190 Gy; n = 27) and TACE/ablation (n = 7) showed highest rates of complete pathologic necrosis (CPN)-63% (n = 17) and 71% (n = 5), respectively. Patients with CPN had a mean lesion size of 2.5 cm, compared with 3.2 cm without CPN (P = .04), irrespective of LRT modality. HCC recurrence was more common in patients without CPN (16%, 6/37) than in those with CPN (3%, 1/36; P = .11). Using Liver Imaging Reporting and Data System (LI-RADS), a nonviable imaging response was 75% sensitive and 57% specific for CPN. CONCLUSIONS Radiation segmentectomy and multimodal therapy significantly improved CPN rates compared with TACE alone. A LI-RADS treatment response of nonviable did not confidently predict CPN.
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Affiliation(s)
- McKenzie Mosenthal
- Department of Radiology, Loyola University Medical Center, Maywood, Illinois
| | - William Adams
- Public Health Sciences, Loyola University Medical Center, Maywood, Illinois
| | - Scott Cotler
- Department of Medicine, Loyola University Medical Center, Maywood, Illinois
| | - Xianzhong Ding
- Department of Pathology, Loyola University Medical Center, Maywood, Illinois
| | - Marc Borge
- Department of Radiology, Loyola University Medical Center, Maywood, Illinois
| | - Angelo Malamis
- Department of Radiology, Loyola University Medical Center, Maywood, Illinois
| | - David Lee
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Tarita Thomas
- Department of Radiation Oncology, Northwestern Memorial Hospital, Chicago, Illinois
| | | | - Parag Amin
- Department of Radiology, Cleveland Clinic Florida, Weston, Florida
| | - Christopher Molvar
- Department of Radiology, Loyola University Medical Center, Maywood, Illinois; Edward Hines Jr. Veterans Affairs Hospital, Hines, Illinois.
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Jiang Z, Yang F, Wang W. Applications of Yttrium-90 ( 90Y) in Hepatocellular Carcinoma. Onco Targets Ther 2024; 17:149-157. [PMID: 38414759 PMCID: PMC10898254 DOI: 10.2147/ott.s445898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 02/17/2024] [Indexed: 02/29/2024] Open
Abstract
Hepatocellular carcinoma (HCC) is the most common primary liver cancer, affecting millions of people worldwide. Due to the lack of systemic radiation therapy in hepatocellular carcinoma, researchers have been investigating the use of yttrium-90 (90Y) radioembolization for local-regional tumor control since the 1960s. With the development of glass and resin 90Y microspheres and the durable local control, good long-term efficacy, and equivalent tumor responsiveness and tolerability of 90Y-selective internal irradiation compared with alternative therapies such as transarterial chemoembolization (TACE) and sorafenib, 90Y radioembolization has gradually been applied in the treatment of hepatocellular carcinoma of all stages. In this article, we summarize the latest progress of 90Y in the treatment of hepatocellular carcinoma in terms of its principle, advantages, indications, contraindications, efficacy and adverse effects.
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Affiliation(s)
- ZhongHao Jiang
- Inner Mongolia Medical University, Department of Hepatobiliary Surgery, Affiliated Hospital of Inner Mongolia Medical University, Inner Mongolia, 010050, People’s Republic of China
| | - Fan Yang
- Inner Mongolia Medical University, Department of Hepatobiliary Surgery, Affiliated Hospital of Inner Mongolia Medical University, Inner Mongolia, 010050, People’s Republic of China
| | - WanXiang Wang
- Inner Mongolia Medical University, Department of Hepatobiliary Surgery, Affiliated Hospital of Inner Mongolia Medical University, Inner Mongolia, 010050, People’s Republic of China
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8
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Villalobos A, Pisanie JLD, Gandhi RT, Kokabi N. Yttrium-90 Radioembolization Dosimetry: Dose Considerations, Optimization, and Tips. Semin Intervent Radiol 2024; 41:63-78. [PMID: 38495257 PMCID: PMC10940044 DOI: 10.1055/s-0044-1779715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Affiliation(s)
- Alexander Villalobos
- Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Johannes L. du Pisanie
- Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Ripal T. Gandhi
- Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Nima Kokabi
- Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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9
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Schönherr J, Seifert P, Gühne F, Winkens T, Rauchfuß F, Settmacher U, Freesmeyer M, Drescher R. Transarterial Radioembolization (TARE) in Patients with Hepatocellular Carcinoma: A Comparison of Palliative with Bridging-to-Transplant Concepts. Cancers (Basel) 2024; 16:235. [PMID: 38201662 PMCID: PMC10778280 DOI: 10.3390/cancers16010235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 01/01/2024] [Accepted: 01/03/2024] [Indexed: 01/12/2024] Open
Abstract
We investigated transarterial radioembolization (TARE) as a palliative measure and bridging-to-transplant therapy in hepatocellular carcinoma (HCC) patients. A total of 167 patients (50 bridging, 117 palliative) with 245 TARE procedures were assessed. Fourteen patients underwent subsequent liver transplantation (LT). Patients undergoing LT exhibited significantly prolonged progression-free survival (PFS) compared to those with bridging-without-transplant (p = 0.033). No significant differences were observed between patients with bridging-without-transplant and palliative cases (p = 0.116). Median overall survival (OS) post-TARE was 16.6 months, with estimated OS rates at 6/12 months of 82.0%/60.5%, respectively. Patients who underwent LT demonstrated statistically significantly longer OS compared to those with bridging-without-transplant (p = 0.001). No marked outcome distinctions were found between bridging-without-transplant and palliative groups. The findings underscored the superiority of LT over alternative treatments. TARE served as an important component in non-LT scenarios, allowing for subsequent therapeutic options. The study reflected the highly variable and complex situations of patients with HCC, emphasizing the need for further investigations to define an optimal multimodal approach.
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Affiliation(s)
- Jacqueline Schönherr
- Clinic of Nuclear Medicine, Jena University Hospital, 07747 Jena, Germany; (J.S.); (P.S.); (F.G.); (T.W.); (R.D.)
| | - Philipp Seifert
- Clinic of Nuclear Medicine, Jena University Hospital, 07747 Jena, Germany; (J.S.); (P.S.); (F.G.); (T.W.); (R.D.)
| | - Falk Gühne
- Clinic of Nuclear Medicine, Jena University Hospital, 07747 Jena, Germany; (J.S.); (P.S.); (F.G.); (T.W.); (R.D.)
| | - Thomas Winkens
- Clinic of Nuclear Medicine, Jena University Hospital, 07747 Jena, Germany; (J.S.); (P.S.); (F.G.); (T.W.); (R.D.)
| | - Falk Rauchfuß
- Center of Transplant Surgery, Department of General, Visceral and Vascular Surgery, Jena University Hospital, 07747 Jena, Germany; (F.R.); (U.S.)
| | - Utz Settmacher
- Center of Transplant Surgery, Department of General, Visceral and Vascular Surgery, Jena University Hospital, 07747 Jena, Germany; (F.R.); (U.S.)
| | - Martin Freesmeyer
- Clinic of Nuclear Medicine, Jena University Hospital, 07747 Jena, Germany; (J.S.); (P.S.); (F.G.); (T.W.); (R.D.)
| | - Robert Drescher
- Clinic of Nuclear Medicine, Jena University Hospital, 07747 Jena, Germany; (J.S.); (P.S.); (F.G.); (T.W.); (R.D.)
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Núñez KG, Sandow T, Gimenez J, Hibino M, Fort D, Cohen AJ, Thevenot PT. Lineage-specific regulation of PD-1 expression in early-stage hepatocellular carcinoma following 90yttrium transarterial radioembolization - Implications in treatment outcomes. Eur J Cancer 2024; 196:113442. [PMID: 37988841 DOI: 10.1016/j.ejca.2023.113442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 11/03/2023] [Accepted: 11/09/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) remains one of the leading causes of cancer-related deaths in the world. Liver-directed therapies, including 90Yttrium (90Y) radioembolization, play an integral role in the management of HCC with excellent response rates. This has led to clinical trials of immunotherapy in combination with 90Y. Elevated PD-1 expression and lymphopenia were recently shown as risk factors for disease progression in early-stage HCC treated with liver-directed therapies. The aim of this study was to investigate PD-1 expression dynamics in bridge/downstage to transplant in HCC patients receiving first-cycle 90Y and evaluate the impact of these changes on response rates and time-to-progression (TTP). METHODS Patients with HCC receiving first-cycle 90Y as a bridge to liver transplantation (n = 99) were prospectively enrolled. Blood specimens were collected before 90Y and again during routine imagining follow-up to analyze PD-1 expression via flow cytometry. Complete and objective response rates (CR and ORR) were determined using mRECIST. RESULTS In 84/88 patients with available follow-up imaging, 83% had a localized ORR with 63% having localized CR. For overall response, 71% and 54% experienced ORR and CR, respectively. Post-90Y PD-1 upregulation in CD8 + associated with HCC progression and decreased TTP. Treatment with 90Y was associated with an anticipated significant post-treatment drop in lymphocytes (P < 0.001) that was independent of PD-1 expression for either CD4+ or CD8+ T cells (P = 0.751 and P = 0.375) and not associated with TTP risk. The change in lymphocytes was not correlated with PD-1 expression following treatment nor TTP. CONCLUSIONS Elevated PD-1 expression on peripheral T cells is associated with increased risk of HCC progression and shorter time to progression in bridging/downstaging to transplant HCC patients undergoing first-cycle 90Y. Treatment-induced lymphopenia was not associated with treatment response, or increased progression risk, suggesting this anticipated adverse event does not impact short-term HCC outcomes.
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Affiliation(s)
- Kelley G Núñez
- Institute of Translational Research, Ochsner Health System, New Orleans, LA, United States
| | - Tyler Sandow
- Interventional Radiology, Ochsner Health System, New Orleans, LA, United States
| | - Juan Gimenez
- Interventional Radiology, Ochsner Health System, New Orleans, LA, United States
| | - Mina Hibino
- Institute of Translational Research, Ochsner Health System, New Orleans, LA, United States
| | - Daniel Fort
- Center for Outcomes Research, Ochsner Health System, New Orleans, LA, United States
| | - Ari J Cohen
- Multi-Organ Transplant Institute, Ochsner Health System, New Orleans, LA, United States; Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Paul T Thevenot
- Institute of Translational Research, Ochsner Health System, New Orleans, LA, United States.
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11
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Ozen M, Patel RK. Ablation versus Radiation Segmentectomy for Small Liver Tumors. Semin Intervent Radiol 2023; 40:511-514. [PMID: 38274221 PMCID: PMC10807957 DOI: 10.1055/s-0043-1777714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
Hepatocellular carcinoma (HCC) is a liver malignancy that affects more than a million people worldwide with a complex multifactorial etiology. After the diagnosis of HCC is made, physicians establish management using the Barcelona Clinic Liver Cancer (BCLC) guidelines revolving around tumor stage, liver function, performance status, and patient preferences. According to recent updates to these guidelines, thermal ablation is the second-best curative option apart from surgical resection for small HCC (< 2 cm). While thermal ablation is standard of care, recent studies have suggested that radiation segmentectomy (RS) has similar outcomes, limited hepatotoxicity, and ultimately a cost-efficient approach. Although there is limited literature on RS, this article compares ablation techniques against radiation segmentectomy for small HCC tumors.
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Affiliation(s)
- Merve Ozen
- Department of Radiology, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Ronak K. Patel
- University of Kentucky College of Medicine, Lexington, Kentucky
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12
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Lam M, Garin E, Palard-Novello X, Mahvash A, Kappadath C, Haste P, Tann M, Herrmann K, Barbato F, Geller B, Schaefer N, Denys A, Dreher M, Fowers KD, Gates V, Salem R. Direct comparison and reproducibility of two segmentation methods for multicompartment dosimetry: round robin study on radioembolization treatment planning in hepatocellular carcinoma. Eur J Nucl Med Mol Imaging 2023; 51:245-257. [PMID: 37698645 PMCID: PMC10684706 DOI: 10.1007/s00259-023-06416-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 08/24/2023] [Indexed: 09/13/2023]
Abstract
PURPOSE Investigate reproducibility of two segmentation methods for multicompartment dosimetry, including normal tissue absorbed dose (NTAD) and tumour absorbed dose (TAD), in hepatocellular carcinoma patients treated with yttrium-90 (90Y) glass microspheres. METHODS TARGET was a retrospective investigation in 209 patients with < 10 tumours per lobe and at least one tumour ≥ 3 cm ± portal vein thrombosis. Dosimetry was compared using two distinct segmentation methods: anatomic (CT/MRI-based) and count threshold-based on pre-procedural 99mTc-MAA SPECT. In a round robin substudy in 20 patients with ≤ 5 unilobar tumours, the inter-observer reproducibility of eight reviewers was evaluated by computing reproducibility coefficient (RDC) of volume and absorbed dose for whole liver, whole liver normal tissue, perfused normal tissue, perfused liver, total perfused tumour, and target lesion. Intra-observer reproducibility was based on second assessments in 10 patients ≥ 2 weeks later. RESULTS 99mTc-MAA segmentation calculated higher absorbed doses compared to anatomic segmentation (n = 209), 43.9% higher for TAD (95% limits of agreement [LoA]: - 49.0%, 306.2%) and 21.3% for NTAD (95% LoA: - 67.6%, 354.0%). For the round robin substudy (n = 20), inter-observer reproducibility was better for anatomic (RDC range: 1.17 to 3.53) than 99mTc-MAA SPECT segmentation (1.29 to 7.00) and similar between anatomic imaging modalities (CT: 1.09 to 3.56; MRI: 1.24 to 3.50). Inter-observer reproducibility was better for larger volumes. Perfused normal tissue volume RDC was 1.95 by anatomic and 3.19 by 99mTc-MAA SPECT, with corresponding absorbed dose RDC 1.46 and 1.75. Total perfused tumour volume RDC was higher, 2.92 for anatomic and 7.0 by 99mTc-MAA SPECT with corresponding absorbed dose RDC of 1.84 and 2.78. Intra-observer variability was lower for perfused NTAD (range: 14.3 to 19.7 Gy) than total perfused TAD (range: 42.8 to 121.4 Gy). CONCLUSION Anatomic segmentation-based dosimetry, versus 99mTc-MAA segmentation, results in lower absorbed doses with superior reproducibility. Higher volume compartments, such as normal tissue versus tumour, exhibit improved reproducibility. TRIAL REGISTRATION NCT03295006.
