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Linder PM, Lan W, Trautwein NF, Brosch-Lenz J, von Beschwitz S, Kupferschläger J, Reischl G, Grözinger G, Dittmann H, la Fougère C, Schmidt FP. Optimization of Y-90 Radioembolization Imaging for Post-Treatment Dosimetry on a Long Axial Field-of-View PET/CT Scanner. Diagnostics (Basel) 2023; 13:3418. [PMID: 37998554 PMCID: PMC10670048 DOI: 10.3390/diagnostics13223418] [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: 10/03/2023] [Revised: 11/07/2023] [Accepted: 11/07/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND PET imaging after yttrium-90 (Y-90) radioembolization is challenging because of the low positron fraction of Y-90 (32 × 10-6). The resulting low number of events can be compensated by the high sensitivity of long axial field-of-view (LAFOV) PET/CT scanners. Nevertheless, the reduced event statistics require optimization of the imaging protocol to achieve high image quality (IQ) and quantification accuracy sufficient for post-treatment dosimetry. METHODS Two phantoms (NEMA IEC and AbdoMan phantoms, mimicking human liver) filled with Y-90 and a 4:1 sphere (tumor)-to-background ratio were scanned for 24 h with the Biograph Vision Quadra (Siemens Healthineers). Eight patients were scanned after Y-90 radioembolization (1.3-4.7 GBq) using the optimized protocol (obtained by phantom studies). The IQ, contrast recovery coefficients (CRCs) and noise were evaluated for their limited and full acceptance angles, different rebinned scan durations, numbers of iterations and post-reconstruction filters. The s-value-based absorbed doses were calculated to assess their suitability for dosimetry. RESULTS The phantom studies demonstrate that two iterations, five subsets and a 4 mm Gaussian filter provide a reasonable compromise between a high CRC and low noise. For a 20 min scan duration, an adequate CRC of 56% (vs. 24 h: 62%, 20 mm sphere) was obtained, and the noise was reduced by a factor of 1.4, from 40% to 29%, using the full acceptance angle. The patient scan results were consistent with those from the phantom studies, and the impacts on the absorbed doses were negligible for all of the studied parameter sets, as the maximum percentage difference was -3.89%. CONCLUSIONS With 2i5s, a 4 mm filter and a scan duration of 20 min, IQ and quantification accuracy that are suitable for post-treatment dosimetry of Y-90 radioembolization can be achieved.
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Affiliation(s)
- Pia M. Linder
- Department of Nuclear Medicine and Clinical Molecular Imaging, University Hospital Tuebingen, 72076 Tuebingen, Germany; (P.M.L.); (W.L.); (S.v.B.); (C.l.F.); (H.D.)
| | - Wenhong Lan
- Department of Nuclear Medicine and Clinical Molecular Imaging, University Hospital Tuebingen, 72076 Tuebingen, Germany; (P.M.L.); (W.L.); (S.v.B.); (C.l.F.); (H.D.)
| | - Nils F. Trautwein
- Department of Nuclear Medicine and Clinical Molecular Imaging, University Hospital Tuebingen, 72076 Tuebingen, Germany; (P.M.L.); (W.L.); (S.v.B.); (C.l.F.); (H.D.)
| | - Julia Brosch-Lenz
- Department of Nuclear Medicine, Klinikum Rechts der Isar, Technical University Munich, 81675 Munich, Germany
| | - Sebastian von Beschwitz
- Department of Nuclear Medicine and Clinical Molecular Imaging, University Hospital Tuebingen, 72076 Tuebingen, Germany; (P.M.L.); (W.L.); (S.v.B.); (C.l.F.); (H.D.)
| | - Jürgen Kupferschläger
- Department of Nuclear Medicine and Clinical Molecular Imaging, University Hospital Tuebingen, 72076 Tuebingen, Germany; (P.M.L.); (W.L.); (S.v.B.); (C.l.F.); (H.D.)
| | - Gerald Reischl
- Werner Siemens Imaging Center, Department of Preclinical Imaging and Radiopharmacy, Eberhard-Karls University Tuebingen, 72074 Tuebingen, Germany;
- Cluster of Excellence iFIT (EXC 2180) “Image Guided and Functionally Instructed Tumor Therapies”, University of Tuebingen, 72074 Tuebingen, Germany
| | - Gerd Grözinger
- Department for Diagnostic and Interventional Radiology, University Hospital Tuebingen, 72076 Tuebingen, Germany;
| | - Helmut Dittmann
- Department of Nuclear Medicine and Clinical Molecular Imaging, University Hospital Tuebingen, 72076 Tuebingen, Germany; (P.M.L.); (W.L.); (S.v.B.); (C.l.F.); (H.D.)
| | - Christian la Fougère
- Department of Nuclear Medicine and Clinical Molecular Imaging, University Hospital Tuebingen, 72076 Tuebingen, Germany; (P.M.L.); (W.L.); (S.v.B.); (C.l.F.); (H.D.)
- Cluster of Excellence iFIT (EXC 2180) “Image Guided and Functionally Instructed Tumor Therapies”, University of Tuebingen, 72074 Tuebingen, Germany
| | - Fabian P. Schmidt
- Department of Nuclear Medicine and Clinical Molecular Imaging, University Hospital Tuebingen, 72076 Tuebingen, Germany; (P.M.L.); (W.L.); (S.v.B.); (C.l.F.); (H.D.)
- Werner Siemens Imaging Center, Department of Preclinical Imaging and Radiopharmacy, Eberhard-Karls University Tuebingen, 72074 Tuebingen, Germany;
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Jain S, Blume H, Rodriguez L, Petre E, Moussa A, Zhao K, Sotirchos V, Raj N, Reidy D, Ziv E, Alexander E. Hepatic Hilar Block as an Adjunct to Transarterial Embolization of Neuroendocrine Tumors: A Retrospective Review of Safety and Efficacy. Cancers (Basel) 2023; 15:5202. [PMID: 37958376 PMCID: PMC10647661 DOI: 10.3390/cancers15215202] [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: 08/25/2023] [Revised: 10/09/2023] [Accepted: 10/27/2023] [Indexed: 11/15/2023] Open
Abstract
PURPOSE This study investigates whether hepatic hilar nerve blocks (HHNB) provide safe, effective analgesia in patients with neuroendocrine tumors (NET) treated with transarterial embolization (TAE). METHODS The retrospective study included all NETs treated with TAE or TAE + HHNB from 1/2020 to 8/2022. Eighty-five patients (45 men), mean age 62 years, were treated in 165 sessions (TAE, n = 153; TAE + HHNB, n = 12). For HHNBs, ≤10 mL bupivacaine HCl 0.25% ± 2 mg methylprednisolone were injected under ultrasound guidance. The aims were to assess safety of HHNB and reduction in pain. Groups were compared with Pearson's chi-squared and Wilcoxon rank sum tests. Logistic regression assessed independent risk factors for pain. RESULTS No immediate complications from HHNBs were reported. No difference in incidence of major complications between TAE and TAE + HHNB one month post-embolization was observed (7.19% vs. 8.33%, p = 0.895). No differences in mean length of hospital stay after treatment were observed (TAE 2.2 days [95%CI: 1.74-2.56] vs. TAE + HHNB 2.8 days [95%CI: 1.43-4.26]; p = 0.174). Post-procedure pain was reported in 88.2% of TAE and 75.0% of TAE + HHNB patients (p = 0.185). HHNB recipients were more likely to use analgesic patches (25.0% vs. 5.88%; p = 0.014). No other differences in analgesic use were observed. CONCLUSIONS HHNBs can safely be performed in patients with NETs. No difference in hospital stays or analgesic drug use was observed. Managing pain after TAE is an important goal; further study is warranted.
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Affiliation(s)
- Samagra Jain
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA; (S.J.); (H.B.); (L.R.); (E.P.); (A.M.); (K.Z.); (V.S.); (E.Z.)
- Baylor College of Medicine, School of Medicine, One Baylor Plaza, Houston, TX 77004, USA
| | - Harrison Blume
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA; (S.J.); (H.B.); (L.R.); (E.P.); (A.M.); (K.Z.); (V.S.); (E.Z.)
- Albert Einstein College of Medicine, School of Medicine, 1300 Morris Park Ave, Bronx, NY 10461, USA
| | - Lee Rodriguez
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA; (S.J.); (H.B.); (L.R.); (E.P.); (A.M.); (K.Z.); (V.S.); (E.Z.)
| | - Elena Petre
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA; (S.J.); (H.B.); (L.R.); (E.P.); (A.M.); (K.Z.); (V.S.); (E.Z.)
| | - Amgad Moussa
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA; (S.J.); (H.B.); (L.R.); (E.P.); (A.M.); (K.Z.); (V.S.); (E.Z.)
| | - Ken Zhao
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA; (S.J.); (H.B.); (L.R.); (E.P.); (A.M.); (K.Z.); (V.S.); (E.Z.)
| | - Vlasios Sotirchos
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA; (S.J.); (H.B.); (L.R.); (E.P.); (A.M.); (K.Z.); (V.S.); (E.Z.)
| | - Nitya Raj
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA; (N.R.); (D.R.)
| | - Diane Reidy
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA; (N.R.); (D.R.)
| | - Etay Ziv
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA; (S.J.); (H.B.); (L.R.); (E.P.); (A.M.); (K.Z.); (V.S.); (E.Z.)
| | - Erica Alexander
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA; (S.J.); (H.B.); (L.R.); (E.P.); (A.M.); (K.Z.); (V.S.); (E.Z.)
