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Chlorogiannis DD, Moussa AM, Zhao K, Alexander ES, Sofocleous CT, Sotirchos VS. Imaging Considerations before and after Liver-Directed Locoregional Treatments for Metastatic Colorectal Cancer. Diagnostics (Basel) 2024; 14:772. [PMID: 38611685 PMCID: PMC11011364 DOI: 10.3390/diagnostics14070772] [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: 03/10/2024] [Revised: 03/28/2024] [Accepted: 04/02/2024] [Indexed: 04/14/2024] Open
Abstract
Colorectal cancer is a leading cause of cancer-related death. Liver metastases will develop in over one-third of patients with colorectal cancer and are a major cause of morbidity and mortality. Even though surgical resection has been considered the mainstay of treatment, only approximately 20% of the patients are surgical candidates. Liver-directed locoregional therapies such as thermal ablation, Yttrium-90 transarterial radioembolization, and stereotactic body radiation therapy are pivotal in managing colorectal liver metastatic disease. Comprehensive pre- and post-intervention imaging, encompassing both anatomic and metabolic assessments, is invaluable for precise treatment planning, staging, treatment response assessment, and the prompt identification of local or distant tumor progression. This review outlines the value of imaging for colorectal liver metastatic disease and offers insights into imaging follow-up after locoregional liver-directed therapy.
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Affiliation(s)
| | - Amgad M. Moussa
- Interventional Radiology Service, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Ken Zhao
- Interventional Radiology Service, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Erica S. Alexander
- Interventional Radiology Service, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | | | - Vlasios S. Sotirchos
- Interventional Radiology Service, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
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Binzaqr S, Debordeaux F, Blanc JF, Papadopoulos P, Hindie E, Lapouyade B, Pinaquy JB. Efficacy of Selective Internal Radiation Therapy for Hepatocellular Carcinoma Post-Incomplete Response to Chemoembolization. Pharmaceuticals (Basel) 2023; 16:1676. [PMID: 38139803 PMCID: PMC10747012 DOI: 10.3390/ph16121676] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 11/20/2023] [Accepted: 11/28/2023] [Indexed: 12/24/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is one of the most common neoplasms worldwide and the third most common cause of cancer-related death. Several liver-targeted intra-arterial therapies are available for unresectable HCC, including selective internal radiation therapy (SIRT) and trans-arterial chemoembolization (TACE). Those two are the most used treatment modalities in localized non-operable HCC. TACE is the treatment option for patients with stage B, according to the BCLC staging system. In contrast, SIRT does not have an official role in the treatment algorithm, but recent studies showed promising outcomes in patients treated with SIRT. Although TACE is globally a safe procedure, it might provoke several vascular complications such as spasms, inflammatory constriction, and, in severe cases, occlusion, dissection, or collateralization. Hence, it is acclaimed that those complications could restrain the targeted response of the radio-embolization when we use it as second-line therapy post TACE. In this study, we will assess the efficacity of SIRT using Yttrium 90 Microspheres post incomplete or failure response to TACE. In our retrospective study, we had 23 patients who met the inclusion criteria. Furthermore, those patients have been followed radiologically and biologically. Then, we evaluated the therapeutic effect according to the mRECIST criteria, in addition to the personalized dose analysis. We found 8 patients were treated with TheraSphere®, with a median tumor absorbed dose of 445 Gy, while 15 received SIR-Spheres® treatment with a mean tumor dose of 268 Gy. After radiological analysis, 56.5% of the patients had a complete response, and 17.3% showed partial response, whereas 13% had stable disease and 13% had progressive disease. For patients treated with SIRT after an incomplete response or failure to TACE, we found an objective response rate of 73.8%. Despite the known vascular complications of TACE, SIRT can give a favorable response.
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Affiliation(s)
- Salma Binzaqr
- Faculty of Medicine, University of Bordeaux, 33405 Talence, France; (J.-F.B.)
- Department of Nuclear Medicine, CHU Bordeaux, 33000 Bordeaux, France; (F.D.); (J.-B.P.)
| | - Frederic Debordeaux
- Department of Nuclear Medicine, CHU Bordeaux, 33000 Bordeaux, France; (F.D.); (J.-B.P.)
| | - Jean-Frédéric Blanc
- Faculty of Medicine, University of Bordeaux, 33405 Talence, France; (J.-F.B.)
- Department of Hepato-Gastroenterology and Oncology, CHU Bordeaux, 33000 Bordeaux, France
| | - Panteleimon Papadopoulos
- Department of Diagnostic and Interventional Radiology, CHU Bordeaux, 33000 Bordeaux, France; (P.P.); (B.L.)
| | - Elif Hindie
- Faculty of Medicine, University of Bordeaux, 33405 Talence, France; (J.-F.B.)
- Department of Nuclear Medicine, CHU Bordeaux, 33000 Bordeaux, France; (F.D.); (J.-B.P.)
| | - Bruno Lapouyade
- Department of Diagnostic and Interventional Radiology, CHU Bordeaux, 33000 Bordeaux, France; (P.P.); (B.L.)
| | - Jean-Baptiste Pinaquy
- Department of Nuclear Medicine, CHU Bordeaux, 33000 Bordeaux, France; (F.D.); (J.-B.P.)
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Garg T, Shrigiriwar A, Habibollahi P, Cristescu M, Liddell RP, Chapiro J, Inglis P, Camacho JC, Nezami N. Intraarterial Therapies for the Management of Hepatocellular Carcinoma. Cancers (Basel) 2022; 14:cancers14143351. [PMID: 35884412 PMCID: PMC9322128 DOI: 10.3390/cancers14143351] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 07/05/2022] [Accepted: 07/07/2022] [Indexed: 12/11/2022] Open
Abstract
Image-guided locoregional therapies play a crucial role in the management of patients with hepatocellular carcinoma (HCC). Transarterial therapies consist of a group of catheter-based treatments where embolic agents are delivered directly into the tumor via their supplying arteries. Some of the transarterial therapies available include bland embolization (TAE), transarterial chemoembolization (TACE), drug-eluting beads-transarterial chemoembolization (DEB-TACE), selective internal radioembolization therapy (SIRT), and hepatic artery infusion (HAI). This article provides a review of pre-procedural, intra-procedural, and post-procedural aspects of each therapy, along with a review of the literature. Newer embolotherapy options and future directions are also briefly discussed.
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Affiliation(s)
- Tushar Garg
- Division of Vascular and Interventional Radiology, Russell H Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (T.G.); (R.P.L.)
| | - Apurva Shrigiriwar
- Division of Gastroenterology and Hepatology, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA;
| | - Peiman Habibollahi
- Department of Interventional Radiology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Mircea Cristescu
- Vascular and Interventional Radiology Division, Department of Radiology, Medical College of Wisconsin, Milwaukee, WI 53226, USA;
| | - Robert P. Liddell
- Division of Vascular and Interventional Radiology, Russell H Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (T.G.); (R.P.L.)
| | - Julius Chapiro
- Section of Vascular and Interventional Radiology, Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT 06510, USA;
| | - Peter Inglis
- Division of Vascular and Interventional Radiology, Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA;
| | - Juan C. Camacho
- Department of Clinical Sciences, College of Medicine, Florida State University, Tallahassee, FL 32306, USA;
- Vascular and Interventional Radiology, Radiology Associates of Florida, Sarasota, FL 34239, USA
| | - Nariman Nezami
- Division of Vascular and Interventional Radiology, Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA;
- Experimental Therapeutics Program, University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, Baltimore, MD 21201, USA
- Correspondence:
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Lu Z, Chen G, Lyu Y, Chen Y, Mok GSP. Technical Note: Respiratory impacts on static and respiratory gated 99m Tc-MAA SPECT/CT for liver radioembolization- A simulation study. Med Phys 2022; 49:5330-5339. [PMID: 35446448 DOI: 10.1002/mp.15682] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 03/25/2022] [Accepted: 04/12/2022] [Indexed: 11/06/2022] Open
Abstract
PURPOSE We aimed to evaluate respiratory impacts on static and respiratory gated (RG) 99m Tc-MAA SPECT in terms of respiratory motion (RM) blur, attenuation correction (AC) and volume-of-interest (VOI) segmentation on lung shunt faction (LSF) and tumor-to-normal liver ratio (TNR) estimation for liver radioembolization therapy planning. METHODS The XCAT phantom was used to simulate a population of 300 phantoms, modelling various anatomical variations, tumor characteristics, respiratory motion amplitudes, LSFs and TNRs. One hundred and twenty noisy projections of average activity maps near end-expiration (End-EX) and whole respiratory cycle were simulated analytically, modeling attenuation and geometric collimator-detector-response (GCDR). The OS-EM algorithm was employed for reconstruction, modeling AC and GCDR. RM effect was evaluated for static SPECT, while AC and VOI mismatch effects were investigated independently and together for static and RG SPECT utilizing one gate, i.e., End-EX. LSF and TNR errors were measured based on the ground truth. Lesions with different characteristics were also investigated for static and RG SPECT. RESULTS RM overestimates LSF and underestimates TNR. The VOI mismatch caused the largest errors in both RG and static SPECT for LSF and TNR estimation, reaching 160% and -52% correspondingly with extremely mismatched VOIs for RG SPECT, even larger than those for static SPECT. With matched AC and VOIs, RG SPECT has better performance than static SPECT. Larger TNR errors are associated with tumors of smaller sizes and higher TNR for static SPECT. CONCLUSIONS The VOI segmentation mismatch has a stronger impact, followed by RM and AC in static 99m Tc-MAA SPECT/CT. This effect is more pronounced for RG SPECT. When VOI masks are derived from a matched CT, RG SPECT is generally superior to static SPECT for LSF and TNR estimation. The performance of RG SPECT could be worse than static SPECT when a mismatched CT is used for segmentation. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Zhonglin Lu
- Biomedical Imaging Laboratory (BIG), Department of Electrical and Computer Engineering, Faculty of Science and Technology, University of Macau, Taipa, Macau SAR, China
| | - Gefei Chen
- Biomedical Imaging Laboratory (BIG), Department of Electrical and Computer Engineering, Faculty of Science and Technology, University of Macau, Taipa, Macau SAR, China
| | - Yingqing Lyu
- Biomedical Imaging Laboratory (BIG), Department of Electrical and Computer Engineering, Faculty of Science and Technology, University of Macau, Taipa, Macau SAR, China
| | - Yue Chen
- Department of Nuclear Medicine, The Affiliated Hospital of Southwest Medical University, Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, Sichuan, China
| | - Greta S P Mok
- Biomedical Imaging Laboratory (BIG), Department of Electrical and Computer Engineering, Faculty of Science and Technology, University of Macau, Taipa, Macau SAR, China.,Center for Cognitive and Brain Sciences, Institute of Collaborative Innovation, University of Macau, Taipa, Macau SAR, China.,Ministry of Education Frontiers Science Center for Precision Oncology, Faculty of Health Science, University of Macau, Taipa, Macau SAR, China
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Waddell JJ, Townsend PH, Collins ZS, Walter C. Liver-Directed Therapy for Metastatic Colon Cancer: Update. CURRENT COLORECTAL CANCER REPORTS 2022. [DOI: 10.1007/s11888-022-00474-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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6
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Villalobos A, Soliman MM, Majdalany BS, Schuster DM, Galt J, Bercu ZL, Kokabi N. Yttrium-90 Radioembolization Dosimetry: What Trainees Need to Know. Semin Intervent Radiol 2020; 37:543-554. [PMID: 33328711 PMCID: PMC7732571 DOI: 10.1055/s-0040-1720954] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Alexander Villalobos
- Division of Interventional Radiology and Image Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Mohamed M. Soliman
- Weill Cornell Medicine – Qatar School of Medicine, Education City, Al Luqta St, Ar-Rayyan, Qatar
| | - Bill S. Majdalany
- Division of Interventional Radiology and Image Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - David M. Schuster
- Division of Nuclear and Molecular Imaging, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - James Galt
- Division of Nuclear and Molecular Imaging, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Zachary L. Bercu
- Division of Interventional Radiology and Image Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Nima Kokabi
- Division of Interventional Radiology and Image Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
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Understanding fundamentals of hepatocellular carcinoma to design next-generation chitosan nano-formulations: Beyond chemotherapy stride. J Drug Deliv Sci Technol 2020. [DOI: 10.1016/j.jddst.2020.101723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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8
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Pang F, Li Y, Zhang W, Xia C, He Q, Li Z, Xiao L, Song S, Dong P, Zhou H, Shao T, Cai H, Li L. Biodegradable 131 Iodine-Labeled Microspheres: Potential Transarterial Radioembolization Biomaterial for Primary Hepatocellular Carcinoma Treatment. Adv Healthc Mater 2020; 9:e2000028. [PMID: 32431090 DOI: 10.1002/adhm.202000028] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 04/28/2020] [Indexed: 02/05/2023]
Abstract
Transarterial radioembolization with radionuclide-labeled microspheres is successfully used in hepatocellular carcinoma (HCC) treatment, but the non-biodegradability and rapid settlement of the microsphere material are associated with unsatisfied distribution and unable for multiple administrations. In this study, a novel biodegradable chitosan-collagen composite microsphere (CCM) with ideal settlement rate is prepared. The Fourier-transform infrared spectroscopy (FTIR) and scanning electron microscopy (SEM) results indicate CCMs have desirable shapes with diameters around 10 µm, and considerable biodegradability within 12 weeks. These CCMs are successfully radiolabeled with 131 I and processed efficiency of 70.4 MBq mg-1 of microspheres as well as favorable stability in vitro. Then, 131 I-CCMs are injected into rats with orthotopic HCC via the hepatic artery which effectively improves the median overall survival from 19 to 44 days (p < 0.05). Single photon emission computed tomography (SPECT/CT) imaging and immunohistochemical analysis indicate well-localized biodistribution and consistent stability of 131 I-CCMs in the liver over 28 days. Magnetic resonance imaging (MRI) and gross specimens monitoring confirm the inhibited tumor growth after 131 I-CCMs treatment. In conclusion, these biodegradable 131 I-CCMs exhibit optimal radiolabeling efficiency, stability, and favorably radioembolization effect for orthotopic HCC in a rodent model, suggesting potential for interventional cancer therapy.
