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Criss CR, Makary MS. Liver-Directed Locoregional Therapies for Neuroendocrine Liver Metastases: Recent Advances and Management. Curr Oncol 2024; 31:2076-2091. [PMID: 38668057 PMCID: PMC11049250 DOI: 10.3390/curroncol31040154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 03/27/2024] [Accepted: 04/03/2024] [Indexed: 04/28/2024] Open
Abstract
Neuroendocrine tumors (NETs) are a heterogeneous class of cancers, predominately occurring in the gastroenteropancreatic system, which pose a growing health concern with a significant rise in incidence over the past four decades. Emerging from neuroendocrine cells, these tumors often elicit paraneoplastic syndromes such as carcinoid syndrome, which can manifest as a constellation of symptoms significantly impacting patients' quality of life. The prognosis of NETs is influenced by their tendency for metastasis, especially in cases involving the liver, where the estimated 5-year survival is between 20 and 40%. Although surgical resection remains the preferred curative option, challenges emerge in cases of neuroendocrine tumors with liver metastasis (NELM) with multifocal lobar involvement, and many patients may not meet the criteria for surgery. Thus, minimally invasive and non-surgical treatments, such as locoregional therapies, have surfaced. Overall, these approaches aim to prioritize symptom relief and aid in overall tumor control. This review examines locoregional therapies, encompassing catheter-driven procedures, ablative techniques, and radioembolization therapies. These interventions play a pivotal role in enhancing progression-free survival and managing hormonal symptoms, contributing to the dynamic landscape of evolving NELM treatment. This review meticulously explores each modality, presenting the current state of the literature on their utilization and efficacy in addressing NELM.
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Affiliation(s)
- Cody R. Criss
- Department of Internal Medicine, OhioHealth Riverside Methodist Hospital, Columbus, OH 43214, USA;
| | - Mina S. Makary
- Division of Interventional Radiology, Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, OH 43240, USA
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DePietro DM, Li X, Shamimi-Noori SM. Chemoembolization Beyond Hepatocellular Carcinoma: What Tumors Can We Treat and When? Semin Intervent Radiol 2024; 41:27-47. [PMID: 38495263 PMCID: PMC10940046 DOI: 10.1055/s-0043-1777716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Liver metastases are the most common malignancy found in the liver and are 20 to 40 times more common than primary hepatic tumors, including hepatocellular carcinoma. Patients with liver metastases often present with advanced disease and are not eligible for curative-intent surgery or ablative techniques. The unique hepatic arterial blood supply of liver metastases allows interventional radiologists to target these tumors with transarterial therapies. Transarterial chemoembolization (TACE) has been studied in the treatment of liver metastases originating from a variety of primary malignancies and has demonstrated benefits in terms of hepatic progression-free survival, overall survival, and symptomatic relief, among other benefits. Depending on the primary tumor from which they originate, liver metastases may have different indications for TACE, may utilize different TACE regimens and techniques, and may result in different post-procedural outcomes. This review offers an overview of TACE techniques and specific considerations in the treatment of liver metastases, provides an in-depth review of TACE in the treatment of liver metastases originating from colorectal cancer, neuroendocrine tumor, and uveal melanoma, which represent some of the many tumors beyond hepatocellular carcinoma that can be treated by TACE, and summarizes data regarding when one should consider TACE in their treatment algorithms.
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Affiliation(s)
- Daniel M. DePietro
- Division of Interventional Radiology, Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Xin Li
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Susan M. Shamimi-Noori
- Division of Interventional Radiology, Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Harrelson A, Wang R, Stewart A, Ingram C, Gillis A, Rose JB, El-Rayes B, Azmi A, Chen H. Management of neuroendocrine tumor liver metastases. Am J Surg 2023; 226:623-630. [PMID: 37657968 DOI: 10.1016/j.amjsurg.2023.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 07/15/2023] [Accepted: 08/14/2023] [Indexed: 09/03/2023]
Abstract
BACKGROUND Neuroendocrine Tumors (NETs) are a group of tumors that arise from neuroendocrine cells, and are increasing in incidence worldwide. These tumors often metastasize to the liver, and management of these neuroendocrine tumor liver metastases (NELMs) requires a multi-disciplinary approach. We aim to provide a comprehensive update for treatment of NELMs. METHODS We completed a comprehensive systemic review of papers involving the diagnosis, treatment, and outcomes of NELMs. We identified 1612 records via Scopus database literature search. Two independent authors reviewed these records, with 318 meeting criteria for inclusion in the final systemic review. RESULTS Primary tumor resection with resection of liver metastases is the treatment of choice for patients with NELMs. Liver-directed therapies and liver transplantation can be considered for patients with unresectable liver metastases. Systemic medical therapy is used for managing tumor burden and symptoms caused by NELMs. CONCLUSIONS Advancement in liver-directed and targeted systemic therapies provide improved options for patients with unresectable tumors. Given the complexity of NELMs, management of NELMs necessitates multidisciplinary teams at comprehensive health centers.
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Affiliation(s)
- Alex Harrelson
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Rongzhi Wang
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Addison Stewart
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Clark Ingram
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Andrea Gillis
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - J Bart Rose
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Bassel El-Rayes
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Asfar Azmi
- Department of Oncology, Karmanos Cancer Institute, Detroit, MI, USA
| | - Herbert Chen
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA.
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Clift AK, Thomas R, Frilling A. Developments in interventional management of hepatic metastases from neuroendocrine tumours. Best Pract Res Clin Endocrinol Metab 2023; 37:101798. [PMID: 37468404 DOI: 10.1016/j.beem.2023.101798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
Neuroendocrine tumours commonly metastasise to the liver, particularly those arising from the intestinal tract and pancreas. Whilst surgery offers the only approach with intent to cure, the vast majority of patients with neuroendocrine liver metastases are ineligible. Liver-directed interventional therapies seek to exploit the patho-anatomy of the blood supply of hepatic metastases to deliver therapy to liver deposits. This may involve percutaneous ablation, bland embolization, or the selective infusion of chemotherapeutics, targeted agents or radiolabelled embolic material. Retrospective case series evidence has characterised objective response rates, disease control rates, and longer-term outcomes associated with each approach. Recent advances in this field include ongoing comparative trials of different techniques, but more importantly, combinations of interventional liver-directed therapies and other systemic therapy in multimodal treatment concepts.
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Affiliation(s)
- Ashley Kieran Clift
- Cancer Research UK Oxford Centre, University of Oxford, Oxford, United Kingdom; Department of Surgery & Cancer, Imperial College London, London, United Kingdom.
| | - Robert Thomas
- Department of Imaging, Imperial College Healthcare NHS Trust, London, United Kingdom.
| | - Andrea Frilling
- Department of Surgery & Cancer, Imperial College London, London, United Kingdom.
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Bai J, Song J, Zhang Y, Li X, Yan L, Hu P, Tang Q. Transcatheter arterial embolization in patients with neuroendocrine neoplasms related to liver metastasis with different blood supplies. Cancer Med 2023; 12:18578-18587. [PMID: 37587855 PMCID: PMC10557847 DOI: 10.1002/cam4.6464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 08/01/2023] [Accepted: 08/07/2023] [Indexed: 08/18/2023] Open
Abstract
PURPOSE Liver metastasis is one of the most important factors affecting the prognosis of patients with neuroendocrine neoplasms (NENs). Transhepatic artery embolization (TAE) is the main local treatment of NENs with liver metastasis (NENLM). This study aimed to elucidate the differences between pancreatic and rectal NENLM with a discrepancy in blood supply. METHODS A total of 32 patients with NENLM of different primary sites received 102 TAE treatments at our hospital. Clinical features, such as age, sex, World Health Organization (WHO) tumour grade and progression-free survival (PFS), were compared between patients with pancreatic and rectal NENLM with different blood supplies. The total follow-up time is 1-5 years. RESULTS There were 12 cases with tumours originating from the rectum or pancreas, respectively. Other tumour-originated sites included the duodenum (two cases, 6.25%), the thymus and lung (four cases, 12.5%), and the unknown (two cases, 6.25%). The average age of patients was 51.59 years, and 17 (53.1%) were men. WHO grade 1, 2 or 3 tumours occurred in three (9.4%), 23 (71.9%) and six (18.7%) patients, respectively. Hepatic tumour burdens of low (<25%), middle (25%-50%) and high (>50%) levels were found in 13 (40.6%), eight (25%) and 11 (34.4%) patients, respectively. There were more patients with hypervascular pancreatic NENLM than with hypovascular rectal NENLM (p = 0.005). Tumour shrinkage in all cases with NENLM was 50% with an objective response rate of 37.5%, disease control rate of 75% and PFS of 12 months. Disease progression (p = 0.09), tumour shrinkage (p = 0.07) and death (p = 0.19) were more prominent in the pancreatic NENLM group than in the rectal NENLM group. Progression-free survival was not reached in the pancreatic NENLM group, which was more prominent than in the rectal NENLM group (7 months; hazard ration, 0.22; 95% confidence interval, 0.07-0.76; p = 0.016). The main adverse events were abdominal pain (71.9%) and transaminase elevation (50%), which were more common in pancreatic NENLM than in rectal NENLM. CONCLUSIONS Transhepatic artery embolization treatment is markedly effective and safe for treating NENLM, especially pancreatic NENLM.
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Affiliation(s)
- Jianan Bai
- Department of Geriatric Gastroenterology, The First Affiliated Hospital with Nanjing Medical University, Institute of Neuroendocrine TumorNanjing Medical UniversityNanjingChina
| | - Jinhua Song
- Department of Hepatobiliary SurgeryThe First Affiliated Hospital with Nanjing Medical UniversityNanjingChina
| | - Yang Zhang
- Department of Geriatric Gastroenterology, The First Affiliated Hospital with Nanjing Medical University, Institute of Neuroendocrine TumorNanjing Medical UniversityNanjingChina
| | - Xiaolin Li
- Department of Geriatric Gastroenterology, The First Affiliated Hospital with Nanjing Medical University, Institute of Neuroendocrine TumorNanjing Medical UniversityNanjingChina
| | - Lijun Yan
- Department of Geriatric Gastroenterology, The First Affiliated Hospital with Nanjing Medical University, Institute of Neuroendocrine TumorNanjing Medical UniversityNanjingChina
| | - Ping Hu
- Department of Geriatric Gastroenterology, The First Affiliated Hospital with Nanjing Medical University, Institute of Neuroendocrine TumorNanjing Medical UniversityNanjingChina
| | - Qiyun Tang
- Department of Geriatric Gastroenterology, The First Affiliated Hospital with Nanjing Medical University, Institute of Neuroendocrine TumorNanjing Medical UniversityNanjingChina
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Wang ZY, Xie CF, Feng KL, Xiong CM, Huang JH, Chen QL, Zhong C, Zhou ZW. Drug-eluting beads versus conventional transarterial chemoembolization for the treatment of unresectable hepatocellular carcinoma: A meta-analysis. Medicine (Baltimore) 2023; 102:e34527. [PMID: 37653749 PMCID: PMC10470720 DOI: 10.1097/md.0000000000034527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 06/19/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND Transarterial chemoembolization (TACE) consists of conventional TACE (cTACE) and drug-eluting beads TACE (DEB-TACE). The benefits of the 2 treatments remain controversial. We conduct this meta-analysis to assess the efficacy and safety of the 2 methods for the patients with unresectable hepatocellular carcinoma. METHODS In order to get a sound conclusion, we did thorough search all relevant studies with clear and stringent keyword criteria on the main databases. Objective tumor response rate, overall survival (OS) rate and adverse events were calculated and analyzed by RevMan 5.3 software. The random-effects or fixed-effects model was applied to pool the estimates according to Cochran Q test and I2 statistics. RESULTS Twenty-four studies involving 2987 patients were eligible. DEB-TACE significantly improved objective tumor response rate (OR) (risk ratio [RR] = 1.27, 95% confidence interval [CI] [1.08, 1.48]; P = .003). While as for 1-year, 2-year, 3-year, 5-year OS rates, there were no evidences to indicate that DEB-TACE was significantly better than cTACE (RR = 1.05, 95% CI [0.99, 1.11]; P = .08), (RR = 1.02, 95% CI [0.93, 1.11]; P = .68), (RR = 0.92, 95% CI [0.77, 1.10]; P = .37), (RR = 0.92, 95% CI [0.47, 1.80]; P = .81), respectively. Adverse events rate (AE) was also similar in both groups (RR = 1.11, 95% CI [0.99,1.26]; P = .08). CONCLUSION This meta-analysis demonstrates that DEB-TACE is not superior than cTACE regarding to OS and AE. However, DEB-TACE still be considered to provide a better objective tumor response rate for patients with unresectable hepatocellular carcinoma.