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Affiliation(s)
- Marnix Lam
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Etienne Garin
- Nuclear Medicine Department, Eugene Marquis Center, Rennes, France
| | | | - Armeen Mahvash
- Department of Interventional Radiology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Cheenu Kappadath
- Department of Interventional Radiology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Paul Haste
- Department of Clinical Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mark Tann
- Department of Clinical Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Ken Herrmann
- Department of Nuclear Medicine, University of Duisburg-Essen, and German Cancer Consortium (DKTK)-University Hospital Essen, Essen, Germany
| | - Francesco Barbato
- Department of Nuclear Medicine, University of Duisburg-Essen, and German Cancer Consortium (DKTK)-University Hospital Essen, Essen, Germany
| | - Brian Geller
- Department of Radiology, University of Florida, Gainesville, FL, USA
| | - Niklaus Schaefer
- Department of Nuclear Medicine and Molecular Imaging, Lausanne University Hospital CHUV, University of Lausanne, Lausanne, Switzerland
| | - Alban Denys
- Department of Radiology and Interventional Radiology, Lausanne University Hospital CHUV, University of Lausanne, Lausanne, Switzerland
| | | | | | - Vanessa Gates
- Department of Radiology, Northwestern Feinberg School of Medicine, Chicago, IL, USA
| | - Riad Salem
- Department of Radiology, Northwestern Feinberg School of Medicine, Chicago, IL, USA
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13
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Kamal O, Horvat N, Arora S, Chaudhry H, Elmohr M, Khanna L, Nepal PS, Wungjramirun M, Nandwana SB, Shenoy-Bhangle AS, Lee J, Kielar A, Marks R, Elsayes K, Fung A. Understanding the role of radiologists in complex treatment decisions for patients with hepatocellular carcinoma. Abdom Radiol (NY) 2023; 48:3677-3687. [PMID: 37715846 PMCID: PMC11234513 DOI: 10.1007/s00261-023-04033-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 08/18/2023] [Accepted: 08/20/2023] [Indexed: 09/18/2023]
Abstract
Hepatocellular carcinoma (HCC) is the most common primary malignant tumor of the liver and represents a significant global health burden. Management of HCC can be challenging due to multiple factors, including variable expectations for treatment outcomes. Several treatment options are available, each with specific eligibility and ineligibility criteria, and are provided by a multidisciplinary team of specialists. Radiologists should be aware of the types of treatment options available, as well as the criteria guiding the development of individualized treatment plans. This awareness enables radiologists to contribute effectively to patient-centered multidisciplinary tumor boards for HCC and play a central role in reassessing care plans when the treatment response is deemed inadequate. This comprehensive review aims to equip radiologists with an overview of HCC staging systems, treatment options, and eligibility criteria. The review also discusses the significance of imaging in HCC diagnosis, treatment planning, and monitoring treatment response. Furthermore, we highlight the crucial branch points in the treatment decision-making process that depend on radiological interpretation.
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Affiliation(s)
- Omar Kamal
- Department of Diagnostic Radiology, Oregon Health & Science University, Mail Code: L340, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA.
| | - Natally Horvat
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | | | | | | | | | - Manida Wungjramirun
- Department of Diagnostic Radiology, Oregon Health & Science University, Mail Code: L340, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | | | | | - James Lee
- University of Kentucky, Lexington, KY, USA
| | | | | | | | - Alice Fung
- Department of Diagnostic Radiology, Oregon Health & Science University, Mail Code: L340, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
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14
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Yu Q, Khanjyan M, Fidelman N, Pillai A. Contemporary applications of Y90 for the treatment of hepatocellular carcinoma. Hepatol Commun 2023; 7:e0288. [PMID: 37782464 PMCID: PMC10545406 DOI: 10.1097/hc9.0000000000000288] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 08/18/2023] [Indexed: 10/03/2023] Open
Abstract
Transarterial radioembolization (TARE) with yttrium-90 (90Y) microspheres has been widely adopted for the treatment of HCC. Recent advances in yttrium-90 (90Y) dosimetry have led to durable local responses. Radiation segmentectomy has become a viable alternative to thermal ablation for early-stage HCC (Barcelona Clinic Liver Cancer 0 and A) and has been commonly used as a bridge to transplant. TARE is also commonly used for downstaging to transplant using traditional lobar dosimetry and radiation segmentectomy techniques. Radiation lobectomy has a dual role in local tumor control and induction of contralateral liver lobe hypertrophy as a bridge to resection for patients with an inadequate future liver remnant. TARE continues to provide disease control for patients with limited vascular invasion and may be an alternative to systemic therapy for patients with localized advanced disease. The potential synergy between TARE and immunotherapy has been recognized, and prospective studies evaluating this combination are needed for patients with Barcelona Clinic Liver Cancer B and C HCC.
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Affiliation(s)
- Qian Yu
- Department of Radiology, University of Chicago Medical Center, University of Chicago, Chicago, Illinois, USA
| | - Michael Khanjyan
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California, USA
| | - Nicholas Fidelman
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California, USA
| | - Anjana Pillai
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Chicago Medical Center, University of Chicago, Chicago, Illinois, USA
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15
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Masior Ł, Krasnodębski M, Kuncewicz M, Karaban K, Jaszczyszyn I, Kruk E, Małecka-Giełdowska M, Korzeniowski K, Figiel W, Krawczyk M, Wróblewski T, Grąt M. Alpha-Fetoprotein Response after First Transarterial Chemoembolization (TACE) and Complete Pathologic Response in Patients with Hepatocellular Cancer. Cancers (Basel) 2023; 15:3962. [PMID: 37568778 PMCID: PMC10417598 DOI: 10.3390/cancers15153962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 07/27/2023] [Accepted: 07/31/2023] [Indexed: 08/13/2023] Open
Abstract
Transarterial chemoembolization (TACE) is used as a bridging treatment in liver transplant candidates with hepatocellular carcinoma (HCC). Alpha-fetoprotein (AFP) is the main tumor marker used for HCC surveillance. The aim of this study was to assess the potential of using the AFP change after the first TACE in the prediction of complete tumor necrosis. The study comprised 101 patients with HCC who underwent liver transplantation (LT) after TACE in the period between January 2011 and December 2020. The ΔAFP was defined as the difference between the AFP value before the first TACE and AFP either before the second TACE or the LT. The receiver operator characteristics (ROC) curves were used to identify an optimal cut-off value. Complete tumor necrosis was found in 26.1% (18 of 69) and 6.3% (2 of 32) of patients with an initial AFP level under and over 100 ng/mL, respectively (p = 0.020). The optimal cut-off value of ΔAFP for the prediction of complete necrosis was a decline of ≥10.2 ng/mL and ≥340.5 ng/mL in the corresponding subgroups. Complete tumor necrosis rates were: 62.5% (5 of 8) in patients with an initial AFP < 100 ng/mL and decline of ≥10.2 ng/mL; 21.3% (13 of 61) in patients with an initial AFP < 100 ng/mL and decline of <10.2 ng/mL; 16.7% (2 of 12) in patients with an initial AFP > 100 ng/mL and decline of ≥340.5 ng/mL; and null in 20 patients with an initial AFP > 100 ng/mL and decline of <340.5 ng/mL, respectively (p = 0.003). The simple scoring system, based on the initial AFP and AFP decline after the first treatment, distinguished between a high, intermediate and low probability of complete necrosis, with an area under the ROC curve of 0.699 (95% confidence intervals 0.577 to 0.821, p = 0.001). Combining the initial AFP with its change after the first treatment enables early identification of the efficacy of TACE.
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Affiliation(s)
- Łukasz Masior
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, 02-097 Warsaw, Poland; (M.K.); (M.K.); (K.K.); (I.J.); (E.K.); (W.F.); (M.K.); (T.W.); (M.G.)
| | - Maciej Krasnodębski
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, 02-097 Warsaw, Poland; (M.K.); (M.K.); (K.K.); (I.J.); (E.K.); (W.F.); (M.K.); (T.W.); (M.G.)
| | - Mikołaj Kuncewicz
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, 02-097 Warsaw, Poland; (M.K.); (M.K.); (K.K.); (I.J.); (E.K.); (W.F.); (M.K.); (T.W.); (M.G.)
| | - Kacper Karaban
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, 02-097 Warsaw, Poland; (M.K.); (M.K.); (K.K.); (I.J.); (E.K.); (W.F.); (M.K.); (T.W.); (M.G.)
| | - Igor Jaszczyszyn
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, 02-097 Warsaw, Poland; (M.K.); (M.K.); (K.K.); (I.J.); (E.K.); (W.F.); (M.K.); (T.W.); (M.G.)
| | - Emilia Kruk
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, 02-097 Warsaw, Poland; (M.K.); (M.K.); (K.K.); (I.J.); (E.K.); (W.F.); (M.K.); (T.W.); (M.G.)
| | | | | | - Wojciech Figiel
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, 02-097 Warsaw, Poland; (M.K.); (M.K.); (K.K.); (I.J.); (E.K.); (W.F.); (M.K.); (T.W.); (M.G.)
| | - Marek Krawczyk
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, 02-097 Warsaw, Poland; (M.K.); (M.K.); (K.K.); (I.J.); (E.K.); (W.F.); (M.K.); (T.W.); (M.G.)
| | - Tadeusz Wróblewski
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, 02-097 Warsaw, Poland; (M.K.); (M.K.); (K.K.); (I.J.); (E.K.); (W.F.); (M.K.); (T.W.); (M.G.)
| | - Michał Grąt
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, 02-097 Warsaw, Poland; (M.K.); (M.K.); (K.K.); (I.J.); (E.K.); (W.F.); (M.K.); (T.W.); (M.G.)
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16
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Soin A, Lesurtel M, Bhangui P, Cocchi L, Bouattour M, Clavien PA. Are patients with hepatocellular carcinoma and portal vein tumour thrombosis candidates for liver transplantation? J Hepatol 2023; 78:1124-1129. [PMID: 37208099 DOI: 10.1016/j.jhep.2023.03.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 03/27/2023] [Indexed: 05/21/2023]
Abstract
In this debate, the authors consider whether patients with hepatocellular carcinoma (HCC) and portal vein tumour thrombosis are candidates for liver transplantation (LT). The argument for LT in this context is based on the premise that, following successful downstaging treatment, LT confers a much greater clinical benefit in terms of survival outcomes than the available alternative (palliative systemic therapy). A major argument against relates to limitations in the quality of evidence for LT in this setting - in relation to study design, as well as heterogeneity in patient characteristics and downstaging protocols. While acknowledging the superior outcomes offered by LT for patients with portal vein tumour thrombosis, the counterargument is that expected survival in such patients is still below accepted thresholds for LT and, indeed, the levels achieved for other patients who receive transplants beyond the Milan criteria. Based on the available evidence, it seems too early for consensus guidelines to recommend such an approach, however, it is hoped that with higher quality evidence and standardised downstaging protocols, LT may soon be more widely indicated, including for this population with high unmet clinical need.
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Affiliation(s)
- Arvinder Soin
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Gurgaon, India
| | - Mickaël Lesurtel
- Department of HPB Surgery & Liver Transplantation, APHP Beaujon Hospital, University of Paris Cité, 100, bd General Leclerc, 92110 Clichy, France
| | - Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Gurgaon, India
| | - Lorenzo Cocchi
- Department of HPB Surgery & Liver Transplantation, APHP Beaujon Hospital, University of Paris Cité, 100, bd General Leclerc, 92110 Clichy, France
| | - Mohamed Bouattour
- Department of Hepatology, APHP Beaujon Hospital, University of Paris Cité, 100, Bd General Leclerc, 92110 Clichy, France
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17
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Shimada S, Shamaa T, Ivanics T, Kitajima T, Adhnan M, Collins K, Rizzari M, Yoshida A, Abouljoud M, Salgia R, Nagai S. Multiple Pretransplant Treatments for Patients Without Pathological Complete Response may Worsen Posttransplant Outcomes in Patients with Hepatocellular Carcinoma. Ann Surg Oncol 2023; 30:1408-1419. [PMID: 36434482 DOI: 10.1245/s10434-022-12789-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 10/28/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Liver transplant (LT) candidates with hepatocellular carcinoma (HCC) often receive cancer treatment before transplant. We investigated the impact of pre-transplant treatment for HCC on the risk of posttransplant recurrence. METHODS Adult HCC patients with LT at our institution between 2013 and 2020 were included. The impact of pre-LT cancer treatments on the cumulative recurrence was evaluated, using the Gray and Fine-Gray methods adjusted for confounding factors. Outcomes were considered in two ways: 1) by pathologically complete response (pCR) status within patients received pre-LT treatment; and 2) within patients without pCR, grouped by pre-LT treatment as A) none; B) one treatment; C) multiple treatments. RESULTS The sample included 179 patients, of whom 151 (84%) received pretreatment and 42 (28% of treated) demonstrated pCR. Overall, 22 (12%) patients experienced recurrence. The 5-year cumulative post-LT recurrence rate was significantly lower in patients with pCR than those without pCR (4.8% vs. 19.2%, P = 0.03). In bivariable analyses, pCR significantly decreased risk of recurrence. Among the 137 patients without pCR (viable HCC in the explant), 28 (20%) had no pretreatment (A), 70 (52%) had one treatment (B), and 39 (20%) had multiple treatments (C). Patients in Group C had higher 5-year recurrence rates than those in A or B (39.6% vs. 8.2%, 6.5%, P = 0.004 and P < 0.001, respectively). In bivariable analyses, multiple treatments was significantly associated with recurrence. CONCLUSIONS pCR is a favorable prognostic factor after LT. When pCR was not achieved by pre-LT treatment, the number of treatments might be associated with post-LT oncological prognosis.