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Denizmen D, Isik EG, Buyukkaya F, Kuyumcu S. 68 Ga-FAPI04 Versus 68 Ga-DOTATATE PET/CT in a Patient With Multiple Meningioma. Clin Nucl Med 2023; 48:e244-e245. [PMID: 36881633 DOI: 10.1097/rlu.0000000000004617] [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: 03/08/2023]
Abstract
ABSTRACT We present the 68 Ga-DOTATATE and 68 Ga-FAPI (fibroblast activation protein inhibitor) PET/CT findings of a 61-year-old man diagnosed with atypical World Health Organization grade II multiple meningiomas. The patient has been stable for 2 years following multiple surgeries and external radiotherapy because of recurring disease until he recently described frequent headaches, and a follow-up examination confirmed new meningioma lesions on MRI. However, the patient was inoperable and was referred for 68 Ga-DOTATATE PET/CT to determine eligibility for salvage peptide receptor radionuclide therapy. He also underwent fibroblast activation protein-targeted imaging using 68 Ga-FAPI04 PET/CT, which revealed heterogeneous, low to mild fibroblast activation protein expression across multiple meningioma lesions.
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Affiliation(s)
- Dilara Denizmen
- From the Department of Nuclear Medicine, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
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Diagnostic Management of Gastroenteropancreatic Neuroendocrine Neoplasms: Technique Optimization and Tips and Tricks for Radiologists. Tomography 2023; 9:217-246. [PMID: 36828370 PMCID: PMC9958666 DOI: 10.3390/tomography9010018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 01/22/2023] [Accepted: 01/23/2023] [Indexed: 01/31/2023] Open
Abstract
Gastroenteropancreatic neuroendocrine neoplasms (GEP-NENs) comprise a heterogeneous group of neoplasms, which derive from cells of the diffuse neuroendocrine system that specializes in producing hormones and neuropeptides and arise in most cases sporadically and, to a lesser extent, in the context of complex genetic syndromes. Furthermore, they are primarily nonfunctioning, while, in the case of insulinomas, gastrinomas, glucagonomas, vipomas, and somatostatinomas, they produce hormones responsible for clinical syndromes. The GEP-NEN tumor grade and cell differentiation may result in different clinical behaviors and prognoses, with grade one (G1) and grade two (G2) neuroendocrine tumors showing a more favorable outcome than grade three (G3) NET and neuroendocrine carcinoma. Two critical issues should be considered in the NEN diagnostic workup: first, the need to identify the presence of the tumor, and, second, to define the primary site and evaluate regional and distant metastases. Indeed, the primary site, stage, grade, and function are prognostic factors that the radiologist should evaluate to guide prognosis and management. The correct diagnostic management of the patient includes a combination of morphological and functional evaluations. Concerning morphological evaluations, according to the consensus guidelines of the European Neuroendocrine Tumor Society (ENETS), computed tomography (CT) with a contrast medium is recommended. Contrast-enhanced magnetic resonance imaging (MRI), including diffusion-weighted imaging (DWI), is usually indicated for use to evaluate the liver, pancreas, brain, and bones. Ultrasonography (US) is often helpful in the initial diagnosis of liver metastases, and contrast-enhanced ultrasound (CEUS) can solve problems in characterizing the liver, as this tool can guide the biopsy of liver lesions. In addition, intraoperative ultrasound is an effective tool during surgical procedures. Positron emission tomography (PET-CT) with FDG for nonfunctioning lesions and somatostatin analogs for functional lesions are very useful for identifying and evaluating metabolic receptors. The detection of heterogeneity in somatostatin receptor (SSTR) expression is also crucial for treatment decision making. In this narrative review, we have described the role of morphological and functional imaging tools in the assessment of GEP-NENs according to current major guidelines.
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The Evolving Role of Radioembolization in the Treatment of Neuroendocrine Liver Metastases. Cancers (Basel) 2022; 14:cancers14143415. [PMID: 35884479 PMCID: PMC9322914 DOI: 10.3390/cancers14143415] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/10/2022] [Accepted: 07/12/2022] [Indexed: 02/01/2023] Open
Abstract
Simple Summary This review provides basic insights into radioembolization, also known as selective internal radiation therapy, in patients suffering from neuroendocrine liver metastases. Radioembolization is a treatment that uses radioactive beads that are implanted intra-arterially to locally irradiate liver tumors. The available literature on radioembolization in neuroendocrine liver metastases show promising results in terms of efficacy and toxicity and will be discussed in more detail. However, data in the field of NELM need clarification, and this review also discusses the caveats, challenges and new insights when considering radioembolization in neuroendocrine liver metastases. Abstract At diagnosis, 21–50% of neuroendocrine tumors already have distant metastases, of which the liver is most commonly affected. Unfortunately, the presence of neuroendocrine liver metastases (NELM) is the most incriminating factor for survival. At NELM diagnosis, 60–70% of patients suffer from bilobar multifocal disease, making them ineligible for surgical resection. With limited systemic options, a clinical need for liver-directed treatments exists. Trans-arterial (bland) embolization, chemoembolization and radioembolization have been increasingly used in the treatment of NELM. In recent years, radioembolization (also known as selective internal radiation therapy) has gained attention due to promising tumor reductive results, limited toxicities and increasing scientific evidence. This review provides basic insights into radioembolization as a technique, a summary of available literature on radioembolization in NELM, and discusses caveats, challenges and new insights when considering radioembolization in NELM.
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Katharina Ingenerf M, Karim H, Fink N, Ilhan H, Ricke J, Treitl KM, Schmid-Tannwald C. Apparent diffusion coefficients (ADC) in response assessment of transarterial radioembolization (TARE) for liver metastases of neuroendocrine tumors (NET): a feasibility study. Acta Radiol 2022; 63:877-888. [PMID: 34225464 PMCID: PMC9194807 DOI: 10.1177/02841851211024004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background In patients with hepatic neuroendocrine tumors (NETs) locoregional therapies
such as transarterial radioembolization (TARE) are increasingly applied.
Response evaluation remains challenging and previous studies assessing
response with diffusion-weighted imaging (DWI) have been inconclusive. Purpose To perform a feasibility study to evaluate if response assessment with
quantitative apparent diffusion coefficient (ADC) in patients with liver
metastases of NETs after TARE will be possible. Material and Methods Retrospectively, 43 patients with 120 target lesions who obtained abdominal
magnetic resonance imaging (MRI) with DWI 39±28 days before and 74±46 days
after TARE were included. Intralesional ADC (ADCmin,
ADCmax, and ADCmean) were measured for a maximum
number of three lesions per patient on baseline and post-interventional DWI.
Tumor response was categorized according to RECIST 1.1 and mRECIST. Results TARE resulted in partial remission (PR) in 23% (63%), in stable disease (SD)
in 73% (23%), in progressive disease (PD) in 5% (7%) and in complete
response (CR) in 0% (1%) according to RECIST 1.1 (mRECIST, respectively).
ADC values increased significantly (P<0.005) after TARE
in the PR group whereas there was no significant change in the PD group.
Post-therapeutic ADC values of SD lesions increased significantly when
evaluated by RECIST 1.1 but not if evaluated by mRECIST. Percentual changes
of ADCmean values were slightly higher for responders compared to
non-responders (P<0.05). Conclusion ADC values seem to represent an additional marker for treatment response
evaluation after TARE in patients with secondary hepatic NET. A conclusive
study seems feasible though patient-based evaluation and overall survival
and progression free survival as alternate primary endpoints should be
considered.
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Affiliation(s)
- Maria Katharina Ingenerf
- Klinik und Poliklinik für Radiologie, Klinikum der Universität München, LMU München, Munich, Germany
| | - Homeira Karim
- Klinik und Poliklinik für Radiologie, Klinikum der Universität München, LMU München, Munich, Germany
| | - Nicola Fink
- Klinik und Poliklinik für Radiologie, Klinikum der Universität München, LMU München, Munich, Germany
| | - Harun Ilhan
- Department of Nuclear Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Jens Ricke
- Klinik und Poliklinik für Radiologie, Klinikum der Universität München, LMU München, Munich, Germany
| | - Karla-Maria Treitl
- Klinik und Poliklinik für Radiologie, Klinikum der Universität München, LMU München, Munich, Germany
| | - Christine Schmid-Tannwald
- Klinik und Poliklinik für Radiologie, Klinikum der Universität München, LMU München, Munich, Germany
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Kimura Y, Ghosn M, Cheema W, Adusumilli PS, Solomon SB, Srimathveeralli G. Expanding the role of interventional oncology for advancing precision immunotherapy of solid tumors. Mol Ther Oncolytics 2022; 24:194-204. [PMID: 35036524 PMCID: PMC8752905 DOI: 10.1016/j.omto.2021.12.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Adoptive cell therapy with chimeric antigen receptors (CAR) T cells has proven effective for hematologic malignancies, but success in solid tumors has been impeded by poor intratumoral infiltration, exhaustion of effector cells from antigen burden, and an immunosuppressive tumor microenvironment. Results from recent clinical trials and preclinical studies lend promising evidence of locoregional approaches for CAR T cell delivery, priming the tumor microenvironment, and performing adjuvant therapies that sustain T cell activity. Interventional oncology is a subspeciality of interventional radiology where imaging guidance is used to perform percutaneous and catheter-directed procedures for localized, non-surgical therapy or interrogation of solid tumors. Interventional oncology provides unique synergies with immunotherapy, which has been well-studied to improve treatment efficacy while reducing toxicities associated with systemic treatment. Besides aiding in CAR T cell delivery, priming, or the stimulation of the tumor microenvironment to promote effector survival and function, interventional oncology can also aid in the monitoring of treatment response through selective, multiplex tumor sampling and catheter-based venous sampling. This review presents an overview of interventional oncology, its various procedures, and its potential for advancing CAR T cell immunotherapy of solid tumors.