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Affiliation(s)
- Fuwen Pang
- Laboratory of Clinical Nuclear MedicineDepartment of Nuclear MedicineWest China Hospital of Sichuan University Chengdu 610041 China
| | - Yuhao Li
- Laboratory of Clinical Nuclear MedicineDepartment of Nuclear MedicineWest China Hospital of Sichuan University Chengdu 610041 China
| | - Wenjie Zhang
- Laboratory of Clinical Nuclear MedicineDepartment of Nuclear MedicineWest China Hospital of Sichuan University Chengdu 610041 China
| | - Chunchao Xia
- Department of RadiologyWest China Hospital of Sichuan University Chengdu 610041 China
| | - Qing He
- Department of OncologyWest China Hospital of Sichuan University Chengdu 610041 China
| | - Zhenlin Li
- Department of RadiologyWest China Hospital of Sichuan University Chengdu 610041 China
| | - Liu Xiao
- Laboratory of Clinical Nuclear MedicineDepartment of Nuclear MedicineWest China Hospital of Sichuan University Chengdu 610041 China
| | - Simin Song
- Department of Nuclear MedicineCentral Hospital Guangyuan China
| | - Ping Dong
- Laboratory of Clinical Nuclear MedicineDepartment of Nuclear MedicineWest China Hospital of Sichuan University Chengdu 610041 China
| | - Huijun Zhou
- Laboratory of Clinical Nuclear MedicineDepartment of Nuclear MedicineWest China Hospital of Sichuan University Chengdu 610041 China
| | - Tuo Shao
- Division of Nuclear Medicine and Molecular ImagingMassachusetts General Hospital & Department of RadiologyHarvard Medical School Boston MA 02114 USA
| | - Huawei Cai
- Laboratory of Clinical Nuclear MedicineDepartment of Nuclear MedicineWest China Hospital of Sichuan University Chengdu 610041 China
| | - Lin Li
- Laboratory of Clinical Nuclear MedicineDepartment of Nuclear MedicineWest China Hospital of Sichuan University Chengdu 610041 China
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Castro R, Libânio D, Heitor P, Jácome M, Silva R. Yttrium-90-Induced Gastropathy: A Potential Equivocal Finding. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2020; 27:443-445. [PMID: 33251296 DOI: 10.1159/000507202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 12/30/2019] [Indexed: 11/19/2022]
Affiliation(s)
- Rui Castro
- Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto, Portugal
| | - Diogo Libânio
- Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto, Portugal
| | - Pedro Heitor
- Department of Pathology, Portuguese Oncology Institute of Porto, Porto, Portugal
| | - Manuel Jácome
- Department of Pathology, Portuguese Oncology Institute of Porto, Porto, Portugal
| | - Rui Silva
- Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto, Portugal
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Radioactive Microspheres. Clin Nucl Med 2020. [DOI: 10.1007/978-3-030-39457-8_35] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Critical review of multidisciplinary non-surgical local interventional ablation techniques in primary or secondary liver malignancies. J Contemp Brachytherapy 2019; 11:589-600. [PMID: 31969919 PMCID: PMC6964346 DOI: 10.5114/jcb.2019.90466] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 10/15/2019] [Indexed: 12/21/2022] Open
Abstract
Local non-surgical interventional percutaneous ablation represents nowadays an important part of the potential treatment strategies. Although surgical ablation represents the gold standard, in the past decade there was an expansion in the use of non-surgical ablative techniques: radiofrequency, microwave, laser, cryoablation, irreversible electroporation, and interventional radiotherapy (brachytherapy) in primary as well as secondary liver cancers. With the growing experience in the field, there was implemented a new pillar for cancer treatment, together with surgery, chemotherapy as well as radiotherapy, so-called interventional oncology (IO). To date, there are no published papers regarding a comparative interdisciplinary evaluation of all these non-surgical interventional local ablation therapies. Our paper offers a critical interdisciplinary overview of the treatments in both primary and secondary liver tumors, including from a cost-effective point of view. Furthermore, the present status of education in IO and a comparison of actual economic aspects of the treatments are also provided.
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Ho CL, Chen S, Cheung SK, Leung TWT. Significant Value of 11C-Acetate and 18F-Fluorodeoxyglucose PET/Computed Tomography on 90Y Microsphere Radioembolization for Hepatocellular Carcinoma. PET Clin 2019; 14:459-467. [DOI: 10.1016/j.cpet.2019.06.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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de Azevedo MDBM, Melo VHS, Soares CRJ, Gamarra LF, Barros CHN, Tasic L. Poly(3-hydroxi-butyrate-co-3-hydroxy-valerate) (PHB-HV) microparticles loaded with holmium acetylacetonate as potential contrast agents for magnetic resonance images. Int J Nanomedicine 2019; 14:6869-6889. [PMID: 31507318 PMCID: PMC6718972 DOI: 10.2147/ijn.s191274] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 03/11/2019] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Biodegradable polymers that contain radioactive isotopes such as Holmium 166 have potential applications as beta particle emitters in tumor tissues. Also, Ho(III) is paramagnetic, which makes it suitable as a contrast agent for magnetic resonance (MR) images. METHODS Holmium acetylacetonate (Ho(acac)3) loaded poly(3-hydroxy-butyrate-co-3-hydroxy-valerate) microspheres, with 5% or 8% of 3-hydroxy-valerate (HV), were prepared by emulsification/evaporation process within 20-53 μm size. Microspheres characterization was done using scanning electron microscopy, energy-dispersive X-ray, and infrared spectroscopies. The release of holmium(III) in sodium phosphate buffer (pH 7.4) was followed for 9 days with inductively coupled plasma. Finally, T2 and T2* magnetic resonance images (MRI) were acquired and compared with the MRI of the inclusion complex of holmium acetylacetonate in some β-cyclodextrins. RESULTS Holmium acetylacetonate loading, evaluated by thermogravimetry, was up to 20 times higher for copolymer with 5% of HV. It was shown that microspheres loaded with Ho(acac)3 exhibited an accumulation of Ho(III) on their surfaces but were stable over time, as no expressive release of holmium(III) was detected in 9-day exposition to sodium phosphate buffer. Holmium acetylacetonate in both microspheres or inclusion complexes was very efficient in obtaining T2 and T2* weighted images in magnetic resonance, thus, might be used as contrast agents. CONCLUSION This is the first description of the use of inclusion complexes of holmium acetylacetonate in biodegradable polymers as contrast agents. New investigations are underway to evaluate the resistance of PHB-HV polymer microparticles to nuclear activation to assess their potential for use as radiopharmaceuticals for the treatment of liver cancer.
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Affiliation(s)
| | - Vitor HS Melo
- Centro de Biotecnologia, IPEN/CNEN-SP, São Paulo, Brazil
| | | | | | - Caio HN Barros
- School of Chemical and Bioprocess Engineering, University College Dublin, Dublin, Ireland
- Instituto de Química, UNICAMP, SP, Campinas, Brazil
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Kemeny N, Kurilova I, Li J, Camacho JC, Sofocleous CT. Liver-Directed and Systemic Therapies for Colorectal Cancer Liver Metastases. Cardiovasc Intervent Radiol 2019; 42:1240-1254. [DOI: 10.1007/s00270-019-02284-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 07/03/2019] [Indexed: 02/07/2023]
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15
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Alis D, Durmaz ESM, Gulsen F, Bas A, Kabasakal L, Sager S, Numan F. Prognostic value of ADC measurements in predicting overall survival in patients undergoing 90Y radioembolization for colorectal cancer liver metastases. Clin Imaging 2019; 57:124-130. [PMID: 31220677 DOI: 10.1016/j.clinimag.2019.05.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Revised: 05/06/2019] [Accepted: 05/28/2019] [Indexed: 12/14/2022]
Abstract
AIM To assess the ability of diffusion-weighted imaging (DWI) in predicting the overall survival in patients who underwent Yttrium 90 radioembolization (90Y-RE) for colorectal liver metastases (CLM) with other well-established clinical and imaging parameters by comparing the pre- and post-treatment apparent diffusion coefficient (ADC) values of the lesions. METHODS A total of 81 metastatic lesions of 27 consecutive patients who underwent DWI before and after the 90Y-RE session were enrolled in the study. ADC values were calculated from the entire (ADCe) and peripheral (ADCp) tumor on pre- and post-treatment DWI, and any relative increase in ADC >0% accepted as a functional imaging response. The impact of functional imaging response in addition to other well-known parameters including Response Evaluation Criteria in Solid Tumors (RECIST), hepatic tumor burden, Eastern Cooperative Oncology Group performance status (ECOG-PS) and the presence of extrahepatic metastases in predicting overall survival (OS) was assessed using Kaplan-Meier curves and Cox-regression analyses. RESULTS The median OS of the patients was 10 months (range, 6-20 months) while the median OS of the responders being significantly longer than the non-responders for ADCe and ADCp (median 11 vs 7 months, P = 0.003; median 12 vs. 7 months, P < 0.0001, respectively). The RECIST score was also significantly affected the OS (progressive or stable disease median 8 months vs. partial response 15 indent months, P = 0.019). The other parameters including hepatic tumor burden, gender, ECOG score, the involvement of the liver lobes, and the presence of extrahepatic metastases were not associated with the OS. In multivariate analysis, only ADCp remained as an independent predictor of OS (P = 0.003, HR = 19.878). CONCLUSION Any increase in relative ADCp or ADCe values after Y90-RE treatment was associated with longer OS in CLM patients, and DWI seems to be valuable imaging biomarker in predicting OS in CLM patients during the early post-interventional period after 90Y-RE.
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Affiliation(s)
- Deniz Alis
- Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Department of Radiology, Istanbul, Turkey.
| | - Emine Sebnem Memis Durmaz
- Ministry of Health, Buyukcekmece Mimar Sinan Hospital, Buyukcekmece, Department of Radiology, Istanbul, Turkey
| | - Fatih Gulsen
- Istanbul University-Cerrahpasa, Cerrahpasa School of Medicine, Department of Interventional Radiology, Fatih, Istanbul, Turkey
| | - Ahmet Bas
- Istanbul University-Cerrahpasa, Cerrahpasa School of Medicine, Department of Interventional Radiology, Fatih, Istanbul, Turkey
| | - Levent Kabasakal
- Istanbul University-Cerrahpasa, Cerrahpasa School of Medicine, Department of Nuclear Medicine, Fatih, Istanbul, Turkey.
| | - Sait Sager
- Istanbul University-Cerrahpasa, Cerrahpasa School of Medicine, Department of Nuclear Medicine, Fatih, Istanbul, Turkey
| | - Furuzan Numan
- Istanbul University-Cerrahpasa, Cerrahpasa School of Medicine, Department of Interventional Radiology, Fatih, Istanbul, Turkey
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Abstract
With the increasing incidence of hepatocellular carcinoma (HCC) and its high mortality rates, effective treatment options are of urgent need, preferably in a multidisciplinary setting. In the management of those patients, interventional radiologists play a key role. In this article, we reviewed the current literature for regional, intraarterial treatment strategies of advanced-stage HCC including conventional transarterial chemoembolization, transarterial embolization, transarterial embolization with drug-eluting beads, and selective internal radiation therapy.