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Affiliation(s)
- Shingo Shimada
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Health System, Detroit, MI, USA
| | - Tayseer Shamaa
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Health System, Detroit, MI, USA
| | - Tommy Ivanics
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Health System, Detroit, MI, USA
| | - Toshihiro Kitajima
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Health System, Detroit, MI, USA
| | - Mohamed Adhnan
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Health System, Detroit, MI, USA
| | - Kelly Collins
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Health System, Detroit, MI, USA
| | - Michael Rizzari
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Health System, Detroit, MI, USA
| | - Atsushi Yoshida
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Health System, Detroit, MI, USA
| | - Marwan Abouljoud
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Health System, Detroit, MI, USA
| | - Reena Salgia
- Division of Gastroenterology and Hepatology, Henry Ford Health System, Detroit, MI, USA
| | - Shunji Nagai
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Health System, Detroit, MI, USA.
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Guven DC, Yildirim HC, Chalabiyev E, Kus F, Yilmaz F, Yasar S, Akyildiz A, Aktas BY, Yalcin S, Dizdar O. Emerging treatment strategies in hepatobiliary cancer. Expert Rev Anticancer Ther 2023; 23:243-256. [PMID: 36803258 DOI: 10.1080/14737140.2023.2183844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
INTRODUCTION There have been significant advances in the treatment of hepatobiliary cancers, especially for advanced-stage disease. However, data is limited for optimal therapy selection in the first line and sequencing of available options. AREAS COVERED This review covers the systemic treatment of hepatobiliary cancers with an emphasis on the advanced stage. The previously published and ongoing trials will be discussed to create an algorithm for the current practice and to give future perspectives on how the field could go forward. EXPERT OPINION While there is no standard-of-care option in the adjuvant treatment of hepatocellular cancer, capecitabine is the standard of care for biliary tract cancer. The efficacy of adjuvant gemcitabine and cisplatin and the added benefit of radiotherapy to chemotherapy are yet to be defined. For the advanced stage, immunotherapy-based combinations became the standard of care for both hepatocellular and biliary tract cancers. The molecularly targeted therapy has profoundly changed the second-line and later treatment for biliary tract cancers, while the optimal second-line treatment for advanced hepatocellular cancer is yet to be defined due to rapid advances in the first-line setting.
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Affiliation(s)
- Deniz Can Guven
- Department of Medical Oncology, Hacettepe University Cancer Institute, Ankara, Turkey
| | - Hasan Cagri Yildirim
- Department of Medical Oncology, Hacettepe University Cancer Institute, Ankara, Turkey
| | - Elvin Chalabiyev
- Department of Medical Oncology, Hacettepe University Cancer Institute, Ankara, Turkey
| | - Fatih Kus
- Department of Medical Oncology, Hacettepe University Cancer Institute, Ankara, Turkey
| | - Feride Yilmaz
- Department of Medical Oncology, Hacettepe University Cancer Institute, Ankara, Turkey
| | - Serkan Yasar
- Department of Medical Oncology, Hacettepe University Cancer Institute, Ankara, Turkey
| | - Arif Akyildiz
- Department of Medical Oncology, Hacettepe University Cancer Institute, Ankara, Turkey
| | - Burak Yasin Aktas
- Department of Medical Oncology, Hacettepe University Cancer Institute, Ankara, Turkey
| | - Suayib Yalcin
- Department of Medical Oncology, Hacettepe University Cancer Institute, Ankara, Turkey
| | - Omer Dizdar
- Department of Medical Oncology, Hacettepe University Cancer Institute, Ankara, Turkey
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19
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Liver Resection and Transplantation Following Yttrium-90 Radioembolization for Primary Malignant Liver Tumors: A 15-Year Single-Center Experience. Cancers (Basel) 2023; 15:cancers15030733. [PMID: 36765691 PMCID: PMC9913597 DOI: 10.3390/cancers15030733] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 01/13/2023] [Accepted: 01/22/2023] [Indexed: 01/27/2023] Open
Abstract
Radioembolization (RE) may help local control and achieve tumor reduction while hypertrophies healthy liver and provides a test of time. For liver transplant (LT) candidates, it may attain downstaging for initially non-candidates and bridging during the waitlist. METHODS Patients diagnosed with HCC and ICC treated by RE with further liver resection (LR) or LT between 2005-2020 were included. All patients selected were discarded for the upfront surgical approach for not accomplishing oncological or surgical safety criteria after a multidisciplinary team assessment. Data for clinicopathological details, postoperative, and survival outcomes were retrospectively reviewed from a prospectively maintained database. RESULTS A total of 34 patients underwent surgery following RE (21 LR and 13 LT). Clavien-Dindo grade III-IV complications and mortality rates were 19.0% and 9.5% for LR and 7.7% and 0% for LT, respectively. After RE, for HCC and ICC patients in the LR group, 10-year OS rates were 57% and 60%, and 10-year DFS rates were 43.1% and 60%, respectively. For HCC patients in the LT group, 10-year OS and DFS rates from RE were 51.3% and 43.3%, respectively. CONCLUSION Liver resection after RE is safe and feasible with optimal short-term outcomes. Patients diagnosed with unresectable or high biological risk HCC or ICC, treated with RE, and rescued by LR may achieve optimal global and DFS rates. On the other hand, bridging or downstaging strategies to LT with RE in HCC patients show adequate recurrence rates as well as long-term survival.
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Yu CY, Huang PH, Tsang LLC, Hsu HW, Lim WX, Weng CC, Huang TL, Hsu CC, Chen CL, Ou HY, Cheng YF. Yttrium-90 Radioembolization as the Major Treatment of Hepatocellular Carcinoma. J Hepatocell Carcinoma 2023; 10:17-26. [PMID: 36660410 PMCID: PMC9843618 DOI: 10.2147/jhc.s385478] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 01/04/2023] [Indexed: 01/12/2023] Open
Abstract
Background The purpose of this study was to assess the safety and efficacy of Yttrium-90 radioembolization using in unresectable hepatocellular carcinoma. Methods From 2017 to 2021, 32 patients with unresectable hepatocellular carcinoma, with mean tumor diameter about 7cm (21 males, 11 females; median age, 57.5 years of age), treated with Yttrium-90 radioembolization using resin microspheres were reviewed at pre-Yttrium-90 and post-Yttrium-90 follow-up. Tumor response was assessed according to the modified Response Evaluation Criteria in Solid Tumors. Outcomes including overall survival and progression-free survival were reported. Results Median follow-up was 18 months. At follow-up examinations at 3-, 6-, and 12-months follow-up, the overall survival rates were 94%, 87% and 59%, and the progression-free survival rates were 78%, 64% and 60%, respectively. Complete response, partial response, stable disease, and progressive disease were noted in 7 (21.9%), 14 (43.7%), 4 (12.5%), and 7 (21.9%) patients, respectively. The disease control rate was 78.1%, the objective response rate was 65.6%, and the successful downstage rate was 34.4% (11 of 32). Nine of thirty-two patients underwent resection or transplantation after Yttrium-90 radioembolization with 2-year overall survival being 100%. No serious adverse events occurred after Yttrium-90 treatment. Worse overall survival was related to the larger tumor, higher stage, Eastern Cooperative Oncology Group performance status, and Child-Pugh score. And worse progression-free survival was related to the higher tumor burden, and pre-Yttrium-90 serum α-fetoprotein level >100. Conclusion Yttrium-90 Radioembolization can control hepatocellular carcinoma well even in advanced diseases. Patients successfully downstaging/bridging to resection or transplantation have excellent overall survival.
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Affiliation(s)
- Chun-Yen Yu
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Po-Hsun Huang
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Leo Leung-Chit Tsang
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Hsien-Wen Hsu
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Wei-Xiong Lim
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Ching-Chun Weng
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Tung-Liang Huang
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chien-Chin Hsu
- Department of Nuclear Medicine, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chao-Long Chen
- Liver Transplantation Center and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Hsin-You Ou
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yu-Fan Cheng
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, Kaohsiung, Taiwan,Correspondence: Yu-Fan Cheng; Hsin-You Ou, Tel/Fax +88677317123-3027, Email ;
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21
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Patel MV, Davies H, Williams AO, Bromilow T, Baker H, Mealing S, Holmes H, Anderson N, Ahmed O. Transarterial therapies in patients with hepatocellular carcinoma eligible for transarterial embolization: a US cost-effectiveness analysis. J Med Econ 2023; 26:1061-1071. [PMID: 37632520 DOI: 10.1080/13696998.2023.2248840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 08/10/2023] [Accepted: 08/14/2023] [Indexed: 08/28/2023]
Abstract
OBJECTIVES To assess the cost-effectiveness of transarterial radioembolization (TARE) versus conventional transarterial chemoembolization (cTACE) and drug-eluting beads chemoembolization (DEE-TACE) for patients with unresectable early- to intermediate-stage hepatocellular carcinoma (HCC). DESIGN A cohort-based Markov model with a five-year time horizon was developed to evaluate the cost-effectiveness of the three embolization treatments. Upon entering the model, patients with HCC received either TARE or one of the two other embolization treatments. Patients remained in a "watch and wait" state for tumor downstaging that allowed them to move to health states such as liver transplant, resection, systemic therapies, or cure. Clinical input parameters were retrieved from the published literature, and where values could not be sourced, assumptions were made and validated by clinical experts. Health benefits were quantified using quality-adjusted life years (QALYs). Cost input parameters were obtained from various sources, including the Medicare Cost Report, IBM® Micromedex RED BOOK, and published literature. RESULTS At five years, TARE was found to be cost-saving (saving $15,779 per person compared to cTACE) and produced 0.33 more QALYs per person than cTACE. TARE cost $13,696 more but produced 0.33 more QALYs than DEE-TACE, with an incremental cost-effectiveness ratio of $41,474 per QALY gained at five years. After accounting for parameter uncertainty, the likelihood of TARE being cost-effective was at least 90% against all comparators at a cost-effectiveness threshold of $100,000 per QALY gained. CONCLUSIONS TARE produces more QALYs than cTACE and DEE-TACE, with a high probability of being cost-effective against both comparators.
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Affiliation(s)
- Mikin V Patel
- Section of Interventional Radiology, Department of Radiology, University of Chicago Medicine, Chicago, IL, USA
| | - Heather Davies
- York Health Economics Consortium, University of York, Heslington, UK
| | | | - Tom Bromilow
- York Health Economics Consortium, University of York, Heslington, UK
| | - Hannah Baker
- York Health Economics Consortium, University of York, Heslington, UK
| | - Stuart Mealing
- York Health Economics Consortium, University of York, Heslington, UK
| | - Hayden Holmes
- York Health Economics Consortium, University of York, Heslington, UK
| | | | - Osman Ahmed
- Section of Interventional Radiology, Department of Radiology, University of Chicago Medicine, Chicago, IL, USA
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22
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Salem R, Padia SA, Lam M, Chiesa C, Haste P, Sangro B, Toskich B, Fowers K, Herman JM, Kappadath SC, Leung T, Sze DY, Kim E, Garin E. Clinical, dosimetric, and reporting considerations for Y-90 glass microspheres in hepatocellular carcinoma: updated 2022 recommendations from an international multidisciplinary working group. Eur J Nucl Med Mol Imaging 2023; 50:328-343. [PMID: 36114872 PMCID: PMC9816298 DOI: 10.1007/s00259-022-05956-w] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 08/23/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE In light of recently published clinical reports and trials, the TheraSphere Global Dosimetry Steering Committee (DSC) reconvened to review new data and to update previously published clinical and dosimetric recommendations for the treatment of hepatocellular carcinoma (HCC). METHODS The TheraSphere Global DSC is comprised of health care providers across multiple disciplines involved in the treatment of HCC with yttrium-90 (Y-90) glass microsphere-based transarterial radioembolization (TARE). Literature published between January 2019 and September 2021 was reviewed, discussed, and adjudicated by the Delphi method. Recommendations included in this updated document incorporate both the results of the literature review and the expert opinion and experience of members of the committee. RESULTS Committee discussion and consensus led to the expansion of recommendations to apply to five common clinical scenarios in patients with HCC to support more individualized efficacious treatment with Y-90 glass microspheres. Existing clinical scenarios were updated to reflect recent developments in dosimetry approaches and broader treatment paradigms evolving for patients presenting with HCC. CONCLUSION Updated consensus recommendations are provided to guide clinical and dosimetric approaches for the use of Y-90 glass microsphere TARE in HCC, accounting for disease presentation, tumor biology, and treatment intent.