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Affiliation(s)
- Yasushi Kimura
- Department of Mechanical and Industrial Engineering, University of Massachusetts, Amherst, MA, USA
| | - Mario Ghosn
- Interventional Radiology Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Waseem Cheema
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Prasad S. Adusumilli
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Stephen B. Solomon
- Interventional Radiology Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Govindarajan Srimathveeralli
- Department of Mechanical and Industrial Engineering, University of Massachusetts, Amherst, MA, USA
- Department of Biomedical Engineering, University of Massachusetts at Amherst, Amherst, MA, USA
- Institute for Applied Life Sciences, University of Massachusetts at Amherst, Amherst, MA, USA
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Imaging of Neuroendocrine Neoplasms: Monitoring Treatment Response—AJR Expert Panel Narrative Review. AJR Am J Roentgenol 2022; 218:767-780. [DOI: 10.2214/ajr.21.27159] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Hudson JM, Chung HTK, Chu W, Taggar A, Davis LE, Hallet J, Law CHL, Singh S, Myrehaug S. Stereotactic Ablative Radiotherapy for the Management of Liver Metastases from Neuroendocrine Neoplasms: A Preliminary Study. Neuroendocrinology 2022; 112:153-160. [PMID: 33530088 DOI: 10.1159/000514914] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 01/21/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Liver metastases are common in patients with neuroendocrine neoplasms. The role of stereotactic ablative radiotherapy (SABR) is not well understood in this population. OBJECTIVE The objective of this study was to evaluate the safety and efficacy of SABR in treating well-differentiated neuroendocrine liver metastases (WD-NELM). METHODS A retrospective review of patients with WD-NELM treated with SABR was conducted between January 2015 and July 2019. Demographic, treatment, and clinical/radiographic follow-up data were abstracted. RECIST 1.1 criteria were applied to each individual target to evaluate the response to treatment. Local control (LC) and progression-free survival (PFS) were determined using the Kaplan-Meier methodology. Toxicity was reported according to the CTCAE v5.0. RESULTS Twenty-five patients with a total of 53 liver metastases treated with SABR were identified. Most patients (68%) had midgut tumors, were grade 2 (80%), and had high-volume intrahepatic and/or extrahepatic disease (76%). The median number of liver metastases treated was 2, with a median size of 2.5 cm. The median radiation dose delivered was 50 Gy/5 fractions. The median follow-up was 14 months; 24 of the 25 patients were alive at the time of analysis. The objective response rate was 32%, with improvement or stability in 96% of lesions treated. The median time to best response was 9 months. The 1-year LC and PFS were 92 and 44%, respectively. No grade 3/4 acute or late toxicity was identified. CONCLUSIONS Liver SABR is a safe and promising means of providing LC for WD-NELM. This treatment modality should be evaluated in selected patients in concert with strategies to manage systemic disease.
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Affiliation(s)
- John Monte Hudson
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Hans Tse-Kan Chung
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - William Chu
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Amandeep Taggar
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Laura Ellen Davis
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Québec, Canada
| | - Julie Hallet
- Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Calvin How Lim Law
- Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Simron Singh
- Division of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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Fleckenstein FN, Roesel MJ, Krajewska M, Auer TA, Collettini F, Maleitzke T, Böning G, Torsello GF, Fehrenbach U, Gebauer B. Combining Transarterial Radioembolization (TARE) and CT-Guided High-Dose-Rate Interstitial Brachytherapy (CT-HDRBT): A Retrospective Analysis of Advanced Primary and Secondary Liver Tumor Treatment. Cancers (Basel) 2021; 14:cancers14010072. [PMID: 35008236 PMCID: PMC8750400 DOI: 10.3390/cancers14010072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 12/16/2021] [Accepted: 12/21/2021] [Indexed: 12/09/2022] Open
Abstract
Simple Summary Clinical management of advanced stages of primary and secondary liver tumors remains challenging. Combining different treatment approaches to create the most effective therapy for patients is, however, often necessary. With this study we aim to analyze the efficacy and safety of a combined intrahepatic treatment of transarterial radioembolization and CT-guided high-dose-rate interstitial brachytherapy. Our study showed that patients not responding to systemic chemotherapy or suffering from tumor relapse after surgical resection might benefit from a combined minimal-invasive treatment. Abstract Purpose: Treatment of patients with primary and secondary liver tumors remains challenging. This study analyzes the efficacy and safety of transarterial radioembolization (TARE) combined with CT-guided high-dose-rate interstitial brachytherapy (CT-HDRBT) for the treatment of primary and secondary liver tumors. Patients and Methods: A total of 77 patients (30 female) with various liver malignancies were treated. Primary endpoints were median overall survival (OS) and time to untreatable progression (TTUP). Additionally, subgroup analyses were performed in consideration of diagnosis and procedure sequence. Median OS and TTUP prediction were estimated using Kaplan–Meier analysis and hazard ratios (HR) were calculated using a multivariate Cox proportional hazard model. Results: A total of 115 CT-HDRBT and 96 TARE procedures were performed with no significant complications recorded. Median OS and TTUP were 29.8 (95% CI 18.1–41.4) and 23.8 (95% CI 9.6–37.9) months. Median OS for hepatocellular carcinoma (HCC)-, cholangiocarcinoma carcinoma (CCA) and colorectal cancer (CRC) patients was 29.8, 29.6 and 34.4 months. Patients starting with TARE had a median OS of 26.0 (95% CI 14.5–37.5) compared to 33.7 (95% CI 21.6–45.8) months for patients starting with CT-HDRBT. Hazard ratio of 1.094 per month was shown for patients starting with CT-HDRBT. Conclusion: Combining TARE and CT-HDRBT is effective and safe for the treatment of advanced stage primary and secondary liver tumors. Our data indicate that early TARE during the disease progression may have a positive effect on survival.
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Affiliation(s)
- Florian Nima Fleckenstein
- Department of Diagnostic and Interventional Radiology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 13353 Berlin, Germany; (M.J.R.); (T.A.A.); (F.C.); (G.B.); (G.F.T.); (U.F.); (B.G.)
- BIH Charité Clinician Scientist Program, Berlin Institute of Health at Charité-Universitätsmedizin Berlin, 10178 Berlin, Germany;
- Correspondence: ; Tel.: +49-30-450-657297
| | - Maximilian Julius Roesel
- Department of Diagnostic and Interventional Radiology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 13353 Berlin, Germany; (M.J.R.); (T.A.A.); (F.C.); (G.B.); (G.F.T.); (U.F.); (B.G.)
| | - Maja Krajewska
- Institute of Biometry and Clinical Epidemiology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany;
| | - Timo Alexander Auer
- Department of Diagnostic and Interventional Radiology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 13353 Berlin, Germany; (M.J.R.); (T.A.A.); (F.C.); (G.B.); (G.F.T.); (U.F.); (B.G.)
- BIH Charité Clinician Scientist Program, Berlin Institute of Health at Charité-Universitätsmedizin Berlin, 10178 Berlin, Germany;
| | - Federico Collettini
- Department of Diagnostic and Interventional Radiology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 13353 Berlin, Germany; (M.J.R.); (T.A.A.); (F.C.); (G.B.); (G.F.T.); (U.F.); (B.G.)
- BIH Charité Clinician Scientist Program, Berlin Institute of Health at Charité-Universitätsmedizin Berlin, 10178 Berlin, Germany;
| | - Tazio Maleitzke
- BIH Charité Clinician Scientist Program, Berlin Institute of Health at Charité-Universitätsmedizin Berlin, 10178 Berlin, Germany;
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 13353 Berlin, Germany
- Julius Wolff Institute, Berlin Institute of Health at Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany
| | - Georg Böning
- Department of Diagnostic and Interventional Radiology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 13353 Berlin, Germany; (M.J.R.); (T.A.A.); (F.C.); (G.B.); (G.F.T.); (U.F.); (B.G.)
| | - Giovanni Federico Torsello
- Department of Diagnostic and Interventional Radiology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 13353 Berlin, Germany; (M.J.R.); (T.A.A.); (F.C.); (G.B.); (G.F.T.); (U.F.); (B.G.)
| | - Uli Fehrenbach
- Department of Diagnostic and Interventional Radiology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 13353 Berlin, Germany; (M.J.R.); (T.A.A.); (F.C.); (G.B.); (G.F.T.); (U.F.); (B.G.)
| | - Bernhard Gebauer
- Department of Diagnostic and Interventional Radiology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 13353 Berlin, Germany; (M.J.R.); (T.A.A.); (F.C.); (G.B.); (G.F.T.); (U.F.); (B.G.)