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Affiliation(s)
- Zi-Yu Wang
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
- Lingnan Medical Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
- The First Clinical Medical School of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Chun-Feng Xie
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
- Lingnan Medical Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
- The First Clinical Medical School of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Kun-Liang Feng
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
- Lingnan Medical Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
- The First Clinical Medical School of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Cheng-Ming Xiong
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
- Lingnan Medical Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jun-Hai Huang
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
- Lingnan Medical Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Qing-Lian Chen
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
- Lingnan Medical Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Chong Zhong
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
- Lingnan Medical Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Zhai-Wen Zhou
- Department of Radiology, the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
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Fohlen A, Beaudouin R, Alvès A, Bouhier-Leporrier K, Pasik C, Pelage JP. Conventional Transarterial Chemo embolization Using Streptozocin in Patients with Unresectable Neuroendocrine Liver Metastases. Cancers (Basel) 2023; 15:4021. [PMID: 37627049 PMCID: PMC10452304 DOI: 10.3390/cancers15164021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/01/2023] [Accepted: 08/03/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND The purpose of this study was to evaluate the clinical, biological and radiological responses to, and tolerability of, conventional transarterial chemoembolization (cTACE) using streptozocin for unresectable neuroendocrine liver metastases. PATIENTS AND METHODS A total of 52 patients with predominant liver disease were treated with cTACE using an emulsion of streptozocin, Lipiodol and embolization particles. A sequential approach was favored in patients with high liver tumor burden. Clinical, biological and radiological responses were evaluated using carcinoid symptoms, biomarkers and mRecist criteria, respectively. RESULTS A total of 127 procedures were performed with a sequential approach in 65% of patients. All patients received streptozocin and Lipiodol. Carcinoid syndrome was improved in 69% of patients after treatment (p = 0.01). Post-embolization syndrome was reported in 78% of patients. At the end of all cTACE, objective response and non-progressive disease were 32% and 70%, respectively. Progression-free survival was 18.3 ± 13.3 months (median 14.9) and median overall survival (OS) from start of treatment was 74 months. The OS at 1 year, 2 years, 3 years and 5 years was 91% (IC = 84-99%), 84% (CI = 72-95%), 69% (CI = 53-84%) and 63% (C = 46-81%), respectively. CONCLUSIONS cTACE using streptozocin is an effective and well-tolerated palliative option for patients with neuroendocrine liver metastases, associated with prolonged survival and delayed time to progression.
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Affiliation(s)
- Audrey Fohlen
- Interventional Radiology, Caen University Medical Center, 14033 Caen, France; (A.F.); (R.B.)
- Centre National de la Recherche Scientifique, Imaging & Therapeutic Strategies for Cancer & Brain Tissue UMR 6030 GIP CYCERON “ISTCT-CERVOxy”, Normandie Caen University, 14000 Caen, France
| | - Remi Beaudouin
- Interventional Radiology, Caen University Medical Center, 14033 Caen, France; (A.F.); (R.B.)
| | - Arnaud Alvès
- Department of Digestive Surgery, Caen University Medical Center, 14033 Caen, France;
- Interdisciplinary Research Unit for Cancer Prevention and Treatment “ANTICIPE”, Inserm Unity UMR 1086, Normancy Caen University, Calvados General Tumor Registry, Centre François Baclesse, 14000 Caen, France
| | - Karine Bouhier-Leporrier
- Department of Hepato-Gastroenterology and Digestive Oncology, Caen University Medical Center, 14033 Caen, France;
| | | | - Jean-Pierre Pelage
- Interventional Radiology, Caen University Medical Center, 14033 Caen, France; (A.F.); (R.B.)
- Centre National de la Recherche Scientifique, Imaging & Therapeutic Strategies for Cancer & Brain Tissue UMR 6030 GIP CYCERON “ISTCT-CERVOxy”, Normandie Caen University, 14000 Caen, France
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Victory Srinivasan N, Venugopal S. A Comparison of the Outcomes of Transarterial Chemoembolization and Transarterial Radioembolization in the Management of Neuroendocrine Liver Metastases in Adults: A Systematic Review. Cureus 2023; 15:e40592. [PMID: 37469827 PMCID: PMC10353751 DOI: 10.7759/cureus.40592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 06/17/2023] [Indexed: 07/21/2023] Open
Abstract
The purpose of this article is to review the existing English scientific literature and determine the superior modality between transarterial chemoembolization (TACE) and radioembolization (TARE) in the treatment of neuroendocrine liver metastases (NELMs). To that end, we followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to search PubMed, the Cochrane Library, and Google Scholar. We identified 14 observational studies and no randomized controlled trials (RCTs) investigating the use of TACE or TARE to treat NELM. We used the Newcastle-Ottawa Scale to assess the risk of bias in these studies. We concluded that TACE and TARE appeared to have similar outcomes when comparing overall survival, progression-free survival, radiological response, symptomatic response, and the incidence of severe adverse events. Further large-scale RCTs are needed to identify the superior modality conclusively. We also identified several unique prognostic factors for overall survival, such as the neutrophil-lymphocyte ratio, volumetric multiparametric magnetic resonance imaging, serum albumin, alkaline phosphatase, and pancreastatin.
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Affiliation(s)
| | - Sathish Venugopal
- Neurology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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Evaluation of the effectiveness of transarterial chemoembolization with drug-saturable microspheres with irinotecan for the treatment of patients with neuroendocrine tumors with liver metastases. КЛИНИЧЕСКАЯ ПРАКТИКА 2023. [DOI: 10.17816/clinpract115017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Since 2021, transarterial chemoembolization of the hepatic arteries (TACHE) has been included in the recommendations of professional communities for the treatment of liver metastases from neuroendocrine tumors. However, the heterogeneity of this group of patients and the methods of chemoembolization with a limited range of cytostatics used in the treatment makes it difficult to analyze the data and introduce the method into combination therapy regimens.The aim of the study was to study the effectiveness of transarterial chemoembolization with drug-saturable microspheres with irinotecan for the treatment of patients with neuroendocrine tumors with liver metastases.Materials and methods. A retrospective, observational, uncontrolled study of 34 patients with liver metastases from neuroendocrine cancer who underwent 52 TACs with irinotecan. Group 1 consisted of 15 patients who already had liver metastases at the time of detection of the primary focus, group 2 - 19 people in whom liver metastases appeared after a lapse of time since the detection of the primary focus. To plan and evaluate the effectiveness of chemoembolization, computed tomography and magnetic resonance imaging were used every 10-15 weeks during systemic treatment. All patients received systemic NEO therapy before and after embolization.Results. An increase in time without progression from 101 [57; 120] and 145 [89; 263] after chemotherapy up to 300 [134; 344] and 304 [240;342] after TACE in groups 1 and 2, respectively, with no difference between groups (p0.05). We did not find a linear relationship between the doubling time of the tumor and the difference in the volume of the tumor lesion (R2 0.1085 and 0.0265 in groups 1 and 2). When comparing intragroup scores, there was a statistically significant difference (p0.05) in tumor volume reduction and progression-free time between patients who underwent TACE immediately and those who underwent TACE after chemotherapy. Radiation and angiographic semiotics of liver metastases varied within the same organ and depended on the size of metastases.Conclusions. TACE with irinotecan drug-saturable microspheres is an effective method for the treatment of liver metastases of neuroendocrine cancer, allowing to increase the time without progression.
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Surgery, Liver Directed Therapy and Peptide Receptor Radionuclide Therapy for Pancreatic Neuroendocrine Tumor Liver Metastases. Cancers (Basel) 2022; 14:cancers14205103. [PMID: 36291892 PMCID: PMC9599940 DOI: 10.3390/cancers14205103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/19/2022] [Accepted: 10/12/2022] [Indexed: 11/16/2022] Open
Abstract
Pancreatic neuroendocrine tumors (PNETs) are described by the World Health Organization (WHO) classification by grade (1–3) and degree of differentiation. Grade 1 and 2; well differentiated PNETs are often characterized as relatively “indolent” tumors for which locoregional therapies have been shown to be effective for palliation of symptom control and prolongation of survival even in the setting of advanced disease. The treatment of liver metastases includes surgical and non-surgical modalities with varying degrees of invasiveness; efficacy; and risk. Most of these modalities have not been prospectively compared. This paper reviews literature that has been published on treatment of pancreatic neuroendocrine liver metastases using surgery; liver directed embolization and peptide receptor radionuclide therapy (PRRT). Surgery is associated with the longest survival in patients with resectable disease burden. Liver-directed (hepatic artery) therapies can sometimes convert patients with borderline disease into candidates for surgery. Among the three embolization modalities; the preponderance of data suggests chemoembolization offers superior radiographic response compared to bland embolization and radioembolization; but all have similar survival. PRRT was initially approved as salvage therapy in patients with advanced disease that was not amenable to resection or embolization; though the role of PRRT is evolving rapidly
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Miszczuk M, Chapiro J, Minh DD, van Breugel JMM, Smolka S, Rexha I, Tegel B, Lin M, Savic LJ, Hong K, Georgiades C, Nezami N. Analysis of Tumor Burden as a Biomarker for Patient Survival with Neuroendocrine Tumor Liver Metastases Undergoing Intra-Arterial Therapies: A Single-Center Retrospective Analysis. Cardiovasc Intervent Radiol 2022; 45:1494-1502. [PMID: 35941241 PMCID: PMC9587516 DOI: 10.1007/s00270-022-03209-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 06/20/2022] [Indexed: 11/02/2022]
Abstract
PURPOSE To assess the value of quantitative analysis of tumor burden on baseline MRI for prediction of survival in patients with neuroendocrine tumor liver metastases (NELM) undergoing intra-arterial therapies. MATERIALS AND METHODS This retrospective single-center analysis included 122 patients with NELM who received conventional (n = 74) or drug-eluting beads, (n = 20) chemoembolization and radioembolization (n = 28) from 2000 to 2014. Overall tumor diameter (1D) and area (2D) of up to 3 largest liver lesions were measured on baseline arterially contrast enhanced MR images. Three-dimensional quantitative analysis was performed using the qEASL tool (IntelliSpace Portal Version 8, Philips) to calculate enhancing tumor burden (the ratio between enhancing tumor volume and total liver volume). Based on Q-statistics, patients were stratified into low tumor burden (TB) or high TB. RESULTS The survival curves were significantly separated between low TB and high TB groups for 1D (p < 0.001), 2D (p < 0.001) and enhancing TB (p = 0.008) measurements, with, respectively, 2.7, 2.6 and 2.2 times longer median overall survival (MOS) in the low TB group (p < 0.001, p < 0.001 and p = 0.008). Multivariate analysis showed that 1D, 2D, and enhancing TB were independent prognostic factors for MOS, with respective hazard ratios of 0.4 (95%CI: 0.2-0.6, p < 0.001), 0.4 (95%CI: 0.3-0.7, p < 0.001) and 0.5 (95%CI: 0.3-0.8, p = 0.003). CONCLUSION The overall tumor diameter, overall tumor area, and enhancing tumor burden are strong prognostic factors of overall survival in patients with neuroendocrine tumor liver metastases undergoing intra-arterial therapies.
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Affiliation(s)
- Milena Miszczuk
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, USA
| | - Julius Chapiro
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, USA
| | - Duc Do Minh
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, USA
- Department of Radiology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt- Universität zu Berlin, 13353 Berlin, Germany
| | | | - Susanne Smolka
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, USA
- Department of Radiology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt- Universität zu Berlin, 13353 Berlin, Germany
| | - Irvin Rexha
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, USA
- Department of Radiology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt- Universität zu Berlin, 13353 Berlin, Germany
| | - Bruno Tegel
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, USA
- Department of Radiology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt- Universität zu Berlin, 13353 Berlin, Germany
| | - MingDe Lin
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, USA
| | - Lynn Jeanette Savic
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, USA
- Department of Radiology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt- Universität zu Berlin, 13353 Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Kelvin Hong
- Division of Vascular and Interventional Radiology, Russel H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christos Georgiades
- Division of Vascular and Interventional Radiology, Russel H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nariman Nezami
- Division of Vascular and Interventional Radiology, Russel H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Division of Vascular and Interventional Radiology, Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, 22 Greene St, Baltimore, MD 21201, USA
- Experimental Therapeutics Program, University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, MD, Baltimore, USA
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12
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Fernandes CJ, Leung G, Eads JR, Katona BW. Gastroenteropancreatic Neuroendocrine Tumors. Gastroenterol Clin North Am 2022; 51:625-647. [PMID: 36153114 DOI: 10.1016/j.gtc.2022.06.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Gastroenteropancreatic neuroendocrine tumors (GEP-NETs) are the most common type of neuroendocrine tumors and are being increasingly identified in clinical practice. The diagnosis, staging, management, and surveillance of GEP-NETs rely heavily on endoscopy, and consequently, it is important for gastroenterologists to have a solid understanding of these tumors. This article reviews the presentation, diagnosis, and management of both localized and advanced GEP-NETs, with increased emphasis on the role of endoscopy, to enable gastroenterologists and other practitioners to have the necessary tools for the care of patients with these tumors.