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Affiliation(s)
- Riad Salem
- Department of Radiology, Northwestern Feinberg School of Medicine, 676 N. St. Clair, Suite 800, Chicago, IL, USA.
| | - Siddharth A Padia
- Department of Radiology, University of California-Los Angeles, Los Angeles, CA, USA
| | - Marnix Lam
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Carlo Chiesa
- Department of Nuclear Medicine, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Paul Haste
- Department of Interventional Radiology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Bruno Sangro
- Liver Unit, Clinica Universidad de Navarra and CIBEREHD, Pamplona, Spain
| | - Beau Toskich
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Kirk Fowers
- Boston Scientific Corporation, Marlborough, MA, USA
| | - Joseph M Herman
- Department of Radiation Medicine, Northwell Health, New Hyde Park, NY, USA
| | - S Cheenu Kappadath
- Department of Imaging Physics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Thomas Leung
- Comprehensive Oncology Centre, Hong Kong Sanatorium and Hospital, Hong Kong, Hong Kong
| | - Daniel Y Sze
- Department of Radiology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Edward Kim
- Department of Interventional Radiology, Mount Sinai, New York City, NY, USA
| | - Etienne Garin
- INSERM, INRA, Centre de Lutte Contre Le Cancer Eugène Marquis, Institut NUMECAN (Nutrition Metabolisms and Cancer), Univ Rennes, 35000, Rennes, France
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23
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Yan H, Xiang Z, Zhao C, Zou S, Huang M. Long-term Outcomes of Patients with Hepatocellular Carcinoma Who Underwent Microwave Ablation after Downstaging with Transarterial Chemoembolization to Barcelona Clinic Liver Cancer Stage A. J Vasc Interv Radiol 2022; 34:768-776. [PMID: 36581194 DOI: 10.1016/j.jvir.2022.12.466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 10/23/2022] [Accepted: 12/19/2022] [Indexed: 12/28/2022] Open
Abstract
PURPOSE To compare the clinical results of microwave ablation (MWA) between patients downstaged to Barcelona Clinic Liver Cancer (BCLC) Stage A with transarterial chemoembolization (TACE) and those initially classified as BCLC Stage A. MATERIALS AND METHODS From January 2012 to May 2017, 1,087 patients were reviewed retrospectively using propensity score matching (1:1): 86 patients underwent MWA as a curative treatment after downstaging to BCLC Stage A by TACE (downstaging group) and 86 patients initially classified as BCLC Stage A underwent MWA (control group). The overall survival (OS) and disease-free survival (DFS) between the 2 groups were compared. RESULTS The 1-, 3-, and 5-year OS rates were 95.3%, 79.1%, and 58.1%, respectively, in the downstaging group and 93.0%, 81.4%, and 61.6%, respectively, in the control group (hazard ratio [HR], 0.75; 95% CI, 0.50-1.13; P = .162). The 1-, 3-, and 5-year DFS rates were 80.2%, 50.0%, and 24.4%, respectively, in the downstaging group and 77.9%, 52.3%, and 27.9%, respectively, in the control group (HR, 1.08; 95% CI, 0.76-1.53; P = .678). No significant differences were found in OS and DFS. CONCLUSIONS The long-term prognosis in patients with HCC who underwent MWA after downstaging to BCLC Stage A using TACE was similar to that in patients with initial BCLC Stage A.
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Affiliation(s)
- Huzheng Yan
- Department of Interventional Radiology, the Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China; Department of Minimally Invasive & Interventional Radiology, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Zhanwang Xiang
- Department of Interventional Radiology, the Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Chenghao Zhao
- Department of Interventional Radiology, the Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Sibin Zou
- Department of Interventional Radiology, the Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Mingsheng Huang
- Department of Interventional Radiology, the Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.
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24
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Yttrium-90 Radioembolization: Current Indications and Outcomes. J Gastrointest Surg 2022; 27:604-614. [PMID: 36547759 DOI: 10.1007/s11605-022-05559-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 12/06/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND Radioembolization (RE) with 90Yttrium (Y90) has generally been used to treat patients with advanced disease. Recent data suggest, however, that RE is also safe and feasible to treat patients with early or intermediate stage disease. We herein review the current evidence regarding the use of RE with Y90 for patients with HCC. METHODS A comprehensive review of the literature was performed using MEDLINE/PubMed and Web of Science databases with a search end date of August 1, 2022. RESULTS Patients with HCC are often treated according to the BCLC staging system. Among patients with early-stage HCC (BCLC A), intermediate-stage HCC (BCLC B), and advanced-stage HCC (BCLC C), RE with Y90 has demonstrated promising results with comparable overall survival, time to disease progression, and radiological response compared with other standard of care treatment modalities. Moreover, Y90 RE can be used as a downstaging treatment modality for patients with advanced HCC who have a disease burden that is initially outside LT criteria. Radiation lobectomy (RL) has been described as a treatment modality with the intent of treating the ipsilateral liver that harbors the HCC, while also causing compensatory hypertrophy of the future liver remnant (FLR). CONCLUSION While initially considered as a palliative option for HCC patients, Y90 RE has emerged as an important part of the multi-modality care of patients with HCC across a wide spectrum of clinical indications.
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25
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Liu R, Li H, Qiu Y, Liu H, Cheng Z. Recent Advances in Hepatocellular Carcinoma Treatment with Radionuclides. Pharmaceuticals (Basel) 2022; 15:1339. [PMID: 36355512 PMCID: PMC9694760 DOI: 10.3390/ph15111339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 10/25/2022] [Accepted: 10/25/2022] [Indexed: 06/20/2024] Open
Abstract
As the third leading cause of cancer death worldwide, hepatocellular carcinoma (HCC) is characterized by late detection, difficult diagnosis and treatment, rapid progression, and poor prognosis. Current treatments for liver cancer include surgical resection, radiofrequency ablation, liver transplantation, chemotherapy, external radiation therapy, and internal radionuclide therapy. Radionuclide therapy is the use of high-energy radiation emitted by radionuclides to eradicate tumor cells, thus achieving the therapeutic effect. Recently, with the continuous development of biomedical technology, the application of radionuclides in treatment of HCC has progressed steadily. This review focuses on three types of radionuclide-based treatment regimens, including transarterial radioembolization (TARE), radioactive seed implantation, and radioimmunotherapy. Their research progress and clinical applications are summarized. The advantages, limitations, and clinical potential of radionuclide treatment of HCC are discussed.
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Affiliation(s)
- Ruiqi Liu
- Institute of Molecular Medicine, College of Life and Health Sciences, Northeastern University, Shenyang 110000, China
| | - Hong Li
- Institute of Molecular Medicine, College of Life and Health Sciences, Northeastern University, Shenyang 110000, China
| | - Yihua Qiu
- Institute of Molecular Medicine, College of Life and Health Sciences, Northeastern University, Shenyang 110000, China
| | - Hongguang Liu
- Institute of Molecular Medicine, College of Life and Health Sciences, Northeastern University, Shenyang 110000, China
| | - Zhen Cheng
- State Key Laboratory of Drug Research, Molecular Imaging Center, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai 201203, China
- Shandong Laboratory of Yantai Drug Discovery, Bohai Rim Advanced Research Institute for Drug Discovery, Yantai 264117, China
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26
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Goyal P, Salem R, Mouli SK. Role of interventional oncology in hepatocellular carcinoma: Future best practice beyond current guidelines. Br J Radiol 2022; 95:20220379. [PMID: 35867889 PMCID: PMC9815732 DOI: 10.1259/bjr.20220379] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is a leading cause of cancer-related deaths globally. Liver transplant remains the goal of curative treatment, but limited supply of organs decreases accessibility and prolongs waiting time to transplantation. Therefore, interventional oncology therapies have been used to treat the majority of HCC patients, including those awaiting transplant. The Barcelona Clinic Liver Cancer (BCLC) classification is the most widely used staging system in management of HCC that helps allocate treatments. Since its inception in 1999, it was updated for the fifth time in November 2021 and for the first time shaped by expert opinions outside the core BCLC group. The most recent version includes additional options for early-stage disease, substratifies intermediate disease into three groups, and lists alternates to Sorafenib that can double the expected survival of advanced-stage disease. The group also proposed a new BCLC staging schema for disease progression, and endorsed treatment stage migration (TSM) directly into the main staging and treatment algorithm. This article reviews the recent developments underlying the current BCLC guidelines and highlights ongoing research, particularly involving radioembolization, that will shape future best practice.
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Affiliation(s)
- Piyush Goyal
- Department of Radiology, Section of Interventional Radiology, Northwestern Feinberg School of Medicine, Chicago, Illinois, United States
| | - Riad Salem
- Department of Radiology, Section of Interventional Radiology, Northwestern Feinberg School of Medicine, Chicago, Illinois, United States
| | - Samdeep K. Mouli
- Department of Radiology, Section of Interventional Radiology, Northwestern Feinberg School of Medicine, Chicago, Illinois, United States
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Rothenberger NJ, Yu Q, Ramasamy SK, Van Ha T, Zangan S, Navuluri R, Ahmed O. Segmental Yttrium-90 Radioembolization as an Initial Treatment for Solitary Unresectable HCC. THE ARAB JOURNAL OF INTERVENTIONAL RADIOLOGY 2022. [DOI: 10.1055/s-0042-1758698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Abstract
Objectives To evaluate the objective response rate (ORR), time to progression (TTP), and overall survival (OS) in patients with unresectable solitary HCC less than 5 cm who were treated with 90Y glass microspheres infused at a segmental level.
Materials and Methods Single-institution retrospective study of 35 patients with unresectable HCC deemed not suitable for percutaneous ablation who underwent segmental transarterial radioembolization (TARE) treatment. Eligibility criteria included patients with solitary, unilobar, < 5 cm unresectable HCC lesions who underwent TARE as a primary treatment strategy between November 2012 and April 2020. Imaging follow-up was performed on each patient at 3-, 6-, and 12 months post-treatment. Local and the overall tumor response was evaluated using mRECIST criteria, and primary endpoints were ORR, TTP, and OS. Adverse events (AEs) were graded for severity using the Common Terminology Criteria for Adverse Events (CTCAE) v.5.0.
Statistical Analysis Patient demographics, baseline characteristics, and treatment characteristics were analyzed using descriptive statistics. Predictors of survival were analyzed with Cox proportional hazards regression. Kaplan–Meier analysis was used to evaluate OS.
Results Median tumor size was 3 cm (range: 1.0-4.8 cm) in the 35 patients studied, with 25.7% (9/35) being the Eastern Cooperative Oncology Group (ECOG) 0 and 62.9% (22/35) ECOG 1. Most patients (88.5%, 31/35) were of the Barcelona Clinic Liver Cancer (BCLC) stage C, with one patient each classified as BCLC-A and BCLC-0, respectively. For 34.2% (12/35), TARE functioned as a bridge to transplantation. Transplanted patients exhibited a median pathologic necrosis of 98% (IQR 7.5). Combined ORR for local and overall mRECIST at 12 months post-TARE was 94.3% and 85.7%, respectively. All patients had a mean local TTP of 11.9 months (CI: 2.7–21.0) and global TTP of 13.2 months (CI: 6.4–20.0). Among the 14.3% (5/35) of patients who experienced AEs following treatment, 80% (4/5) were Grade 1, one patient experienced a Grade 4, and all events resolved within 1 month of treatment. Total OS at 1 year was 97%, whereas patients who underwent OLT had an OS of 100%.
Conclusion Segmental TARE was a safe and effective treatment for solitary unresectable HCC less than 5 cm. When used as a bridge to transplant, explants showed near complete pathologic necrosis of treated lesions.