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11
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Abstract
90 Yttrium (Y90) radioembolization has been shown to improve outcomes for primary and metastatic liver cancers, but there is limited understanding of the optimal timing and safety of combining systemic therapies with Y90 treatment. Both therapeutic effects and toxicities could be synergistic depending on the timing and dosing of different coadministration paradigms. In particular, patients with liver-only or liver-dominant metastatic disease progression are often on systemic therapy when referred to interventional radiology for consideration of Y90 treatment. Interventional radiologists are frequently asked to offer insight into whether or not to hold systemic therapy, and for how long, prior to and following transarterial therapy. This study reviews the current evidence regarding the timing and safety of systemic therapy with Y90 treatment for hepatocellular carcinoma, metastatic colorectal carcinoma, intrahepatic cholangiocarcinoma, metastatic neuroendocrine tumors, and other hepatic metastases. A particular focus is placed on the timing, dosing, and toxicities of combined therapy.
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Affiliation(s)
- Tarub S Mabud
- Division of Vascular Interventional Radiology, Department of Radiology, NYU Langone Health, New York, New York
| | - Ryan Hickey
- Division of Vascular Interventional Radiology, Department of Radiology, NYU Langone Health, New York, New York
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12
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Effraimidis G, Knigge U, Rossing M, Oturai P, Rasmussen ÅK, Feldt-Rasmussen U. Multiple endocrine neoplasia type 1 (MEN-1) and neuroendocrine neoplasms (NENs). Semin Cancer Biol 2021; 79:141-162. [PMID: 33905872 DOI: 10.1016/j.semcancer.2021.04.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 01/03/2021] [Accepted: 04/16/2021] [Indexed: 12/14/2022]
Abstract
Neuroendocrine neoplasms (NENs) are relatively rare neoplasms with 6.4-times increasing age-adjusted annual incidence during the last four decades. NENs arise from neuroendocrine cells, which release hormones in response to neuronal stimuli and they are distributed into organs and tissues. The presentation and biological behaviour of the NENs are highly heterogeneous, depending on the organ. The increased incidence is mainly due to increased awareness and improved detection methods both in the majority of sporadic NENs (non-inherited), but also the inherited groups of neoplasms appearing in at least ten genetic syndromes. The most important one is multiple endocrine neoplasia type 1 (MEN-1), caused by mutations in the tumour suppressor gene MEN1. MEN-1 has been associated with different tumour manifestations of NENs e.g. pancreas, gastrointestinal tract, lungs, thymus and pituitary. Pancreatic NENs tend to be less aggressive when arising in the setting of MEN-1 compared to sporadic pancreatic NENs. There have been very important improvements over the past years in both genotyping, genetic counselling and family screening, introduction and validation of various relevant biomarkers, as well as newer imaging modalities. Alongside this development, both medical, surgical and radionuclide treatments have also advanced and improved morbidity, quality of life and mortality in many of these patients. Despite this progress, there is still space for improving insight into the genetic and epigenetic factors in relation to the biological mechanisms determining NENs as part of MEN-1. This review gives a comprehensive update of current evidence for co-occurrence, diagnosis and treatment of MEN-1 and neuroendocrine neoplasms and highlight the important progress now finding its way to international guidelines in order to improve the global management of these patients.
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Affiliation(s)
- Grigoris Effraimidis
- ENETS Neuroendocrine Tumor Centre of Excellence, Rigshospitalet, Copenhagen University Hospital, Denmark; Department of Medical Endocrinology and Metabolism, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Ulrich Knigge
- ENETS Neuroendocrine Tumor Centre of Excellence, Rigshospitalet, Copenhagen University Hospital, Denmark; Department of Medical Endocrinology and Metabolism, Rigshospitalet, Copenhagen University Hospital, Denmark; Department of Surgery and Transplantation, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Maria Rossing
- Centre for Genomic Medicine, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Peter Oturai
- Department of Clinical Physiology, Nuclear Medicine & PET, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Åse Krogh Rasmussen
- ENETS Neuroendocrine Tumor Centre of Excellence, Rigshospitalet, Copenhagen University Hospital, Denmark; Department of Medical Endocrinology and Metabolism, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Ulla Feldt-Rasmussen
- ENETS Neuroendocrine Tumor Centre of Excellence, Rigshospitalet, Copenhagen University Hospital, Denmark; Department of Medical Endocrinology and Metabolism, Rigshospitalet, Copenhagen University Hospital, Denmark; Institute of Clinical Medicine, Faculty of Health Sciences, Copenhagen University, Denmark.
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13
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Clift AK, Frilling A. Liver-Directed Therapies for Neuroendocrine Neoplasms. Curr Oncol Rep 2021; 23:44. [PMID: 33721122 DOI: 10.1007/s11912-021-01030-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2021] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW To comprehensively synthesise and appraise the available evidence regarding therapies for metastatic neuroendocrine neoplasms that exploit the hepatic vasculature to deliver therapy to liver metastases. RECENT FINDINGS Various techniques including transarterial embolisation/chemoembolisation (TAE/TACE) and selective internal radiotherapy (SIRT, also termed radioembolisation [RE]) have been examined in patents with neuroendocrine liver metastases. Variations in the radioactive agents for selective internal radiotherapy (SIRT) have been explored, such as the use of Holmium-166, in addition to more established agents such as Yttrium-90. Recent trials have examined the safety and efficacy of combining liver-targeted therapy with systemic treatments, such as peptide receptor radionuclide therapy. More retrospective case series of liver-directed modalities will not provide additional knowledge. Randomised clinical trials have begun to compare the efficacy of different forms of liver-directed therapies, and also their combination with systemic treatment. Their results are expected to guide optimal treatment sequencing within multimodal concepts.
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Affiliation(s)
- Ashley Kieran Clift
- CRUK Oxford Centre, University of Oxford, Oxford, UK.,Department of Surgery & Cancer, Imperial College London, London, UK
| | - Andrea Frilling
- Department of Surgery & Cancer, Imperial College London, London, UK. .,Department of Surgery and Cancer, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK.
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14
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Preston E, Shaida N. Selective internal radiation therapy in the management of primary and metastatic disease in the liver. Br J Hosp Med (Lond) 2021; 82:1-11. [PMID: 33646031 DOI: 10.12968/hmed.2020.0624] [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: 11/11/2022]
Abstract
Selective internal radiation therapy is a type of brachytherapy used to provide targeted radiotherapy, most commonly to treat primary or metastatic disease within the liver. This review outlines current clinical practice, dosimetric considerations, the pre-treatment workup and safety considerations before treatment. It also examines the clinical evidence for its use in patients with both primary and metastatic disease within the liver.
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Affiliation(s)
- Emma Preston
- Department of Vascular Surgery, Lister Hospital, Stevenage, UK
| | - Nadeem Shaida
- Department of Interventional Radiology, Addenbrooke's Hospital, Cambridge, UK
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15
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Tai E, Kennedy S, Farrell A, Jaberi A, Kachura J, Beecroft R. Comparison of transarterial bland and chemoembolization for neuroendocrine tumours: a systematic review and meta-analysis. Curr Oncol 2020; 27:e537-e546. [PMID: 33380868 PMCID: PMC7755439 DOI: 10.3747/co.27.6205] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background Treatment of hepatic metastases from neuroendocrine tumours improves survival and symptom relief. Hepatic arterial embolotherapy techniques include transarterial chemoembolization (tace) and bland embolization (tae). The relative efficacy of the techniques is controversial. The purpose of the present study was to use a meta-analysis and systematic review to compare tace with tae in the treatment of hepatic metastases. Methods A literature search identified studies comparing tace and tae for treatment of hepatic metastases. Outcomes of interest included overall survival (os), progression-free survival (pfs), radiographic response, complications, and symptom control. The hazard ratios (hrs) and odds ratios (ors) were estimated and pooled. Results Eight studies and 504 patients were included. No statistically significant differences between tace and tae were observed for os at 1, 2, and 5 years or for hrs [1-year or: 0.72; 95% confidence interval (ci): 0.27 to 1.94; p < 0.52; 2-year or: 0.69; 95% ci: 0.43 to 1.11; p < 0.12; 5-year or: 0.91; 95% ci: 0.37 to 2.24; p < 0.85; hr: 0.96; 95% ci: 0.73 to 1.24; p < 0.74]. No statistically significant differences between tace and tae were observed for pfs at 1, 2, and 5 years or for hrs (1-year or: 0.71; 95% ci: 0.38 to 1.55; p < 0.30; 2-year or: 0.83; 95% ci: 0.33 to 2.06; p < 0.69; 5-year or: 0. 91; 95% ci: 0.37 to 2.24; p < 0.85; hr: 0.99-1.74; 95% ci: 0.74 to 1.73; p < 0.97). Both techniques are safe and effective for symptom control. Conclusions No statistically significant differences between tace and tae were observed for os and pfs.