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Affiliation(s)
- Thomas J Vogl
- Institute for Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany.
| | - Tatjana Gruber-Rouh
- Institute for Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
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Abu Rmilah A, Zhou W, Nelson E, Lin L, Amiot B, Nyberg SL. Understanding the marvels behind liver regeneration. WILEY INTERDISCIPLINARY REVIEWS-DEVELOPMENTAL BIOLOGY 2019; 8:e340. [PMID: 30924280 DOI: 10.1002/wdev.340] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 02/18/2019] [Accepted: 02/22/2019] [Indexed: 02/06/2023]
Abstract
Tissue regeneration is a process by which the remaining cells of an injured organ regrow to offset the missed cells. This field is relatively a new discipline that has been a focus of intense research by clinicians, surgeons, and scientists for decades. It constitutes the cornerstone of tissue engineering, creation of artificial organs, and generation and utilization of therapeutic stem cells to undergo transformation to different types of mature cells. Many medical experts, scientists, biologists, and bioengineers have dedicated their efforts to deeply comprehend the process of liver regeneration, striving for harnessing it to invent new therapies for liver failure. Liver regeneration after partial hepatectomy in rodents has been extensively studied by researchers for many years. It is divided into three important distinctive phases including (a) Initiation or priming phase which includes an overexpression of specific genes to prepare the liver cells for replication, (b) Proliferation phase in which the liver cells undergo a series of cycles of cell division and expansion and finally, (c) termination phase which acts as brake to stop the regenerative process and prevent the liver tissue overgrowth. These events are well controlled by cytokines, growth factors, and signaling pathways. In this review, we describe the function, embryology, and anatomy of human liver, discuss the molecular basis of liver regeneration, elucidate the hepatocyte and cholangiocyte lineages mediating this process, explain the role of hepatic progenitor cells and elaborate the developmental signaling pathways and regulatory molecules required to procure a complete restoration of hepatic lobule. This article is categorized under: Adult Stem Cells, Tissue Renewal, and Regeneration > Regeneration Signaling Pathways > Global Signaling Mechanisms Gene Expression and Transcriptional Hierarchies > Cellular Differentiation.
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Affiliation(s)
- Anan Abu Rmilah
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic, Rochester, Minnesota
| | - Wei Zhou
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic, Rochester, Minnesota
| | - Erek Nelson
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic, Rochester, Minnesota
| | - Li Lin
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic, Rochester, Minnesota
| | - Bruce Amiot
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic, Rochester, Minnesota
| | - Scott L Nyberg
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic, Rochester, Minnesota
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18
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Coretti S, Rumi F, Sacchini D, Cicchetti A. SIR-Spheres ® Y-90 resin microspheres in chemotherapy refractory or intolerant patients with metastatic colorectal cancer. GLOBAL & REGIONAL HEALTH TECHNOLOGY ASSESSMENT 2019. [DOI: 10.1177/2284240319847446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Selective internal radiation therapy is a form of intra-arterial brachytherapy used to treat primary liver cancer and liver metastases. This article aims to provide an overview of the clinical, economic, organizational legal, social and ethical impact of selective internal radiation therapy using SIR-Spheres Y-90 resin microspheres in the treatment of patients with unresectable, liver-dominant metastatic colorectal cancer who are refractory to or intolerant of chemotherapy. A systematic literature review was performed by querying PubMed, Scopus, EBSCO, CRD and GIN. Two reviewers blindly screened the records retrieved against predefined inclusion/exclusion criteria. The selected studies where summarized following a simplified version of the EuNetHTA Core Model® 2.1. The studies included evaluated selective internal radiation therapy in first-line or further-line treatment and showed a good safety and tolerability profile and significant improvement in efficacy expressed as time to liver progression, progression-free survival and overall survival. Selective internal radiation therapy should be provided in specialized centres and administered by a multidisciplinary team. A hub-and-spoke network could be a viable option to guarantee access to this technology across jurisdictions. The lack of a specific diagnosis-related group tariff accounting for the cost of the device could be seen as the major obstacle to a fair diffusion of this technology. The economic evaluations currently available show the cost-effectiveness of this technology in the population under study. Selective internal radiation therapy using SIR-Spheres Y-90 resin microspheres appears to be a clinically effective and cost-effective option in the treatment of metastatic colorectal cancer patients who are chemotherapy refractory or chemotherapy intolerant.
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Affiliation(s)
- Silvia Coretti
- Graduate School of Health Economics and Management, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Filippo Rumi
- Graduate School of Health Economics and Management, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Dario Sacchini
- Institute of Bioethics, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Americo Cicchetti
- Graduate School of Health Economics and Management, Università Cattolica del Sacro Cuore, Rome, Italy
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19
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Kurilova I, Beets-Tan RGH, Flynn J, Gönen M, Ulaner G, Petre EN, Edward Boas F, Ziv E, Yarmohammadi H, Klompenhouwer EG, Cercek A, Kemeny NA, Sofocleous CT. Factors Affecting Oncologic Outcomes of 90Y Radioembolization of Heavily Pre-Treated Patients With Colon Cancer Liver Metastases. Clin Colorectal Cancer 2018; 18:8-18. [PMID: 30297264 DOI: 10.1016/j.clcc.2018.08.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 08/22/2018] [Accepted: 08/23/2018] [Indexed: 12/13/2022]
Abstract
INTRODUCTION The purpose of this study was to identify predictors of overall (OS) and liver progression-free survival (LPFS) following Yttrium-90 radioembolization (RAE) of heavily pretreated patients with colorectal cancer liver metastases (CLM), as well as to create and validate a predictive nomogram for OS. MATERIALS AND METHODS Metabolic, anatomic, laboratory, pathologic, genetic, primary disease, and procedure-related factors, as well as pre- and post-RAE therapies in 103 patients with CLM treated with RAE from September 15, 2009 to March 21, 2017 were analyzed. LPFS was defined by Response Evaluation Criteria In Solid Tumors 1.1 and European Organization for Research and Treatment of Cancer criteria. Prognosticators of OS and LPFS were selected using univariate Cox regression, adjusted for clustering and competing risk analysis (for LPFS), and subsequently tested in multivariate analysis (MVA). The nomogram was built using R statistical software and internally validated using bootstrap resampling. RESULTS Patients received RAE at a median of 30.9 months (range, 3.4-161.7 months) after detection of CLM. The median OS and LPFS were 11.3 months (95% confidence interval, 7.9-15.1 months) and 4 months (95% confidence interval, 3.3-4.8 months), respectively. Of the 40 parameters tested, 6 were independently associated with OS in MVA. These baseline parameters included number of extrahepatic disease sites (P < .001), carcinoembryonic antigen (P < .001), albumin (P = .005), alanine aminotransferase level (P < .001), tumor differentiation level (P < .001), and the sum of the 2 largest tumor diameters (P < .001). The 1-year OS of patients with total points of < 25 versus > 80 was 90% and 10%, respectively. Bootstrap resampling showed good discrimination (optimism corrected c-index = 0.745) and calibration (mean absolute prediction error = 0.299) of the nomogram. Only baseline maximum standardized uptake value was significant in MVA for LPFS prediction (P < .001; SHR = 1.06). CONCLUSION The developed nomogram included 6 pre-RAE parameters and provided good prediction of survival post-RAE in heavily pretreated patients. Baseline maximum standardized uptake value was the single significant predictor of LPFS.
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Affiliation(s)
- Ieva Kurilova
- Department of Interventional Oncology/Radiology, Memorial Sloan Kettering Cancer Center, New York, NY; Department of Radiology, Netherlands Cancer Institute, Amsterdam, The Netherlands; GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - Regina G H Beets-Tan
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, The Netherlands; GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - Jessica Flynn
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Mithat Gönen
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Gary Ulaner
- Molecular Imaging and Therapy Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Elena N Petre
- Department of Interventional Oncology/Radiology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - F Edward Boas
- Department of Interventional Oncology/Radiology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Etay Ziv
- Department of Interventional Oncology/Radiology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Hooman Yarmohammadi
- Department of Interventional Oncology/Radiology, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Andrea Cercek
- Department of Gastrointestinal Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Nancy A Kemeny
- Department of Gastrointestinal Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Constantinos T Sofocleous
- Department of Interventional Oncology/Radiology, Memorial Sloan Kettering Cancer Center, New York, NY.
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20
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Correlation of radiation dose and activity with clinical outcomes in metastatic colorectal cancer after selective internal radiation therapy using yttrium-90 resin microspheres. Nucl Med Commun 2018; 39:915-920. [PMID: 30124600 DOI: 10.1097/mnm.0000000000000887] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE Yttrium-90 (Y)-resin microspheres are prescribed using activity. We evaluated overall survival (OS) and radiographic tumor response after selective internal radiation therapy (SIRT) with resin microspheres in patients with liver metastases from colorectal cancer. PATIENTS AND METHODS We retrospectively reviewed 60 metastatic colorectal cancer patients treated at our institution with SIRT using Y-resin microspheres. Each patient underwent pre-SIRT MRI or computed tomography imaging of the liver with intravenous contrast. Patients underwent post-treatment imaging at 2-3-month intervals with response assessed according to unidimensional Response Evaluation Criteria in Solid Tumors (RECIST) criteria as well as published three-dimensional volumetric criteria. We then related the prescribed activity established by the body surface area method and the corresponding prescribed dose to radiographic treatment response and OS. RESULTS The median follow-up after the first SIRT treatment was 8.9 months. The mean prescribed activity and the prescribed dose were 26.6 mCi and 52.8 Gy, respectively. OS was not significantly associated with either prescribed activity or prescribed dose. Prescribed dose was also not related to response. However, a significant relationship was found between a higher prescribed activity and an improved radiographic response by RECIST (P=0.04) at the second follow-up. CONCLUSION The prescribed activity of Y-resin microspheres may be correlated with radiographic response by RECIST criteria at 4-6 months post-treatment. For a more accurate prediction of response, a valid dose calculation model based on post-Y PET dosimetry is likely needed given the heterogeneous dose delivery seen in SIRT.
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21
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Rognoni C, Ciani O, Sommariva S, Bargellini I, Bhoori S, Cioni R, Facciorusso A, Golfieri R, Gramenzi A, Mazzaferro V, Mosconi C, Ponziani F, Sacco R, Trevisani F, Tarricone R. Trans-arterial radioembolization for intermediate-advanced hepatocellular carcinoma: a budget impact analysis. BMC Cancer 2018; 18:715. [PMID: 29976149 PMCID: PMC6034232 DOI: 10.1186/s12885-018-4636-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 06/26/2018] [Indexed: 12/31/2022] Open
Abstract
Background Trans-arterial radio-embolization (TARE) is an emerging treatment for the management of hepatocellular carcinoma (HCC). TARE may compete with systemic chemotherapy, sorafenib, in intermediate stage patients with prior chemoembolization failure or advanced patients with tumoral macrovascular invasion with no extra-hepatic spread and good liver function. We performed a budget impact analysis (BIA) evaluating the expected changes in the expenditure for the Italian Healthcare Service within scenarios of increased utilization of TARE in place of sorafenib over the next five years. Methods Starting from patient level data from three oncology centres in Italy, a Markov model was developed to project on a lifetime horizon survivals and costs associated to matched cohorts of intermediate-advanced HCC patients treated with TARE or sorafenib. The initial model has been integrated with epidemiological data to perform a BIA comparing the current scenario with 20 and 80% utilization rates for TARE and sorafenib, respectively, with increasing utilization rates of TARE of 30, 40 and 50% over the next 1, 3 and 5 years. Results Compared to the current scenario, progressively increasing utilization rates of TARE over sorafenib in the next 5 years is expected to save globally about 7 million Euros. Conclusions Radioembolization can be considered a valuable treatment option for patients with intermediate-advanced HCC. These findings enrich the evidence about the economic sustainability of TARE in comparison to standard systemic chemotherapy within the context of a national healthcare service. Electronic supplementary material The online version of this article (10.1186/s12885-018-4636-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Carla Rognoni
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, Via Roentgen 1, 20136, Milan, Italy.