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Affiliation(s)
| | - Qian Yu
- Department of Radiology, University of Chicago, Chicago, Illinois, United States
| | - Shakthi K. Ramasamy
- Department of Radiology, Stanford University, Stanford, California, United States
| | - Thuong Van Ha
- Department of Radiology, University of Chicago, Chicago, Illinois, United States
| | - Steven Zangan
- Department of Radiology, University of Chicago, Chicago, Illinois, United States
| | - Rakesh Navuluri
- Department of Radiology, University of Chicago, Chicago, Illinois, United States
| | - Osman Ahmed
- Department of Radiology, University of Chicago, Chicago, Illinois, United States
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28
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Couillard AB, Knott EA, Zlevor AM, Mezrich JD, Cristescu MM, Agarwal P, Ziemlewicz TJ, Longhurst C, Lubner MG, Hinshaw JL, Said A, Laeseke PF, Lucey MR, Rice JP, Foley D, Al-Adra D, Lee FT. Microwave ablation as bridging to liver transplant for patients with hepatocellular carcinoma: a single-center retrospective analysis. J Vasc Interv Radiol 2022; 33:1045-1053. [PMID: 35667580 DOI: 10.1016/j.jvir.2022.05.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 05/03/2022] [Accepted: 05/27/2022] [Indexed: 11/28/2022] Open
Abstract
PURPOSE To evaluate the efficacy and safety of microwave (MW) ablation as first-line locoregional therapy (LRT) for bridging patients with hepatocellular carcinoma (HCC) to liver transplant. MATERIALS AND METHODS This retrospective study evaluated 88 patients who received percutaneous MW ablation for 141 tumors as first-line LRT for HCC and listed for liver transplantation at a single medical center between 2011 and 2019. Overall survival rate status-post liver transplant, waitlist retention and disease progression were evaluated using Kaplan-Meier techniques. RESULTS Of 88 patients (72M, 16F, mean age 60 years, MELD=11.2) listed for transplant, median waitlist time was 9.4 months (IQR: 5.5 - 18.9). Seventy-one patients (80.7%) received transplant after median wait time of 8.5 months. Seventeen patients (19.3%) were removed from the waitlist, four (4.5%) due to tumors outside of the Milan criteria (HCC-specific dropout). No difference in tumor size or AFP was seen in transplanted vs. non-transplanted patients at time of ablation (2.1 vs. 2.1 cm and 34.4 vs. 34.7 ng/mL for transplanted vs. non-transplanted, respectively, p>0.05). Five of 88 patients (5.1%) experienced adverse events after ablation; however, all recovered. There were no cases of tract seeding. The local tumor progression (LTP) rate was 7.2%. The overall survival status-post liver transplant at 5-years was 76.7% and the disease-specific survival after LT was 89.6% with a median follow-up of 61 months for all patients. CONCLUSION MW ablation appears to be safe and effective for bridging patients with HCC to liver transplant without waitlist removal from seeding, adverse events, or local tumor progression.
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Affiliation(s)
| | - Emily A Knott
- University of Wisconsin-Madison: Department of Radiology
| | - Annie M Zlevor
- University of Wisconsin-Madison: Department of Radiology
| | | | | | | | | | - Colin Longhurst
- Department of Carbone Cancer Center; Department of Biostatistics and Medical Informatics
| | | | - J Louis Hinshaw
- University of Wisconsin-Madison: Department of Radiology; Department of Urology
| | | | - Paul F Laeseke
- University of Wisconsin-Madison: Department of Radiology
| | | | | | | | | | - Fred T Lee
- University of Wisconsin-Madison: Department of Radiology; Department of Urology; Department of Biomedical Engineering.
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29
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Zane KE, Nagib PB, Jalil S, Mumtaz K, Makary MS. Emerging curative-intent minimally-invasive therapies for hepatocellular carcinoma. World J Hepatol 2022; 14:885-895. [PMID: 35721283 PMCID: PMC9157708 DOI: 10.4254/wjh.v14.i5.885] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 02/20/2022] [Accepted: 04/26/2022] [Indexed: 02/06/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is the most common cause of liver malignancy and the fourth leading cause of cancer deaths universally. Cure can be achieved for early stage HCC, which is defined as 3 or fewer lesions less than or equal to 3 cm in the setting of Child-Pugh A or B and an ECOG of 0. Patients outside of these criteria who can be down-staged with loco-regional therapies to resection or liver transplantation (LT) also achieve curative outcomes. Traditionally, surgical resection, LT, and ablation are considered curative therapies for early HCC. However, results from recently conducted LEGACY study and DOSISPHERE trial demonstrate that transarterial radio-embolization has curative outcomes for early HCC, leading to its recent incorporation into the Barcelona clinic liver criteria guidelines for early HCC. This review is based on current evidence for curative-intent loco-regional therapies including radioembolization for early-stage HCC.
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Affiliation(s)
- Kylie E Zane
- College of Medicine, The Ohio State University, Columbus, OH 43210, United States
| | - Paul B Nagib
- College of Medicine, The Ohio State University, Columbus, OH 43210, United States
| | - Sajid Jalil
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Khalid Mumtaz
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Mina S Makary
- Division of Vascular and Interventional Radiology, Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
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Shah MB, Villagomez Rubio DA, Orozco G, Desai S, Ancheta A, Gupta M, Mei X, Evers BM, Gedaly R, Cannon RM. Outcomes in Elderly Patients Undergoing Liver Transplantation Compared with Liver-Directed Ablative Therapy in Early-Stage Hepatocellular Carcinoma. J Am Coll Surg 2022; 234:892-899. [PMID: 35426403 DOI: 10.1097/xcs.0000000000000135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Orthotopic liver transplantation (OLT) is the accepted treatment in patients with unresectable, early-stage hepatocellular carcinoma (HCC) in the setting of cirrhosis. Due to increasing waitlist demand for OLT, determining optimal groups for transplant is critical. Elderly patients are known to have poorer postoperative outcomes. Considering the effectiveness of liver-directed therapies for HCC, we sought to determine whether elderly patients received survival benefit from OLT over liver-directed therapy alone. STUDY DESIGN The National Cancer Database participant use file was used to analyze data between 2004 and 2017. Only patients ≥70 years of age who received OLT or liver-directed therapy alone were included. Patients with alpha-fetoprotein >500 ng/mL or missing alpha-fetoprotein values were excluded. Baseline demographic variables, model for end-stage liver disease score, and overall survival from time of diagnosis were collected. Descriptive statistics, Kaplan-Meier survival, Cox proportional hazards model, and propensity score matching were used. RESULTS A total of 2,377 patients received ablative therapy alone, and 214 patients received OLT. Multivariable analysis and Kaplan-Meier showed that OLT conferred a significant survival benefit compared to liver-directed therapy alone. Age was also associated with a yearly 3% increase in risk of mortality. Propensity-matched analysis adjusting also demonstrated a significant survival benefit for elderly patients receiving OLT compared to liver-directed therapy alone. CONCLUSION Despite increased age and associated comorbidities being factors associated with poor outcomes, OLT confers a survival advantage compared to liver-directed ablative therapies alone in selected elderly patients with HCC. OLT should be offered in medically appropriate elderly patients with HCC.
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Affiliation(s)
- Malay B Shah
- From the Department of Surgery, Division of Transplantation (Shah, Rubio, Orozco, Desai, Ancheta, Gupta, Mei, Gedaly), University of Kentucky, Lexington, KY
| | - Diego A Villagomez Rubio
- From the Department of Surgery, Division of Transplantation (Shah, Rubio, Orozco, Desai, Ancheta, Gupta, Mei, Gedaly), University of Kentucky, Lexington, KY
| | - Gabriel Orozco
- From the Department of Surgery, Division of Transplantation (Shah, Rubio, Orozco, Desai, Ancheta, Gupta, Mei, Gedaly), University of Kentucky, Lexington, KY
| | - Siddharth Desai
- From the Department of Surgery, Division of Transplantation (Shah, Rubio, Orozco, Desai, Ancheta, Gupta, Mei, Gedaly), University of Kentucky, Lexington, KY
| | - Alexandre Ancheta
- From the Department of Surgery, Division of Transplantation (Shah, Rubio, Orozco, Desai, Ancheta, Gupta, Mei, Gedaly), University of Kentucky, Lexington, KY
| | - Meera Gupta
- From the Department of Surgery, Division of Transplantation (Shah, Rubio, Orozco, Desai, Ancheta, Gupta, Mei, Gedaly), University of Kentucky, Lexington, KY
| | - Xiaonan Mei
- From the Department of Surgery, Division of Transplantation (Shah, Rubio, Orozco, Desai, Ancheta, Gupta, Mei, Gedaly), University of Kentucky, Lexington, KY
| | - B Mark Evers
- Department of Surgery, Markey Cancer Center (Evers), University of Kentucky, Lexington, KY
| | - Roberto Gedaly
- From the Department of Surgery, Division of Transplantation (Shah, Rubio, Orozco, Desai, Ancheta, Gupta, Mei, Gedaly), University of Kentucky, Lexington, KY
| | - Robert M Cannon
- Department of Surgery, Division of Transplantation, University of Alabama at Birmingham, Birmingham, AL (Cannon)
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Hepatocellular carcinoma radiation segmentectomy treatment intensification prior to liver transplantation increases rates of complete pathologic necrosis: an explant analysis of 75 tumors. Eur J Nucl Med Mol Imaging 2022; 49:3892-3897. [PMID: 35441860 DOI: 10.1007/s00259-022-05776-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 03/21/2022] [Indexed: 02/06/2023]
Abstract
PURPOSE To verify the correlation between yttrium-90 glass microsphere radiation segmentectomy treatment intensification of hepatocellular carcinoma (HCC) and complete pathologic necrosis (CPN) at liver transplantation. METHODS A retrospective, single center, analysis of patients with HCC who received radiation segmentectomy prior to liver transplantation from 2016 to 2021 was performed. The tumor treatment intensification cohort (n = 38) was prescribed radiation segmentectomy as per response recommendations identified in a previously published baseline cohort study (n = 37). Treatment intensification and baseline cohort treatment parameters were compared for rates of CPN. Both cohorts were then combined for an overall analysis of treatment parameter correlation with CPN. RESULTS Sixty-three patients with a combined 75 tumors were analyzed. Specific activity, dose, and treatment activity were significantly higher in the treatment intensification cohort (all p < 0.01), while particles per cubic centimeter of treated liver were not. CPN was achieved in 76% (n = 29) of tumors in the treatment intensification cohort compared to 49% (n = 18) in the baseline cohort (p = 0.013). The combined cohort CPN rate was 63% (n = 47). ROC analysis showed that specific activity ≥ 327 Bq (AUC 0.75, p < 0.001), dose ≥ 446 Gy (AUC 0.69, p = 0.005), and treatment activity ≥ 2.55 Gbq (AUC 0.71, p = 0.002) were predictive of CPN. Multivariate logistic regression demonstrated that a specific activity ≥ 327 Bq was the sole independent predictor of CPN (p = 0.013). CONCLUSION Radiation segmentectomy treatment intensification for patients with HCC prior to liver transplantation increases rates of CPN. While dose strongly correlated with pathologic response, specific activity was the most significant independent radiation segmentectomy treatment parameter associated with CPN.
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Zhao X, Sun X, Huang W, Chen R, Chen K, Nie L, Fang C. A microenvironment-responsive FePt probes for imaging-guided Fenton-enhanced radiotherapy of hepatocellular carcinoma. J Nanobiotechnology 2022; 20:100. [PMID: 35241082 PMCID: PMC8892710 DOI: 10.1186/s12951-022-01305-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 02/11/2022] [Indexed: 02/07/2023] Open
Abstract
Hepatocellular carcinoma (HCC) continues to be one of the most fatal malignancies with increasing morbidity, and potent therapeutics are urgently required given its insensitivity to traditional treatments. Here, we have developed a microenvironment-responsive FePt probes for the highly efficient Fenton-enhanced radiotherapy (FERT) of HCC. The selective release of Fe2+ in the acidic tumor microenvironment, but not in normal tissue, together with enhanced levels of hydrogen peroxide produced through the Pt radiosensitization effect, facilitates the generation of an enormous amount of hydroxyl radicals through the Fenton reaction, thereby extending the radiotherapeutic cascade and realizing a powerful therapeutic efficacy for HCC. Moreover, the "burst" release of Fe2+ contributes to the T2-to-T1 magnetic resonance imaging (MRI) switching effect, which informs the release of Fe2+, making imaging-guided cancer therapy feasible. This work not only breaks the bottleneck of traditional radiotherapy for HCC while minimally affecting normal tissues, but also provides a new strategy for FERT imaging guidance.
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Affiliation(s)
- Xingyang Zhao
- Department of Hepatobiliary Surgery, Zhujiang Hospital, Southern Medical University, Guangzhou, 510280, China
- Guangdong Provincial Clinical and Engineering Center of Digital Medicine, Guangzhou, 510280, China
| | - Xiang Sun
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnosis & Center for Molecular Imaging and Translational Medicine, School of Public Health, Xiamen University, Xiamen, 361102, China
| | - Wenchao Huang
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnosis & Center for Molecular Imaging and Translational Medicine, School of Public Health, Xiamen University, Xiamen, 361102, China
| | - Ronghe Chen
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnosis & Center for Molecular Imaging and Translational Medicine, School of Public Health, Xiamen University, Xiamen, 361102, China
| | - Kang Chen
- Department of Hepatobiliary Surgery, Zhujiang Hospital, Southern Medical University, Guangzhou, 510280, China
- Guangdong Provincial Clinical and Engineering Center of Digital Medicine, Guangzhou, 510280, China
| | - Liming Nie
- Medical Research Center, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China.
| | - Chihua Fang
- Department of Hepatobiliary Surgery, Zhujiang Hospital, Southern Medical University, Guangzhou, 510280, China.
- Guangdong Provincial Clinical and Engineering Center of Digital Medicine, Guangzhou, 510280, China.
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Guiu B, Garin E, Allimant C, Edeline J, Salem R. TARE in Hepatocellular Carcinoma: From the Right to the Left of BCLC. Cardiovasc Intervent Radiol 2022; 45:1599-1607. [PMID: 35149884 DOI: 10.1007/s00270-022-03072-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 01/23/2022] [Indexed: 02/06/2023]
Abstract
The Barcelona Clinic Liver Cancer (BCLC) system is the most commonly used staging system for hepatocellular carcinoma (HCC) in Western countries. BCLC aims to categorize patients into five stages with different prognoses and to allocate treatment according to these stages based on the best possible contemporary evidence. Transarterial radioembolization (TARE) has recently entered at the left of the BCLC algorithm (i.e., BCLC 0-A), mainly because of negative phase III trials in BCLC C stage. TARE has shown a steady increase in nationwide studies over the past 20 years and has even been adopted in some tertiary centers as the primary HCC treatment across all BCLC stages. We aimed to review the history of TARE in HCC, starting from advanced HCC and gradually expanding to earlier stages at the left of the BCLC system.