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Affiliation(s)
- E Tai
- Division of Interventional Radiology, Joint Department of Medical Imaging, University Health Network, Toronto, ON
| | - S Kennedy
- Division of Interventional Radiology, Joint Department of Medical Imaging, University Health Network, Toronto, ON
| | - A Farrell
- Library and Information Services, Toronto General Hospital, Toronto, ON
| | - A Jaberi
- Division of Interventional Radiology, Joint Department of Medical Imaging, University Health Network, Toronto, ON
| | - J Kachura
- Division of Interventional Radiology, Joint Department of Medical Imaging, University Health Network, Toronto, ON
| | - R Beecroft
- Division of Interventional Radiology, Joint Department of Medical Imaging, University Health Network, Toronto, ON
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16
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Pollock RF, Brennan VK, Peters R, Paprottka PM. Association between objective response rate and overall survival in metastatic neuroendocrine tumors treated with radioembolization: a systematic literature review and regression analysis. Expert Rev Anticancer Ther 2020; 20:997-1009. [PMID: 32930618 DOI: 10.1080/14737140.2020.1814748] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Neuroendocrine tumors (NETs) are a heterogeneous group of cancers arising from neuroendocrine cells. The aim was to evaluate objective response rate (ORR) as a predictor of overall survival (OS) in patients with metastatic NETs (mNETs) treated with radioembolization (RE). METHODS Randomized controlled trials and observational studies of RE treatment of mNETs were identified by systematic literature review (SLR). Pooled ORR and OS estimates were calculated and a weighted generalized linear model (GLM) of ORR as a predictor of OS was derived, stratified by ORR assessment criteria and RE type (Yttrium-90 resin or glass microspheres). RESULTS The SLR identified 32 observational studies. Mean ORR was 41% (95% confidence interval 38-45%). The Yttrium-90 resin and glass microsphere GLMs accounted for 59% and 57% of OS deviance, respectively. ORR was a significant predictor of OS in the resin microspheres model (p < 0.001), but not the glass microspheres model (p = 0.11). CONCLUSIONS A weighted GLM showed a significant relationship between ORR and OS in patients with mNETs treated with Yttrium-90 resin microspheres. ORR could therefore potentially be an OS surrogate in future trials of Yttrium-90 resin microspheres. Further research is needed to confirm the relationship between ORR and OS and the difference between resin and glass microspheres.
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Affiliation(s)
- Richard F Pollock
- Department of Health Economics and Outcomes Research, Covalence Research Ltd , London, UK
| | - Victoria K Brennan
- Health Economics, Pricing, Reimbursement & Market Access, Sirtex Medical United Kingdom Ltd , London, UK
| | - Ralph Peters
- Health Economics, Pricing, Reimbursement & Market Access, Sirtex Medical United Kingdom Ltd , London, UK
| | - Philipp M Paprottka
- Department of Interventional Radiology, Klinikum Rechts der Isar der Technischen Universität München , Munich, Germany
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17
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Clinical Application of Trans-Arterial Radioembolization in Hepatic Malignancies in Europe: First Results from the Prospective Multicentre Observational Study CIRSE Registry for SIR-Spheres Therapy (CIRT). Cardiovasc Intervent Radiol 2020; 44:21-35. [PMID: 32959085 PMCID: PMC7728645 DOI: 10.1007/s00270-020-02642-y] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 09/02/2020] [Indexed: 01/27/2023]
Abstract
Purpose To address the lack of prospective data on the real-life clinical application of trans-arterial radioembolization (TARE) in Europe, the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) initiated the prospective observational study CIRSE Registry for SIR-Spheres® Therapy (CIRT). Materials and Methods Patients were enrolled from 1 January 2015 till 31 December 2017. Eligible patients were adult patients treated with TARE with Y90 resin microspheres for primary or metastatic liver tumours. Patients were followed up for 24 months after treatment, whereas data on the clinical context of TARE, overall survival (OS) and safety were collected. Results Totally, 1027 patients were analysed. 68.2% of the intention of treatment was palliative. Up to half of the patients received systemic therapy and/or locoregional treatments prior to TARE (53.1%; 38.3%). Median overall survival (OS) was reported per cohort and was 16.5 months (95% confidence interval (CI) 14.2–19.3) for hepatocellular carcinoma, 14.6 months (95% CI 10.9–17.9) for intrahepatic cholangiocarcinoma. For liver metastases, median OS for colorectal cancer was 9.8 months (95% CI 8.3–12.9), 5.6 months for pancreatic cancer (95% CI 4.1–6.6), 10.6 months (95% CI 7.3–14.4) for breast cancer, 14.6 months (95% CI 7.3–21.4) for melanoma and 33.1 months (95% CI 22.1–nr) for neuroendocrine tumours. Statistically significant prognostic factors in terms of OS include the presence of ascites, cirrhosis, extra-hepatic disease, patient performance status (Eastern Cooperative Oncology Group), number of chemotherapy lines prior to TARE and tumour burden. Thirty-day mortality rate was 1.0%. 2.5% experienced adverse events grade 3 or 4 within 30 days after TARE. Conclusion In the real-life clinical setting, TARE is largely considered to be a part of a palliative treatment strategy across indications and provides an excellent safety profile. Level of evidence Level 3. Trial registration ClinicalTrials.gov NCT02305459. Electronic supplementary material The online version of this article (10.1007/s00270-020-02642-y) contains supplementary material, which is available to authorized users.
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18
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The Role of Interventional Radiology for the Treatment of Hepatic Metastases from Neuroendocrine Tumor: An Updated Review. J Clin Med 2020; 9:jcm9072302. [PMID: 32698459 PMCID: PMC7408651 DOI: 10.3390/jcm9072302] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/08/2020] [Accepted: 07/10/2020] [Indexed: 02/07/2023] Open
Abstract
Interventional radiology plays an important role in the management of patients with neuroendocrine tumor liver metastasis (NELM). Transarterial embolization (TAE), transarterial chemoembolization (TACE), and selective internal radiation therapy (SIRT) are intra-arterial therapies available for these patients in order to improve symptoms and overall survival. These treatment options are proposed in patients with NELM not responding to systemic therapies and without extrahepatic progression. Currently, available data suggest that TAE should be preferred to TACE in patients with NELM from extrapancreatic origin because of similar efficacy and better patient tolerance. TACE is more effective in patients with pancreatic NELM and SIRT has shown promising results along with good tolerance. However, large randomized controlled trials are still lacking in this setting. Available literature mainly consists in small sample size and retrospective studies with important technical heterogeneity. The purpose of this review is to provide an updated overview of the currently reported endovascular interventional radiology procedures that are used for the treatment of NELM.
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19
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Surgical treatment of non-functioning pancreatic neuroendocrine tumors: current controversies and challenges. JOURNAL OF PANCREATOLOGY 2020. [DOI: 10.1097/jp9.0000000000000047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
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20
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Helmberger T, Arnold D, Bilbao JI, de Jong N, Maleux G, Nordlund A, Peynircioglu B, Sangro B, Sharma RA, Walk A. Clinical Application of Radioembolization in Hepatic Malignancies: Protocol for a Prospective Multicenter Observational Study. JMIR Res Protoc 2020; 9:e16296. [PMID: 32319960 PMCID: PMC7203613 DOI: 10.2196/16296] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 01/30/2020] [Accepted: 02/21/2020] [Indexed: 12/22/2022] Open
Abstract
Background Radioembolization, also known as transarterial radioembolization or selective internal radiation therapy with yttrium-90 (90Y) resin microspheres, is an established treatment modality for patients with primary and secondary liver tumors. However, large-scale prospective observational data on the application of this treatment in a real-life clinical setting is lacking. Objective The main objective is to collect data on the clinical application of radioembolization with 90Y resin microspheres to improve the understanding of the impact of this treatment modality in its routine practice setting. Methods Eligible patients are 18 years or older and receiving radioembolization for primary and secondary liver tumors as part of routine practice, as well as have signed informed consent. Data is collected at baseline, directly after treatment, and at every 3-month follow-up until 24 months or study exit. The primary objective of the Cardiovascular and Interventional Radiological Society of Europe Registry for SIR-Spheres Therapy (CIRT) is to observe the clinical application of radioembolization. Secondary objectives include safety, effectiveness in terms of overall survival, progression-free survival (PFS), liver-specific PFS, imaging response, and change in quality of life. Results Between January 2015 and December 2017, 1047 patients were included in the study. The 24-month follow-up period ended in December 2019. The first results are expected in the third quarter of 2020. Conclusions The CIRT is the largest observational study on radioembolization to date and will provide valuable insights to the clinical application of this treatment modality and its real-life outcomes. Trial Registration ClinicalTrials.gov NCT02305459; https://clinicaltrials.gov/ct2/show/NCT02305459 International Registered Report Identifier (IRRID) DERR1-10.2196/16296
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Affiliation(s)
- Thomas Helmberger
- Department of Radiology, Neuroradiology and Minimal-Invasive Therapy, Klinikum Bogenhausen, München, Germany
| | - Dirk Arnold
- Oncology and Hematology, Asklepios Tumorzentrum Hamburg, Asklepios Klinik Altona, Hamburg, Germany
| | - José I Bilbao
- Interventional Radiology, Clinica Universidad de Navarra, Pamplona, Spain
| | - Niels de Jong
- Cardiovascular and Interventional Radiological Society of Europe, Vienna, Austria
| | - Geert Maleux
- Radiologie, Universitair Ziekenhuis Leuven, Leuven, Belgium
| | | | - Bora Peynircioglu
- Department of Radiology, School of Medicine, Hacettepe University, Ankara, Turkey
| | - Bruno Sangro
- Liver Unit, Clínica Universidad de Navarra, Pamplona, Spain.,Instituto de Investigación Sanitaria de Navarra, Pamplona, Spain.,Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Pamplona, Spain
| | - Ricky A Sharma
- National Institute for Health Research University College London Hospitals Biomedical Research Centre, University College London Cancer Institute, University College London, London, United Kingdom
| | - Agnes Walk
- Cardiovascular and Interventional Radiological Society of Europe, Vienna, Austria
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Tsilimigras DI, Squires MH, Cloyd JM, Pawlik TM. Treatment strategies for neuroendocrine liver metastases: an update. Expert Opin Orphan Drugs 2019. [DOI: 10.1080/21678707.2019.1651639] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Diamantis I. Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Malcolm H. Squires
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jordan M. Cloyd
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Timothy M. Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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22
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Frilling A, Clift AK, Braat AJAT, Alsafi A, Wasan HS, Al-Nahhas A, Thomas R, Drymousis P, Habib N, Tait PN. Radioembolisation with 90Y microspheres for neuroendocrine liver metastases: an institutional case series, systematic review and meta-analysis. HPB (Oxford) 2019; 21:773-783. [PMID: 30733049 DOI: 10.1016/j.hpb.2018.12.014] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Revised: 12/03/2018] [Accepted: 12/11/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Neuroendocrine liver metastases are clinically challenging due to their frequent disseminated distribution. This study aims to present a British experience with an emerging modality, radioembolisation with yttrium-90 labelled microspheres, and embed this within a meta-analysis of response and survival outcomes. METHODS A retrospective case series of patients treated with SIR-Spheres (radiolabelled resin microspheres) was performed. Results were included in a systematic review and meta-analysis of published results with glass or resin microspheres. Objective response rate (ORR) was defined as complete or partial response. Disease control rate (DCR) was defined as complete/partial response or stable disease. RESULTS Twenty-four patients were identified. ORR and DCR in the institutional series was 14/24 and 21/24 at 3 months. Overall survival and progression-free survival at 3-years was 77.6% and 50.4%, respectively. There were no grade 3/4 toxicities post-procedure. A fixed-effects pooled estimate of ORR of 51% (95% CI: 47%-54%) was identified from meta-analysis of 27 studies. The fixed-effects weighted average DCR was 88% (95% CI: 85%-90%, 27 studies). CONCLUSION Current data demonstrate evidence of the clinical effectiveness and safety of radioembolisation for neuroendocrine liver metastases. Prospective randomised studies to compare radioembolisation with other liver directed treatment modalities are needed.
