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Yu Q, Wang Y, Ungchusri E, Pillai A, Liao CY, Fung J, DiSabato D, Baker T, Patel M, Van Ha T, Ahmed O. Modified Radiation Lobectomy Strategy of Radioembolization for Right-Sided Unresectable Primary Liver Tumors. J Vasc Interv Radiol 2024; 35:989-997.e2. [PMID: 38490364 DOI: 10.1016/j.jvir.2024.03.005] [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: 10/03/2023] [Revised: 02/18/2024] [Accepted: 03/02/2024] [Indexed: 03/17/2024] Open
Abstract
PURPOSE To assess the safety and effectiveness of using modified radiation lobectomy (mRL) to treat primary hepatic tumors located in the right hepatic lobe (Segments V-VIII) and to determine future liver remnant (FLR) hypertrophy. MATERIALS AND METHODS A retrospective review was performed at a single institution to include 19 consecutive patients (7 females, 12 males) who underwent single-session mRL for right-sided primary hepatic tumors: 15 received segmentectomy plus lobectomy (segmental dose of >190 Gy and lobar dose of >80 Gy); 4 were treated with the double-segmental approach (dominant segments of >190 Gy and nondominant segments of >80 Gy). Treated tumors included 13 hepatocellular carcinoma (HCC), 4 cholangiocarcinoma (CCA), and 2 mixed-type HCC-CCA with a median dominant tumor size of 5.3 cm (interquartile range [IQR], 3.7-7.3 cm). FLR of the left hepatic lobe was measured at baseline, T1 (4-8 weeks), T2 (2-4 months), T3 (4-6 months), and T4 (9-12 months). RESULTS Objective tumor response and tumor control were achieved in 17 of the 19 (89.5%) and 18 of the 19 (94.7%) patients, respectively. FLR hypertrophy was observed at T1 (median, 47.8%; P = .025), T2 (median, 48.4%; P = .012), T3 (median, 50.4%; P = .015), and T4 (median, 59.1%; P < .001). Patients without cirrhosis demonstrated greater hypertrophy by 6 months (median, 55.8% vs 47.2%; P = .031). One patient developed a Grade 3 adverse event (ascites requiring paracentesis) at 1-month follow-up. Grade ≥2 serum toxicities were associated with worse baseline Child-Pugh Score, serum albumin, and total bilirubin (P < .05). Among 7 patients who underwent neoadjuvant mRL, 2 underwent resection and 1 received liver transplant. CONCLUSIONS mRL appears safe and effective for treatment of right-sided primary hepatic tumors with the benefit of promoting FLR hypertrophy.
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Affiliation(s)
- Qian Yu
- Department of Radiology, University of Chicago Medical Center, University of Chicago, Chicago, Illinois.
| | - Yating Wang
- Hematology and Oncology, Ascension Providence Hospital, Southfield, Michigan
| | - Ethan Ungchusri
- Department of Radiology, University of Chicago Medical Center, University of Chicago, Chicago, Illinois
| | - Anjana Pillai
- Division of Gastroenterology, Hepatology, and Nutrition, University of Chicago Medical Center, University of Chicago, Chicago, Illinois
| | - Chih-Yi Liao
- Department of Medicine; Hematology and Oncology, University of Chicago Medical Center, University of Chicago, Chicago, Illinois
| | - John Fung
- Department of Surgery, Section of Transplant Surgery, The University of Chicago Medicine, Chicago, Illinois
| | - Diego DiSabato
- Department of Surgery, Section of Transplant Surgery, The University of Chicago Medicine, Chicago, Illinois
| | - Talia Baker
- Department of Surgery, Division of Transplantation and Advanced Hepatobiliary Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Mikin Patel
- Department of Radiology, University of Chicago Medical Center, University of Chicago, Chicago, Illinois
| | - Thuong Van Ha
- Department of Radiology, University of Chicago Medical Center, University of Chicago, Chicago, Illinois
| | - Osman Ahmed
- Department of Radiology, University of Chicago Medical Center, University of Chicago, Chicago, Illinois