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Affiliation(s)
- Conrad J Fernandes
- Department of Medicine, Hospital of the University of Pennsylvania, 3400 Civic Center Boulevard, 751 South Pavilion, Philadelphia, PA 19104, USA
| | - Galen Leung
- Division of Gastroenterology and Hepatology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Boulevard, 751 South Pavilion, Philadelphia, PA 19104, USA
| | - Jennifer R Eads
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Boulevard, 751 South Pavilion, Philadelphia, PA 19104, USA
| | - Bryson W Katona
- Division of Gastroenterology and Hepatology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Boulevard, 751 South Pavilion, Philadelphia, PA 19104, USA.
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13
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Adam LC, Savic LJ, Chapiro J, Letzen B, Lin M, Georgiades C, Hong KK, Nezami N. Response assessment methods for patients with hepatic metastasis from rare tumor primaries undergoing transarterial chemoembolization. Clin Imaging 2022; 89:112-119. [PMID: 35777239 PMCID: PMC9470015 DOI: 10.1016/j.clinimag.2022.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 06/17/2022] [Accepted: 06/19/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE This study assessed the response to conventional transarterial chemoembolization (cTACE) in patients with liver metastases from rare tumor primaries using one-dimensional (1D) and three-dimensional (3D) quantitative response assessment methods, and investigate the relationship of lipiodol deposition in predicting response. MATERIALS AND METHODS This retrospective bicentric study included 16 patients with hepatic metastases from rare tumors treated with cTACE between 2002 and 2017. Multi-phasic MR imaging obtained before and after cTACE was used for assessment of response. Response evaluation criteria in solid tumors (RECIST) and modified-RECIST (mRECIST) were utilized for 1D response assessment, and volumetric RECIST (vRECIST) and enhancement-based quantitative European Association for Study of the Liver EASL (qEASL) were used for 3D response assessment. The same day post-cTACE CT scan was analyzed to quantify intratumoral lipiodol deposition (%). RESULTS The mean and standard deviation (SD) of diameter of treated lesions per targeted area was 7.5 ± 5.4 cm, and the mean and SD of number of metastases in each targeted area was 4.2 ± 4.6. cTACE was technically successful in all patients, without major complications. While RECIST and vRECIST methods did not allocate patients with partial response, mRECIST and qEASL identified patients with partial response. Intratumoral lipiodol deposition significantly predicted treatment response according qEASL (R2 = 0.470, p < 0.01), while no association was shown between lipiodol deposition within treated tumor area and RECIST or mRECIST (p > 0.212). CONCLUSION 3D quantitative volumetric response analysis can be used for stratification of response to cTACE in patients with hepatic metastases originating from rare primary tumors. Lipiodol deposition could potentially be used as an early surrogate to predict response to cTACE.
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Affiliation(s)
- Lucas C Adam
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA; Institute of Radiology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität, and Berlin Institute of Health, 10117 Berlin, Germany
| | - Lynn J Savic
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA; Institute of Radiology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität, and Berlin Institute of Health, 10117 Berlin, Germany; Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité (Junior) (Digital) Clinician Scientist Program, Charitéplatz 1, 10117 Berlin, Germany
| | - Julius Chapiro
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA
| | - Brian Letzen
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA
| | - MingDe Lin
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA; Visage Imaging, Inc., San Diego, CA, USA
| | - Christos Georgiades
- Division of Vascular and Interventional Radiology, Russel H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kelvin K Hong
- Division of Vascular and Interventional Radiology, Russel H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nariman Nezami
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA; Division of Vascular and Interventional Radiology, Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA; Experimental Therapeutics Program, University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, Baltimore, MD, USA.
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14
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Sharma R, Slater S, Evans J, Martinez M, Ward C, Izadi H, Wernig F, Thomas R. ArTisaN trial protocol: a single Centre, open-label, phase II trial of the safety and efficacy of TheraSphere selective internal radiation therapy (SIRT) in the treatment of inoperable metastatic (liver) neuroendocrine neoplasia (NENs). BMC Cancer 2022; 22:800. [PMID: 35858849 PMCID: PMC9297626 DOI: 10.1186/s12885-022-09859-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 07/06/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Neuroendocrine neoplasias (NENs) are a rare type of malignancy that arise from the cells of the neuroendocrine system. Most patients present with advanced, unresectable disease, typically with metastases to the liver. The presence of liver metastases dictates prognosis and there has been a number of studies investigating therapies that reduce the burden of liver disease. Selective Internal Radiation Therapy (SIRT) allows the delivery of targeted high dose radiation directly to tumours, with relative sparing of the surrounding liver tissue. Here, we describe the design and rationale of ArtTisaN, a phase II study to assess efficacy and tolerability of SIRT using TheraSpheres for the management of liver metastases secondary to NENs. METHODS Twenty-four eligible participants will be recruited to receive SIRT with TheraSpheres. The primary objective is to determine the objective response rate to treatment, defined as the rate of best overall response in the treated liver volume. In addition, total hepatic response and overall response will be assessed according to RECIST 1.1. The second co-primary objective is to determine the incidence of adverse and serious adverse device events. The secondary objectives are progression free survival, overall survival and quality of life. Additional exploratory objectives include investigation of circulating biomarkers of response and identification of a radiomic signature of response. DISCUSSION This trial will provide prospective evidence on the efficacy of SIRT using TheraSpheres for the management of liver metastases. TRIAL REGISTRATION NCT04362436 .
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Affiliation(s)
- Rohini Sharma
- grid.7445.20000 0001 2113 8111Division of Surgery and Cancer, Hammersmith Hospital, Imperial College London, Du Cane Road, London, W12 0NN UK
| | - Susanna Slater
- grid.7445.20000 0001 2113 8111Department of Oncology, Hammersmith Hospital, Imperial College NHS Healthcare Trust, Du Cane Road, London, W12 0HS UK
| | - Joanne Evans
- grid.7445.20000 0001 2113 8111Department of Oncology, Hammersmith Hospital, Imperial College NHS Healthcare Trust, Du Cane Road, London, W12 0HS UK
| | - Maria Martinez
- grid.7445.20000 0001 2113 8111Division of Surgery and Cancer, Hammersmith Hospital, Imperial College London, Du Cane Road, London, W12 0NN UK
| | - Caroline Ward
- grid.7445.20000 0001 2113 8111Division of Surgery and Cancer, Hammersmith Hospital, Imperial College London, Du Cane Road, London, W12 0NN UK
| | - Hooshang Izadi
- grid.7628.b0000 0001 0726 8331Department of Mechanical Engineering and Mathematical Sciences, Oxford Brookes University, Oxford, UK
| | - Florian Wernig
- grid.7445.20000 0001 2113 8111Department of Endocrinology, Hammersmith Hospital, Imperial College NHS Healthcare Trust, Du Cane Road, London, W12 0HS UK
| | - Rob Thomas
- grid.7445.20000 0001 2113 8111Department of Interventional Radiology, Hammersmith Hospital, Imperial College NHS Healthcare Trust, Du Cane Road, London, W12 0HS UK
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15
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Papamichail M, Pizanias M, Heaton ND, M P, M P, Nd H. Minimizing the risk of small-for-size syndrome after liver surgery. Hepatobiliary Pancreat Dis Int 2022; 21:113-133. [PMID: 34961675 DOI: 10.1016/j.hbpd.2021.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 12/06/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Primary and secondary liver tumors are not always amenable to resection due to location and size. Inadequate future liver remnant (FLR) may prevent patients from having a curative resection or may result in increased postoperative morbidity and mortality from complications related to small-for-size syndrome (SFSS). DATA SOURCES This comprehensive review analyzed the principles, mechanism and risk factors associated with SFSS and presented current available options in the evaluation of FLR when planning liver surgery. In addition, it provided a detailed description of specific modalities that can be used before, during or after surgery, in order to optimize the conditions for a safe resection and minimize the risk of SFSS. RESULTS Several methods which aim to reduce tumor burden, preserve healthy liver parenchyma, induce hypertrophy of FLR or prevent postoperative complications help minimize the risk of SFSS. CONCLUSIONS With those techniques the indications of radical treatment for patients with liver tumors have significantly expanded. The successful outcome depends on appropriate patient selection, the individualization and modification of interventions and the right timing of surgery.
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Affiliation(s)
- Michail Papamichail
- Department of Hepato-Pancreato-Biliary Surgery, Royal Blackburn Hospital, Blackburn BB2 3HH, UK.
| | - Michail Pizanias
- Department of General Surgery, Whittington Hospital, London N19 5NF, UK
| | - Nigel D Heaton
- Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Institute of Liver Studies, Kings Health Partners at King's College Hospital NHS Trust, London SE5 9RS, UK
| | - Papamichail M
- Department of Hepato-Pancreato-Biliary Surgery, Royal Blackburn Hospital, Blackburn BB2 3HH, UK; Department of General Surgery, Whittington Hospital, London N19 5NF, UK; Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Institute of Liver Studies, Kings Health Partners at King's College Hospital NHS Trust, London SE5 9RS, UK
| | - Pizanias M
- Department of Hepato-Pancreato-Biliary Surgery, Royal Blackburn Hospital, Blackburn BB2 3HH, UK; Department of General Surgery, Whittington Hospital, London N19 5NF, UK; Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Institute of Liver Studies, Kings Health Partners at King's College Hospital NHS Trust, London SE5 9RS, UK
| | - Heaton Nd
- Department of Hepato-Pancreato-Biliary Surgery, Royal Blackburn Hospital, Blackburn BB2 3HH, UK; Department of General Surgery, Whittington Hospital, London N19 5NF, UK; Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Institute of Liver Studies, Kings Health Partners at King's College Hospital NHS Trust, London SE5 9RS, UK
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16
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Siebenhüner AR, Langheinrich M, Friemel J, Schaefer N, Eshmuminov D, Lehmann K. Orchestrating Treatment Modalities in Metastatic Pancreatic Neuroendocrine Tumors-Need for a Conductor. Cancers (Basel) 2022; 14:cancers14061478. [PMID: 35326628 PMCID: PMC8946777 DOI: 10.3390/cancers14061478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 02/28/2022] [Accepted: 03/10/2022] [Indexed: 12/11/2022] Open
Abstract
Simple Summary Pancreatic neuroendocrine tumors (pNET) are a heterogeneous and challenging entity, and today’s guidelines offer a variety of treatment modalities, while surgery has a clear role for patients with resectable tumors and early stages, advanced, or metastatic pNET may benefit from treatments that were evaluated in randomized controlled studies during the last year. With this review, we aim to provide an updated view on treatment options for metastatic pNET. Abstract Pancreatic neuroendocrine tumors (pNETs) are a vast growing disease. Over 50% of these tumors are recognized at advanced stages with lymph node, liver, or distant metastasis. An ongoing controversy is the role of surgery in the metastatic setting as dedicated systemic treatments have emerged recently and shown benefits in randomized trials. Today, liver surgery is an option for advanced pNETs if the tumor has a favorable prognosis, reflected by a low to moderate proliferation index (G1 and G2). Surgery in this well-selected population may prolong progression-free and overall survival. Optimal selection of a treatment plan for an individual patient should be considered in a multidisciplinary tumor board. However, while current guidelines offer a variety of modalities, there is so far only a limited focus on the right timing. Available data is based on small case series or retrospective analyses. The focus of this review is to highlight the right time-point for surgery in the setting of the multimodal treatment of an advanced pancreatic neuroendocrine tumor.