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Affiliation(s)
- Andrea Frilling
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital, London, W12 0HS, United Kingdom
| | - Ashley K Clift
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital, London, W12 0HS, United Kingdom
| | - Arthur J A T Braat
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, 3508, GA Utrecht, the Netherlands
| | - Ali Alsafi
- Department of Imaging, Imperial College London, Hammersmith Hospital, London, W12 0HS, United Kingdom
| | - Harpreet S Wasan
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital, London, W12 0HS, United Kingdom
| | - Adil Al-Nahhas
- Department of Nuclear Medicine, Imperial College London, Hammersmith Hospital, London, W12 0HS, United Kingdom
| | - Robert Thomas
- Department of Imaging, Imperial College London, Hammersmith Hospital, London, W12 0HS, United Kingdom
| | - Panagiotis Drymousis
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital, London, W12 0HS, United Kingdom
| | - Nagy Habib
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital, London, W12 0HS, United Kingdom
| | - Paul N Tait
- Department of Imaging, Imperial College London, Hammersmith Hospital, London, W12 0HS, United Kingdom
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23
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Mohamed A, Strosberg JR. Medical Management of Gastroenteropancreatic Neuroendocrine Tumors: Current Strategies and Future Advances. J Nucl Med 2019; 60:721-727. [DOI: 10.2967/jnumed.118.214882] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 01/13/2019] [Indexed: 12/14/2022] Open
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Radioembolization with 90Y Resin Microspheres of Neuroendocrine Liver Metastases: International Multicenter Study on Efficacy and Toxicity. Cardiovasc Intervent Radiol 2019; 42:413-425. [DOI: 10.1007/s00270-018-2148-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 12/15/2018] [Indexed: 01/27/2023]
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Radioembolization Versus Bland Embolization for Hepatic Metastases from Small Intestinal Neuroendocrine Tumors: Short-Term Results of a Randomized Clinical Trial. World J Surg 2018; 42:506-513. [PMID: 29167951 PMCID: PMC5762793 DOI: 10.1007/s00268-017-4324-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background Radioembolization (RE) with intra-arterial administration of 90Y microspheres is a promising technique for the treatment of liver metastases from small intestinal neuroendocrine tumors (SI-NET) not amenable to surgery or local ablation. However, studies comparing RE to other loco-regional therapies are lacking. The aim of this randomized study was to compare the therapeutic response and safety after RE and bland hepatic arterial embolization (HAE), and to investigate early therapy-induced changes with diffusion-weighted MRI (DWI-MRI). Methods Eleven patients were included in a prospective randomized controlled pilot study, six assigned to RE and five to HAE. Response according to RECIST 1.1 using MRI or CT at 3 and 6 months post-treatment was recorded as well as changes in DWI-MRI parameters after 1 month. Data on biochemical tumor response, toxicity, and side effects were also collected. Results Three months after treatment, all patients in the HAE group showed partial response according to RECIST while none in the RE group did (p = 0.0022). After 6 months, the response rates were 4/5 (80%) and 2/6 (33%) in the HAE and RE groups, respectively (NS). DWI-MRI metrics could not predict RECIST response, but lower pretreatment ADC(120–800) and larger ADC(0–800) increase at 1 month were related to larger decrease in tumor diameter when all tumors were counted. Conclusion HAE resulted in significantly higher RECIST response after 3 months, but no difference compared to RE remained after 6 months. These preliminary findings indicate that HAE remains a safe option for the treatment of liver metastases from SI-NET, and further studies are needed to establish the role of RE and the predictive value of MR-DWI. Electronic supplementary material The online version of this article (10.1007/s00268-017-4324-9) contains supplementary material, which is available to authorized users.
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Werner RA, Bundschuh RA, Bundschuh L, Javadi MS, Higuchi T, Weich A, Sheikhbahaei S, Pienta KJ, Buck AK, Pomper MG, Gorin MA, Lapa C, Rowe SP. Molecular imaging reporting and data systems (MI-RADS): a generalizable framework for targeted radiotracers with theranostic implications. Ann Nucl Med 2018; 32:512-522. [PMID: 30109562 PMCID: PMC6182628 DOI: 10.1007/s12149-018-1291-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 08/09/2018] [Indexed: 01/15/2023]
Abstract
Both prostate-specific membrane antigen (PSMA)- and somatostatin receptor (SSTR)-targeted positron emission tomography (PET)-based imaging agents for prostate carcinoma and neuroendocrine tumors, respectively, are seeing rapidly expanding use. In addition to diagnostic applications, both classes of radiotracers can be used to triage patients for theranostic endoradiotherapy. While interpreting PSMA- or SSTR-targeted PET/computed tomography (CT) scans, the reader has to be aware of certain pitfalls. Adding to the complexity of the interpretation of those imaging agents, both normal biodistribution, and also false-positive and -negative findings differ between PSMA- and SSTR-targeted PET radiotracers. Herein summarized under the umbrella term molecular imaging reporting and data systems (MI-RADS), two novel RADS classifications for PSMA- and SSTR-targeted PET imaging are described (PSMA- and SSTR-RADS). Notably, PSMA- and SSTR-RADS are structured in a reciprocal fashion, i.e., if the reader is familiar with one system, the other system can readily be applied, as well. In the present review, we will discuss the most common pitfalls on PSMA- and SSTR-targeted PET/CT, briefly introduce PSMA- and SSTR-RADS, and define a potential future role of the umbrella framework MI-RADS compared to other classification systems.