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Yu Q, Neale M, Ungchusri E, Rothenberger NJ, Liao C, Patel M, Pillai A, Navuluri R, Ahmed O, Ha TV. Tumor Size and Watershed Area Correlate with Incomplete Treatment and Tumor Progression after Selective Radioembolization for Hepatocellular Carcinoma. J Vasc Interv Radiol 2024:S1051-0443(24)00125-8. [PMID: 38336031 DOI: 10.1016/j.jvir.2024.01.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 01/26/2024] [Accepted: 01/31/2024] [Indexed: 02/12/2024] Open
Abstract
PURPOSE To identify factors of incomplete treatment after segmental transarterial radioembolization (TARE) for treatment-naive and solitary hepatocellular carcinoma (HCC). MATERIALS AND METHODS A total of 75 consecutive patients (age, 68.5 years [SD ± 8.0]; 25/75 [33.3%] women) with treatment-naive, solitary HCC underwent segmental or subsegmental TARE with glass microspheres (tumor size, 3.8 cm [SD ± 2.2]; administered dose, 222.6 Gy [SD ± 123.9]) at a single institution from November 2015 to June 2022. Radiologic response and progression-free survival (PFS) were assessed as per modified Response Evaluation Criteria in Solid Tumors. RESULTS Complete treatment was achieved in 48 of 75 (64.0%) patients (mean follow-up, 33.2 months [SD ± 27.4]). Patients with incomplete treatment (27/75, 36%) presented with larger tumor size (5.0 [SD ± 2.5] vs 3.1 [SD ± 1.6] cm; P = .0001), with more tumors located in the watershed zone (81.5% vs 41.7%; P = .001). These patients were less likely to be bridged to transplant or resection (22.2% vs 52.1%; P = .015). Watershed tumors demonstrated worse target tumor PFS (median PFS, 19 months vs not reached; P = .0104) and overall PFS (9.1 months vs not reached; P = .0077). Watershed location was associated with worse PFS among tumors >3 cm in size (8.4 months vs not reached; P = .035) but not in tumors ≤3 cm in size (52.2 months vs not reached; P = .915). CONCLUSIONS Tumor size and watershed location were associated with incomplete treatment after segmental TARE for HCC. Watershed tumors were associated with worse PFS, particularly tumors larger than 3 cm. These tumors may require careful treatment planning and repeated treatments to ensure a durable response.
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Affiliation(s)
- Qian Yu
- Department of Radiology, University of Chicago Medical Center, University of Chicago, Chicago, Illinois.
| | - Monika Neale
- Department of Radiology, Cleveland Clinic, Cleveland, Ohio
| | - Ethan Ungchusri
- Department of Radiology, University of Chicago Medical Center, University of Chicago, Chicago, Illinois
| | | | - Chuanhong Liao
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois
| | - Mikin Patel
- Department of Radiology, University of Chicago Medical Center, University of Chicago, Chicago, Illinois
| | - Anjana Pillai
- Department of Hepatology, University of Chicago Medical Center, University of Chicago, Chicago, Illinois
| | - Rakesh Navuluri
- Department of Radiology, University of Chicago Medical Center, University of Chicago, Chicago, Illinois
| | - Osman Ahmed
- Department of Radiology, University of Chicago Medical Center, University of Chicago, Chicago, Illinois
| | - Thuong Van Ha
- Department of Radiology, University of Chicago Medical Center, University of Chicago, Chicago, Illinois
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Mourad SN, De la Garza-Ramos C, Toskich BB. Radiation Segmentectomy for the Treatment of Hepatocellular Carcinoma: A Practical Review of Evidence. Cancers (Basel) 2024; 16:669. [PMID: 38339418 PMCID: PMC10854641 DOI: 10.3390/cancers16030669] [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: 01/18/2024] [Revised: 02/02/2024] [Accepted: 02/03/2024] [Indexed: 02/12/2024] Open
Abstract
Radiation segmentectomy is a versatile, safe, and effective ablative therapy for early-stage hepatocellular carcinoma. Advances in radiation segmentectomy patient selection, procedural technique, and dosimetry have positioned this modality as a curative-intent and guideline-supported treatment for patients with solitary HCC. This review describes key radiation segmentectomy concepts and summarizes the existing literary knowledgebase.