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Affiliation(s)
- Alexander R. Siebenhüner
- Clinic for Gastroenterology and Hepatology, University Hospital Zurich and University of Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland
- ENETS Center of Excellence Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland;
- Correspondence: ; Tel.: +41-44-255-11-11
| | - Melanie Langheinrich
- Department of Visceral Surgery, University Hospital Greifswald, Ferdinand-Sauerbruch-Strasse, D-17475 Greifswald, Germany;
| | - Juliane Friemel
- Institute for Pathologie, University Bern, Murtenstrasse 31, CH-3008 Bern, Switzerland;
| | - Niklaus Schaefer
- Department of Nuclear Medicine, University Hospital Lausanne, Rue du Bugnon 46, CH-1011 Lausanne, Switzerland;
| | - Dilmurodjon Eshmuminov
- Department of Surgery and Transplantation, University Hospital of Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland;
| | - Kuno Lehmann
- ENETS Center of Excellence Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland;
- Department of Surgery and Transplantation, University Hospital of Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland;
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Huang J, Liu B, Lin M, Zhang X, Zheng Y, Xie X, Xu M, Xie X. Ultrasound-guided percutaneous radiofrequency ablation in treatment of neuroendocrine tumor liver metastases:a single-center experience. Int J Hyperthermia 2022; 39:497-503. [PMID: 35285400 DOI: 10.1080/02656736.2022.2048094] [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] Open
Affiliation(s)
- Jingzhi Huang
- Department of Medical Ultrasound, Division of Interventional Ultrasound, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Baoxian Liu
- Department of Medical Ultrasound, Division of Interventional Ultrasound, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Manxia Lin
- Department of Medical Ultrasound, Division of Interventional Ultrasound, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiaoer Zhang
- Department of Medical Ultrasound, Division of Interventional Ultrasound, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yanling Zheng
- Department of Medical Ultrasound, Division of Interventional Ultrasound, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiaoyan Xie
- Department of Medical Ultrasound, Division of Interventional Ultrasound, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ming Xu
- Department of Medical Ultrasound, Division of Interventional Ultrasound, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiaohua Xie
- Department of Medical Ultrasound, Division of Interventional Ultrasound, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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18
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Wong TY, Zhang KS, Gandhi RT, Collins ZS, O'Hara R, Wang EA, Vaheesan K, Matsuoka L, Sze DY, Kennedy AS, Brown DB. Long-term outcomes following 90Y Radioembolization of neuroendocrine liver metastases: evaluation of the radiation-emitting SIR-spheres in non-resectable liver tumor (RESiN) registry. BMC Cancer 2022; 22:224. [PMID: 35232410 PMCID: PMC8889709 DOI: 10.1186/s12885-022-09302-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 02/11/2022] [Indexed: 01/08/2023] Open
Abstract
Background The goal of this study was to evaluate efficacy and safety of 90Y radioembolization for neuroendocrine liver metastases (NELM) in a multicenter registry. Methods One hundred-seventy patients with NELM were enrolled in the registry (NCT 02685631). Prior treatments included hepatic resection (n = 23, 14%), arterial therapy (n = 62, 36%), octreotide (n = 119, 83%), cytotoxic chemotherapy (n = 58, 41%), biologic therapy (n = 49, 33%) and immunotherapy (n = 10, 6%). Seventy-seven (45%) patients had extrahepatic disease. Seventy-eight (48%), 61 (37%), and 25 (15%) patients were Eastern Cooperative Oncology Group (ECOG) performance status of 0, 1, or ≥ 2. Tumor grade was known in 81 (48%) patients: 57 (70%) were well-, 12 (15%) moderate-, and 12 (15%) poorly-differentiated. Kaplan-Meier analysis and log rank tests were performed to compare overall and progression-free survival (OS/PFS) by tumor location and grade. Toxicities were reported using Common Terminology Criteria for Adverse Events v.5. Cox Proportional Hazards were calculated for pancreatic primary, performance status, extrahepatic disease at treatment, unilobar treatment, baseline ascites, and > 25% tumor burden. Results One, 2, and 3-year OS rates were 75, 62 and 46%, respectively. Median OS was 33 months [(95% CI: 25-not reached (NR)]. The longest median OS was in patients with pancreatic (42 months, 95% CI: 33-NR) and hindgut 41 months, 95% CI: 12-NR) primaries. The shortest OS was in foregut primaries (26 months; 95% CI: 23-NR; X2 = 7, p = 0.1). Median OS of well-differentiated tumors was 36 months (95% CI: 10-NR), compared to 44 (95% CI: 7-NR) and 25 (95% CI: 3-NR) months for moderate and poorly differentiated tumors. Median progression-free survival (PFS) was 25 months with 1, 2, and 3-year PFS rates of 70, 54, and 35%, respectively. Thirteen patients (7.6%) developed grade 3 hepatic toxicity, most commonly new ascites (n = 8, 5%) at a median of 5.5 months. Performance status of ≥2 (HR 2.7, p = 0.01) and baseline ascites (HR 2.8, P = 0.049) predicted shorter OS. Discussion In a population with a high incidence of extrahepatic disease, 90Y was effective and safe in treatment of NELM, with median OS of 41 months for well differentiated tumors. Grade 3 or greater hepatic toxicity was developed in 7.6% of patients. Trial registration NCT 02685631.
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Affiliation(s)
- Thomas Y Wong
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, 1161 21st Avenue S, CCC-1118 Medical Center North, Nashville, TN, 37232, USA
| | - Kevin S Zhang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ripal T Gandhi
- Miami Cardiac and Vascular Institute, Baptist Hospital, Miami, FL, USA
| | - Zachary S Collins
- Interventional Radiology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Ryan O'Hara
- Interventional Radiology, University of Utah Medical Center, Salt Lake City, UT, USA
| | - Eric A Wang
- Interventional Radiology, Carolinas Medical Center, Charlotte, NC, USA
| | - Kirubahara Vaheesan
- Interventional Radiology, Saint Louis University Hospital, St. Louis, MO, USA
| | - Lea Matsuoka
- Transplant Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Daniel Y Sze
- Interventional Radiology, Stanford University Medical Center, Palo Alto, CA, USA
| | - Andrew S Kennedy
- Radiation Oncology, Sarah Cannon Research Institute, Nashville, TN, USA
| | - Daniel B Brown
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, 1161 21st Avenue S, CCC-1118 Medical Center North, Nashville, TN, 37232, USA.
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Nagel I, Herrmann K, Lahner H, Rischpler C, Weber F. Combined medical therapy, nuclear medicine therapy and other therapies in metastatic neuroendocrine tumor. Nucl Med Mol Imaging 2022. [DOI: 10.1016/b978-0-12-822960-6.00156-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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20
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Cazzato RL, Hubelé F, De Marini P, Ouvrard E, Salvadori J, Addeo P, Garnon J, Kurtz JE, Greget M, Mertz L, Goichot B, Gangi A, Imperiale A. Liver-Directed Therapy for Neuroendocrine Metastases: From Interventional Radiology to Nuclear Medicine Procedures. Cancers (Basel) 2021; 13:cancers13246368. [PMID: 34944988 PMCID: PMC8699378 DOI: 10.3390/cancers13246368] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 12/16/2021] [Accepted: 12/17/2021] [Indexed: 12/25/2022] Open
Abstract
Neuroendocrine neoplasms (NENs) are rare and heterogeneous epithelial tumors most commonly arising from the gastroenteropancreatic (GEP) system. GEP-NENs account for approximately 60% of all NENs, and the small intestine and pancreas represent two most common sites of primary tumor development. Approximately 80% of metastatic patients have secondary liver lesions, and in approximately 50% of patients, the liver is the only metastatic site. The therapeutic strategy depends on the degree of hepatic metastatic invasion, ranging from liver surgery or percutaneous ablation to palliative treatments to reduce both tumor volume and secretion. In patients with grade 1 and 2 NENs, locoregional nonsurgical treatments of liver metastases mainly include percutaneous ablation and endovascular treatments, targeting few or multiple hepatic metastases, respectively. In the present work, we provide a narrative review of the current knowledge on liver-directed therapy for metastasis treatment, including both interventional radiology procedures and nuclear medicine options in NEN patients, taking into account the patient clinical context and both the strengths and limitations of each modality.
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Affiliation(s)
- Roberto Luigi Cazzato
- Interventional Radiology, University Hospitals of Strasbourg, Strasbourg University, 67000 Strasbourg, France; (R.L.C.); (P.D.M.); (J.G.); (M.G.); (A.G.)
- Oncology, Institut de Cancérologie de Strasbourg Europe (ICANS), Strasbourg University, 67200 Strasbourg, France;
| | - Fabrice Hubelé
- Nuclear Medicine and Molecular Imaging, Institut de Cancérologie de Strasbourg Europe (ICANS), University Hospitals of Strasbourg, Strasbourg University, 67200 Strasbourg, France; (F.H.); (E.O.)
| | - Pierre De Marini
- Interventional Radiology, University Hospitals of Strasbourg, Strasbourg University, 67000 Strasbourg, France; (R.L.C.); (P.D.M.); (J.G.); (M.G.); (A.G.)
| | - Eric Ouvrard
- Nuclear Medicine and Molecular Imaging, Institut de Cancérologie de Strasbourg Europe (ICANS), University Hospitals of Strasbourg, Strasbourg University, 67200 Strasbourg, France; (F.H.); (E.O.)
| | - Julien Salvadori
- Radiophysics, Institut de Cancérologie de Strasbourg Europe (ICANS), 67200 Strasbourg, France;
| | - Pietro Addeo
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Hospitals of Strasbourg, 67200 Strasbourg, France;
| | - Julien Garnon
- Interventional Radiology, University Hospitals of Strasbourg, Strasbourg University, 67000 Strasbourg, France; (R.L.C.); (P.D.M.); (J.G.); (M.G.); (A.G.)
| | - Jean-Emmanuel Kurtz
- Oncology, Institut de Cancérologie de Strasbourg Europe (ICANS), Strasbourg University, 67200 Strasbourg, France;
| | - Michel Greget
- Interventional Radiology, University Hospitals of Strasbourg, Strasbourg University, 67000 Strasbourg, France; (R.L.C.); (P.D.M.); (J.G.); (M.G.); (A.G.)
| | - Luc Mertz
- Radiophysics, University Hospitals of Strasbourg, 67000 Strasbourg, France;
| | - Bernard Goichot
- Internal Medicine, Diabetes and Metabolic Disorders, University Hospitals of Strasbourg, Strasbourg University, 67200 Strasbourg, France;
| | - Afshin Gangi
- Interventional Radiology, University Hospitals of Strasbourg, Strasbourg University, 67000 Strasbourg, France; (R.L.C.); (P.D.M.); (J.G.); (M.G.); (A.G.)
- School of Biomedical Engineering and Imaging Science, King’s College London, Strand, London WC2R 2LS, UK
| | - Alessio Imperiale
- Nuclear Medicine and Molecular Imaging, Institut de Cancérologie de Strasbourg Europe (ICANS), University Hospitals of Strasbourg, Strasbourg University, 67200 Strasbourg, France; (F.H.); (E.O.)
- Molecular Imaging—DRHIM, IPHC, UMR 7178, CNRS/Unistra, 67037 Strasbourg, France
- Correspondence: ; Tel.: +33-3-68-76-74-48; Fax: +33-3-68-76-72-56
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21
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Lucatelli P, Burrel M, Guiu B, de Rubeis G, van Delden O, Helmberger T. CIRSE Standards of Practice on Hepatic Transarterial Chemoembolisation. Cardiovasc Intervent Radiol 2021; 44:1851-1867. [PMID: 34694454 DOI: 10.1007/s00270-021-02968-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 09/04/2021] [Indexed: 12/15/2022]
Abstract
This CIRSE Standards of Practice document is aimed at interventional radiologists and provides best practices for performing transarterial chemoembolisation. It has been developed by an expert writing group under the guidance of the CIRSE Standards of Practice Committee. It will encompass all technical details reflecting European practice of different TACE procedures (Lp-TACE, DEM-TACE, DSM-TACE, b-TACE) as well as revising the existing literature on the various clinical indications (HCC, mCRC, ICC, NET). Finally, new frontiers of development will also be discussed.
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Affiliation(s)
- Pierleone Lucatelli
- Vascular and Interventional Radiology Unit, Department of Radiological Oncological and Anatomo-Pathological Sciences, Sapienza University of Rome, Rome, Italy.
| | - Marta Burrel
- Radiology Department, Hospital Clínic of Barcelona, Barcelona, Spain
| | - Boris Guiu
- Department of Radiology, Montpellier School of Medicine, St-Eloi University Hospital, Montpellier, France
| | - Gianluca de Rubeis
- Vascular and Interventional Radiology Unit, Department of Radiological Oncological and Anatomo-Pathological Sciences, Sapienza University of Rome, Rome, Italy
- Department of Diagnostic Radiology, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
| | - Otto van Delden
- Department of Interventional Radiology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Thomas Helmberger
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, Bogenhausen Hospital, Munich, Germany
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22
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Manchec B, Kokabi N, Narayanan G, Niekamp A, Peña C, Powell A, Schiro B, Gandhi R. Radioembolization of Secondary Hepatic Malignancies. Semin Intervent Radiol 2021; 38:445-452. [PMID: 34629712 DOI: 10.1055/s-0041-1732318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Cancer has become the leading cause of mortality in America, and the majority of patients eventually develop hepatic metastasis. As liver metastases are frequently unresectable, the value of liver-directed therapies, such as transarterial radioembolization (TARE), has become increasingly recognized as an integral component of patient management. Outcomes after radioembolization of hepatic malignancies vary not only by location of primary malignancy but also by tumor histopathology. This article reviews the outcomes of TARE for the treatment of metastatic colorectal cancer, metastatic breast cancer, and metastatic neuroendocrine tumors, as well as special considerations when treating metastatic disease with TARE.