| | - Oriana Ciani
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, Via Roentgen 1, 20136, Milan, Italy.,Evidence synthesis and modelling for health improvement (ESMI), University of Exeter Medical School, South Cloisters St Luke's Campus Exeter, Exeter, UK
| | - Silvia Sommariva
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, Via Roentgen 1, 20136, Milan, Italy.,College of Public Health, University of South Florida, Tampa, USA
| | - Irene Bargellini
- Azienda Ospedaliero-Universitaria Pisana, Via Roma 67, Pisa, Italy
| | - Sherrie Bhoori
- Department of Surgery, Liver Surgery, Transplantation and Gastroenterology, Istituto Nazionale Tumori Fondazione IRCCS, National Cancer Institute, Via G. Venezian 1, Milan, Italy
| | - Roberto Cioni
- Azienda Ospedaliero-Universitaria Pisana, Via Roma 67, Pisa, Italy
| | - Antonio Facciorusso
- Department of Surgery, Liver Surgery, Transplantation and Gastroenterology, Istituto Nazionale Tumori Fondazione IRCCS, National Cancer Institute, Via G. Venezian 1, Milan, Italy
| | - Rita Golfieri
- Azienda Ospedaliero-Universitaria di Bologna, Policlinico S.Orsola-Malpighi, Bologna, Italy
| | - Annagiulia Gramenzi
- Azienda Ospedaliero-Universitaria di Bologna, Policlinico S.Orsola-Malpighi, Bologna, Italy
| | - Vincenzo Mazzaferro
- Department of Surgery, Liver Surgery, Transplantation and Gastroenterology, Istituto Nazionale Tumori Fondazione IRCCS, National Cancer Institute, Via G. Venezian 1, Milan, Italy
| | - Cristina Mosconi
- Azienda Ospedaliero-Universitaria di Bologna, Policlinico S.Orsola-Malpighi, Bologna, Italy
| | - Francesca Ponziani
- Department of Surgery, Liver Surgery, Transplantation and Gastroenterology, Istituto Nazionale Tumori Fondazione IRCCS, National Cancer Institute, Via G. Venezian 1, Milan, Italy
| | - Rodolfo Sacco
- Azienda Ospedaliero-Universitaria Pisana, Via Roma 67, Pisa, Italy
| | - Franco Trevisani
- Azienda Ospedaliero-Universitaria di Bologna, Policlinico S.Orsola-Malpighi, Bologna, Italy
| | - Rosanna Tarricone
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, Via Roentgen 1, 20136, Milan, Italy.,Department of Social and Political Sciences, Bocconi University, Via Roentgen 1, Milan, Italy
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22
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Barabasch A, Heinzel A, Bruners P, Kraemer NA, Kuhl CK. Diffusion-weighted MRI Is Superior to PET/CT in Predicting Survival of Patients Undergoing 90Y Radioembolization of Hepatic Metastases. Radiology 2018; 288:764-773. [PMID: 29786487 DOI: 10.1148/radiol.2018170408] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Purpose To determine the relationship between diffusion-weighted (DW) liver MR images obtained 4-6 weeks after lobar yttrium 90 (90Y) treatment and overall survival in comparison with PET/CT or established oncologic factors known to affect survival. Materials and Methods The institutional review board approved this prospective intraindividual comparative study in 36 consecutive patients (25 women) with liver-dominant metastases (20 colorectal, 14 breast, two other) (mean age, 60 years ± 10 [standard deviation]) who underwent fluorine 18 (18F) fluorodeoxyglucose (FDG) PET/CT and DW MRI before and 4-6 weeks after 90Y radioembolization. DW MRI response was defined as a mean minimal apparent diffusion coefficient increase of more than 30%; PET/CT response was defined as a mean maximal standardized uptake value decrease of more than 30%. Kaplan-Meier curves, log-rank test, and multivariable Cox regression analyses were used to compare patient survival as a function of imaging and Response Evaluation Criteria in Solid Tumors (RECIST) response, pretreatment Eastern Cooperative Oncology Group (ECOG) performance status (PS) (0 vs 1), hepatic tumor load (<25% vs ≥25%), and presence versus absence of extrahepatic disease. Results Thirty-five of the 36 patients were observed until death (median survival, 36 weeks). Response was observed with PET/CT in 18 of 36 patients (50%). Median survival was 39 weeks in patients who responded to PET/CT versus 27 weeks in those who did not (P = .60). Response was observed with DW MRI in 24 of 36 patients (67%). Median survival was 53 weeks in DW MRI responders versus 20 weeks in nonresponders (P = .01). At multivariable analysis, DW MRI response was the only independent predictor of survival (P < .01). Response based on RECIST parameters, ECOG PS, hepatic tumor load, and presence of extrahepatic metastases did not correlate with survival. Conclusion In patients with hepatic metastases undergoing 90Y radioembolization, prediction of response to therapy with DW MRI was superior to that with PET/CT and established oncologic factors.
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Affiliation(s)
- Alexandra Barabasch
- From the Departments of Diagnostic and Interventional Radiology (A.B., P.B., N.A.K., C.K.K.) and Nuclear Medicine (A.H.), University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany
| | - Alexander Heinzel
- From the Departments of Diagnostic and Interventional Radiology (A.B., P.B., N.A.K., C.K.K.) and Nuclear Medicine (A.H.), University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany
| | - Philipp Bruners
- From the Departments of Diagnostic and Interventional Radiology (A.B., P.B., N.A.K., C.K.K.) and Nuclear Medicine (A.H.), University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany
| | - Nils A Kraemer
- From the Departments of Diagnostic and Interventional Radiology (A.B., P.B., N.A.K., C.K.K.) and Nuclear Medicine (A.H.), University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany
| | - Christiane K Kuhl
- From the Departments of Diagnostic and Interventional Radiology (A.B., P.B., N.A.K., C.K.K.) and Nuclear Medicine (A.H.), University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany
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23
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Kurilova I, Beets-Tan RGH, Ulaner GA, Boas FE, Petre EN, Yarmohammadi H, Ziv E, Deipolyi AR, Brody LA, Gonen M, Sofocleous CT. 90Y Resin Microspheres Radioembolization for Colon Cancer Liver Metastases Using Full-Strength Contrast Material. Cardiovasc Intervent Radiol 2018; 41:1419-1427. [PMID: 29766239 DOI: 10.1007/s00270-018-1985-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 05/07/2018] [Indexed: 01/22/2023]
Abstract
OBJECTIVES To assess safety and efficacy of 90Y resin microspheres administration using undiluted non-ionic contrast material (UDCM) {100% Omnipaque-300 (Iohexol)} in both the "B" and "D" lines. MATERIALS AND METHODS We reviewed all colorectal cancer liver metastases patients treated with 90Y resin microspheres radioembolization (RAE) from 2009 to 2017. As of April 2013, two experienced operators started using UDCM (study group) instead of standard sandwich infusion (control group). Occurrence of myelosuppression (leukopenia, neutropenia, erythrocytopenia or/and thrombocytopenia), stasis, nontarget delivery (NTD), median fluoroscopy radiation dose (FRD), median infusion time (IT), liver progression-free (LPFS) and overall survivals (OS) was evaluated. Complications within 6 months post-RAE were reported according to CTCAE v3.0 criteria. RESULTS Study and control groups comprised 23(28%) and 58(72%) patients, respectively. Median follow-up was 9.1 months. There was no statistically significant difference in myelosuppression incidence within 6 months post-RAE between groups. Median FRD and IT for study and control groups were 44.6 vs. 97.35 Gy/cm2 (p = 0.048) and 31 vs. 39 min (p = 0.006), respectively. A 38% lower stasis incidence in study group was not significant (p = 0.34). NTD occurred in 1/27(4%) study vs. 5/73(7%) control group procedures (p = 1). Grade 1-2 and grade 3-4 toxicities between study and control group patients were 36%(8/22) vs. 45%(26/58), p = 0.61 and 9%(2/22) vs. 16%(9/58), p = 0.72, respectively. There was no difference in LPFS and OS between groups. CONCLUSION Administration of 90Y resin microspheres using UDCM in both lines is safe and effective, resulting in lower fluoroscopy radiation dose and shorter infusion time, without evidence of myelosuppression or increased stasis incidence.
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Affiliation(s)
- I Kurilova
- Interventional Radiology Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.,Department of Radiology, Netherlands Cancer Institute, Amsterdam, The Netherlands.,GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - R G H Beets-Tan
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, The Netherlands.,GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - G A Ulaner
- Molecular Imaging and Therapy Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - F E Boas
- Interventional Radiology Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
| | - E N Petre
- Interventional Radiology Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
| | - H Yarmohammadi
- Interventional Radiology Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
| | - E Ziv
- Interventional Radiology Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
| | - A R Deipolyi
- Interventional Radiology Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
| | - L A Brody
- Interventional Radiology Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
| | - M Gonen
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Constantinos T Sofocleous
- Interventional Radiology Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.
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Yang Y, Si T. Yttrium-90 transarterial radioembolization versus conventional transarterial chemoembolization for patients with hepatocellular carcinoma: a systematic review and meta-analysis. Cancer Biol Med 2018; 15:299-310. [PMID: 30197797 PMCID: PMC6121048 DOI: 10.20892/j.issn.2095-3941.2017.0177] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Objective: To compare the effects and safety of conventional transarterial chemoembolization (cTACE) and yttrium-90 transarterial radioembolization [TARE (90Y)] for hepatocellular carcinoma (HCC) Methods: Nine high-quality observational studies, one low bias-risk randomized controlled trial (RCT), and one moderate bias-risk RCT included 1,652 patients [cTACE, 1,124; TARE (90Y), 528], from whom data were extracted for this systematic review and meta-analysis. Results: The extracted study outcomes included 1-year and 2-year overall survival (OS) rates, objective responses (ORs), and serious adverse events (AEs). 1-year OS rates: OR = 0.939, 95 % CI: 0.705-1.251, P = 0.66. 2-year OS rates: overall pooled OR = 0.641, 95% CI: 0.382-1.075, P = 0.092; observational study subgroup OR = 0.575, 95% CI: 0.336-0.984, P = 0.043; RCT subgroup OR* = 0.641, 95% CI: 0.382-1.075, P = 0.346. OR: overall pooled OR = 0.781, 95% CI: 0.454-1.343, P = 0.371; mRECIST subgroup OR = 0.584, 95 % CI: 0.349-0.976, P = 0.040; WHO subgroup OR = 1.065; 95% CI: 0.500-2.268, P = 0.870. Serious AEs: overall pooled RR = 1.477, 95% CI: 0.864-2.526, P = 0.154; RCT subgroup RR = 0.680, 95% CI: 0.325-1.423, P = 0.306; observational study subgroup RR = 1.925; 95 % CI: 0.978-3.788, P = 0.058.
Conclusions: TARE (90Y) increased 2-year OS rates in the observational subgroup and resulted in better OR rates, according to mRECIST criteria, in comparison with cTACE. Furthermore, a lower risk of AEs was observed for TARE (90Y) than for cTACE.
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Affiliation(s)
- Yi Yang
- School of Medical Imaging, Tianjin Medical University, Tianjin 300203, China.,Department of Interventional Therapy, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer; Key Laboratory of Cancer Prevention and Therapy, Tianjin; Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China
| | - Tongguo Si
- Department of Interventional Therapy, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer; Key Laboratory of Cancer Prevention and Therapy, Tianjin; Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China
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25
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Affonso BB, Motta-Leal-Filho JMD, Cavalcante FDA, Galastri FL, Cavalcante RN, Falsarella PM, Nasser F, Garcia RG. Aspects of images in magnetic resonance of liver tumors treated with transarterial selective internal radiotherapy with yttrium-90. EINSTEIN-SAO PAULO 2017; 16:eRC4015. [PMID: 29267431 PMCID: PMC6066153 DOI: 10.1590/s1679-45082017rc4015] [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: 02/05/2017] [Accepted: 07/30/2017] [Indexed: 08/30/2023] Open
Abstract
Transarterial selective internal radiation therapy with yttrium-90, also known as radioembolization, is a therapy based on the administration of resin or glass microspheres loaded with the radioisotope yttrium-90, via selective arterial catheterization of tumor-feeding vessels. It is classified as a type of locoregional therapy and its main goal is to treat patients with primary or secondary hepatic lesions that are unresectable and not responsive to other therapies. Since it is a new technology still restricted to very few hospitals in Brazil, but used in patients throughout the country, it is necessary to demonstrate the main aspects of hepatic lesions treated with selective internal radiation therapy found in magnetic resonance imaging, and to make specific considerations on interpretation of these images. The objective of this report is to demonstrate the main aspects of magnetic resonance imaging of unresectable primary or secondary hepatic lesions, in patients submitted to transarterial selective internal radiation therapy.