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Affiliation(s)
- Boris Guiu
- Department of Radiology, St-Eloi University Hospital, 80 Avenue Augustin Fliche, 34295, Montpellier, France.
| | - Etienne Garin
- Department of Nuclear Medicine, Centre de Lutte Contre le Cancer Eugène Marquis, 35000, Rennes, France
| | - Carole Allimant
- Department of Radiology, St-Eloi University Hospital, 80 Avenue Augustin Fliche, 34295, Montpellier, France
| | - Julien Edeline
- Department of Oncology, Centre de Lutte Contre le Cancer Eugène Marquis, 35000, Rennes, France
| | - Riad Salem
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, IL, 60611, USA
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Role of Pretransplant Treatments for Patients with Hepatocellular Carcinoma Waiting for Liver Transplantation. Cancers (Basel) 2022; 14:cancers14020396. [PMID: 35053558 PMCID: PMC8773674 DOI: 10.3390/cancers14020396] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 01/09/2022] [Accepted: 01/12/2022] [Indexed: 02/01/2023] Open
Abstract
Simple Summary Hepatocellular carcinoma (HCC) is the fifth most common cancer in men worldwide and the second leading cause of cancer death. Liver transplantation (LT) is one of the treatment options for patients with HCC. Recently, there have been many reports of the usefulness of locoregional therapy, such as transarterial chemoembolization and radiofrequency ablation, for HCC as pretreatment before LT. In Western countries, locoregional therapy is used to bridge until transplantation to prevent drop-outs from the waiting list or for downstaging to treat patients with advanced HCC who initially exceed the criteria for LT. With the progress of locoregional therapy, new reports on the effects of bridging and downstaging locoregional therapy as pretransplant treatment are increasing in number. Abstract Recently, there have been many reports of the usefulness of locoregional therapy such as transarterial chemoembolization and radiofrequency ablation for hepatocellular carcinoma (HCC) as pretreatment before liver transplantation (LT). Locoregional therapy is performed with curative intent in Japan, where living donor LT constitutes the majority of LT due to the critical shortage of deceased donors. However, in Western countries, where deceased donor LT is the main procedure, LT is indicated for early-stage HCC regardless of liver functional reserve, and locoregional therapy is used for bridging until transplantation to prevent drop-outs from the waiting list or for downstaging to treat patients with advanced HCC who initially exceed the criteria for LT. There are many reports of the effect of bridging and downstaging locoregional therapy before LT, and its indications and efficacy are becoming clear. Responses to locoregional therapy, such as changes in tumor markers, the avidity of FDG-PET, etc., are considered useful for successful bridging and downstaging. In this review, the effects of bridging and downstaging locoregional therapy as a pretransplant treatment on the results of transplantation are clarified, focusing on recent reports.
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Salem R, Gabr A. Transarterial Radioembolization Versus Systemic Treatment for Hepatocellular Carcinoma with Macrovascular Invasion: Analysis of the U.S. National Cancer Database. J Nucl Med 2022; 63:57-58. [PMID: 34916247 PMCID: PMC8717188 DOI: 10.2967/jnumed.121.262917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 11/03/2021] [Indexed: 11/16/2022] Open
Affiliation(s)
- Riad Salem
- Department of Interventional Radiology, Northwestern University, Chicago, Illinois
| | - Ahmed Gabr
- Department of Interventional Radiology, Northwestern University, Chicago, Illinois
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Xu L, Chen L, Zhang W. Neoadjuvant treatment strategies for hepatocellular carcinoma. World J Gastrointest Surg 2021; 13:1550-1566. [PMID: 35070063 PMCID: PMC8727178 DOI: 10.4240/wjgs.v13.i12.1550] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 06/27/2021] [Accepted: 11/30/2021] [Indexed: 02/06/2023] Open
Abstract
The incidence of hepatocellular carcinoma (HCC) remains high globally. Surgical treatment is the best treatment for improving the prognosis of patients with HCC. Neoadjuvant therapy plays a key role in preventing tumor progression and even downstaging HCC. The liver transplantation rate and resectability rate have increased for neoadjuvant therapy. Neoadjuvant therapy is effective in different stages of HCC. In this review, we summarized the definition, methods, effects, indications and contraindications of neoadjuvant therapy in HCC, which have significance for guiding treatment.
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Affiliation(s)
- Lei Xu
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
| | - Lin Chen
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
| | - Wei Zhang
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
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Garin E, Pinaquy JB, Bailly C, Sengel C, Mariano-Goulart D, Edeline J, Blanc JF, Bouvier A, Tordo J, Rode A, Becker S, Sefrioui D, de Baere T, Somma C, Mastier C, Goupil J, Chevallier P, Regnault H, Vibert E, Manfredi S, Vicaut E, Patel B, Boucher E, Guiu B. Evaluating the Effectiveness of Yttrium-90 Glass Microspheres in the Treatment of Hepatocellular Carcinoma, Intrahepatic Cholangiocarcinoma, and Metastatic Colorectal Cancer in Practice: Protocol for the Prospective PROACTIF Phase IV Registry Study in France. Cardiovasc Intervent Radiol 2021; 45:1-11. [PMID: 34796373 DOI: 10.1007/s00270-021-03002-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 10/29/2021] [Indexed: 10/19/2022]
Abstract
PRIMARY OBJECTIVE Recently, selective internal radiation therapy using yttrium-90 (Y90) glass microspheres (TheraSphere™) was approved for reimbursement by health authorities in France. The PROACTIF study aims to gather data on effectiveness, patient quality of life, and safety with use of Y90 glass microspheres in real-world clinical settings in France. INCLUSION CRITERIA Patient with a diagnosis of hepatocellular carcinoma (HCC), intrahepatic cholangiocarcinoma (iCC), and/or metastatic colorectal cancer (mCRC) who was treated with a dose of Y90 glass microspheres that has been reimbursed in France and who do not oppose use of their personal medical data. EXCLUSION CRITERIA If data collection is opposed, treatment is reimbursed but not administered, or treatment is administered but not reimbursed. OUTCOME MEASURES Primary outcome measures include overall survival from time of Y90 glass microsphere treatment and quality of life, as assessed using the Functional Assessment of Cancer Therapy- Hepatobiliary questionnaire. ESTIMATED NUMBER OF PATIENTS TO BE INCLUDED This is an open study and there is no set number of patients; 115 have already been enrolled. PLANNED SUBGROUP ANALYSES Analyses will be stratified by disease state (HCC, iCC, or mCRC). Subgroups to be analyzed include age group, unilobar/bilobar disease at baseline, Eastern Cooperative Oncology Group (ECOG) status at baseline, liver tumor burden at baseline, target lesion size, and standard versus multi-compartment personalized dosimetry treatment. PLANNED RECRUITMENT AND OBSERVATION PERIOD Recruitment includes patients who are prescribed and treated with a commercial vial of Y90 glass microspheres between 01 January 2019 and 31 December 2024. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04069468.
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Affiliation(s)
- Etienne Garin
- Nuclear Medicine Unit, Centre Eugene Marquis, Rennes, France
| | | | - Clement Bailly
- Nuclear Medicine Unit, University Hospital, Nantes, France
| | - Christian Sengel
- Radiology and Medical Imaging, CHU Hospital Michallon, Grenoble, France
| | | | | | - Jean-Frederic Blanc
- Hepatology, Gastroenterology, and Digestive Oncology, CHU Bordeaux, Bordeaux, France
| | - Antoine Bouvier
- Department of Radiology, University Hospital, Angers, France
| | - Jeremie Tordo
- Department of Nuclear Medicine, CHU Lyon Sud, Lyon, France
| | - Agnes Rode
- Department of Medical Imaging, CHU Lyon, Lyon, France
| | - Stéphanie Becker
- Departments of Medical Imaging and Nuclear Medicine, Centre Henri Bequerel, Rouen, France
| | - David Sefrioui
- Department of Hepatogastroenterology, Rouen University Hospital, Rouen, France
| | - Thierry de Baere
- Department of Interventional Radiology, Gustave Roussy Cancer Center, Villejuif, France
| | - Claude Somma
- Department of Nuclear Medicine, CHU La Timone, Marseille, France
| | - Charles Mastier
- Department of Radiology, CRLCC Centre Léon Bérard, Lyon, France
| | - Jean Goupil
- Department of Radiology and Medical Imaging, CHU Nimes, Nimes, France
| | | | - Helene Regnault
- Department of Hepatology, Henri Mondor Hospital, Creteil, France
| | - Eric Vibert
- Department of Hepatology and Surgery, Paul Brousse Hospital, Villejuif, France
| | - Sylvain Manfredi
- Department of Digestive Oncology, University Hospital, Dijon, France
| | - Eric Vicaut
- Clinical Trial Unit, AP-HP Groupe Hospitalier Lariboisière - Fernand-Widal, Paris, France
| | - Binal Patel
- Biostatistics, Boston Scientific Corporation, Marlborough, MA, USA
| | - Eveline Boucher
- Interventional Oncology, Boston Scientific Corporation, Marlborough, MA, USA
| | - Boris Guiu
- Department of Radiology, St. Eloi University Hospital - Montpellier School of Medicine, 80 avenue Augustin Fliche, 34295, Montpellier, France.
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Crocetti L, Bozzi E, Scalise P, Bargellini I, Lorenzoni G, Ghinolfi D, Campani D, Balzano E, De Simone P, Cioni R. Locoregional Treatments for Bridging and Downstaging HCC to Liver Transplantation. Cancers (Basel) 2021; 13:5558. [PMID: 34771720 PMCID: PMC8583584 DOI: 10.3390/cancers13215558] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 10/27/2021] [Accepted: 11/03/2021] [Indexed: 02/08/2023] Open
Abstract
Liver transplantation (LT) is the first-line treatment for patients diagnosed with unresectable early-stage hepatocellular carcinoma (HCC) in the setting of cirrhosis. It is well known that HCC patients within the Milan criteria (solitary tumour ≤ 5 cm or ≤3 tumours, each <3 cm) could undergo LT with excellent results. However, there is a growing tendency to enlarge inclusion criteria since the Milan criteria are nowadays considered too restrictive and may exclude patients who would benefit from LT. On the other hand, there is a persistent shortage of donor organs. In this scenario, there is consensus about the role of loco-regional therapy (LRT) during the waiting list to select patients who would benefit more from LT, reducing the risk of drop off from the waiting list as well as decreasing tumour dimension to meet acceptable criteria for LT. In this review, current evidence on the safety, efficacy and utility of LRTs as neoadjuvant therapies before LT are summarized.
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Affiliation(s)
- Laura Crocetti
- Division of Interventional Radiology, Azienda Ospedaliero Universitaria Pisana, 56126 Pisa, Italy; (E.B.); (P.S.); (I.B.); (G.L.); (R.C.)
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, 56126 Pisa, Italy; (D.C.); (P.D.S.)
| | - Elena Bozzi
- Division of Interventional Radiology, Azienda Ospedaliero Universitaria Pisana, 56126 Pisa, Italy; (E.B.); (P.S.); (I.B.); (G.L.); (R.C.)
| | - Paola Scalise
- Division of Interventional Radiology, Azienda Ospedaliero Universitaria Pisana, 56126 Pisa, Italy; (E.B.); (P.S.); (I.B.); (G.L.); (R.C.)
| | - Irene Bargellini
- Division of Interventional Radiology, Azienda Ospedaliero Universitaria Pisana, 56126 Pisa, Italy; (E.B.); (P.S.); (I.B.); (G.L.); (R.C.)
| | - Giulia Lorenzoni
- Division of Interventional Radiology, Azienda Ospedaliero Universitaria Pisana, 56126 Pisa, Italy; (E.B.); (P.S.); (I.B.); (G.L.); (R.C.)
| | - Davide Ghinolfi
- Division of Hepatobiliary Surgery and Liver Transplantation, Azienda Ospedaliero Universitaria Pisana, 56126 Pisa, Italy; (D.G.); (E.B.)
| | - Daniela Campani
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, 56126 Pisa, Italy; (D.C.); (P.D.S.)
- Division of Pathology, Azienda Ospedaliero Universitaria Pisana, 56126 Pisa, Italy
| | - Emanuele Balzano
- Division of Hepatobiliary Surgery and Liver Transplantation, Azienda Ospedaliero Universitaria Pisana, 56126 Pisa, Italy; (D.G.); (E.B.)
| | - Paolo De Simone
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, 56126 Pisa, Italy; (D.C.); (P.D.S.)
- Division of Hepatobiliary Surgery and Liver Transplantation, Azienda Ospedaliero Universitaria Pisana, 56126 Pisa, Italy; (D.G.); (E.B.)
| | - Roberto Cioni
- Division of Interventional Radiology, Azienda Ospedaliero Universitaria Pisana, 56126 Pisa, Italy; (E.B.); (P.S.); (I.B.); (G.L.); (R.C.)