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Affiliation(s)
- Barbara Manchec
- Miami Cardiac and Vascular Institute, Baptist Health South Florida, Miami, Florida.,Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
| | - Nima Kokabi
- Division of Interventional Radiology, Emory University School of Medicine, Atlanta, Georgia
| | - Govindarajan Narayanan
- Miami Cardiac and Vascular Institute, Baptist Health South Florida, Miami, Florida.,Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
| | - Andrew Niekamp
- Miami Cardiac and Vascular Institute, Baptist Health South Florida, Miami, Florida.,Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
| | - Constantino Peña
- Miami Cardiac and Vascular Institute, Baptist Health South Florida, Miami, Florida.,Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
| | - Alex Powell
- Miami Cardiac and Vascular Institute, Baptist Health South Florida, Miami, Florida.,Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
| | - Brian Schiro
- Miami Cardiac and Vascular Institute, Baptist Health South Florida, Miami, Florida.,Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
| | - Ripal Gandhi
- Miami Cardiac and Vascular Institute, Baptist Health South Florida, Miami, Florida.,Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
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23
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Abstract
The chief causes of death of patients with GEPNETs are liver failure from hepatic replacement by tumor in the majority and bowel obstruction in the remainder. Many patients are with liver metastases are actually eligible for hepatic cytoreductive operations, even if they have numerous bilobar metastases and extra-hepatic disease, provided that greater than 70% of the liver tumor volume can be removed. This can often be done by combinations of parenchyma-sparing enucleations, wedge resections and radio frequency ablations. Patients with higher liver tumor burden can be treated with intra-arterial therapies, such as embolization and chemoembolization. Patients with peritoneal carcinomatosis are recommended to undergo cytoreductive operations including peritoneal stripping and bowel resections. Consensus guidelines by experts recommend bisphosphonate therapy for patients with bone metastases, reserving surgical treatment for patients with mechanical issues and/or potential spinal cord compression. Radiation can be employed for isolated painful metastases. PRRT may be an emerging therapy for treatment of bone metastases.
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Affiliation(s)
- Kristen E Limbach
- Department of Surgery, Oregon Health & Science University, Portland, OR, 97239, USA
| | - Rodney F Pommier
- Division of Surgical Oncology, Department of Surgery, Mail Code L619, Oregon Health & Science University, Portland, OR 97239, USA.
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24
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Cao F, Zheng J, Luo J, Zhang Z, Shao G. Treatment efficacy and safety of regorafenib plus drug-eluting beads-transarterial chemoembolization versus regorafenib monotherapy in colorectal cancer liver metastasis patients who fail standard treatment regimens. J Cancer Res Clin Oncol 2021; 147:2993-3002. [PMID: 34302208 PMCID: PMC8397621 DOI: 10.1007/s00432-021-03708-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 06/21/2021] [Indexed: 02/08/2023]
Abstract
Objective This study aimed to evaluate the efficacy and safety of regorafenib plus drug-eluting beads-transarterial chemoembolization (DEB-TACE) versus regorafenib monotherapy in colorectal cancer liver metastases (CRLM) patients who failed standard treatment regimens. Methods Totally, 76 eligible CRLM patients were analyzed, among which 42 patients received regorafenib monotherapy (as regorafenib group) and 34 patients received regorafenib plus DEB-TACE (as regorafenib plus DEB-TACE group). Results Objective response rate (35.3% versus 7.1%, P = 0.002) and disease control rate (76.5% versus 47.6%, P = 0.011) were both increased in regorafenib plus DEB-TACE group compared with regorafenib group; meanwhile, negative conversion rate of carcinoembryonic antigen (66.7% versus 28.6%, P = 0.008) after treatment was elevated in regorafenib plus DEB-TACE group compared with regorafenib group. Notably, progression-free survival (PFS) (median value: 7.6 versus 4.1 months, P < 0.001) and overall survival (OS) (median value: 15.7 versus 9.2 months, P < 0.001) were both higher in regorafenib plus DEB-TACE group compared with regorafenib group. Furthermore, liver function indexes (alanine transaminase, aspartate aminotransferase, and cholinesterase levels) after treatment were all similar between the two groups (all P > 0.05). In addition, the occurrences of upper abdominal distending pain (P < 0.001), nausea and vomiting (P = 0.002) and fever (P = 0.002) were higher in regorafenib plus DEB-TACE group compared with regorafenib group, while the majority of these adverse events were mild and tolerable. Conclusions Regorafenib plus DEB-TACE is superior to regorafenib monotherapy regarding treatment response, PFS and OS, while induces tolerable post-embolization syndrome in CRLM patients who fail standard treatment regimens. Supplementary Information The online version contains supplementary material available at 10.1007/s00432-021-03708-1.
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Affiliation(s)
- Fei Cao
- Department of Interventional Radiology, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, 1 Banshan Dong Lu, Gongshu District, Hangzhou, 310022, Zhejiang, China
| | - Jiaping Zheng
- Department of Interventional Radiology, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, 1 Banshan Dong Lu, Gongshu District, Hangzhou, 310022, Zhejiang, China
| | - Jun Luo
- Department of Interventional Radiology, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, 1 Banshan Dong Lu, Gongshu District, Hangzhou, 310022, Zhejiang, China
| | - Zhewei Zhang
- Department of Interventional Radiology, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, 1 Banshan Dong Lu, Gongshu District, Hangzhou, 310022, Zhejiang, China
| | - Guoliang Shao
- Department of Interventional Radiology, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, 1 Banshan Dong Lu, Gongshu District, Hangzhou, 310022, Zhejiang, China.
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25
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Clift AK, Frilling A. Liver-Directed Therapies for Neuroendocrine Neoplasms. Curr Oncol Rep 2021; 23:44. [PMID: 33721122 DOI: 10.1007/s11912-021-01030-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2021] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW To comprehensively synthesise and appraise the available evidence regarding therapies for metastatic neuroendocrine neoplasms that exploit the hepatic vasculature to deliver therapy to liver metastases. RECENT FINDINGS Various techniques including transarterial embolisation/chemoembolisation (TAE/TACE) and selective internal radiotherapy (SIRT, also termed radioembolisation [RE]) have been examined in patents with neuroendocrine liver metastases. Variations in the radioactive agents for selective internal radiotherapy (SIRT) have been explored, such as the use of Holmium-166, in addition to more established agents such as Yttrium-90. Recent trials have examined the safety and efficacy of combining liver-targeted therapy with systemic treatments, such as peptide receptor radionuclide therapy. More retrospective case series of liver-directed modalities will not provide additional knowledge. Randomised clinical trials have begun to compare the efficacy of different forms of liver-directed therapies, and also their combination with systemic treatment. Their results are expected to guide optimal treatment sequencing within multimodal concepts.
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Affiliation(s)
- Ashley Kieran Clift
- CRUK Oxford Centre, University of Oxford, Oxford, UK.,Department of Surgery & Cancer, Imperial College London, London, UK
| | - Andrea Frilling
- Department of Surgery & Cancer, Imperial College London, London, UK. .,Department of Surgery and Cancer, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK.
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26
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Scoggins CR. TACE or TARE for Unresectable Neuroendocrine Liver Metastases: Can we Finally Start to Focus on Value? Ann Surg Oncol 2021; 28:1876-1877. [PMID: 33507450 DOI: 10.1245/s10434-021-09598-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 01/05/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Charles R Scoggins
- The Hiram C. Polk Jr, MD Department of Surgery, University of Louisville School of Medicine, Louisville, KY, USA.
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Ngo L, Elnahla A, Attia AS, Hussein M, Toraih EA, Kandil E, Killackey M. Chemoembolization Versus Radioembolization for Neuroendocrine Liver Metastases: A Meta-analysis Comparing Clinical Outcomes. Ann Surg Oncol 2021; 28:1950-1958. [PMID: 33393019 DOI: 10.1245/s10434-020-09469-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 10/20/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Studies have shown intra-arterial therapies to be effective in controlling neuroendocrine liver metastases (NELMs), but the evidence supporting the selection of specific methods is limited. This meta-analysis is the first to compare survival outcomes between transarterial chemoembolization (TACE) and transarterial radioembolization (TARE) in the treatment of NELM. METHODS A systematic search according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in PubMed and Embase databases was conducted in February 2020 for published studies comparing survival outcomes between TACE and TARE in the treatment of NELM. RESULTS Six eligible cohort studies with a total of 643 patients were identified. The TACE and TARE groups were similar in terms of age, sex, hepatic tumor burden, tumor grade, and Eastern Cooperative Oncology Group (ECOG) score. The patients treated with TACE had significantly better overall survival (odds ratio [OR], 1.92; 95% confidence interval [CI] 1.14-3.22, p = 0.014) than those treated with TARE. Overall survival ranged from 16.8 to 81.9 months with TACE and from 14.5 to 66.8 months with TARE. No significant differences in hepatic progression-free survival (OR, 1.01; 95% CI 0.75-1.35; p = 0.96) or tumor response were observed within the first 3 months (OR, 2.87; 95% CI 0.81-10.21; p = 0.10) or thereafter (OR, 0.98; 95% CI 0.12-7.86; p = 0.99). The complication rates were similar between the two groups, with 6.9% of the TACE patients versus 8.5% of TARE patients reporting major complications (OR, 1.16; 95% CI 0.54-2.48; p = 0.71) and respectively 44.6% and 58.8% of the TACE and TARE patients reporting minor adverse events (OR, 1.08; 95% CI 0.39-2.99; p = 0.88). CONCLUSIONS Despite similar tumor responses, an overall survival benefit was associated with TACE treatment of NELM compared with TARE treatment. Randomized controlled trials are warranted to confirm this finding and clarify whether certain subpopulations benefit from different transarterial methods.
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Affiliation(s)
- Lisa Ngo
- Tulane University School of Medicine, New Orleans, LA, USA
| | - Ahmed Elnahla
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Abdallah S Attia
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Mohamed Hussein
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Eman A Toraih
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA.,Genetics Unit, Department of Histology and Cell Biology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Emad Kandil
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Mary Killackey
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA.
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28
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Kanabar R, Barriuso J, McNamara MG, Mansoor W, Hubner RA, Valle JW, Lamarca A. Liver Embolisation for Patients with Neuroendocrine Neoplasms: Systematic Review. Neuroendocrinology 2021; 111:354-369. [PMID: 32172229 DOI: 10.1159/000507194] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 03/12/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND Liver embolisation is one of the treatment options available for patients diagnosed with neuro-endocrine neoplasms (NEN). It is still uncertain whether the benefits of the various types of embolisation treatments truly outweigh the complications in NENs. This systematic review assesses the available data relating to liver embolisation in patients with NENs. METHODS Eligible studies (identified using MEDLINE-PubMed) were those reporting data on NEN patients who had undergone any type of liver embolisation. The primary end points were best radiological response and symptomatic response; secondary end-points included progression-free survival (PFS), overall survival (OS) and toxicity. RESULTS Of 598 studies screened, 101 were eligible: 16 were prospective (15.8%). The eligible studies included a total of 5,545 NEN patients, with a median of 39 patients per study (range 5-214). Pooled rate of partial response was 36.6% (38.9% achieved stable disease) and 55.2% of patients had a symptomatic response to therapy when pooled data were analysed. The median PFS and OS were 18.4 months (95% CI 15.5-21.2) and 40.7 months (95% CI 35.2-46.2) respectively. The most common toxicities were found to be abdominal pain (48.8%) and nausea (48.1%). Outcome did not significantly vary depending on the type of embolisation performed. CONCLUSION Liver embolisation provides adequate symptom relief for patients with carcinoid syndrome and is also able to reach partial response in a significant proportion of patients and a reasonable PFS. Quality of studies was limited, highlighting the need of further prospective studies to confirm the most suitable form of liver embolisation in NENs.
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Affiliation(s)
- Rahul Kanabar
- Manchester Medical School, The University of Manchester, Manchester, United Kingdom,
| | - Jorge Barriuso
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Mairéad G McNamara
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Was Mansoor
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Richard A Hubner
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Juan W Valle
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Angela Lamarca
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
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29
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Pollock RF, Brennan VK, Peters R, Paprottka PM. Association between objective response rate and overall survival in metastatic neuroendocrine tumors treated with radioembolization: a systematic literature review and regression analysis. Expert Rev Anticancer Ther 2020; 20:997-1009. [PMID: 32930618 DOI: 10.1080/14737140.2020.1814748] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Neuroendocrine tumors (NETs) are a heterogeneous group of cancers arising from neuroendocrine cells. The aim was to evaluate objective response rate (ORR) as a predictor of overall survival (OS) in patients with metastatic NETs (mNETs) treated with radioembolization (RE). METHODS Randomized controlled trials and observational studies of RE treatment of mNETs were identified by systematic literature review (SLR). Pooled ORR and OS estimates were calculated and a weighted generalized linear model (GLM) of ORR as a predictor of OS was derived, stratified by ORR assessment criteria and RE type (Yttrium-90 resin or glass microspheres). RESULTS The SLR identified 32 observational studies. Mean ORR was 41% (95% confidence interval 38-45%). The Yttrium-90 resin and glass microsphere GLMs accounted for 59% and 57% of OS deviance, respectively. ORR was a significant predictor of OS in the resin microspheres model (p < 0.001), but not the glass microspheres model (p = 0.11). CONCLUSIONS A weighted GLM showed a significant relationship between ORR and OS in patients with mNETs treated with Yttrium-90 resin microspheres. ORR could therefore potentially be an OS surrogate in future trials of Yttrium-90 resin microspheres. Further research is needed to confirm the relationship between ORR and OS and the difference between resin and glass microspheres.