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Affiliation(s)
- Rudolf A Werner
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, 601 N. Caroline St., Baltimore, MD, 21287, USA.,Department of Nuclear Medicine, Comprehensive Heart Failure Center, University Hospital Würzburg, Würzburg, Germany.,European Neuroendocrine Tumor Society (ENETS), Center of Excellence (CoE), NET Zentrum, University Hospital Würzburg, Würzburg, Germany
| | - Ralph A Bundschuh
- Department of Nuclear Medicine, University Medical Center Bonn, Bonn, Germany
| | - Lena Bundschuh
- Department of Nuclear Medicine, University Medical Center Bonn, Bonn, Germany
| | - Mehrbod S Javadi
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, 601 N. Caroline St., Baltimore, MD, 21287, USA
| | - Takahiro Higuchi
- Department of Nuclear Medicine, Comprehensive Heart Failure Center, University Hospital Würzburg, Würzburg, Germany.,Department of Bio Medical Imaging, National Cardiovascular and Cerebral Research Center, Suita, Japan
| | - Alexander Weich
- European Neuroendocrine Tumor Society (ENETS), Center of Excellence (CoE), NET Zentrum, University Hospital Würzburg, Würzburg, Germany.,Department of Internal Medicine II, Gastroenterology, University Hospital Würzburg, Würzburg, Germany
| | - Sara Sheikhbahaei
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, 601 N. Caroline St., Baltimore, MD, 21287, USA
| | - Kenneth J Pienta
- Department of Urology, The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Andreas K Buck
- Department of Nuclear Medicine, Comprehensive Heart Failure Center, University Hospital Würzburg, Würzburg, Germany.,European Neuroendocrine Tumor Society (ENETS), Center of Excellence (CoE), NET Zentrum, University Hospital Würzburg, Würzburg, Germany
| | - Martin G Pomper
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, 601 N. Caroline St., Baltimore, MD, 21287, USA
| | - Michael A Gorin
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, 601 N. Caroline St., Baltimore, MD, 21287, USA.,Department of Urology, The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Constantin Lapa
- Department of Nuclear Medicine, Comprehensive Heart Failure Center, University Hospital Würzburg, Würzburg, Germany.,European Neuroendocrine Tumor Society (ENETS), Center of Excellence (CoE), NET Zentrum, University Hospital Würzburg, Würzburg, Germany
| | - Steven P Rowe
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, 601 N. Caroline St., Baltimore, MD, 21287, USA. .,Department of Urology, The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Randomized Embolization Trial for NeuroEndocrine Tumor Metastases to the Liver (RETNET): study protocol for a randomized controlled trial. Trials 2018; 19:390. [PMID: 30016989 PMCID: PMC6050671 DOI: 10.1186/s13063-018-2782-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 07/04/2018] [Indexed: 01/24/2023] Open
Abstract
Background Neuroendocrine tumors (NETs) are the second most common gastrointestinal malignancy after colon cancer. Up to 90% of patients with NETs develop liver metastases, which are a major determinant of symptoms and survival. Current guidelines recommend embolotherapy for progressive or symptomatic NET liver metastases, but the optimal technique among bland embolization, lipiodol chemoembolization, and drug-eluting bead chemoembolization remains unknown and controversial. Methods/design A prospective, open-label, multicenter randomized controlled trial will be conducted in patients with progressive or symptomatic unresectable NET liver metastases. Patients will be randomized to treatment with bland embolization, lipiodol chemoembolization, or drug-eluting microsphere chemoembolization, with 60 enrollees per arm. The primary endpoint will be hepatic progression-free survival (HPFS) following initial embolotherapy by RECIST criteria. The sample size is powered to detect an HR of 1.78 for HPFS following chemoembolization compared with bland embolization, which was estimated on the basis of existing retrospective studies. Secondary endpoints include overall progression-free survival, duration of symptom control, quality of life, rate of adverse events, and interval between embolotherapy cycles. Interim safety analyses will be performed at 10 and 30 patients per arm. Discussion The RETNET trial is a prospective, multicenter randomized controlled trial designed to determine the optimal embolotherapy technique for NET liver metastases. Trial registration ClinicalTrials.gov, NCT02724540. Registered on March 31, 2016. Electronic supplementary material The online version of this article (10.1186/s13063-018-2782-5) contains supplementary material, which is available to authorized users.
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Abstract
Pancreatic neuroendocrine tumours (PNETs) might occur as a non-familial isolated endocrinopathy or as part of a complex hereditary syndrome, such as multiple endocrine neoplasia type 1 (MEN1). MEN1 is an autosomal dominant disorder characterized by the combined occurrence of PNETs with tumours of the parathyroids and anterior pituitary. Treatments for primary PNETs include surgery. Treatments for non-resectable PNETs and metastases include biotherapy (for example, somatostatin analogues, inhibitors of receptors and monoclonal antibodies), chemotherapy and radiological therapy. All these treatments are effective for PNETs in patients without MEN1; however, there is a scarcity of clinical trials reporting the efficacy of the same treatments of PNETs in patients with MEN1. Treatment of PNETs in patients with MEN1 is challenging owing to the concomitant development of other tumours, which might have metastasized. In recent years, preclinical studies have identified potential new therapeutic targets for treating MEN1-associated neuroendocrine tumours (including PNETs), and these include epigenetic modification, the β-catenin-wingless (WNT) pathway, Hedgehog signalling, somatostatin receptors and MEN1 gene replacement therapy. This Review discusses these advances.
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Affiliation(s)
- Morten Frost
- Academic Endocrine Unit, Oxford Centre for Diabetes, Endocrinology & Metabolism, Radcliffe Department of Medicine, University of Oxford, Churchill Hospital, OX3 7LJ. United Kingdom
- Endocrine Research Unit, University of Southern Denmark, Odense, 5000, Denmark
| | - Kate E Lines
- Academic Endocrine Unit, Oxford Centre for Diabetes, Endocrinology & Metabolism, Radcliffe Department of Medicine, University of Oxford, Churchill Hospital, OX3 7LJ. United Kingdom
| | - Rajesh V Thakker
- Academic Endocrine Unit, Oxford Centre for Diabetes, Endocrinology & Metabolism, Radcliffe Department of Medicine, University of Oxford, Churchill Hospital, OX3 7LJ. United Kingdom
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Werner RA, Solnes LB, Javadi MS, Weich A, Gorin MA, Pienta KJ, Higuchi T, Buck AK, Pomper MG, Rowe SP, Lapa C. SSTR-RADS Version 1.0 as a Reporting System for SSTR PET Imaging and Selection of Potential PRRT Candidates: A Proposed Standardization Framework. J Nucl Med 2018; 59:1085-1091. [DOI: 10.2967/jnumed.117.206631] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 03/14/2018] [Indexed: 12/13/2022] Open
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Kennedy A, Brown DB, Feilchenfeldt J, Marshall J, Wasan H, Fakih M, Gibbs P, Knuth A, Sangro B, Soulen MC, Pittari G, Sharma RA. Safety of selective internal radiation therapy (SIRT) with yttrium-90 microspheres combined with systemic anticancer agents: expert consensus. J Gastrointest Oncol 2017; 8:1079-1099. [PMID: 29299370 PMCID: PMC5750172 DOI: 10.21037/jgo.2017.09.10] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 09/20/2017] [Indexed: 12/12/2022] Open
Abstract
Selective internal radiation therapy (SIRT) with microspheres labelled with the β-emitter yttrium-90 (Y-90) enables targeted delivery of radiation to hepatic tumors. SIRT is primarily used to treat inoperable primary or metastatic liver tumors. Eligible patients have usually been exposed to a variety of systemic anticancer therapies, including cytotoxic agents, targeted biologics, immunotherapy and peptide receptor radionuclide therapy (PRRT). All these treatments have potential interactions with SIRT; however, robust evidence on the safety of these potential combinations is lacking. This paper provides current clinical experiences and expert consensus guidelines for the use of SIRT in combination with the anticancer treatment agents likely to be encountered in clinical practice. It was agreed by the expert panel that precautions need to be taken with certain drugs, but that, in general, systemic therapies do not necessarily have to be stopped to perform SIRT. The authors recommend stopping vascular endothelial growth factor inhibitors 4-6 weeks before SIRT, and restart after the patient has recovered from the procedure. It may also be prudent to stop potent radiosensitizers such as gemcitabine therapy 4 weeks before SIRT, and restart treatment at least 2‒4 weeks later. Data from phase III studies combining SIRT with fluorouracil (5FU) or folinic acid/5FU/oxaliplatin (FOLFOX) suggest that hematological toxicity is more common from the combination than it is from chemotherapy without SIRT. There is no evidence to suggest that chemotherapy increases SIRT-specific gastro-intestinal or liver toxicities.
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Affiliation(s)
- Andrew Kennedy
- Radiation Oncology Research, Sarah Cannon Research Institute, Nashville, Tennessee, USA
| | - Daniel B. Brown
- Department of Radiology and Radiologic Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - John Marshall
- Hematology and Oncology Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington DC, USA
| | - Harpreet Wasan
- Imperial College, Division of Cancer, Hammersmith Hospital, London, UK
| | - Marwan Fakih
- Department of Medical Oncology & Therapeutics Research, City of Hope, Duarte, California, USA
| | - Peter Gibbs
- Western Hospital, Footscray, Victoria, Australia
| | - Alexander Knuth
- National Center for Cancer Care and Research, HMC, Doha, Qatar
| | - Bruno Sangro
- Liver Unit, Clinica Universidad de Navarra, IDISNA, CIBEREHD, Pamplona, Navarra, Spain
| | - Michael C. Soulen
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Ricky A. Sharma
- NIHR University College London Hospitals Biomedical Research Centre, UCL Cancer Institute, University College London, London, UK
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Jia Z, Paz-Fumagalli R, Frey G, Sella DM, McKinney JM, Wang W. Single-institution experience of radioembolization with yttrium-90 microspheres for unresectable metastatic neuroendocrine liver tumors. J Gastroenterol Hepatol 2017; 32:1617-1623. [PMID: 28132407 DOI: 10.1111/jgh.13752] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 01/25/2017] [Accepted: 01/25/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND AIM The aim of this study was to assess the effectiveness of yttrium-90 (90 Y) microspheres for the treatment of unresectable metastatic liver neuroendocrine tumors (NET). METHODS From February 2006 to September 2015, 36 patients (19 male and 17 female, age 63.6 ± 9.4 years) who underwent 90 Y therapy for unresectable liver metastases of NET were included and analyzed retrospectively. All patients received a variety of treatments before 90 Y therapy. The radiological response, symptoms improvement of carcinoid syndrome, tumor marker changes, complications, side effects/toxicity, survival, and factors related to survival were evaluated and analyzed. RESULTS Of the 36 patients, the mean delivered dose of 90 Y was 1.8 ± 0.7 GBq with a total of 40 treatments. Overall disease control rate was 88.9% (32/36) at 3 months following therapy. In 16 patients with carcinoid syndrome, 15 (93.8%) patients had symptomatic improvement. Tumor marker response (5-hydroxyindoleacetic acid [n = 7] and chromogranin A [n = 13]) at 3 months after treatment were as follows: none (n = 0, 4), partial (n = 6, 7), and complete (n = 1, 2). Radiation-induced gastrointestinal ulcers (n = 2, 5.6%) were identified. Side effects included fatigue (n = 31, 86.1%), anorexia (n = 26, 72.2%), nausea (n = 15, 41.7%), vomiting (n = 14, 38.9%), abdominal pain (n = 10, 27.8%), and fever (n = 8, 22.2%). The mean follow-up was 27.0 ± 16.4 months, with a median survival of 41.0 months. Child-Pugh classification (P = 0.008) and lymph node metastases (P = 0.045) had statistically significant influence on overall survival. CONCLUSIONS Yttrium-90 radioembolization can be effective in the treatment of unresectable liver metastases of NET who failed to respond to other treatments.