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Salem R, Johnson GE, Kim E, Riaz A, Bishay V, Boucher E, Fowers K, Lewandowski R, Padia SA. Yttrium-90 Radioembolization for the Treatment of Solitary, Unresectable HCC: The LEGACY Study. Hepatology 2021; 74:2342-2352. [PMID: 33739462 PMCID: PMC8596669 DOI: 10.1002/hep.31819] [Citation(s) in RCA: 226] [Impact Index Per Article: 75.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 03/12/2021] [Accepted: 03/16/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Locoregional therapies, including yttrium-90 radioembolization, play an important role in the treatment of unresectable HCC. The aim of the LEGACY (Local radioEmbolization using Glass Microspheres for the Assessment of Tumor Control with Y-90) study was to evaluate objective response rate (ORR) and duration of response (DoR) in patients with solitary unresectable HCC treated with yttrium-90 glass microspheres. APPROACH AND RESULTS LEGACY is a multicenter, single-arm, retrospective study conducted at three sites that included all eligible, consecutive patients with HCC treated with radioembolization between 2014 and 2017. Eligibility criteria included solitary HCC ≤ 8 cm, Child-Pugh A cirrhosis, and Eastern Cooperative Oncology Group performance status 0-1. Primary endpoints were ORR and DoR based on modified Response Evaluation Criteria in Solid Tumors in the treated area (localized), as evaluated by blinded, independent, central review. Radioembolization was performed with intent of ablative-level dosimetry in a selective fashion when possible. Overall survival was evaluated using Kaplan-Meier and multivariate Cox proportional hazards. Among the 162 patients included, 60.5% were Eastern Cooperative Oncology Group 0, and the median tumor size was 2.7 cm (range: 1-8) according to blinded, independent, central review. Radioembolization served as neoadjuvant therapy for transplantation or resection in 21.0% (34 of 162) and 6.8% (11 of 162) of patients, respectively, and as primary treatment for all others. Median follow-up time was 29.9 months by reverse Kaplan-Meier. ORR (best response) was 88.3% (CI: 82.4-92.4), with 62.2% (CI: 54.1-69.8) exhibiting a DoR ≥ 6 months. Three-year overall survival was 86.6% for all patients and 92.8% for those neoadjuvant patients with resected or transplanted liver. CONCLUSIONS In this multicenter study of radioembolization, clinical meaningful response rates and prolonged DoR were observed in the treatment of unresectable, solitary HCC ≤ 8 cm.
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Affiliation(s)
- Riad Salem
- Department of RadiologyNorthwestern Feinberg School of MedicineChicagoIL
| | - Guy E. Johnson
- Department of RadiologyUniversity of WashingtonSeattleWA
| | - Edward Kim
- Department of RadiologyMount Sinai Health SystemNew YorkNY
| | - Ahsun Riaz
- Department of RadiologyNorthwestern Feinberg School of MedicineChicagoIL
| | - Vivian Bishay
- Department of RadiologyMount Sinai Health SystemNew YorkNY
| | | | | | - Robert Lewandowski
- Department of RadiologyNorthwestern Feinberg School of MedicineChicagoIL
| | - Siddharth A. Padia
- Department of Radiological SciencesUniversity of California Los Angeles Medical CenterLos AngelesCA
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Swersky A, Kulik L, Kalyan A, Grace K, Caicedo JC, Lewandowski RJ, Salem R. Contemporary Algorithm for the Management of Hepatocellular Carcinoma in 2021: The Northwestern Approach. Semin Intervent Radiol 2021; 38:432-437. [PMID: 34629710 DOI: 10.1055/s-0041-1735528] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Hepatocellular carcinoma (HCC) is the most common primary liver cancer and a major cause of cancer-related morbidity and mortality around the world. Frequently, concurrent liver dysfunction and variations in tumor burden make it difficult to design effective and standardized treatment pathways. Contemporary treatment guidelines designed for an era of personalized medicine should consider these features in a more clinically meaningful way to improve outcomes for patients across the HCC spectrum. Given the heterogeneity of HCC, we propose a detailed clinical algorithm for selecting optimal treatment using an evidence-based and practical approach, incorporating liver function, tumor burden, the extent of disease, and ultimate treatment intent, with the goal of individualizing clinical decision making.
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Affiliation(s)
- Adam Swersky
- Section of Interventional Radiology, Department of Radiology, Northwestern Feinberg School of Medicine, Chicago, Illinois
| | - Laura Kulik
- Division of Hepatology, Department of Medicine, Northwestern Feinberg School of Medicine, Chicago, Illinois
| | - Aparna Kalyan
- Division of Medical Oncology, Department of Medicine, Northwestern Feinberg School of Medicine, Chicago, Illinois
| | - Karen Grace
- Section of Interventional Radiology, Department of Radiology, Northwestern Feinberg School of Medicine, Chicago, Illinois
| | - Juan Carlos Caicedo
- Division of Transplantation, Department of Surgery, Northwestern Feinberg School of Medicine, Chicago, Illinois
| | - Robert J Lewandowski
- Section of Interventional Radiology, Department of Radiology, Northwestern Feinberg School of Medicine, Chicago, Illinois
| | - Riad Salem
- Section of Interventional Radiology, Department of Radiology, Northwestern Feinberg School of Medicine, Chicago, Illinois
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Sivananthan G, Tabori NE. Principles of Radioembolization. Semin Intervent Radiol 2021; 38:393-396. [PMID: 34629704 DOI: 10.1055/s-0041-1735606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Radioembolization has become a mainstay therapy in the treatment of primary and secondary liver cancers. This article will specifically discuss a brief history of yttrium treatment as well as an overview of the physical properties of the currently available devices. A discussion of the mechanism of action will be followed by a discussion on patient selection for this treatment.
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Affiliation(s)
- Gajan Sivananthan
- Division of Interventional Radiology, Department of Radiology, Georgetown Medical School, MedStar Washington Hospital Center, Washington, District of Columbia
| | - Nora E Tabori
- Division of Interventional Radiology, Department of Radiology, Georgetown Medical School, MedStar Washington Hospital Center, Washington, District of Columbia
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Qadan M, Fong ZV, Delman AM, Gabr A, Salem R, Shah SA. Review of Use of Y90 as a Bridge to Liver Resection and Transplantation in Hepatocellular Carcinoma. J Gastrointest Surg 2021; 25:2690-2699. [PMID: 34345997 DOI: 10.1007/s11605-021-05095-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 07/07/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND The incidence of hepatocellular carcinoma (HCC) has been rising, and 80% of HCCs are unresectable at the time of presentation. In recent years, Yttrium-90 (Y90) radioembolization has arisen as a potential tool to treat the primary HCC tumor while also inducing contralateral liver hypertrophy to increase future liver remnant volumes. The goal of this multidisciplinary review is to summarize the contemporary evidence on the safety, efficacy, and utility of Y90 as a bridge to liver resection and transplant in patients with HCC. METHODS A narrative review was conducted of the recent literature regarding the utilization of Y90 as a therapy prior to liver resection or transplant in patients with HCC. A specific emphasis was placed on articles published in the last 10 years. RESULTS Y90 radioembolization has demonstrated a high safety profile and increasing utility in bridging and downstaging patients with HCC who subsequently undergo liver resection or transplant. The continuous advancements in treatment strategies and radiation dosimetry have paved the way for the incorporation of Y90 in all stages of HCC with different intents, including downstaging and bridging. CONCLUSIONS Y90 radioembolization can be safely used in the HCC population to bridge patients to resection or transplantation, induce future liver remnant growth, and select for less aggressive tumor biology prior to surgery.
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Affiliation(s)
- Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Zhi Ven Fong
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Aaron M Delman
- Department of Surgery, University of Cincinnati College of Medicine Medical Sciences Building, Room 1555, 231, Sabin Way Cincinnati, Albert, OH, 45267, USA
| | - Ahmed Gabr
- Department of Radiology, Northwestern Feinberg School of Medicine, Chicago, IL, USA
| | - Riad Salem
- Department of Radiology, Northwestern Feinberg School of Medicine, Chicago, IL, USA
| | - Shimul A Shah
- Department of Surgery, University of Cincinnati College of Medicine Medical Sciences Building, Room 1555, 231, Sabin Way Cincinnati, Albert, OH, 45267, USA.
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Kappadath SC, Lopez BP, Salem R, Lam MGEH. Reassessment of the lung dose limits for radioembolization. Nucl Med Commun 2021; 42:1064-1075. [PMID: 34347658 PMCID: PMC8445362 DOI: 10.1097/mnm.0000000000001439] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 04/19/2021] [Indexed: 11/11/2022]
Abstract
Radioembolization, also known as selective internal radiation therapy (SIRT), is an established treatment for the management of patients with unresectable liver tumors. Advances in liver dosimetry and new knowledge about tumor dose-response relationships have helped promote the well-tolerated use of higher prescribed doses, consequently transitioning radioembolization from palliative to curative therapy. Lung dosimetry, unfortunately, has not seen the same advances in dose calculation methodology and renewed consensus in dose limits as normal liver and tumor dosimetry. Therefore, the efficacy of curative radioembolization may be compromised in patients where the current lung dose calculations unnecessarily limit the administered activity. The field is thus at a stage where a systematic review and update of lung dose limits is necessary to advance the clinical practice of radioembolization. This work summarizes the historical context and literature for origins of the current lung dose limits following radioembolization, that is, the 25-year-old, single institution, small patient cohort series that helped establish the lung shunt fraction and dose limits. Newer clinical evidence based on larger patient cohorts that challenges the historical data on lung dose limits are then discussed. We conclude by revisiting the rationale for current lung dose limits and by proposing a staged approach to advance the field of lung dosimetry and thus the practice of radioembolization as a whole.
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Affiliation(s)
- S. Cheenu Kappadath
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston
| | - Benjamin P. Lopez
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston
| | - Riad Salem
- Department of Radiology, Northwestern Memorial Hospital, Chicago, USA
| | - Marnix G. E. H. Lam
- Department of Radiology and Nuclear Medicine, University Medical Center, Utrecht, The Netherlands
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Miller FH, Lopes Vendrami C, Gabr A, Horowitz JM, Kelahan LC, Riaz A, Salem R, Lewandowski RJ. Evolution of Radioembolization in Treatment of Hepatocellular Carcinoma: A Pictorial Review. Radiographics 2021; 41:1802-1818. [PMID: 34559587 DOI: 10.1148/rg.2021210014] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Transarterial radioembolization (TARE) with yttrium 90 has increasingly been performed to treat hepatocellular carcinoma (HCC). TARE was historically used as a palliative lobar therapy for patients with advanced HCC beyond surgical options, ablation, or transarterial chemoembolization, but recent advancements have led to its application across the Barcelona Clinic Liver Cancer staging paradigm. Newer techniques, termed radiation lobectomy and radiation segmentectomy, are being performed before liver resection to facilitate hypertrophy of the future liver remnant, before liver transplant to bridge or downstage to transplant, or as a definite curative treatment. Imaging assessment of therapeutic response to TARE is challenging as the intent of TARE is to deliver local high-dose radiation to tumors through microembolic microspheres, preserving blood flow to promote radiation injury to the tumor. Because of the microembolic nature, early imaging assessment after TARE cannot rely solely on changes in size. Knowledge of the evolving methods of TARE along with the tools to assess posttreatment imaging and response is essential to optimize TARE as a therapeutic option for patients with HCC. ©RSNA, 2021.
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Affiliation(s)
- Frank H Miller
- From the Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, 676 N St. Clair St, Ste 800, Chicago, IL 60611
| | - Camila Lopes Vendrami
- From the Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, 676 N St. Clair St, Ste 800, Chicago, IL 60611
| | - Ahmed Gabr
- From the Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, 676 N St. Clair St, Ste 800, Chicago, IL 60611
| | - Jeanne M Horowitz
- From the Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, 676 N St. Clair St, Ste 800, Chicago, IL 60611
| | - Linda C Kelahan
- From the Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, 676 N St. Clair St, Ste 800, Chicago, IL 60611
| | - Ahsun Riaz
- From the Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, 676 N St. Clair St, Ste 800, Chicago, IL 60611
| | - Riad Salem
- From the Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, 676 N St. Clair St, Ste 800, Chicago, IL 60611
| | - Robert J Lewandowski
- From the Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, 676 N St. Clair St, Ste 800, Chicago, IL 60611
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Management of Liver Tumors during the COVID-19 Pandemic: The Added Value of Selective Internal Radiation Therapy (SIRT). J Clin Med 2021; 10:jcm10194315. [PMID: 34640332 PMCID: PMC8509348 DOI: 10.3390/jcm10194315] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 09/14/2021] [Accepted: 09/20/2021] [Indexed: 12/12/2022] Open
Abstract
Background: In the context of the coronavirus disease 2019 (COVID-19) pandemic, liver-directed therapies (LDTs) may offer minimally invasive integrative tools for tumor control. Among them, selective internal radiation therapy (SIRT) represents a safe, flexible and effective treatment. Purpose of this study is to present our experience with SIRT during the first wave of COVID-19 pandemic and provide an overview of the indications and challenges of SIRT in this scenario. Methods: We retrospectively analyzed the number of patients evaluated by Multidisciplinary Liver Tumor Board (MLTB) and who were undergoing LDTs between March and July 2020 and compared it with 2019. For patients treated with SIRT, clinical data, treatment details and the best radiological response were collected. Results: Compared to 2019, we observed a 27.5% reduction in the number of patients referred to MLTB and a 28.3% decrease in percutaneous ablations; transarterial chemoembolizations were stable, while SIRT increased by 64%. The majority of SIRT patients (75%) had primary tumors, mostly HCC. The best objective response and disease control rates were 56.7% and 72.2%, respectively. Conclusion: The first wave of the COVID-19 pandemic was characterized by an increased demand for SIRT, which represents a safe, flexible and effective treatment, whose manageability will further improve by simplifying the treatment workflow, developing user-friendly and reliable tools for personalized dosimetry and improving interdisciplinary communication.