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Affiliation(s)
- Richard F Pollock
- Department of Health Economics and Outcomes Research, Covalence Research Ltd , London, UK
| | - Victoria K Brennan
- Health Economics, Pricing, Reimbursement & Market Access, Sirtex Medical United Kingdom Ltd , London, UK
| | - Ralph Peters
- Health Economics, Pricing, Reimbursement & Market Access, Sirtex Medical United Kingdom Ltd , London, UK
| | - Philipp M Paprottka
- Department of Interventional Radiology, Klinikum Rechts der Isar der Technischen Universität München , Munich, Germany
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30
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Automated feature quantification of Lipiodol as imaging biomarker to predict therapeutic efficacy of conventional transarterial chemoembolization of liver cancer. Sci Rep 2020; 10:18026. [PMID: 33093524 PMCID: PMC7582153 DOI: 10.1038/s41598-020-75120-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 10/09/2020] [Indexed: 02/08/2023] Open
Abstract
Conventional transarterial chemoembolization (cTACE) is a guideline-approved image-guided therapy option for liver cancer using the radiopaque drug-carrier and micro-embolic agent Lipiodol, which has been previously established as an imaging biomarker for tumor response. To establish automated quantitative and pattern-based image analysis techniques of Lipiodol deposition on 24 h post-cTACE CT as biomarker for treatment response. The density of Lipiodol deposits in 65 liver lesions was automatically quantified using Hounsfield Unit thresholds. Lipiodol deposition within the tumor was automatically assessed for patterns including homogeneity, sparsity, rim, and peripheral deposition. Lipiodol deposition was correlated with enhancing tumor volume (ETV) on baseline and follow-up MRI. ETV on baseline MRI strongly correlated with Lipiodol deposition on 24 h CT (p < 0.0001), with 8.22% ± 14.59 more Lipiodol in viable than necrotic tumor areas. On follow-up, tumor regions with Lipiodol showed higher rates of ETV reduction than areas without Lipiodol (p = 0.0475) and increasing densities of Lipiodol enhanced this effect. Also, homogeneous (p = 0.0006), non-sparse (p < 0.0001), rim deposition within sparse tumors (p = 0.045), and peripheral deposition (p < 0.0001) of Lipiodol showed improved response. This technical innovation study showed that an automated threshold-based volumetric feature characterization of Lipiodol deposits is feasible and enables practical use of Lipiodol as imaging biomarker for therapeutic efficacy after cTACE.
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Outpatient Yttrium-90 microsphere radioembolization: assessment of radiation safety and quantification of post-treatment adverse events causing hospitalization. Radiol Med 2020; 125:971-980. [PMID: 32270335 DOI: 10.1007/s11547-020-01180-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 03/23/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE Quantification of post-interventional adverse events of outpatient SIRT leading to hospitalization and quantification of radiation exposure. MATERIALS AND METHODS In this single-center, retrospective cohort study, we reviewed 212 patients treated with SIRT (90Y-microspheres) for primary and secondary liver malignancies. We searched for adverse events (AEs) and serious adverse events (SAEs), defined as AE's causing hospitalization. Additionally, radiation exposure was measured in 36 patients. RESULTS Seven patients had an SAE (3.3%), four patients had AE without readmission/hospitalization (1.9%) and 201 patients had no complications (94.8%). The mean ambient dose rate at 1 m distance from the source after administration of 90Y-microspheres was 1.88 µSv/h ± 0.74 (± SD) with a range from 4.3 to 0.2 µSv/h. CONCLUSION Outpatient radioembolization with 90Y-microspheres is safe and requires hospitalization only in a very small number of patients. The mean dose rate was low and met the national conditions for outpatient treatment (< 5 µSv/h).
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Ren Y, Chen L, Huang S, Zhou C, Liu J, Shi Q, Yang C, Chen R, Zheng C, Han P, Xiong B. Transarterial chemoembolization of unresectable systemic chemotherapy refractory liver metastases: a retrospective single-center analysis. Abdom Radiol (NY) 2020; 45:2862-2870. [PMID: 32468211 DOI: 10.1007/s00261-020-02584-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the therapeutic efficacy and safety of transarterial chemoembolization (TACE) in the treatment of patients with unresectable colorectal cancer liver metastases (CRCLM) who had failed systemic chemotherapy. In addition, the role of TACE in the treatment of CRCLM is also worth discussing. METHODS This single-center retrospective study evaluated the consecutive medical records of patients with CRCLM treated with TACE from June 2014 to June 2018, who had failed at least two lines of prior chemotherapy. Therapeutic response, overall survival (OS), progression-free survival (PFS), and complications were recorded. RESULTS Fifty-three eligible patients were included in our study. The objective tumor radiologic regression and disease control rates were 52.8% and 79.2%, respectively. Median OS and PFS were 15 months (95% confidence interval [CI] 13.1 months, 16.9 months) and 6 months (95% CI 4.7 months, 7.3 months), respectively. Multivariate analysis found that synchronous metastatic disease, presence of extrahepatic metastasis, and Child-Pugh score B were independent prognostic factor for OS and PFS. Two patients (3.8%) had severe complications. The results of subgroup analysis showed that synchronous liver metastasis and extrahepatic metastasis had an effect on the prognosis of patients, while the primary tumor sites (rectum, left, and right colon) had no effect on the prognosis. CONCLUSIONS TACE is well tolerated and effective in patients with unresectable chemotherapy refractory CRCLM. Meanwhile, the results of this study also indicated that TACE is still a better treatment for these patients.
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33
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Cloyd JM, Ejaz A, Konda B, Makary MS, Pawlik TM. Neuroendocrine liver metastases: a contemporary review of treatment strategies. Hepatobiliary Surg Nutr 2020; 9:440-451. [PMID: 32832495 PMCID: PMC7423566 DOI: 10.21037/hbsn.2020.04.02] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 03/31/2020] [Indexed: 12/12/2022]
Abstract
Well-differentiated neuroendocrine tumors (NETs) are globally increasing in prevalence and the liver is the most common site of metastasis. Neuroendocrine liver metastases (NELM) are heterogeneous in clinical presentation and prognosis. Fortunately, recent advances in diagnostic techniques and therapeutic strategies have improved the multidisciplinary management of this challenging condition. When feasible, surgical resection of NELM offers the best long-term outcomes. General indications for hepatic resection include performance status acceptable for major liver surgery, grade 1 or 2 tumors, absence of extrahepatic disease, adequate size and function of future liver remnant, and feasibility of resecting >90% of metastases. Adjunct therapies including concomitant liver ablation are generally safe when used appropriately and may expand the number of patients eligible for surgery. Among patients with synchronous resectable NELM, resection of the primary either in a staged or combined fashion is recommended. For patients who are not surgical candidates, liver-directed therapies such as transarterial embolization, chemoembolization, and radioembolization can provide locoregional control and improve symptoms of carcinoid syndrome. Multiple systemic therapy options also exist for patients with advanced or progressive disease. Ongoing research efforts are needed to identify novel biomarkers that will define the optimal indications for and sequencing of treatments to be delivered in a personalized fashion.
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Affiliation(s)
- Jordan M. Cloyd
- Departments of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Aslam Ejaz
- Departments of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Bhavana Konda
- Departments of Internal Medicine, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Mina S. Makary
- Departments of Radiology, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Timothy M. Pawlik
- Departments of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
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34
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The Role of Interventional Radiology for the Treatment of Hepatic Metastases from Neuroendocrine Tumor: An Updated Review. J Clin Med 2020; 9:jcm9072302. [PMID: 32698459 PMCID: PMC7408651 DOI: 10.3390/jcm9072302] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/08/2020] [Accepted: 07/10/2020] [Indexed: 02/07/2023] Open
Abstract
Interventional radiology plays an important role in the management of patients with neuroendocrine tumor liver metastasis (NELM). Transarterial embolization (TAE), transarterial chemoembolization (TACE), and selective internal radiation therapy (SIRT) are intra-arterial therapies available for these patients in order to improve symptoms and overall survival. These treatment options are proposed in patients with NELM not responding to systemic therapies and without extrahepatic progression. Currently, available data suggest that TAE should be preferred to TACE in patients with NELM from extrapancreatic origin because of similar efficacy and better patient tolerance. TACE is more effective in patients with pancreatic NELM and SIRT has shown promising results along with good tolerance. However, large randomized controlled trials are still lacking in this setting. Available literature mainly consists in small sample size and retrospective studies with important technical heterogeneity. The purpose of this review is to provide an updated overview of the currently reported endovascular interventional radiology procedures that are used for the treatment of NELM.
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Sartori S, Bianchi L, Di Vece F, Tombesi P. Liver-directed therapies for liver metastases from neuroendocrine neoplasms: Can laser ablation play any role? World J Gastroenterol 2020; 26:3118-3125. [PMID: 32684730 PMCID: PMC7336329 DOI: 10.3748/wjg.v26.i23.3118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 06/12/2020] [Accepted: 06/15/2020] [Indexed: 02/06/2023] Open
Abstract
Aggressive cytoreduction can prolong survival in patients with unresectable liver metastases (LM) from neuroendocrine neoplasms (NEN), and minimally invasive, liver-directed therapies are gaining increasing interest. Catheter-based treatments are used in disseminated disease, whereas ablation techniques are usually indicated when the number of LM is limited. Although radiofrequency ablation (RFA) is by far the most used ablative technique, the goal of this opinion review is to explore the potential role of laser ablation (LA) in the treatment of LM from NEN. LA uses thinner needles than RFA, and this is an advantage when the tumors are in at-risk locations. Moreover, the multi-fiber technique enables the use of one to four laser fibers at once, and each fiber provides an almost spherical thermal lesion of 12-15 mm in diameter. Such a characteristic enables to tailor the size of each thermal lesion to the size of each tumor, sparing the liver parenchyma more than any other liver-directed therapy, and allowing for repeated treatments with low risk of liver failure. A recent retrospective study reporting the largest series of LM treated with LA documents both safety and effectiveness of LA, that can play a useful role in the multimodality approach to LM from NEN.
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Affiliation(s)
- Sergio Sartori
- Department of Internal Medicine, Section of Interventional Ultrasound, St. Anna Hospital, Ferrara 44100, Italy
| | - Lara Bianchi
- Department of Internal Medicine, Section of Interventional Ultrasound, St. Anna Hospital, Ferrara 44100, Italy
| | - Francesca Di Vece
- Department of Internal Medicine, Section of Interventional Ultrasound, St. Anna Hospital, Ferrara 44100, Italy
| | - Paola Tombesi
- Department of Internal Medicine, Section of Interventional Ultrasound, St. Anna Hospital, Ferrara 44100, Italy
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Cloyd JM, Wiseman JT, Pawlik TM. Surgical management of pancreatic neuroendocrine liver metastases. J Gastrointest Oncol 2020; 11:590-600. [PMID: 32655938 PMCID: PMC7340805 DOI: 10.21037/jgo.2019.11.02] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 11/13/2019] [Indexed: 12/12/2022] Open
Abstract
Pancreatic neuroendocrine tumors (PNET) are a heterogeneous group of neoplasms that vary in their clinical presentation, behavior and prognosis. The most common site of metastasis is the liver. Surgical resection of neuroendocrine liver metastases (NELM) is thought to afford the best long-term outcomes when feasible. Initial preoperative workup should include surveillance for carcinoid syndrome, screening for evidence of liver insufficiency, and performance of imaging specific to neuroendocrine tumors such as a somatostatin receptor positron emission tomography scan. Standard surgical principles apply to hepatic surgery for NELM, namely prioritizing low central venous pressure anesthesia, minimizing blood loss, knowledge of liver anatomy, generous use of intraoperative ultrasound, as well as safe parenchymal transection techniques and practices to avoid bile leakage. Knowledge of established prognostic factors may assist with patient selection, which is important for optimizing short- and long-term outcomes of hepatic resection. Adjunct therapies such as concomitant liver ablation are used frequently and are generally safe when used appropriately. For patients with synchronous resectable NELM, resection of the primary either in a staged or combined fashion is recommended. Primary tumor resection in the setting of unresectable metastatic disease is more controversial, however generally recommended if morbidity is acceptable. For patients who are not surgical candidates, due to either patient performance status or burden of liver disease, several liver-directed therapies such as transarterial embolization, chemoembolization, and radioembolization are available to assist with locoregional control, extend progression-free survival (PFS), and improve symptoms of carcinoid syndrome. Multiple systemic therapy options exist for patients with metastatic PNET which are often prioritized for those patients with advanced or progressive disease. A systematic approach in a multi-disciplinary setting is likely to result in the best long-term outcomes for patients with pancreatic NELM. Ongoing research is needed to determine the optimal patient selection for hepatic surgery as well as the ideal treatment sequencing for those patients with NELM.