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Affiliation(s)
- Sophia N. Mourad
- College of Medicine, Florida State University, Orlando, FL 32301, USA
| | | | - Beau B. Toskich
- Division of Interventional Radiology, Mayo Clinic Florida, Jacksonville, FL 32224, USA
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Kang M, Shin Y, Kim Y, Ha S, Sung W. Modeling the Synergistic Impact of Yttrium 90 Radioembolization and Immune Checkpoint Inhibitors on Hepatocellular Carcinoma. Bioengineering (Basel) 2024; 11:106. [PMID: 38391592 PMCID: PMC10886259 DOI: 10.3390/bioengineering11020106] [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: 12/22/2023] [Revised: 01/15/2024] [Accepted: 01/16/2024] [Indexed: 02/24/2024] Open
Abstract
The impact of yttrium 90 radioembolization (Y90-RE) in combination with immune checkpoint inhibitors (ICIs) has recently gained attention. However, it is unclear how sequencing and dosage affect therapeutic efficacy. The purpose of this study was to develop a mathematical model to simulate the synergistic effects of Y90-RE and ICI combination therapy and find the optimal treatment sequences and dosages. We generated a hypothetical patient cohort and conducted simulations to apply different treatments to the same patient. The compartment of models is described with ordinary differential equations (ODEs), which represent targeted tumors, non-targeted tumors, and lymphocytes. We considered Y90-RE as a local treatment and ICIs as a systemic treatment. The model simulations show that Y90-RE and ICIs administered simultaneously yield greater benefits than subsequent sequential therapy. In addition, applying Y90-RE before ICIs has more benefits than applying ICIs before Y90-RE. Moreover, we also observed that the median PFS increased up to 31~36 months, and the DM rates at 3 years decreased up to 36~48% as the dosage of the two drugs increased (p < 0.05). The proposed model predicts a significant benefit of Y90-RE with ICIs from the results of the reduced irradiated tumor burden and the associated immune activation and suppression. Our model is expected to help optimize complex strategies and predict the efficacy of clinical trials for HCC patients.
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Affiliation(s)
- Minah Kang
- Department of Biomedicine and Health Sciences, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
- Department of Biomedical Engineering, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Yerim Shin
- Department of Biomedicine and Health Sciences, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
- Department of Biomedical Engineering, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Yeseul Kim
- Department of Biomedicine and Health Sciences, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
- Department of Biomedical Engineering, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Sangseok Ha
- Department of Biomedicine and Health Sciences, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
- Department of Biomedical Engineering, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Wonmo Sung
- Department of Biomedicine and Health Sciences, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
- Department of Biomedical Engineering, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
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5
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Serhal M, Dadrass F, Kim E, Lewandowski RJ. Radiation Segmentectomy for Hepatocellular Carcinoma. Curr Oncol 2024; 31:617-628. [PMID: 38392039 PMCID: PMC10888093 DOI: 10.3390/curroncol31020045] [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: 12/28/2023] [Revised: 01/19/2024] [Accepted: 01/22/2024] [Indexed: 02/24/2024] Open
Abstract
The application of trans-arterial radioembolization (TARE) with Yttrium-90, historically a palliative treatment option for patients with advanced hepatocellular carcinoma (HCC), is evolving. Radiation segmentectomy (RADSEG), the segmental delivery of an ablative radiation dose, is a treatment option for patients with earlier-stage HCC. This review presents an in-depth exploration of RADSEG, emphasizing its technical considerations, dosimetry advancements, and patient selection. The integration of RADSEG into the Barcelona Clinic Liver Cancer (BCLC) paradigm will be highlighted. RADSEG outcomes concerning safety and efficacy will be explored and compared with traditional locoregional cancer treatments like trans-arterial chemoembolization (TACE), percutaneous thermal ablation, and surgical resection, with an eye on future directions and considerations.
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Affiliation(s)
- Muhamad Serhal
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA;
| | - Farnaz Dadrass
- Department of Radiology, Mount Sinai Health System, New York, NY 10029, USA; (F.D.); (E.K.)
| | - Edward Kim
- Department of Radiology, Mount Sinai Health System, New York, NY 10029, USA; (F.D.); (E.K.)
| | - Robert J. Lewandowski
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA;
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Ozen M, Patel RK. Ablation versus Radiation Segmentectomy for Small Liver Tumors. Semin Intervent Radiol 2023; 40:511-514. [PMID: 38274221 PMCID: PMC10807957 DOI: 10.1055/s-0043-1777714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
Hepatocellular carcinoma (HCC) is a liver malignancy that affects more than a million people worldwide with a complex multifactorial etiology. After the diagnosis of HCC is made, physicians establish management using the Barcelona Clinic Liver Cancer (BCLC) guidelines revolving around tumor stage, liver function, performance status, and patient preferences. According to recent updates to these guidelines, thermal ablation is the second-best curative option apart from surgical resection for small HCC (< 2 cm). While thermal ablation is standard of care, recent studies have suggested that radiation segmentectomy (RS) has similar outcomes, limited hepatotoxicity, and ultimately a cost-efficient approach. Although there is limited literature on RS, this article compares ablation techniques against radiation segmentectomy for small HCC tumors.