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Affiliation(s)
| | | | | | | | | | | | - Felipe Nasser
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
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26
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Orwat KP, Beckham TH, Cooper SL, Ashenafi MS, Anderson MB, Guimaraes M, Yamada R, Marshall DT. Pretreatment albumin may aid in patient selection for intrahepatic Y-90 microsphere transarterial radioembolization (TARE) for malignancies of the liver. J Gastrointest Oncol 2017; 8:1072-1078. [PMID: 29299369 DOI: 10.21037/jgo.2017.06.18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background Hepatic malignancies are common including primary malignancies and metastases. Transarterial radioembolization (TARE) is an important treatment option. We reviewed safety and efficacy of (TARE) in our patients to identify factors that may impact treatment outcomes in a heterogeneous population. Methods All patients that received TARE at the Medical University of South Carolina from March 2006 through May of 2014 were included. Kaplan-Meier estimates on overall survival (OS) from date of first procedure are reported. Potential prognostic factors for OS were evaluated using log rank tests and Cox proportional hazards models. Results In the 114 patients that received TARE at our institution, median follow-up was 6.4 months (range, 0-86 months) with the following histologies: colorectal (CR) n=55, hepatocellular (HC) n=20, cholangiocarcinoma (CC) n=16, neuroendocrine (NE) n=12, breast (BR) n=6, other n=5. At least 1 line of prior systemic therapy was noted in 79% of patients. Median OS was significantly better with NE and BR histology, and in those with normal albumin levels. With an albumin >3.4 median OS was 10.3 months, but was only 3.1 months with an albumin <3 g/dL. Grade ≥2 toxicity was observed in 22 patients (19.3%) including 9 (7.9%) with Grade 3 and 1 (0.9%) with Grade 4 toxicity. Conclusions TARE is a relatively safe and effective treatment for intrahepatic malignancies. Patients with NE and BR histology as well as those with better hepatic synthetic function were associated with significantly better survival. Our data suggest that patients with albumin below 3 g/dL may not derive significant benefit from TARE.
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Affiliation(s)
- Kelly P Orwat
- Department of Radiation Oncology, Medical University of South Carolina, Charleston, SC, USA
| | - Thomas H Beckham
- Department of Radiation Oncology, Medical University of South Carolina, Charleston, SC, USA
| | - Samuel Lewis Cooper
- Department of Radiation Oncology, Medical University of South Carolina, Charleston, SC, USA
| | - Michael S Ashenafi
- Department of Radiation Oncology, Medical University of South Carolina, Charleston, SC, USA
| | | | - Marcelo Guimaraes
- Department of Radiology, Medical University of South Carolina, Charleston, SC, USA
| | - Ricardo Yamada
- Department of Radiology, Medical University of South Carolina, Charleston, SC, USA
| | - David T Marshall
- Department of Radiation Oncology, Medical University of South Carolina, Charleston, SC, USA
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Prophylactic Temporary Occlusion of the Cystic Artery Using a Fibered Detachable Coil During 90Y Radioembolization. Cardiovasc Intervent Radiol 2017; 40:1624-1630. [DOI: 10.1007/s00270-017-1688-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 05/03/2017] [Indexed: 11/26/2022]
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Qian Y, Kumar KA, Dudley SA, Koong AC, Chang DT. Radiation Therapy for Colorectal Liver Metastases. CURRENT COLORECTAL CANCER REPORTS 2017. [DOI: 10.1007/s11888-017-0368-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Al Bandar MH, Kim NK. Current status and future perspectives on treatment of liver metastasis in colorectal cancer (Review). Oncol Rep 2017; 37:2553-2564. [PMID: 28350137 DOI: 10.3892/or.2017.5531] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2016] [Accepted: 03/13/2017] [Indexed: 12/29/2022] Open
Abstract
Liver metastasis is the most common site of colorectal cancer (CRC) metastasis. Approximately half of all colorectal cancer patients will develop liver metastases. Although radical surgery is the standard treatment modality, only 10-20% of patients are deemed eligible for resection. Despite advances in survival with chemotherapy, surgical resection is still considered the only curative option for patients with liver metastases. Much effort has been expended to address patients with metastatic liver disease. The majority of evidence stated a significant survival benefit with surgical resection to reach an overall 5-year survival rate of 35-55% after hepatic resection. However, still majority of patients will experience disease recurrence even after a successful resection. In this review, we describe current status and controversies related to treatment options for CRC liver metastases and its potential for enhancing oncologic outcomes and improving quality of life.
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Affiliation(s)
- Mahdi Hussain Al Bandar
- Department of Surgery, Yonsei University, College of Medicine, Seoul 120-752, Republic of Korea
| | - Nam Kyu Kim
- Department of Surgery, Yonsei University, College of Medicine, Seoul 120-752, Republic of Korea
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Prognostic value of pretreatment diffusion-weighted magnetic resonance imaging for outcome prediction of colorectal cancer liver metastases undergoing 90Y-microsphere radioembolization. J Cancer Res Clin Oncol 2017; 143:1531-1541. [PMID: 28317063 DOI: 10.1007/s00432-017-2395-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 03/12/2017] [Indexed: 12/15/2022]
Abstract
PURPOSE To investigate the clinical potential of pretreatment apparent diffusion coefficient (ADC) on diffusion-weighted magnetic resonance imaging (DWI) for therapy response and outcome prediction in patients with liver-predominant metastatic colorectal cancer (CRC) undergoing radioembolization with 90Yttrium-microspheres (90Y-RE). METHODS Forty-six consecutive patients with unresectable CRC liver metastases underwent standardized clinical DWI on a 1.5 T MR scanner prior to and 4-6 weeks after 90Y-RE. Pretreatment clinical parameters, ADC values derived from region-of-interest analysis, and the corresponding tumor sizes of three treated liver metastases per subject were recorded. Long-term tumor response to radioembolization was categorized into response (partial remission) and nonresponse (stable disease, progressive disease) according to Response Evaluation Criteria in Solid Tumors v1.1 (RECIST) 3 months after treatment. Associations between long-term tumor response and the clinical and imaging parameters were evaluated. The impact of pretreatment clinical and imaging parameters on progression-free survival (PFS) and overall survival (OS) was further assessed by Kaplan-Meier and multivariate Cox-regression analyses. RESULTS Nonresponders had higher hepatic tumor burden (p = 0.021) and lower ADC values than patients responding to 90Y-RE, both pretreatment (986 ± 215 vs. 1162 ± 178; p = 0.036) and posttreatment (1180 ± 350 vs. 1598 ± 225; p = 0.002). ADC values higher than 935 × 10-6 mm2 (5 vs. 3 months; p = 0.022) and hepatic tumor burden ≤25% (6 vs. 3 months; p = 0.014) were associated with longer median PFS, whereas ADC >935 × 10-6 mm2 (14 vs. 6 months; p = 0.02), hepatic tumor burden ≤25% (14 vs. 6 months; p = 0.048), size of the largest metastasis <4.7 cm (18 vs. 7 months; p = 0.024), and Eastern Cooperative Oncology Group (ECOG) score <1 (8 vs. 5 months; p = 0.045) were associated with longer median OS. On multivariate analysis, ADC >935 × 10-6 mm2 and hepatic tumor burden ≤25% remained prognostic factors for PFS, and ADC >935 × 10-6 mm2 and size of the largest metastasis <4.7 cm were independent predictors of OS. CONCLUSION Pretreatment ADC on DWI represents a valuable prognostic biomarker for predicting both the therapeutic efficacy and survival prognosis in CRC liver metastases treated by 90Y-RE, allowing risk stratification and potentially optimizing further treatment strategies.
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Abedi M, Nabid MR, Shirvani-Arani S, Bahrami-Samani A, Vahidfar N. Preparation and biological evaluation of a carrier free 90yttrium labelled porphyrin as a possible agent for targeted therapy of tumor. J PORPHYR PHTHALOCYA 2017. [DOI: 10.1142/s1088424617300038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
In this research article, 5,10,15,20-tetrakis(phenyl)porphyrin (H2TPP) was produced and characterized. Then, radiolabeling of H2TPP was performed using the carrier free Y-90 which was prepared by the use of a home-made yttrium imprinted sorbent. The radiolabeling procedure was accomplished at 60 [Formula: see text] C during 12 h with a suitable radiochemical purity (95 ± 2% ITLC, 99 ± 0.5% HPLC) and specific activity of (1.0 ± 0.1 GBq/mmol). The obtained radio-labeled H2TPP in final formulation was kept for a week in order to investigate the complex stability. Accordingly, the partition coefficient was calculated as log [Formula: see text] 2.05. Furthermore, the biodistribution of the [Formula: see text]Y–TPP was determined in vital organs of normal wild-type rats using scarification studies. The kidneys could mostly remove the radio-complexes from the blood circulation and in less extends from the liver. As a result it is expected that due to its lipophilicity the higher mitochondrial and thus, tumor cell uptake of this radiolabeled porphyrin happens and therefore [Formula: see text]Y–TPP could act as an efficient potential agent for targeted therapy of tumor.
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Affiliation(s)
- Mahvash Abedi
- Department of polymer, Faculty of Chemistry, Shahid Beheshti University, G. C., 1983963113, Tehran, Iran
- Nuclear Science and Technology Research Institute (NSTRI), P.O. Box: 11365-8486, Tehran, Iran
| | - Mohammad Reza Nabid
- Department of polymer, Faculty of Chemistry, Shahid Beheshti University, G. C., 1983963113, Tehran, Iran
| | | | - Ali Bahrami-Samani
- Nuclear Science and Technology Research Institute (NSTRI), P.O. Box: 11365-8486, Tehran, Iran
| | - Nasim Vahidfar
- Nuclear Science and Technology Research Institute (NSTRI), P.O. Box: 11365-8486, Tehran, Iran
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Impact of the activity calculation method used in transarterial radioembolization: a dosimetric comparison between 90Y-SIRSphere and 90Y-TheraSphere therapy. Nucl Med Commun 2017; 37:917-23. [PMID: 27182686 DOI: 10.1097/mnm.0000000000000544] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE Transarterial radioembolization is used to treat primary and secondary liver malignancies. Two commercially available drugs are utilized for the purpose. The aim of our study is to compare the radiation dose delivered to the tumor by these drugs. MATERIALS AND METHODS This study included 86 patients (M : F - 7.6 : 1, median age=50.5 years), 46 patients were treated by Y-TheraSphere and 42 patients were treated by Y-SIRSphere. Activity administered in Y-TheraSphere and Y-SIRSphere was calculated using a modified partition model and a modified body surface area model, respectively. The radiation dose delivered by two drugs was calculated and compared in our study. RESULT Activity administered in Y-TheraSphere was significantly higher than that of Y-SIRSphere. Hence, the radiation dose delivered to the tumor by Y-SIRSphere was significantly lower (58.4%) than that of Y-TheraSphere (P=0.000). CONCLUSION As the radiation dose delivered by Y-SIRSphere was lower than Y-TheraSphere, we believe that the formula for Y-SIRSphere activity calculation needs to be modified so that the optimal dose can be delivered to the tumor.
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Katsanos K, Kitrou P, Spiliopoulos S, Maroulis I, Petsas T, Karnabatidis D. Comparative effectiveness of different transarterial embolization therapies alone or in combination with local ablative or adjuvant systemic treatments for unresectable hepatocellular carcinoma: A network meta-analysis of randomized controlled trials. PLoS One 2017; 12:e0184597. [PMID: 28934265 PMCID: PMC5608206 DOI: 10.1371/journal.pone.0184597] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Accepted: 08/26/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The optimal transcatheter embolization strategy for patients with unresectable hepatocellular carcinoma (HCC) remains elusive. We conducted a systematic review and network meta-analysis (NMA) of different embolization options for unresectable HCC. METHODS Medical databases were searched for randomized controlled trials evaluating bland transarterial embolization (TAE), conventional TACE, drug-eluting bead chemoembolization (DEB-TACE), or transarterial radioembolization (TARE), either alone or combined with adjuvant chemotherapy, or local liver ablation, or external radiotherapy for unresectable HCC up to June 2017. Random effects Bayesian models with a binomial and normal likelihood were fitted (WinBUGS). Primary endpoint was patient survival expressed as hazard ratios (HR) and 95% credible intervals. An exponential model was used to fit patient survival curves. Safety and objective response were calculated as odds ratios (OR) and accompanying 95% credible intervals. Competing treatments were ranked with the SUCRA statistic. Heterogeneity-adjusted effective sample sizes were calculated to evaluate information size for each comparison. Quality of evidence (QoE) was assessed with the GRADE system adapted for NMA reports. All analyses complied with the ISPOR-AMCP-NCP Task Force Report for good practice in NMA. FINDINGS The network of evidence included 55 RCTs (12 direct comparisons) with 5,763 patients with preserved liver function and unresectable HCC (intermediate to advanced stage). All embolization strategies achieved a significant survival gain over control treatment (HR range, 0.42-0.76; very low-to-moderate QoE). However, TACE, DEB-TACE, TARE and adjuvant systemic agents did not confer any survival benefit over bland TAE alone (moderate QoE, except low in case of TARE). There was moderate QoE that TACE combined with external radiation or liver ablation achieved the best patient survival (SUCRA 86% and 96%, respectively). Estimated median survival was 13.9 months in control, 18.1 months in TACE, 20.6 months with DEB-TACE, 20.8 months with bland TAE, 30.1 months in TACE plus external radiotherapy, and 33.3 months in TACE plus liver ablation. TARE was the safest treatment (SUCRA 77%), however, all examined therapies were associated with a significantly higher risk of toxicity over control (OR range, 6.35 to 68.5). TACE, DEB-TACE, TARE and adjuvant systemic agents did not improve objective response over bland embolization alone (OR range, 0.85 to 1.65). There was clinical diversity among included randomized controlled trials, but statistical heterogeneity was low. CONCLUSIONS Chemo- and radio-embolization for unresectable hepatocellular carcinoma may improve tumour objective response and patient survival, but are not more effective than bland particle embolization. Chemoembolization combined with external radiotherapy or local liver ablation may significantly improve tumour response and patient survival rates over embolization monotherapies. Quality of evidence remains mostly low to moderate because of clinical diversity. SYSTEMATIC REVIEW REGISTRATION CRD42016035796 (http://www.crd.york.ac.uk/PROSPERO).