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Affiliation(s)
- Jordan M Cloyd
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner, Columbus, OH, USA
| | - Jason T Wiseman
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner, Columbus, OH, USA
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Interventional Liver-Directed Therapy for Neuroendocrine Metastases: Current Status and Future Directions. Curr Treat Options Oncol 2020; 21:52. [PMID: 32447461 DOI: 10.1007/s11864-020-00751-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OPINION STATEMENT Liver-directed therapy should be considered for patients with unresectable liver metastases from neuroendocrine tumor if symptomatic or progressing despite medical management. Our experience and current literature shows that the bland embolization, chemoembolization, and radioembolization are very effective in controlling symptoms and disease burden in the liver, and that these embolization modalities are similar in terms of efficacy and radiologic response. Their safety profiles differ, however, with recent studies suggesting an increase in biliary toxicity with drug-eluting bead chemoembolization over conventional chemoembolization, and a risk of long-term hepatotoxicity with radioembolization. For this reason, we tailor the type of embolotherapy to each patient according to their clinical status, symptoms, degree of tumor burden, histologic grade, and life expectancy. We do not recommend a "one-size-fits-all" approach. Our general strategy is to use bland embolization as first-line embolotherapy, and radioembolization for patients with high-grade tumors or who have failed other embolotherapy.
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Ebbers SC, Braat AJAT, Moelker A, Stokkel MPM, Lam MGEH, Barentsz MW. Intra-arterial versus standard intravenous administration of lutetium-177-DOTA-octreotate in patients with NET liver metastases: study protocol for a multicenter, randomized controlled trial (LUTIA trial). Trials 2020; 21:141. [PMID: 32024533 PMCID: PMC7003409 DOI: 10.1186/s13063-019-3888-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 11/05/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Lutetium-177-DOTA-octreotate (177Lu-DOTATATE) significantly increases survival and response rates in patients with grade I and grade II neuroendocrine tumors (NETs). However, survival and response rates are significantly lower in patients with bulky liver metastases. Increasing the tumor-absorbed dose in liver metastases may improve response to 177Lu-DOTATATE. The LUTIA (Lutetium Intra-Arterial) study aims to increase the tumor-absorbed dose in liver metastases by intra-arterial (IA) administration of 177Lu-DOTATATE, compared to conventional intravenous (IV) administration. METHODS A multicenter, within-patient randomized controlled trial (RCT) in 26 patients with progressive, liver-dominant, unresectable grade I or grade II NET will be conducted. Patients with bilobar bulky disease will be randomly allocated to receive IA treatment into either the left or the right hepatic artery. Using this approach, one liver lobe will be treated intra-arterially (first-pass effect), while the contralateral lobe will receive an intravenous treatment as a second-pass effect. The primary endpoint of this study is the difference in tumor-to-non-tumor ratio of 177Lu-DOTATATE uptake between the two liver lobes on post-treatment SPECT/CT (IA versus IV). Secondary endpoints include absorbed dose in both liver lobes, tumor response, dose-response relationship, toxicity, uptake in extrahepatic lesions, and renal uptake. DISCUSSION This multicenter, within-patient RCT will investigate whether IA administration of 177Lu-DOTATATE results in a higher activity concentration in liver metastases compared to IV administration. TRIAL REGISTRATION ClinicalTrials.gov, NCT03590119. Registered on 17 July 2018.
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Affiliation(s)
- Sander C Ebbers
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Arthur J A T Braat
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Adriaan Moelker
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Marcel P M Stokkel
- 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
| | - Maarten W Barentsz
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
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Egger ME, Armstrong E, Martin RC, Scoggins CR, Philips P, Shah M, Konda B, Dillhoff M, Pawlik TM, Cloyd JM. Transarterial Chemoembolization vs Radioembolization for Neuroendocrine Liver Metastases: A Multi-Institutional Analysis. J Am Coll Surg 2020; 230:363-370. [PMID: 32032719 DOI: 10.1016/j.jamcollsurg.2019.12.026] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 12/16/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Liver-directed hepatic arterial therapies are associated with improved survival and effective symptom control for patients with unresectable neuroendocrine liver metastases (NELM). Whether transarterial chemoembolization (TACE) or transarterial radioembolization (TARE) with yttrium-90 (y-90) are associated with improved short- or long-term outcomes is unknown. STUDY DESIGN A retrospective review was performed of all patients with NELM undergoing transarterial therapies, from 2000 to 2018, at 2 academic medical centers. Postoperative morbidity, radiographic response according to response evaluation criteria in solid tumors (RECIST) criteria, and long-term outcomes were compared between patients who underwent TACE vs TARE. RESULTS Among 248 patients with NELM, 197 (79%) received TACE and 51 (21%) received TARE. While patients who underwent TACE were more likely to have carcinoid syndrome, larger tumors, and higher chromogranin A levels, there was no difference in tumor differentiation, primary site, bilobar disease, or synchronous presentation. Nearly all TARE treatments (92%) were performed as outpatient procedures, while 99% of TACE patients spent at least 1 night in the hospital. There were no differences in overall morbidity (TARE 13.7% vs TACE 22.6%, p = 0.17), grade III/IV complication (5.9% vs 9.2%, p = 0.58), or 90-day mortality. The disease control rate (DCR) on first post-treatment imaging (RECIST partial/complete response or stable disease) was greater for TACE compared with TARE (96% vs 83%, p < 0.01). However, there was no difference in median overall survival (OS, 35.9 months vs 50.1 months, p = 0.3) or progression-free survival (PFS, 15.9 months vs 19.9 months, p = 0.37). CONCLUSIONS In this retrospective multi-institutional analysis, both TACE and TARE with Y-90 were safe and effective liver-directed therapies for unresectable NELM. Although TARE was associated with a shorter length of hospital stay, TACE demonstrated improved short-term DCR, and both resulted in comparable long term outcomes.
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Affiliation(s)
- Michael E Egger
- Hiram C Polk Jr, MD Department of Surgery, University of Louisville, Louisville, KY
| | - Emily Armstrong
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Robert Cg Martin
- Hiram C Polk Jr, MD Department of Surgery, University of Louisville, Louisville, KY
| | - Charles R Scoggins
- Hiram C Polk Jr, MD Department of Surgery, University of Louisville, Louisville, KY
| | - Prejesh Philips
- Hiram C Polk Jr, MD Department of Surgery, University of Louisville, Louisville, KY
| | - Manisha Shah
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Bhavana Konda
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Jordan M Cloyd
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH.
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Armstrong EA, Beal EW, Shah M, Konda B, Abdel-Misih S, Ejaz A, Dillhoff ME, Pawlik TM, Cloyd JM. Radiographic characteristics of neuroendocrine liver metastases do not predict clinical outcomes following liver resection. Hepatobiliary Surg Nutr 2020; 9:1-12. [PMID: 32140474 DOI: 10.21037/hbsn.2019.06.02] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Background Previous research has demonstrated that specific radiographic criteria, including the presence of calcifications and the enhancement pattern on computed tomography (CT) imaging, correlates with clinicopathologic features and outcomes of patients with gastroenteropancreatic neuroendocrine tumors (NET). We sought to investigate whether these radiographic characteristics were prognostic among patients with neuroendocrine liver metastases (NELM) undergoing surgical resection. Methods The preoperative contrast-enhanced CT scans of all patients who underwent resection of NELM at a single institution between 2000-2015 were retrospectively reviewed. The presence of calcifications was determined on non-contrast phase imaging. Enhancement on the arterial phase scan was categorized as hyperenhancing, hypoenhancing, or mixed. Relevant clinicopathologic characteristics as well as recurrence-free survival (RFS) and overall survival (OS) were compared between groups. Results Among 82 patients who underwent resection of NELM, 57 had available data on calcifications while 51 had data available on arterial enhancement patterns. Among all patients, median age was 58 (IQR: 47-63) and the majority were female (N=48, 59.5%). The most common primary tumor locations were pancreas (N=25, 30.5%) and small bowel (N=27, 32.9%). The most commonly performed operations were right hepatectomy (N=29, 35.4%), bisegmentectomy (N=15, 18.3%), and segmentectomy (N=14, 17.1%). Median tumor number was 4 (IQR: 2-9), median Ki-67 was 5% (IQR: 2-10%), and median size of the largest liver metastasis was 4.5 (IQR: 2.8-7.7) cm. Twelve (21%) patients had tumor calcifications. Among patients with and without calcifications there were no differences in demographics, clinicopathologic characteristics, RFS (P=0.772) or OS (P=0.095). Arterial enhancement was hypoenhancing in 23 (45.1%), hyperenhancing in 10 (19.6%), and mixed in 18 (35.3%). Similarly, there were no differences between arterial enhancement groups in demographics, clinicopathologic characteristics, RFS (P=0.618) or OS (P=0.268). Conclusions Radiographic characteristics on contrast-enhanced CT are not associated with the outcomes of patients undergoing resection of NELM. Future investigations should evaluate the prognostic impact of functional neuroendocrine imaging.
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Affiliation(s)
| | - Eliza W Beal
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Manisha Shah
- Department of Internal Medicine, Division of Medical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Bhavana Konda
- Department of Internal Medicine, Division of Medical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Sherif Abdel-Misih
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Aslam Ejaz
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Mary E Dillhoff
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jordan M Cloyd
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Scoville SD, Cloyd JM, Pawlik TM. New and emerging systemic therapy options for well-differentiated gastroenteropancreatic neuroendocrine tumors. Expert Opin Pharmacother 2019; 21:183-191. [PMID: 31760823 DOI: 10.1080/14656566.2019.1694003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Introduction: Well-differentiated gastroenteropancreatic (GEP) neuroendocrine tumors (NETs) are a heterogeneous group of neoplasms with a wide range of clinical behavior. Multiple treatment modalities exist, including novel and emerging systemic options, and an understanding of the advantages and disadvantages of each is imperative for optimizing the outcomes of patients with GEP-NETs.Areas covered: While surgical resection remains the preferred treatment for localized well-differentiated GEP-NETs, treatment of unresectable disease depends on its extent, location, and distribution as well as underlying aspects of tumor biology. Isolated hepatic metastases can be successfully treated with liver-directed therapies such as hepatic arterial based therapies or ablation. Diffuse metastatic disease often requires systemic treatments such as molecular-targeted therapeutics, peptide receptor radionuclide therapy (PRRT), or traditional chemotherapy. Somatostatin analogs are often the primary treatment option capable of simultaneously inhibiting hormone production and slowing tumor growth.Expert opinion: Recent advances in systemic treatment options for advanced well-differentiated GEP-NETs have emerged due to an improved understanding of the molecular mechanisms responsible for tumor development and progression. Future research is needed to determine the optimal indications for and sequencing of these novel therapies.
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Affiliation(s)
- Steven D Scoville
- Department of Surgery, Division of Surgical Oncology at The Ohio State University, James Cancer Center, Columbus, OH, USA
| | - Jordan M Cloyd
- Department of Surgery, Division of Surgical Oncology at The Ohio State University, James Cancer Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology at The Ohio State University, James Cancer Center, Columbus, OH, USA.,Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research The Ohio State University, Wexner Medical Center, Columbus, USA
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Whooley PD, Flores JP, Fotoohi M, Lin BS. Palliative TACE for hepatic metastases of chromophobe renal cell carcinoma. BMJ Case Rep 2019; 12:12/7/e229207. [PMID: 31308185 DOI: 10.1136/bcr-2019-229207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We describe the case of a man with chromophobe renal cell carcinoma (chRCC) and numerous metastatic lesions restricted to the liver. Despite extensive courses of various systemic targeted chemotherapies, progressive disease was noted on CT and MRI and the patient suffered from persistent abdominal pain associated with his metastatic lesions. The liver lesions and associated symptoms were effectively palliated with serial transarterial chemoembolisation (TACE). While it is unclear if TACE has impacted his overall survival, this case encourages the use of TACE for palliative intent for patients with metastatic chRCC.
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Affiliation(s)
- Peter D Whooley
- Department of Medicine, Virginia Mason Medical Center, Seattle, Washington, USA
| | - John Paul Flores
- Floyd & Delores Jones Cancer Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Mehran Fotoohi
- Division of Interventional Radiology, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Bruce S Lin
- Floyd & Delores Jones Cancer Institute, Virginia Mason Medical Center, Seattle, Washington, USA
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Frilling A, Clift AK, Braat AJAT, Alsafi A, Wasan HS, Al-Nahhas A, Thomas R, Drymousis P, Habib N, Tait PN. Radioembolisation with 90Y microspheres for neuroendocrine liver metastases: an institutional case series, systematic review and meta-analysis. HPB (Oxford) 2019; 21:773-783. [PMID: 30733049 DOI: 10.1016/j.hpb.2018.12.014] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Revised: 12/03/2018] [Accepted: 12/11/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Neuroendocrine liver metastases are clinically challenging due to their frequent disseminated distribution. This study aims to present a British experience with an emerging modality, radioembolisation with yttrium-90 labelled microspheres, and embed this within a meta-analysis of response and survival outcomes. METHODS A retrospective case series of patients treated with SIR-Spheres (radiolabelled resin microspheres) was performed. Results were included in a systematic review and meta-analysis of published results with glass or resin microspheres. Objective response rate (ORR) was defined as complete or partial response. Disease control rate (DCR) was defined as complete/partial response or stable disease. RESULTS Twenty-four patients were identified. ORR and DCR in the institutional series was 14/24 and 21/24 at 3 months. Overall survival and progression-free survival at 3-years was 77.6% and 50.4%, respectively. There were no grade 3/4 toxicities post-procedure. A fixed-effects pooled estimate of ORR of 51% (95% CI: 47%-54%) was identified from meta-analysis of 27 studies. The fixed-effects weighted average DCR was 88% (95% CI: 85%-90%, 27 studies). CONCLUSION Current data demonstrate evidence of the clinical effectiveness and safety of radioembolisation for neuroendocrine liver metastases. Prospective randomised studies to compare radioembolisation with other liver directed treatment modalities are needed.