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Utility of Early Posttreatment PET/CT Evaluation Using FDG or 18F-FCH to Predict Response to 90Y Radioembolization in Patients With Hepatocellular Carcinoma. AJR Am J Roentgenol 2021; 218:359-369. [PMID: 34494448 DOI: 10.2214/ajr.21.26485] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Background: Assessment of hepatocellular carcinoma (HCC) treatment response after transarterial radioembolization (TARE) is challenging, as response by conventional imaging criteria may not become apparent until 6 months after treatment. Though HCC exhibits variability avidity for FDG, some cases of HCC without avidity for FDG show avidity for 18F-FCH. Objectives: To evaluate the utility of early posttreatment evaluation by PET/CT using FDG or 18F-FCH to predict 6-month treatment response and survival after TARE in patients with HCC. Methods: This retrospective study included 37 patients (mean age 67 years; 34 men, 3 women) with documented HCC treated by TARE who underwent both pretreatment FDG PET/CT and 18F-FCH PET/CT, as well as early FDG PET/CT and/or 18F-FCH PET/CT 4-8 weeks after treatment; FDG PET/CT and 18F-FCH PET/CT examinations were performed on separate dates. Only one of 73 initially identified potentially eligible patients was excluded due to lack of HCC avidity for both FDG and 18F-FCH. Response assessment by mRECIST on multiphase CT or MRI was performed at one-month and six-months in 23 patients. Early PET/CT response and one-month mRECIST response were assessed as predictors of six-month mRECIST response. Univariable and multivariable predictors of overall survival (OS) were identified. Results: On pretreatment PET/CT, 28 (76%) patients were FDG-positive, 15 (41%) FCH-positive 6 (16%) both FDG-positive and FCH-positive. Twelve of 28 FDG-positive HCCs exhibited early response by FDG PET/CT; 7 of 15 FCH-positive HCCs exhibited early response by 18F-FCH PET/CT. Twelve (52%) patients exhibited six-month mRECIST response. Early posttreatment PET/CT response exhibited 100% (12/12) sensitivity and 100% (11/11) specificity for six-month mRECIST response, whereas one-month mRECIST response exhibited 67% (8/12) sensitivity and 100% (11/11) specificity for six-month mRECIST response. Early postteatment PET/CT response was a significant independent predictor of OS on univariable (hazard ratio: 0.37, 95% CI: 0.15-0.93, p=.03) and multivariable analyses (hazard ratio: 0.24, 95% CI: 0.08-0.76, p=.01). Conclusion: Early post-TARE evaluation by PET/CT using FDG or 18F-FCH may predict six-month response and OS in patients with HCC. Clinical Impact: Early posttreatment evaluation with PET/CT could help more reliably identify true nonresponders after TARE, which in turn could prompt early adapted therapeutic management.
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De la Garza-Ramos C, Overfield CJ, Montazeri SA, Liou H, Paz-Fumagalli R, Frey GT, McKinney JM, Ritchie CA, Devcic Z, Lewis AR, Harnois DM, Patel T, Toskich BB. Biochemical Safety of Ablative Yttrium-90 Radioembolization for Hepatocellular Carcinoma as a Function of Percent Liver Treated. J Hepatocell Carcinoma 2021; 8:861-870. [PMID: 34368021 PMCID: PMC8335548 DOI: 10.2147/jhc.s319215] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 07/06/2021] [Indexed: 12/20/2022] Open
Abstract
Purpose Transarterial radioembolization can serve as an ablative therapy for early-stage hepatocellular carcinoma (HCC). Given the volumetric variability of liver segments, this study aimed to characterize the safety of ablative radioembolization by determining percent liver treated (%LT) thresholds associated with biochemical toxicity. Patients and Methods Patients with HCC receiving a single ablative radioembolization treatment using glass microspheres from 2017 through 2020 were reviewed. %LT was calculated as treatment angiosome volume divided by whole liver volume. Biochemical toxicities were defined as increases in Albumin-Bilirubin (ALBI) grade or Child-Pugh (CP) class compared to baseline and albumin or bilirubin adverse events (AEs) per the Common Terminology Criteria for Adverse Events. Receiver operating characteristic curves and multivariate logistic regression analyses were performed to assess the impact of %LT on toxicities. Results Of 141 patients analyzed, 53% (n=75) were ALBI 1, 45% (n=64) ALBI 2, 79% (n=111) CP-A, and 21% (n=30) CP-B. A %LT ≥14.5% was associated with grade/class increases in ALBI 2 (p≤0.01) and CP-B patients (p=0.026). In multivariate analysis, a %LT ≥14.5% was an independent predictor of increases in the ALBI 2 and CP-B groups (p<0.01). No significant %LT threshold was found for ALBI 1 and CP-A patients. No grade 3/4 albumin or bilirubin AEs were reported, while grade 2 AEs were related to an initial whole liver volume <1.3 L (p≤0.01). Conclusion Patients with ALBI 2 and CP-B liver function are less likely to have an increase in their respective grade/class when treating <14.5% of the liver using glass microspheres. ALBI 1 and CP-A patients showed no definitive %LT threshold for biochemical toxicity within the range of this study.
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Affiliation(s)
| | - Cameron J Overfield
- Division of Interventional Radiology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - S Ali Montazeri
- Division of Interventional Radiology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Harris Liou
- Alix School of Medicine, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | | | - Gregory T Frey
- Division of Interventional Radiology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - J Mark McKinney
- Division of Interventional Radiology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Charles A Ritchie
- Division of Interventional Radiology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Zlatko Devcic
- Division of Interventional Radiology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Andrew R Lewis
- Division of Interventional Radiology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Denise M Harnois
- Department of Transplant, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Tushar Patel
- Department of Transplant, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Beau B Toskich
- Division of Interventional Radiology, Mayo Clinic Florida, Jacksonville, FL, USA
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Salem R, Li D, Sommer N, Hernandez S, Verret W, Ding B, Lencioni R. Characterization of response to atezolizumab + bevacizumab versus sorafenib for hepatocellular carcinoma: Results from the IMbrave150 trial. Cancer Med 2021; 10:5437-5447. [PMID: 34189869 PMCID: PMC8366100 DOI: 10.1002/cam4.4090] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 03/19/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND IMbrave150 is a phase III trial that assessed atezolizumab + bevacizumab (ATEZO/BEV) versus sorafenib (SOR) in patients with unresectable hepatocellular carcinoma (HCC) and demonstrated a significant improvement in clinical outcomes. Exploratory analyses characterized objective response rate (ORR), depth (DpR), and duration of response (DoR), and patients with a complete response (CR). METHODS Patients were randomized 2:1 to intravenous ATEZO (1200 mg) + BEV (15 mg/kg) every 3 weeks or oral SOR (400 mg) twice daily. Tumors were evaluated using Response Evaluation Criteria in Solid Tumors version 1.1 (RECIST 1.1) and HCC-modified RECIST (mRECIST). ORR by prior treatment and largest baseline liver lesion size, DoR, time to response (TTR), and complete response (TTCR) were analyzed. RESULTS For both criteria, responses favored ATEZO/BEV versus SOR regardless of prior treatment and in patients with lesions ≥3 cm. Median TTR was 2.8 months per RECIST 1.1 (range: 1.2-12.3 months) and 2.8 months per mRECIST (range: 1.1-12.3 months) with ATEZO/BEV. Patients receiving ATEZO/BEV had a greater DpR, per both criteria, across baseline liver lesion sizes. Characteristics of complete responders were similar to those of the intent-to-treat population. In complete responders receiving ATEZO/BEV per mRECIST versus RECIST 1.1, respectively, median TTCR was shorter (5.5 vs. 7.0 months), mean baseline sum of lesion diameter was longer (5.0 [SD, 5.1] vs. 2.6 [SD, 1.4] cm), and mean largest liver lesion size was larger (4.8 [SD, 4.2] vs. 2.3 [SD, 1.0] cm). CONCLUSIONS These data highlight the improved ORR, DpR, and CR rates with ATEZO/BEV in unresectable HCC.
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Affiliation(s)
- Riad Salem
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Evanston, IL, USA
| | - Daneng Li
- Department of Medical Oncology, City of Hope Comprehensive Cancer Center and Beckman Research Institute, Duarte, CA, USA
| | | | | | | | | | - Riccardo Lencioni
- Department of Radiology, University of Pisa School of Medicine, Pisa, Italy.,Miami Cancer Institute, Miami, FL, USA
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Gao Y, Lyu L, Feng Y, Li F, Hu Y. A review of cutting-edge therapies for hepatocellular carcinoma (HCC): Perspectives from patents. Int J Med Sci 2021; 18:3066-3081. [PMID: 34400877 PMCID: PMC8364461 DOI: 10.7150/ijms.59930] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 05/11/2021] [Indexed: 12/13/2022] Open
Abstract
Rationale: Hepatocellular carcinoma (HCC) is a challenging disease due to its heterogenous etiology. Several breakthroughs have occurred in treatment of HCC, associated with an enormous number of patent publications for a variety of HCC treatment modalities. As patents can provide valuable information for academic research and commercial development, this study aims to unravel the cutting-edge therapies for HCC by using patents as an indicator. The outcome from this analysis may offer meaningful insights for respective policymaking, strategic plan and research and development (R&D) prioritization. Methods: Derwent Innovation platform was employed to collect the sample data of patents related to HCC treatment technologies worldwide as of December 31, 2019. Data inclusion, screening and exclusion were according to the rules of preferred reporting items for systematic reviews and meta-analyses (PRISMA). Technologies were classified based on Barcelona Clinic Liver Cancer (BCLC) staging system and recent clinical publications. Patent citation network analysis was carried out to identify and understand HCC therapeutic technology flow. Results: A dataset of 2543 patent documents and 528 patent families was generated. 11 technological categories were classified. Numerous researches were focalized on refinements in technologies and innovations within the field of HCC therapy, and the major achievements are technology advancement on molecular target therapy, chemotherapy, locoregional therapy, combination therapy and immunotherapy with demonstrated clinical benefits. In patent citation network, Notch pathway investigation, antibody drug conjugate (ADC) technology development and drug eluting beads trans artery chemoembolization (DEB-TACE) advancement are the major technological communities involving patents with the greatest future exploratory potential. Conclusion: Numerous emerging technologies have been identified in this study, in which exploring novel therapeutic targets in molecular target therapy, more localized and visible locoregional therapy and combination of immunotherapy with target therapy or other traditional therapies are highlighted as the future trends in treating HCC.
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Affiliation(s)
| | | | | | | | - Yuanjia Hu
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Taipa, Macao, China
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50
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Esagian SM, Kakos CD, Giorgakis E, Burdine L, Barreto JC, Mavros MN. Adjuvant Transarterial Chemoembolization Following Curative-Intent Hepatectomy Versus Hepatectomy Alone for Hepatocellular Carcinoma: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Cancers (Basel) 2021; 13:2984. [PMID: 34203692 PMCID: PMC8232114 DOI: 10.3390/cancers13122984] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/07/2021] [Accepted: 06/09/2021] [Indexed: 02/07/2023] Open
Abstract
The role of adjuvant transarterial chemoembolization (TACE) for patients with resectable hepatocellular carcinoma (HCC) undergoing hepatectomy is currently unclear. We performed a systematic review of the literature using the MEDLINE, Embase, and Cochrane Library databases. Random-effects meta-analysis was carried out to compare the overall survival (OS) and recurrence-free survival (RFS) of patients with resectable HCC undergoing hepatectomy followed by adjuvant TACE vs. hepatectomy alone in randomized controlled trials (RCTs). The risk of bias was assessed using the Risk of Bias 2.0 tool. Meta-regression analyses were performed to explore the effect of hepatitis B viral status, microvascular invasion, type of resection (anatomic vs. parenchymal-sparing), and tumor size on the outcomes. Ten eligible RCTs, reporting on 1216 patients in total, were identified. The combination of hepatectomy and adjuvant TACE was associated with superior OS (hazard ratio (HR): 0.66, 95% confidence interval (CI): 0.52 to 0.85; p < 0.001) and RFS (HR: 0.70, 95% CI: 0.56 to 0.88; p < 0.001) compared to hepatectomy alone. There were significant concerns regarding the risk of bias in most of the included studies. Overall, adjuvant TACE may be associated with an oncologic benefit in select HCC patients. However, the applicability of these findings may be limited to Eastern Asian populations, due to the geographically restricted sample. High-quality multinational RCTs, as well as predictive tools to optimize patient selection, are necessary before adjuvant TACE can be routinely implemented into standard practice. PROSPERO Registration ID: CRD42021245758.
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Affiliation(s)
- Stepan M. Esagian
- Oncology Working Group, Society of Junior Doctors, 15123 Athens, Greece;
| | - Christos D. Kakos
- Surgery Working Group, Society of Junior Doctors, 15123 Athens, Greece;
| | - Emmanouil Giorgakis
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (E.G.); (L.B.); (J.C.B.)
| | - Lyle Burdine
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (E.G.); (L.B.); (J.C.B.)
| | - J. Camilo Barreto
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (E.G.); (L.B.); (J.C.B.)
| | - Michail N. Mavros
- Surgery Working Group, Society of Junior Doctors, 15123 Athens, Greece;
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (E.G.); (L.B.); (J.C.B.)
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