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Affiliation(s)
- Konstantinos Katsanos
- Department of Interventional Radiology, Patras University Hospital, School of Medicine, Rion, Greece
- Department of Interventional Radiology, Guy's and St. Thomas' Hospitals, NHS Foundation Trust, King's Health Partners, London, United Kingdom
- * E-mail: ,
| | - Panagiotis Kitrou
- Department of Interventional Radiology, Patras University Hospital, School of Medicine, Rion, Greece
| | - Stavros Spiliopoulos
- Department of Interventional Radiology, Attikon University Hospital, School of Medicine, Athens, Greece
| | - Ioannis Maroulis
- Department of Liver Surgery, Patras University Hospital, School of Medicine, Rion, Greece
| | - Theodore Petsas
- Department of Interventional Radiology, Patras University Hospital, School of Medicine, Rion, Greece
| | - Dimitris Karnabatidis
- Department of Interventional Radiology, Patras University Hospital, School of Medicine, Rion, Greece
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Sofue K, Yoshikawa T, Ohno Y, Negi N, Inokawa H, Sugihara N, Sugimura K. Improved image quality in abdominal CT in patients who underwent treatment for hepatocellular carcinoma with small metal implants using a raw data-based metal artifact reduction algorithm. Eur Radiol 2016; 27:2978-2988. [DOI: 10.1007/s00330-016-4660-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 11/14/2016] [Accepted: 11/16/2016] [Indexed: 12/13/2022]
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Zampino M, Magni E, Ravenda P, Cella C, Bonomo G, Della Vigna P, Galdy S, Spada F, Varano G, Mauri G, Fazio N, Orsi F. Treatments for colorectal liver metastases: A new focus on a familiar concept. Crit Rev Oncol Hematol 2016; 108:154-163. [DOI: 10.1016/j.critrevonc.2016.11.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 10/09/2016] [Accepted: 11/13/2016] [Indexed: 11/17/2022] Open
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Rosenbaum CENM, van den Hoven AF, Braat MNGJA, Koopman M, Lam MGEH, Zonnenberg BA, Verkooijen HM, van den Bosch MAAJ. Yttrium-90 radioembolization for colorectal cancer liver metastases: a prospective cohort study on circulating angiogenic factors and treatment response. EJNMMI Res 2016; 6:92. [PMID: 28004357 PMCID: PMC5177600 DOI: 10.1186/s13550-016-0236-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 11/04/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Yttrium-90 radioembolization (90Y-RE) as a treatment for liver tumours induces radiation damage and hypoxia in liver tissue, which is also a trigger for systemic release of angiogenic factors, potentially stimulating tumour growth. We examined changes in circulating angiogenic factors following 90Y-RE and investigated the association between response and angiogenic factors. In this prospective study, 42 patients with unresectable, chemorefractory metastatic colorectal cancer (CRCLM) were treated with 90Y-RE. Blood samples were collected pre-treatment and at 0, 1, 3, 7 and 30 days of follow-up. Response was measured with MRI according to RECIST 1.1 at 1 month and subsequently 3-month interval until progressive disease (PD) occurred. Associations between circulating angiogenic factors and response were examined with linear mixed model analysis. RESULTS Following 90Y-RE, three angiogenic factors demonstrated an increase in plasma levels, i.e., vascular endothelial growth factor (VEGF), hepatocyte growth factor (HGF) and angiopoietin-2 (Ang-2). Non-responders (= PD at 1-month follow-up, n = 10) had a significant increase of Ang-2 and HGF at 3 and 7 days post treatment compared to responders (= stable disease or better, n = 32), who showed little to no changes in plasma levels (respectively p = 0.01 and p = 0.007). Median overall survival was 9.2 months (95% confidence interval 6.1-12.4). CONCLUSIONS Significant increases in plasma levels of Ang-2 and HGF in the first week after treatment were associated with rapid progressive disease of liver lesions at 1 month after 90Y-RE. Combination of 90Y-RE with anti-angiogenic therapy may reduce these effects and result in better response.
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Affiliation(s)
- C E N M Rosenbaum
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Room E.01.132, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - A F van den Hoven
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Room E.01.132, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - M N G J A Braat
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Room E.01.132, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - M Koopman
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M G E H Lam
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Room E.01.132, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - B A Zonnenberg
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Room E.01.132, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - H M Verkooijen
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Room E.01.132, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - M A A J van den Bosch
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Room E.01.132, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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Gandhi M, Choo SP, Thng CH, Tan SB, Low ASC, Cheow PC, Goh ASW, Tay KH, Lo RHG, Goh BKP, Wong JS, Ng DCE, Soo KC, Liew WM, Chow PKH. Single administration of Selective Internal Radiation Therapy versus continuous treatment with sorafeNIB in locally advanced hepatocellular carcinoma (SIRveNIB): study protocol for a phase iii randomized controlled trial. BMC Cancer 2016; 16:856. [PMID: 27821083 PMCID: PMC5100089 DOI: 10.1186/s12885-016-2868-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 10/13/2016] [Indexed: 02/08/2023] Open
Abstract
Background Approximately 20 % of hepatocellular carcinoma (HCC) patients diagnosed in the early stages may benefit from potentially curative ablative therapies such as surgical resection, transplantation or radiofrequency ablation. For patients not eligible for such options, prognosis is poor. Sorafenib and Selective Internal Radiation Therapy (SIRT) are clinically proven treatment options in patients with unresectable HCC, and this study aims to assess overall survival following either SIRT or Sorafenib therapy for locally advanced HCC patients. Methods This investigator-initiated, multi-centre, open-label, randomized, controlled trial will enrol 360 patients with locally advanced HCC, as defined by Barcelona Clinic Liver Cancer stage B or stage C, without distant metastases, and which is not amenable to immediate curative treatment. Exclusion criteria include previous systemic therapy, metastatic disease, complete occlusion of the main portal vein, or a Child-Pugh score of >7. Eligible patients will be randomised 1:1 and stratified by centre and presence or absence of portal vein thrombosis to receive either a single administration of SIRT using yttrium-90 resin microspheres (SIR-Spheres®, Sirtex Medical Limited, Sydney, Australia) targeted at HCC in the liver by the trans-arterial route or continuous oral Sorafenib (Nexavar®, Bayer Pharma AG, Berlin, Germany) at a dose of 400 mg twice daily until disease progression, no further response, complete regression or unacceptable toxicity. Patients for both the Sorafenib and SIRT arms will be followed-up every 4 weeks for the first 3 months and 12 weekly thereafter. Overall survival is the primary endpoint, assessed for the intention-to-treat population. Secondary endpoints are tumour response rate, time-to-tumour progression, progression free survival, quality of life and down-staging to receive potentially curative therapy. Discussion Definitive data comparing these two therapies will help to determine clinical practice in the large group of patients with locally advanced HCC and improve outcomes for such patients. Trial registration ClinicalTrials.gov identifier, NCT01135056, first received 24, May 2010.
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Affiliation(s)
- Mihir Gandhi
- Biostatistics, Singapore Clinical Research Institute, #02-01, Nanos, 31 Biopolis Way, Singapore, Singapore.,Centre for Quantitative Medicine, Duke-NUS Medical School, 8 College Road, Singapore, Singapore.,Tampere Center for Child Health Research, University of Tampere and Tampere University Hospital, Tempere, Finland
| | - Su Pin Choo
- Division of Medical Oncology, National Cancer Centre Singapore, 11 Hospital Drive, Singapore, Singapore
| | - Choon Hua Thng
- Division of Oncologic Imaging, National Cancer Centre Singapore, 11 Hospital Drive, Singapore, Singapore
| | - Say Beng Tan
- Office of Research, Singapore Health Services, 31 Third Hospital Avenue, #03-03 Bowyer Block C, Singapore, Singapore.,Clinical Sciences, Duke-NUS Medical School, 8 College Road, Singapore, Singapore
| | - Albert Su Chong Low
- Department of Diagnostic Radiology, Singapore General Hospital, Outram Road, Singapore, Singapore
| | - Peng Chung Cheow
- Department of Hepato-pancreato-biliary and Transplant Surgery, Singapore General Hospital, Outram Road, Singapore, Singapore
| | - Anthony Soon Whatt Goh
- Department of Nuclear Medicine and PET, Singapore General Hospital, Outram Road, Singapore, Singapore
| | - Kiang Hiong Tay
- Department of Diagnostic Radiology, Singapore General Hospital, Outram Road, Singapore, Singapore
| | - Richard Hoau Gong Lo
- Department of Diagnostic Radiology, Singapore General Hospital, Outram Road, Singapore, Singapore
| | - Brian Kim Poh Goh
- Department of Hepato-pancreato-biliary and Transplant Surgery, Singapore General Hospital, Outram Road, Singapore, Singapore
| | - Jen San Wong
- Department of Hepato-pancreato-biliary and Transplant Surgery, Singapore General Hospital, Outram Road, Singapore, Singapore
| | - David Chee Eng Ng
- Department of Nuclear Medicine and PET, Singapore General Hospital, Outram Road, Singapore, Singapore
| | - Khee Chee Soo
- Division of Surgical Oncology, National Cancer Centre Singapore, 11 Hospital Drive, Singapore, Singapore
| | - Wei Ming Liew
- Project Management, Singapore Clinical Research Institute, #02-01, Nanos, 31 Biopolis Way, Singapore, Singapore
| | - Pierce K H Chow
- Department of Hepato-pancreato-biliary and Transplant Surgery, Singapore General Hospital, Outram Road, Singapore, Singapore. .,Office of Clinical, Academic and Faculty Affairs, Duke-NUS Medical School, 8 College Road, Singapore, Singapore. .,Program in Translational and Clinical Liver Research, National Cancer Centre Singapore, Singapore, Singapore.
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Aramburu J, Antón R, Rivas A, Ramos JC, Sangro B, Bilbao JI. Liver cancer arterial perfusion modelling and CFD boundary conditions methodology: a case study of the haemodynamics of a patient-specific hepatic artery in literature-based healthy and tumour-bearing liver scenarios. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2016; 32:e02764. [PMID: 26727946 DOI: 10.1002/cnm.2764] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 12/14/2015] [Accepted: 12/14/2015] [Indexed: 06/05/2023]
Abstract
Some of the latest treatments for unresectable liver malignancies (primary or metastatic tumours), which include bland embolisation, chemoembolisation, and radioembolisation, among others, take advantage of the increased arterial blood supply to the tumours to locally attack them. A better understanding of the factors that influence this transport may help improve the therapeutic procedures by taking advantage of flow patterns or by designing catheters and infusion systems that result in the injected beads having increased access to the tumour vasculature. Computational analyses may help understand the haemodynamic patterns and embolic-microsphere transport through the hepatic arteries. In addition, physiological inflow and outflow boundary conditions are essential in order to reliably represent the blood flow through arteries. This study presents a liver cancer arterial perfusion model based on a literature review and derives boundary conditions for tumour-bearing liver-feeding hepatic arteries based on the arterial perfusion characteristics of normal and tumorous liver segment tissue masses and the hepatic artery branching configuration. Literature-based healthy and tumour-bearing realistic scenarios are created and haemodynamically analysed for the same patient-specific hepatic artery. As a result, this study provides boundary conditions for computational fluid dynamics simulations that will allow researchers to numerically study, for example, various intravascular devices used for liver disease intra-arterial treatments with different cancer scenarios. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Jorge Aramburu
- Thermal and Fluids Engineering Division, Mechanical Department, Tecnun-University of Navarra, Pº Manuel Lardizabal, 13, 20018, Donostia-San Sebastián, Spain
| | - Raúl Antón
- Thermal and Fluids Engineering Division, Mechanical Department, Tecnun-University of Navarra, Pº Manuel Lardizabal, 13, 20018, Donostia-San Sebastián, Spain.