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Affiliation(s)
- Zhongzhi Jia
- Department of Interventional Radiology, The Second People's Hospital of Changzhou, Nanjing Medical University, Changzhou, China
| | | | - Gregory Frey
- Department of Radiology, Mayo Clinic, Jacksonville, Florida, USA
| | - David M Sella
- Department of Radiology, Mayo Clinic, Jacksonville, Florida, USA
| | - J Mark McKinney
- Department of Radiology, Mayo Clinic, Jacksonville, Florida, USA
| | - Weiping Wang
- Department of Radiology, Mayo Clinic, Jacksonville, Florida, USA
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Treatment Strategies for Metastatic Neuroendocrine Tumors of the Gastrointestinal Tract. Curr Treat Options Oncol 2017; 18:14. [PMID: 28286921 DOI: 10.1007/s11864-017-0461-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OPINION STATEMENT The therapeutic landscape of gastroenteropancreatic-neuroendocrine tumors (GEP-NETs) has evolved significantly in recent years. Current and emerging treatment options include somatostatin analogs, radiolabeled somatostatin analogs, the mTOR inhibitor everolimus, and the tyrosine kinase inhibitor sunitinib. Although high-quality data from phase III trials are lacking, cytotoxic agents are commonly used for the treatment of poorly differentiated neuroendocrine carcinomas and well-differentiated NETs originating in the pancreas. Hepatic-directed therapies are recommended for patients with slow-growing, liver-predominant disease but have never been compared to systemic agents. Telotristat ethyl, a novel serotonin synthesis inhibitor, has recently demonstrated efficacy in palliating diarrhea in patients with poorly controlled carcinoid syndrome. In the absence of definite predictive biomarkers, therapeutic decisions in most cases rely on clinical and pathological criteria. However, navigating the current therapeutic algorithm may be challenging, and future trials need to address several important questions: what is the best sequence of treatment? Is there a role for combination therapies in GEP-NETs? Are neoadjuvant, adjuvant, or maintenance strategies safe and effective? Do all NET patients require active treatment? What new molecular targets can be clinically exploited? A tight integration between basic and clinical research is needed to further advance the field of NETs.
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Schippers AC, Collettini F, Steffen IG, Wieners G, Denecke T, Pavel M, Wust P, Gebauer B. Initial Experience with CT–Guided High-Dose-Rate Brachytherapy in the Multimodality Treatment of Neuroendocrine Tumor Liver Metastases. J Vasc Interv Radiol 2017; 28:672-682. [DOI: 10.1016/j.jvir.2016.07.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 07/09/2016] [Accepted: 07/09/2016] [Indexed: 02/07/2023] Open
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Vogl TJ, Koch SA, Lotz G, Gebauer B, Willinek W, Engelke C, Brüning R, Zeile M, Wacker F, Vogel A, Radeleff B, Scholtz JE. Percutaneous Isolated Hepatic Perfusion as a Treatment for Isolated Hepatic Metastases of Uveal Melanoma: Patient Outcome and Safety in a Multi-centre Study. Cardiovasc Intervent Radiol 2017; 40:864-872. [PMID: 28144756 DOI: 10.1007/s00270-017-1588-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 01/25/2017] [Indexed: 12/22/2022]
Abstract
PURPOSE Percutaneous isolated hepatic perfusion (PIHP) with Melphalan has been developed as a treatment for patients with isolated hepatic metastases of uveal melanoma. We discuss patient outcome and safety in a retrospective multi-centre study. MATERIALS AND METHODS Between 2012 and 2016 18 patients with un-resectable isolated hepatic metastases of uveal melanoma received single or repeated PIHP with Melphalan (n = 35) at seven sites. Progression-free time, overall survival time (OS) and tumour response by means of RECIST 1.1 criteria were evaluated. Peri- and post-procedural adverse events (AE) were registered. Patients' life quality was assessed using four-point scale questionnaires. RESULTS Of 18 patients, initial PIHP treatment resulted in partial response (PR) in eight, stable disease (SD) in seven and progressive disease (PD) in three cases. Nine patients underwent second PIHP with PR in eight cases and PD in one case. Six patients were evaluated after third PIHP with PR in five patients and SD in one patient. Two patients received fourth PIHP with PD in both cases. Median OS was 9.6 months (range 1.6-41.0 months). Median progression-free survival time was 12.4 months (range 0.9-41.0 months) with 1-year survival of 44%. Most common post-procedural AE grade 3 and 4 were temporary leukopenia (n = 11) and thrombocytopenia (n = 8). Patients' self-assessments showed good ratings for overall health and quality of life with only slight changes after PIHP, and a high degree of satisfaction with PIHP treatment. CONCLUSION PIHP with Melphalan proved to be a relatively safe, minimal-invasive and repeatable treatment for patients with non-resectable hepatic metastases of uveal melanoma.
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Affiliation(s)
- Thomas J Vogl
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Silvia A Koch
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Gösta Lotz
- Department of Anesthesiology, Intensive-Care Medicine and Pain Therapy, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Bernhard Gebauer
- Department of Diagnostic and Interventional Radiology, Campus Charité Mitte, Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Winfried Willinek
- Department of Diagnostic and Interventional Radiology, Brüderkrankenhaus Trier, Nordallee 1, 54292, Trier, Germany
| | - Christoph Engelke
- Department of Diagnostic and Interventional Radiology, Evangelisches Krankenhaus Göttingen-Weende gGmbH, An der Lutter 24, 37075, Göttingen, Germany
| | - Roland Brüning
- Department of Diagnostic and Interventional Radiology, Asklepios Klinik Barmbek, Rübenkamp 220, 22291, Hamburg, Germany
| | - Martin Zeile
- Department of Diagnostic and Interventional Radiology, Asklepios Klinik Barmbek, Rübenkamp 220, 22291, Hamburg, Germany
| | - Frank Wacker
- Department of Diagnostic and Interventional Radiology, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Arndt Vogel
- Department of Gastroenterology, Hepatology and Endocrinology, Medizinische Hochschule Hannover, Hannover, Germany
| | - Boris Radeleff
- Department of Diagnostic and Interventional Radiology, Heidelberg University Hospital, Voßstraße 2, 69115, Heidelberg, Germany
| | - Jan-Erik Scholtz
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany. .,Cardiac MR PET CT Program, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge StreetSuite 400, Boston, MA, 02141, USA.
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Embolotherapy for Neuroendocrine Tumor Liver Metastases: Prognostic Factors for Hepatic Progression-Free Survival and Overall Survival. Cardiovasc Intervent Radiol 2016; 40:69-80. [PMID: 27738818 DOI: 10.1007/s00270-016-1478-z] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Accepted: 09/27/2016] [Indexed: 12/27/2022]
Abstract
PURPOSE The purpose of the study was to evaluate prognostic factors for survival outcomes following embolotherapy for neuroendocrine tumor (NET) liver metastases. MATERIALS AND METHODS This was a multicenter retrospective study of 155 patients (60 years mean age, 57 % male) with NET liver metastases from pancreas (n = 71), gut (n = 68), lung (n = 8), or other/unknown (n = 8) primary sites treated with conventional transarterial chemoembolization (TACE, n = 50), transarterial radioembolization (TARE, n = 64), or transarterial embolization (TAE, n = 41) between 2004 and 2015. Patient-, tumor-, and treatment-related factors were evaluated for prognostic effect on hepatic progression-free survival (HPFS) and overall survival (OS) using unadjusted and propensity score-weighted univariate and multivariate Cox proportional hazards models. RESULTS Median HPFS and OS were 18.5 and 125.1 months for G1 (n = 75), 12.2 and 33.9 months for G2 (n = 60), and 4.9 and 9.3 months for G3 tumors (n = 20), respectively (p < 0.05). Tumor burden >50 % hepatic volume demonstrated 5.5- and 26.8-month shorter median HPFS and OS, respectively, versus burden ≤50 % (p < 0.05). There were no significant differences in HPFS or OS between gut or pancreas primaries. In multivariate HPFS analysis, there were no significant differences among embolotherapy modalities. In multivariate OS analysis, TARE had a higher hazard ratio than TACE (unadjusted Cox model: HR 2.1, p = 0.02; propensity score adjusted model: HR 1.8, p = 0.11), while TAE did not differ significantly from TACE. CONCLUSION Higher tumor grade and tumor burden prognosticated shorter HPFS and OS. TARE had a higher hazard ratio for OS than TACE. There were no significant differences in HPFS among embolotherapy modalities.
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