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Affiliation(s)
- Andrea Frilling
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital, London, W12 0HS, United Kingdom
| | - Ashley K Clift
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital, London, W12 0HS, United Kingdom
| | - Arthur J A T Braat
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, 3508, GA Utrecht, the Netherlands
| | - Ali Alsafi
- Department of Imaging, Imperial College London, Hammersmith Hospital, London, W12 0HS, United Kingdom
| | - Harpreet S Wasan
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital, London, W12 0HS, United Kingdom
| | - Adil Al-Nahhas
- Department of Nuclear Medicine, Imperial College London, Hammersmith Hospital, London, W12 0HS, United Kingdom
| | - Robert Thomas
- Department of Imaging, Imperial College London, Hammersmith Hospital, London, W12 0HS, United Kingdom
| | - Panagiotis Drymousis
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital, London, W12 0HS, United Kingdom
| | - Nagy Habib
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital, London, W12 0HS, United Kingdom
| | - Paul N Tait
- Department of Imaging, Imperial College London, Hammersmith Hospital, London, W12 0HS, United Kingdom
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Lv Y, Han X, Xu XF, Ji Y, Zhou YH, Sun HC, Zhou J, Fan J, Lou WH, Huang C. Risk factors affecting prognosis in metachronous liver metastases from WHO classification G1 and G2 gastroenteropancreatic neuroendocrine tumors after initial R0 surgical resection. BMC Cancer 2019; 19:335. [PMID: 30961559 PMCID: PMC6454726 DOI: 10.1186/s12885-019-5457-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Accepted: 03/12/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Here we describe the treatments and prognosis for metachronous metastases from gastroenteropancreatic neuroendocrine tumors (GEP-NETs) after initial R0 surgical resection at a large center in China. METHODS The clinicopathological data and survival outcomes for 108 patients (median age, 54.0 years) with metachronous hepatic metastatic GEP-NETs disease who were initially treated using R0 surgical resection between August 2003 and July 2014 were analyzed using one-way comparisons, survival analysis, and a predictive nomogram. RESULTS Fifty-five (50.9%) patients had pancreatic NETs and 92 (85.2%) had G2 primary tumors. For treatment of the hepatic metastases, 48 (44.4%) patients received liver-directed local treatment (metastasectomy, radiofrequency ablation, transcatheter arterial chemoembolization, etc.), 15 (13.9%) received systemic treatment (interferon, somatostatin analogs, etc.), and 45 (41.7%) received both treatments. Multivariable analyses revealed that OS was associated with hepatic tumor number (P < 0.001), treatment modality (P = 0.045), and elevated Ki-67 index between the metastatic and primary lesions (P = 0.027). The predictive nomogram C-index was 0.63. CONCLUSIONS A higher Ki-67 index in metastases compared to primary tumor was an independent factor for poor prognosis. Local treatment was associated with prolonged survival of hepatic metastatic GEP-NET patients. Optimal treatment strategies based on clinicopathological characteristics should be developed.
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Affiliation(s)
- Yang Lv
- 0000 0004 1755 3939grid.413087.9Department of Pancreatic Surgery, Zhongshan Hospital, Fudan University, 136 Yi Xue Yuan Rd, Shanghai, 200032 China
| | - Xu Han
- 0000 0004 1755 3939grid.413087.9Department of Pancreatic Surgery, Zhongshan Hospital, Fudan University, 136 Yi Xue Yuan Rd, Shanghai, 200032 China
| | - Xue-Feng Xu
- 0000 0004 1755 3939grid.413087.9Department of Pancreatic Surgery, Zhongshan Hospital, Fudan University, 136 Yi Xue Yuan Rd, Shanghai, 200032 China
| | - Yuan Ji
- 0000 0004 1755 3939grid.413087.9Department of Pathology, Zhongshan Hospital, Fudan University, 136 Yi Xue Yuan Rd, Shanghai, 200032 China
| | - Yu-Hong Zhou
- 0000 0004 1755 3939grid.413087.9Department of Oncology, Zhongshan Hospital, Fudan University, 136 Yi Xue Yuan Rd, Shanghai, 200032 China
| | - Hui-Chuan Sun
- 0000 0004 1755 3939grid.413087.9Department of Liver Surgery and Transplantation, Liver Cancer Institute and Zhongshan Hospital, Fudan University, 136 Yi Xue Yuan Rd, Shanghai, 200032 China
- 0000 0004 0369 313Xgrid.419897.aKey Laboratory for Carcinogenesis and Cancer Invasion, Chinese Ministry of Education, Beijing, China
| | - Jian Zhou
- 0000 0004 1755 3939grid.413087.9Department of Liver Surgery and Transplantation, Liver Cancer Institute and Zhongshan Hospital, Fudan University, 136 Yi Xue Yuan Rd, Shanghai, 200032 China
- 0000 0004 0369 313Xgrid.419897.aKey Laboratory for Carcinogenesis and Cancer Invasion, Chinese Ministry of Education, Beijing, China
| | - Jia Fan
- 0000 0004 1755 3939grid.413087.9Department of Liver Surgery and Transplantation, Liver Cancer Institute and Zhongshan Hospital, Fudan University, 136 Yi Xue Yuan Rd, Shanghai, 200032 China
- 0000 0004 0369 313Xgrid.419897.aKey Laboratory for Carcinogenesis and Cancer Invasion, Chinese Ministry of Education, Beijing, China
| | - Wen-Hui Lou
- 0000 0004 1755 3939grid.413087.9Department of Pancreatic Surgery, Zhongshan Hospital, Fudan University, 136 Yi Xue Yuan Rd, Shanghai, 200032 China
| | - Cheng Huang
- 0000 0004 1755 3939grid.413087.9Department of Liver Surgery and Transplantation, Liver Cancer Institute and Zhongshan Hospital, Fudan University, 136 Yi Xue Yuan Rd, Shanghai, 200032 China
- 0000 0004 0369 313Xgrid.419897.aKey Laboratory for Carcinogenesis and Cancer Invasion, Chinese Ministry of Education, Beijing, China
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Cloyd JM, Konda B, Shah MH, Pawlik TM. The emerging role of targeted therapies for advanced well-differentiated gastroenteropancreatic neuroendocrine tumors. Expert Rev Clin Pharmacol 2019; 12:101-108. [PMID: 30582383 DOI: 10.1080/17512433.2019.1561273] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Gastroenteropancreatic (GEP) neuroendocrine tumors (NETs) are unique and complex neoplasms, exhibiting a wide spectrum of diverse clinical behaviors. The contemporary management of well-differentiated GEP-NETs is marked by the availability of a wide range of targeted therapies. Areas Covered: For patients with localized or oligometastatic disease, surgical resection remains the preferred approach and is associated with excellent long-term outcomes. For patients with unresectable but isolated liver metastases, multiple liver-directed therapies, including hepatic arterial based therapies and ablative techniques, exist. For patients with metastatic and progressive disease, a number of systemic therapies exist: molecular targeted agents, peptide receptor radionuclide therapy (PRRT), and systemic chemotherapy. Furthermore, somatostatin analogs (SSA) are an important component of therapy, both effectively controlling symptoms of hormonal overproduction and contributing to slowing tumor progression. Expert Opinion: In the near future, advances in our understanding of tumor biology, genetics, immunology, nanotechnology, and radiation pharmacology should only continue to expand the availability of targeted therapies, improving the outcomes of patients with GEP-NETs. We herein review the management of advanced well-differentiated GEP-NETS with a particular emphasis on the role of targeted therapies.
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Affiliation(s)
- Jordan M Cloyd
- a Surgery Division of Surgical Oncology , The Ohio State University Wexner Medical Center , Columbus , OH , USA
| | - Bhavana Konda
- b Internal Medicine , Division of Medical Oncology , Columbus , OH , USA
| | - Manisha H Shah
- c Internal Medicine , Division of Medical Oncology , Columbus , OH , USA
| | - Timothy M Pawlik
- d Department of Surgery The Urban Meyer III and Shelley Meyer Chair for Cancer Research Professor of Surgery, Oncology, and Health Services Management and Policy , The Ohio State University, Wexner Medical Center , Columbus , OH , USA
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Abstract
This article reviews the role of surgical and medical management in patients with Zollinger-Ellison syndrome (ZES) due to a gastrin-secreting neuroendocrine tumor (gastrinoma). It concentrates on the status at present but also briefly reviews the changes over time in treatment approaches. Generally, surgical and medical therapy are complementary today; however, in some cases, such as patients with ZES and multiple endocrine neoplasia type 1, the treatment approach remains controversial.
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Affiliation(s)
- Jeffrey A Norton
- Department of Surgery, Stanford University School of Medicine, 291 campus Drive, Stanford, CA 94305-5101, USA
| | - Deshka S Foster
- Department of Surgery, Stanford University School of Medicine, 291 campus Drive, Stanford, CA 94305-5101, USA
| | - Tetsuhide Ito
- Neuroendocrine Tumor Centra, Fukuoka Sanno Hospital, International University of Health and Welfare, 3-6-45 Momochihama, Sawara-Ku, Fukuoka 814-0001, Japan
| | - Robert T Jensen
- Digestive Diseases Branch, NIDDK, National Institutes of Health, Building 10, Room 9C-103, Bethesda, MD 20892-1804, USA.
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de Mestier L, Zappa M, Hentic O, Vilgrain V, Ruszniewski P. Liver transarterial embolizations in metastatic neuroendocrine tumors. Rev Endocr Metab Disord 2017; 18:459-471. [PMID: 28975561 DOI: 10.1007/s11154-017-9431-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The management of patients with well-differentiated neuroendocrine tumors (NET) and non-resectable liver metastases is challenging. Liver-directed transarterial embolization (TAE), transarterial chemo-embolization (TACE) and selective internal radiation therapy (SIRT) have a place of choice among other treatment modalities. However, their utilization relies on a low level of proof, due to the lack of prospective data, the absence of comparative studies and considerable heterogeneity between local practices. TAE and TACE generally achieve average symptomatic, biological and radiological responses of 75%, 56% and 50%, with progression-free survival of 12-18 months, with acceptable tolerance. Although not clearly demonstrated, TACE may be more effective than TAE in pancreatic NET, but not in small-intestine NET. SIRT has been developed more recently and may achieve similar results, with improved tolerance, but decreased cost-effectiveness, although no prospective comparison has been published to date. There is currently no strong argument to choose between TAE, TACE and SIRT, and they have not been compared to other treatment modalities. The evaluation of their efficacy has mostly relied on criteria based on size variations, which do not take into account tumor viability and metabolism, and thus may not be relevant. These techniques may be especially effective when performed as first-line therapies, in patients with non-major liver involvement (<75%) and with hypervascular metastases. Finally, studies exploring their combination with systemic therapies are ongoing.
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Affiliation(s)
- Louis de Mestier
- Department of Gastroenterology and Pancreatology, DHU UNITY, ENETS Center of Excellence, Beaujon Hospital (APHP), Paris-Diderot University, 100 boulevard du Général Leclerc, 92110, Clichy, France.
| | - Magaly Zappa
- Department of Radiology, DHU UNITY, ENETS Center of Excellence, Beaujon Hospital (APHP), Paris-Diderot University, Clichy, France
| | - Olivia Hentic
- Department of Gastroenterology and Pancreatology, DHU UNITY, ENETS Center of Excellence, Beaujon Hospital (APHP), Paris-Diderot University, 100 boulevard du Général Leclerc, 92110, Clichy, France
| | - Valérie Vilgrain
- Department of Radiology, DHU UNITY, ENETS Center of Excellence, Beaujon Hospital (APHP), Paris-Diderot University, Clichy, France
| | - Philippe Ruszniewski
- Department of Gastroenterology and Pancreatology, DHU UNITY, ENETS Center of Excellence, Beaujon Hospital (APHP), Paris-Diderot University, 100 boulevard du Général Leclerc, 92110, Clichy, France
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