- Instituto de Investigación Sanitaria de Navarra (IdiSNA), Av. Pio XII, 36, 31008, Pamplona, Spain.
| | - Alejandro Rivas
- Thermal and Fluids Engineering Division, Mechanical Department, Tecnun-University of Navarra, Pº Manuel Lardizabal, 13, 20018, Donostia-San Sebastián, Spain
| | - Juan Carlos Ramos
- Thermal and Fluids Engineering Division, Mechanical Department, Tecnun-University of Navarra, Pº Manuel Lardizabal, 13, 20018, Donostia-San Sebastián, Spain
| | - Bruno Sangro
- Instituto de Investigación Sanitaria de Navarra (IdiSNA), Av. Pio XII, 36, 31008, Pamplona, Spain
- Clínica Universidad de Navarra, Av. Pio XII, 36, 31008, Pamplona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Av. Pio XII, 36, 31008, Pamplona, Spain
| | - José Ignacio Bilbao
- Instituto de Investigación Sanitaria de Navarra (IdiSNA), Av. Pio XII, 36, 31008, Pamplona, Spain
- Clínica Universidad de Navarra, Av. Pio XII, 36, 31008, Pamplona, Spain
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Salman A, Simoneau E, Hassanain M, Chaudhury P, Boucher LM, Valenti D, Cabrera T, Nudo C, Metrakos P. Combined sorafenib and yttrium-90 radioembolization for the treatment of advanced hepatocellular carcinoma. ACTA ACUST UNITED AC 2016; 23:e472-e480. [PMID: 27803608 DOI: 10.3747/co.23.2827] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS In this pilot study, we assessed the safety and tolerability of combining sorafenib with 90Y radioembolization for the treatment of unresectable hepatocellular carcinoma (hcc). METHODS The study, conducted prospectively during 2009-2012, included eligible patients with unresectable hcc and a life expectancy of at least 12 weeks. Each patient received sorafenib (400 mg twice daily) for 6-8 weeks before 90Y treatment. Safety and tolerability were assessed. RESULTS Of the 40 patients enrolled, 29 completed treatment (combined therapy). In the initial cohort, the most common cause of hcc was hepatitis C (32.5%), and most patients were staged Child A (82.5%). The 29 patients who completed the study had similar baseline characteristics. Grades 1 and 2 toxicities accounted for 77.8% of all adverse events reported. The most common toxicities reported were fatigue (19.0%), alteration in liver function (7.9%), and diarrhea (6.3%). There were 12 grade 3 and 2 grade 4 toxicity events reported. One patient died of liver failure within 30 days after treatment. During the study, the sorafenib dose was reduced in 6 patients (20.7%), and sorafenib had to be interrupted in 4 patients (13.8%) and discontinued in 4 patients (13.8%). The disease control rate was 72.4% per the modified Response Evaluation Criteria in Solid Tumors, and tumour necrosis was observed in 82.8% of patients. Overall survival in patients undergoing combined therapy was 12.4 months. CONCLUSIONS Preliminary results demonstrate the safety and tolerability of combining 90Y radioembolization and sorafenib for advanced hcc. A larger prospective study is needed to determine the extent of the survival benefit.
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Affiliation(s)
- A Salman
- Department of Surgery, Division of Hepatopancreatobiliary and Transplant Surgery, McGill University, Montreal, QC
| | - E Simoneau
- Department of Surgery, Division of Hepatopancreatobiliary and Transplant Surgery, McGill University, Montreal, QC
| | - M Hassanain
- Department of Oncology, McGill University, Montreal, QC; Department of Surgery, King Saud University, Riyadh, Saudi Arabia
| | - P Chaudhury
- Department of Surgery, Division of Hepatopancreatobiliary and Transplant Surgery, McGill University, Montreal, QC; Department of Oncology, McGill University, Montreal, QC
| | - L M Boucher
- Department of Radiology, Division of Interventional Radiology, McGill University, Montreal, QC
| | - D Valenti
- Department of Radiology, Division of Interventional Radiology, McGill University, Montreal, QC
| | - T Cabrera
- Department of Radiology, Division of Interventional Radiology, McGill University, Montreal, QC
| | - C Nudo
- Department of Medicine, Division of Hepatology, McGill University, Montreal, QC
| | - P Metrakos
- Department of Surgery, Division of Hepatopancreatobiliary and Transplant Surgery, McGill University, Montreal, QC; Department of Oncology, McGill University, Montreal, QC
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van den Hoven AF, Prince JF, Bruijnen RCG, Verkooijen HM, Krijger GC, Lam MGEH, van den Bosch MAAJ. Surefire infusion system versus standard microcatheter use during holmium-166 radioembolization: study protocol for a randomized controlled trial. Trials 2016; 17:520. [PMID: 27782851 PMCID: PMC5080784 DOI: 10.1186/s13063-016-1643-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 10/05/2016] [Indexed: 12/31/2022] Open
Abstract
Background An anti-reflux catheter (ARC) may increase the tumor absorbed dose during radioembolization (RE) by elimination of particle reflux and its effects on hemodynamics. Since the catheter is fixed in a centro-luminal position, it may also increase the predictive accuracy of a scout dose administration before treatment. The purpose of the SIM trial is to compare the effects of ARC use during RE with holmium-166 (166Ho) microspheres in patients with colorectal liver metastases (CRLM), with the use of a standard end-hole microcatheter. Methods/Design A within-patient randomized controlled trial (RCT) will be conducted in 25 patients with unresectable chemorefractory liver-dominant CRLM. Study participants will undergo a 166Ho scout dose procedure in the morning and a therapeutic procedure in the afternoon. The ARC will be randomly allocated to the left/right hepatic artery, and a standard microcatheter will be used in the contralateral artery. SPECT/CT imaging will be performed for quantitative analyses of the microsphere distribution directly after the scout and treatment procedure. Baseline and follow-up investigations include 18F-FDG-PET + liver CT, clinical and laboratory examinations. The primary endpoint is the comparison of tumor to non-tumor (T/N) activity ratio in both groups. Secondary endpoints include comparisons of mean absorbed dose in tumors and healthy liver tissue, infusion efficiency, the predictive value of 166Ho scout dose for tumor response. In the entire cohort, a dose-response relationship, clinical toxicity, and overall survival will be assessed. The sample was determined for the expectation that the ARC will increase the T/N ratio by 25 % (mean T/N ratio 2.0 vs. 1.6). Discussion The SIM trial is a within-patient RCT that will assess whether 166Ho RE treatment can be optimized by using an ARC. Trial registration The SIM trial is registered at clinicaltrials.gov (NCT02208804). Registered on 31 July 2014. Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1643-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Andor F van den Hoven
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Jip F Prince
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Rutger C G Bruijnen
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Helena M Verkooijen
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Gerard C Krijger
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Marnix G E H Lam
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Maurice A A J van den Bosch
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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Balogh J, Victor D, Asham EH, Burroughs SG, Boktour M, Saharia A, Li X, Ghobrial RM, Monsour HP. Hepatocellular carcinoma: a review. J Hepatocell Carcinoma 2016; 3:41-53. [PMID: 27785449 PMCID: PMC5063561 DOI: 10.2147/jhc.s61146] [Citation(s) in RCA: 725] [Impact Index Per Article: 90.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Hepatocellular carcinoma (HCC) is the most common primary liver malignancy and is a leading cause of cancer-related death worldwide. In the United States, HCC is the ninth leading cause of cancer deaths. Despite advances in prevention techniques, screening, and new technologies in both diagnosis and treatment, incidence and mortality continue to rise. Cirrhosis remains the most important risk factor for the development of HCC regardless of etiology. Hepatitis B and C are independent risk factors for the development of cirrhosis. Alcohol consumption remains an important additional risk factor in the United States as alcohol abuse is five times higher than hepatitis C. Diagnosis is confirmed without pathologic confirmation. Screening includes both radiologic tests, such as ultrasound, computerized tomography, and magnetic resonance imaging, and serological markers such as α-fetoprotein at 6-month intervals. Multiple treatment modalities exist; however, only orthotopic liver transplantation (OLT) or surgical resection is curative. OLT is available for patients who meet or are downstaged into the Milan or University of San Francisco criteria. Additional treatment modalities include transarterial chemoembolization, radiofrequency ablation, microwave ablation, percutaneous ethanol injection, cryoablation, radiation therapy, systemic chemotherapy, and molecularly targeted therapies. Selection of a treatment modality is based on tumor size, location, extrahepatic spread, and underlying liver function. HCC is an aggressive cancer that occurs in the setting of cirrhosis and commonly presents in advanced stages. HCC can be prevented if there are appropriate measures taken, including hepatitis B virus vaccination, universal screening of blood products, use of safe injection practices, treatment and education of alcoholics and intravenous drug users, and initiation of antiviral therapy. Continued improvement in both surgical and nonsurgical approaches has demonstrated significant benefits in overall survival. While OLT remains the only curative surgical procedure, the shortage of available organs precludes this therapy for many patients with HCC.
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Affiliation(s)
- Julius Balogh
- Sherrie and Alan Conover Center for Liver Disease and Transplantation
- Division of Transplantation, Department of Surgery
| | - David Victor
- Sherrie and Alan Conover Center for Liver Disease and Transplantation
- Department of Gastroenterology and Transplant Hepatology
- Department of Medicine, Houston Methodist Hospital, Houston, TX, USA
| | - Emad H Asham
- Sherrie and Alan Conover Center for Liver Disease and Transplantation
- Division of Transplantation, Department of Surgery
| | - Sherilyn Gordon Burroughs
- Sherrie and Alan Conover Center for Liver Disease and Transplantation
- Division of Transplantation, Department of Surgery
| | - Maha Boktour
- Sherrie and Alan Conover Center for Liver Disease and Transplantation
- Division of Transplantation, Department of Surgery
| | - Ashish Saharia
- Sherrie and Alan Conover Center for Liver Disease and Transplantation
- Division of Transplantation, Department of Surgery
| | - Xian Li
- Sherrie and Alan Conover Center for Liver Disease and Transplantation
- Division of Transplantation, Department of Surgery
| | - R Mark Ghobrial
- Sherrie and Alan Conover Center for Liver Disease and Transplantation
- Division of Transplantation, Department of Surgery
| | - Howard P Monsour
- Sherrie and Alan Conover Center for Liver Disease and Transplantation
- Department of Gastroenterology and Transplant Hepatology
- Department of Medicine, Houston Methodist Hospital, Houston, TX, USA
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Srinivas SM, Nasr EC, Kunam VK, Bullen JA, Purysko AS. Administered activity and outcomes of glass versus resin (90)Y microsphere radioembolization in patients with colorectal liver metastases. J Gastrointest Oncol 2016; 7:530-9. [PMID: 27563442 DOI: 10.21037/jgo.2016.03.09] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Given the differences in size, specific activity, and dosing methods for glass yttrium-90 microspheres ((90)Y-glass) and resin (90)Y microspheres ((90)Y-resin), these therapies may expose the liver to different amounts of radiation, thereby affecting their efficacy and tolerability. We aimed to compare the prescribed activity of (90)Y-glass and (90)Y-resin for real-world patients undergoing selective internal radiation therapy (SIRT) for liver-dominant metastatic colorectal cancer (mCRC) and to assess efficacy and safety outcomes in these patients. METHODS We examined the records of 28 consecutive patients with unresectable colorectal liver metastases treated with SIRT between June 2008 and May 2011 at our institution. Using baseline CT and MR images, we calculated a projected activity as if we had used the other product and compared it to the actual prescribed activity of (90)Y-glass and (90)Y-resin for each SIRT treatment per manufacturer guidelines. Progression and adverse events were evaluated at follow up visits. Survival was analyzed by the Kaplan-Meier method. RESULTS For (90)Y-glass treatments with a mean prescribed (90)Y activity of 1.77 GBq, the mean projected (90)Y-resin activity was 0.84 GBq. For (90)Y-resin treatments with a mean prescribed (90)Y activity of 1.05 GBq, the mean projected (90)Y-glass activity was 2.48 GBq. The median survival was 9.3 months versus 18.2 months for (90)Y-glass and (90)Y-resin, respectively (P=0.292). During the second year after SIRT, the hazard ratio of death for patients treated with (90)Y-glass versus (90)Y-resin was 4.0 (95% CI: 1.3, 12.3; P=0.017). No significant difference in progression, adverse events or liver toxicity was observed. CONCLUSIONS Using manufacturer recommended guidelines, (90)Y-resin delivers significantly less activity than (90)Y-glass to patients with liver-dominant mCRC undergoing SIRT with no significant difference in adverse events and a trend toward improved survival.