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Affiliation(s)
- Merve Ozen
- Department of Radiology, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Ronak K. Patel
- University of Kentucky College of Medicine, Lexington, Kentucky
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De la Garza-Ramos C, Montazeri SA, Musto KR, Kapp MD, Lewis AR, Frey G, Paz-Fumagalli R, Ilyas S, Harnois DM, Majeed U, Patel T, Toskich B. Outcomes of Radiation Segmentectomy for Hepatocellular Carcinoma in Patients with Non-Alcoholic Fatty Liver Disease versus Chronic Viral Hepatitis. J Hepatocell Carcinoma 2023; 10:987-996. [PMID: 37383543 PMCID: PMC10295464 DOI: 10.2147/jhc.s414853] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 06/01/2023] [Indexed: 06/30/2023] Open
Abstract
Purpose To compare the outcomes of radiation segmentectomy for early-stage hepatocellular carcinoma (HCC) in patients with non-alcoholic fatty liver disease (NAFLD) versus hepatitis C virus (HCV). Materials and Methods A retrospective analysis of consecutive patients with NAFLD- or HCV-related HCC treated with radiation segmentectomy from 01/2017-06/2022 was performed. Eligibility criteria included solitary tumor ≤8 cm or up to 3 HCC ≤3 cm, ECOG 0-1, and absence of vascular invasion or extrahepatic spread. Imaging best response was assessed per modified Response Evaluation Criteria in Solid Tumors. Target tumor and overall progression, time-to-progression (TTP), and overall survival (OS) were calculated. All outcomes were censored for liver transplantation (LT). Complete pathologic response (CPN) was assessed in patients who underwent LT. Results Of 142 patients included (NAFLD: 61; HCV: 81), most had cirrhosis (NAFLD: 87%; HCV: 86%) and small tumors (median size NAFLD: 2.3 cm; HCV: 2.5 cm). Patients with NAFLD had higher BMI (p<0.001) and worse ALBI scores (p=0.003). Patients with HCV were younger (p<0.001) and had higher AFP levels (p=0.034). Median radiation dose (NAFLD: 508 Gy; HCV: 452 Gy) and specific activity (NAFLD: 700 Bq; HCV: 698 Bq) were similar between cohorts. Objective response was 100% and 97% in the NAFLD and HCV cohorts, respectively. Target tumor progression occurred in 1 (2%) NAFLD and 8 (10%) HCV patients. Target tumor TTP was not met for either cohort. Overall progression occurred in 23 (38%) NAFLD and 39 (48%) HCV patients. Overall TTP was 17.4 months (95% CI 13.5-22.2) in NAFLD and 13.5 months (95% CI 0.4-26.6) in HCV patients (p=0.86). LT was performed in 27 (44%) NAFLD and 33 (41%) HCV patients, with a CPN rate of 63% and 54%, respectively. OS was not met in the NAFLD cohort and was 53.9 months (95% CI 32.1-75.7) in the HCV cohort (p=0.15). Conclusion Although NAFLD and HCV are associated with different mechanisms of liver injury, patients with early-stage HCC treated with radiation segmentectomy achieve comparable outcomes.
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Affiliation(s)
| | - S Ali Montazeri
- Division of Interventional Radiology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Kaitlyn R Musto
- Division of Interventional Radiology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Melissa D Kapp
- Division of Interventional Radiology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Andrew R Lewis
- Division of Interventional Radiology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Gregory Frey
- Division of Interventional Radiology, Mayo Clinic Florida, Jacksonville, FL, USA
| | | | - Sumera Ilyas
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, MN, USA
| | | | - Umair Majeed
- Division of Hematology and Medical Oncology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Tushar Patel
- Department of Transplant, Mayo Clinic, Florida, FL, USA
| | - Beau Toskich
- Division of Interventional Radiology, Mayo Clinic Florida, Jacksonville, FL, USA
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8
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Toskich B, Krishnan S. Radiation Segmentectomy-Ablative and Conformal Radiation Therapy With High Rates of Complete Pathologic Response. Int J Radiat Oncol Biol Phys 2023; 115:279-280. [PMID: 36621230 DOI: 10.1016/j.ijrobp.2022.08.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 08/13/2022] [Indexed: 01/07/2023]
Affiliation(s)
- Beau Toskich
- Division of Interventional Radiology, Mayo Clinic Florida, Jacksonville, Florida.
| | - Sunil Krishnan
- Department of Radiation Oncology, Mayo Clinic Florida, Jacksonville, Florida
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