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Affiliation(s)
- Shyam M Srinivas
- Department of Nuclear Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Elie C Nasr
- Department of Nuclear Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Vamsi K Kunam
- Department of Radiology, SUNY Downstate University Hospital, Brooklyn, NY, USA
| | - Jennifer A Bullen
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Andrei S Purysko
- Department of Nuclear Medicine, Cleveland Clinic, Cleveland, OH, USA; ; Section of Abdominal Imaging, Cleveland Clinic, Cleveland, OH, USA
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Ludwig JM, Zhang D, Xing M, Kim HS. Meta-analysis: adjusted indirect comparison of drug-eluting bead transarterial chemoembolization versus 90Y-radioembolization for hepatocellular carcinoma. Eur Radiol 2016; 27:2031-2041. [PMID: 27562480 DOI: 10.1007/s00330-016-4548-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 07/29/2016] [Accepted: 08/08/2016] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To investigate comparative effectiveness of drug-eluting bead transarterial chemoembolization (DEB-TACE) versus Yttrium-90 (90Y)-radioembolization for hepatocellular carcinoma (HCC). METHODS Studies comparing conventional (c)TACE versus 90Y-radioembolization or DEB-TACE for HCC treatment were identified using PubMed/Medline, Embase, and Cochrane databases. The adjusted indirect meta-analytic method for effectiveness comparison of DEB-TACE versus 90Y-radioembolization was used. Wilcoxon rank-sum test was used to compare baseline characteristics. A priori defined sensitivity analysis of stratified study subgroups was performed for primary outcome analyses. Publication bias was tested by Egger's and Begg's tests. RESULTS Fourteen studies comparing DEB-TACE or 90Y-radioembolization with cTACE were included. Analysis revealed a 1-year overall survival benefit for DEB-TACE over 90Y-radioembolization (79 % vs. 54.8 %; OR: 0.57; 95 %CI: 0.355-0.915; p = 0.02; I-squared: 0 %; p > 0.5), but not for the 2-year (61 % vs. 34 %; OR: 0.65; 95%CI: 0.294-1.437; p = 0.29) and 3-year survival (56.4 % vs. 20.9 %; OR: 0.713; 95 % CI: 0.21-2.548; p = 0.62). There was significant heterogeneity in the 2- and 3-year survival analyses. The pooled median overall survival was longer for DEB-TACE (22.6 vs. 14.7 months). There was no significant difference in tumour response rate. CONCLUSION DEB-TACE and 90Y-radioembolization are efficacious treatments for patients suffering from HCC; DEB-TACE demonstrated survival benefit at 1-year compared to 90Y-radioembolization but direct comparison is warranted for further evaluation. KEY POINTS • This meta-analysis shows greater 1-year survival benefit for DEB-TACE over 90 Y-radioembolization. • DEB-TACE has a favourable 2- & 3-year survival benefit trend over 90 Y-radioembolization. • No significant difference for tumour response was detected. • Direct comparison of these methods for a more robust evaluation is warranted.
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Affiliation(s)
- Johannes M Ludwig
- Division of Interventional Radiology, Department of Radiology and Biomedical Imaging, Yale School of Medicine, 330 Cedar Street, TE 2-224, New Haven, CT, 06510, USA
| | - Di Zhang
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, 130 De Soto Street, Pittsburgh, PA, 15261, USA
| | - Minzhi Xing
- Division of Interventional Radiology, Department of Radiology and Biomedical Imaging, Yale School of Medicine, 330 Cedar Street, TE 2-224, New Haven, CT, 06510, USA
| | - Hyun S Kim
- Division of Interventional Radiology, Department of Radiology and Biomedical Imaging, Yale School of Medicine, 330 Cedar Street, TE 2-224, New Haven, CT, 06510, USA. .,Yale Cancer Center, Yale School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA.
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44
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Use of Yttrium-90 Radioembolization for Management of Colorectal Liver Metastases. CURRENT COLORECTAL CANCER REPORTS 2016. [DOI: 10.1007/s11888-016-0328-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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45
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Fan KY, Wild AT, Halappa VG, Kumar R, Ellsworth S, Ziegler M, Garg T, Rosati LM, Su Z, Hacker-Prietz A, Pawlik TM, Cosgrove DP, Hong KK, Kamel IR, Geschwind JF, Herman JM. Neuroendocrine tumor liver metastases treated with yttrium-90 radioembolization. Contemp Clin Trials 2016; 50:143-9. [PMID: 27520932 DOI: 10.1016/j.cct.2016.08.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 07/21/2016] [Accepted: 08/08/2016] [Indexed: 01/30/2023]
Abstract
OBJECTIVE Yttrium-90 (Y-90) radioembolization is an emerging treatment option for unresectable neuroendocrine liver metastases (NELM). However, the data regarding this treatment are currently limited. This study evaluates the efficacy and tolerability of Y-90 radioembolization and identifies prognostic factors for radiographic response and survival. METHODS AND MATERIALS Thirty-eight patients underwent Y-90 radioembolization for NELM at our institution between April 2004 and February 2012. Patients were assessed radiographically (RECIST criteria, enhancement), serologically, and clinically at 1month, and then at every 3months after treatment for tumor response, toxicity, and survival outcomes. RESULTS Median length of follow-up was 17.0months (IQR, 9.0-37.0). Median survival was 29.2months. Three patients (9%) had a radiographic complete response to treatment, 6 (17%) had a partial response, 21 (60%) had stable disease, and 5 (14%) developed progressive disease. Two factors were significantly associated with a good radiographic response (complete/partial response): islet cell histological subtype (p=0.043) and hepatic tumor burden ≥33% (p=0.031). Multivariate analysis revealed that patients requiring multiple Y-90 treatments (HR 2.9, p=0.035) and patients who had previously failed systemic therapy with octreotide/chemotherapy (HR 4.4, p=0.012) had worse survival. Grade 3 serologic toxicity was observed in 2 patients (5%; hyperbilirubinemia, elevated alkaline phosphatase) after treatment. Grade 3 non-serologic toxicities included abdominal pain (11%), fatigue (11%), nausea/vomiting (5%), ascites (5%), dyspnea (3%), diarrhea (3%), and peripheral edema (3%). No grade 4 or 5 toxicity was reported. CONCLUSIONS Y-90 radioembolization is a promising treatment option for inoperable NELM and is associated with low rates of grade≥3 toxicity.
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Affiliation(s)
- Katherine Y Fan
- Department of Radiation Oncology & Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Aaron T Wild
- Department of Radiation Oncology & Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Vivek G Halappa
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rachit Kumar
- Department of Radiation Oncology & Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Susannah Ellsworth
- Department of Radiation Oncology & Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mark Ziegler
- Department of Radiation Oncology & Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tanu Garg
- Department of Radiation Oncology & Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lauren M Rosati
- Department of Radiation Oncology & Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Zheng Su
- Department of Statistics, Deerfield Institute, New York, NY, USA; Department of Statistics, Stanford University, Palo Alto, CA, USA
| | - Amy Hacker-Prietz
- Department of Radiation Oncology & Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Timothy M Pawlik
- Surgery, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David P Cosgrove
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kelvin K Hong
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ihab R Kamel
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jean-Francois Geschwind
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Joseph M Herman
- Department of Radiation Oncology & Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Surrogate Imaging Biomarkers of Response of Colorectal Liver Metastases After Salvage Radioembolization Using 90Y-Loaded Resin Microspheres. AJR Am J Roentgenol 2016; 207:661-70. [PMID: 27384594 DOI: 10.2214/ajr.15.15202] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The purpose of the present study is to evaluate Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1, tumor attenuation criteria, Choi criteria, and European Organization for Research and Treatment of Cancer (EORTC) PET criteria as measures of response and subsequent predictors of liver progression-free survival (PFS) after radioembolization (RE) of colorectal liver metastases (CLM). The study also assesses interobserver variability for measuring tumor attenuation using a single 2D ROI on a simple PACS workstation. MATERIALS AND METHODS We performed a retrospective review of the clinical RE database at our institution, to identify patients treated in the salvage setting for CLM between December 2009 and March 2013. Response was evaluated on FDG PET scans, with the use of EORTC PET criteria, and on portal venous phase CT scans, with the use of RECIST 1.1, tumor attenuation criteria, and Choi criteria. Two independent blinded observers measured tumor attenuation using a single 2D ROI. The intraclass correlation coefficient (ICC) for interobserver variability was assessed. Kaplan-Meier methodology was used to calculate liver PFS, and the log-rank test was used to assess the response criteria as predictors of liver PFS. RESULTS A total of 25 patients with 46 target tumors were enrolled in the study. The ICC was 0.95 at baseline and 0.98 at response evaluation. Among the 25 patients, more responders (i.e., partial response) were identified on the basis of EORTC PET criteria (n = 14), Choi criteria (n = 15), and tumor attenuation criteria (n = 13) than on the basis of RECIST 1.1 (n = 2). The median liver PFS was 3.0 months (95% CI, 2.1-4.0 months). Response identified on the basis of EORTC PET criteria (p < 0.001), Choi criteria (p < 0.001), or tumor attenuation criteria (p = 0.01) predicted liver PFS; however, response identified by RECIST 1.1 did not (p = 0.1). CONCLUSION RECIST 1.1 has poor sensitivity for detecting metabolic responses classified by EORTC PET criteria. EORTC PET criteria, Choi criteria, and tumor attenuation criteria appear to be equally reliable surrogate imaging biomarkers of liver PFS after RE in patients with CLM.
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Transportal Radioembolization as Salvage Hepatocellular Carcinoma Therapy to Maintain Liver Transplant Candidacy. J Vasc Interv Radiol 2016; 26:1479-83. [PMID: 26408214 DOI: 10.1016/j.jvir.2015.06.029] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Revised: 06/17/2015] [Accepted: 06/19/2015] [Indexed: 01/18/2023] Open
Abstract
A 53-year-old woman with chronic hepatitis B and multifocal hepatocellular carcinoma was unable to receive transarterial radioembolization and had disease progression despite multiple chemoembolizations and systemic chemotherapy. Transportal radioembolization (TPRE) to maintain transplant candidacy was performed. Two lesions (1.7 cm, 1.4 cm) were treated with a single session of TPRE. Imaging performed at 4 months after TPRE demonstrated complete response in one lesion and stable disease in the other. This case illustrates TPRE as a salvage therapy for hepatocellular carcinoma in select patients.
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Diffusion-weighted magnetic resonance imaging predicts survival in patients with liver-predominant metastatic colorectal cancer shortly after selective internal radiation therapy. Eur Radiol 2016; 27:966-975. [DOI: 10.1007/s00330-016-4430-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 03/15/2016] [Accepted: 05/20/2016] [Indexed: 12/14/2022]
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Outcomes of Radioembolization in the Treatment of Hepatocellular Carcinoma with Portal Vein Invasion: Resin versus Glass Microspheres. J Vasc Interv Radiol 2016; 27:812-821.e2. [DOI: 10.1016/j.jvir.2016.01.147] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Revised: 01/08/2016] [Accepted: 01/26/2016] [Indexed: 01/02/2023] Open
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Tong AKT, Kao YH, Too CW, Chin KFW, Ng DCE, Chow PKH. Yttrium-90 hepatic radioembolization: clinical review and current techniques in interventional radiology and personalized dosimetry. Br J Radiol 2016; 89:20150943. [PMID: 26943239 DOI: 10.1259/bjr.20150943] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
In recent years, yttrium-90 ((90)Y) microsphere radioembolization has been establishing itself as a safe and efficacious treatment for both primary and metastatic liver cancers. This extends to both first-line therapies as well as in the salvage setting. In addition, radioembolization appears efficacious for patients with portal vein thrombosis, which is currently a contraindication for surgery, transplantation and transarterial chemoembolization. This article reviews the efficacy and expanding use of (90)Y microsphere radioembolization with an added emphasis on recent advances in personalized dosimetry and interventional radiology techniques. Directions for future research into combination therapies with radioembolization and expansion into sites other than the liver are also explored.
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Affiliation(s)
- Aaron K T Tong
- 1 Department of Nuclear Medicine and PET, Singapore General Hospital, Singapore
| | - Yung Hsiang Kao
- 2 Department of Nuclear Medicine, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Chow Wei Too
- 3 Department of Diagnostic Radiology, Singapore General Hospital, Singapore
| | | | - David C E Ng
- 1 Department of Nuclear Medicine and PET, Singapore General Hospital, Singapore
| | - Pierce K H Chow
- 5 Department of Hepato-Pancreato-Biliary (HPB) and Transplant Surgery, Singapore General Hospital Surgical Oncology, National Cancer Centre, Singapore
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