Hepatic artery dissection in a patient on bevacizumab resulting in pseudoaneurysm formation

Celiac trunk aortic dissection induced by bevacizumab therapy for rectal cancer: A case report

RATIONALE

Bevacizumab (Bev) is a humanized monoclonal antibody that targets vascular endothelial growth factor A and is primarily used for the treatment of various solid tumors. Aortic dissection (AD) is a severe vascular disease caused by the tearing of the intimal layer of the aorta or bleeding within the aortic wall, resulting in the separation of different layers of the aortic wall. However, the pathogenesis is not fully understood. Some studies have suggested that Bev treatment is associated with the occurrence of AD.

PATIENT CONCERNS

A 67-year-old Chinese male was diagnosed with rectal cancer accompanied by liver and lung metastasis. Three days after starting combined chemotherapy with Bev, the patient developed persistent abdominal pain. Abdominal CT scan revealed celiac trunk AD in the abdominal aorta.

DIAGNOSES

The patient was diagnosed with rectal cancer accompanied by liver and lung metastases. Abdominal CT tomography revealed a celiac trunk AD.

INTERVENTIONS

Somatostatin combined with valsartan was used to control blood pressure. The patient was subsequently referred for vascular surgery and underwent an abdominal aortic angiography. Conservative treatment was continued.

OUTCOMES

Three months after the initiation of treatment, follow-up abdominal CT scans showed stability in the condition of celiac trunk AD, with no abdominal pain or hypertension. There were no signs of worsening dissection, aneurysm formation, or inadequate perfusion of end organs.

LESSONS

There may be a connection between Bev and elevated blood pressure as well as celiac trunk AD.

Phase I prospective trial of TAS-102 (trifluridine and tipiracil) and radioembolization with 90Y resin microspheres for chemo-refractory colorectal liver metastases

BACKGROUND

Extrahepatic disease progression limits clinical efficacy of Yttrium-90 (⁹⁰Y) radioembolization (TARE) for patients with chemotherapy-refractory metastatic colorectal cancer (mCRC). Trifluridine and tipiracil (TAS-102) has overall survival benefit for patients with refractory mCRC and may be a radiosensitizer.

METHODS

Sequential lobar TARE using ⁹⁰Y resin microspheres in combination with TAS-102 in 28-day cycles were used to treat adult patients with bilobar liver-dominant chemo-refractory mCRC according to 3 + 3 dose escalation design with a 12-patient dose expansion cohort. Study objectives were to establish safety and determine maximum tolerated dose (MTD) of TAS-102 in combination with TARE.

RESULTS

A total of 21 patients (14 women, 7 men) with median age of 60 years were enrolled. No dose limiting toxicities were observed. Treatment related severe adverse events included cytopenias (10 patients, 48%) and radioembolization-induced liver disease (2 patients, 10%). Disease control rate in the liver lobes treated with TARE was 100%. Best observed radiographic responses were partial response for 4 patients (19%) and stable disease for 12 patients (57%).

CONCLUSIONS

The combination of TAS-102 and TARE for patients with liver-dominant mCRC is safe and consistently achieves disease control within the liver.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT02602327 (first posted 11/11/2015).

Current Approach to Planning Angiography and MAA Administration

Transarterial radioembolization of primary and secondary hepatic malignancies utilizing yttrium-90 microspheres is a commonly performed treatment by interventional radiologists. Traditionally performed as a two-part procedure, a diagnostic angiography is performed 1 to 3 weeks prior to treatment with the injection of technetium-99m-macroaggregated albumin followed by planar scintigraphy in the nuclear medicine department. Careful attention must be paid to the details during the diagnostic angiography to ensure the delivery of a safe and optimal dose to the diseased liver and to minimize radiation-induced damage to both unaffected liver and adjacent structures. In this article, we will review the steps and considerations that must be made during the angiography planning and discuss current and future areas of research.

Radioembolization in the Setting of Systemic Therapies

90 Yttrium (Y90) radioembolization has been shown to improve outcomes for primary and metastatic liver cancers, but there is limited understanding of the optimal timing and safety of combining systemic therapies with Y90 treatment. Both therapeutic effects and toxicities could be synergistic depending on the timing and dosing of different coadministration paradigms. In particular, patients with liver-only or liver-dominant metastatic disease progression are often on systemic therapy when referred to interventional radiology for consideration of Y90 treatment. Interventional radiologists are frequently asked to offer insight into whether or not to hold systemic therapy, and for how long, prior to and following transarterial therapy. This study reviews the current evidence regarding the timing and safety of systemic therapy with Y90 treatment for hepatocellular carcinoma, metastatic colorectal carcinoma, intrahepatic cholangiocarcinoma, metastatic neuroendocrine tumors, and other hepatic metastases. A particular focus is placed on the timing, dosing, and toxicities of combined therapy.

Radioembolization of Colorectal Liver Metastases: Indications, Technique, and Outcomes

Liver metastases are a major cause of death from colorectal cancer. Intraarterial therapy options for colorectal liver metastases include chemoinfusion via a hepatic arterial pump or port, irinotecan-loaded drug-eluting beads, and radioembolization using ⁹⁰Y microspheres. Intraarterial therapy allows the delivery of a high dose of chemotherapy or radiation into liver tumors while minimizing the impact on liver parenchyma and avoiding systemic effects. Specificity in intraarterial therapy can be achieved both through preferential arterial flow to the tumor and through selective catheter positioning. In this review, we discuss indications, contraindications, preprocedure evaluation, activity prescription, follow-up, outcomes, and complications of radioembolization of colorectal liver metastases. Methods for preventing off-target embolization, increasing the specificity of microsphere delivery, and reducing the lung-shunt fraction are discussed. There are 2 types of ⁹⁰Y microspheres: resin and glass. Because glass microspheres have a higher activity per particle, they can deliver a particular radiation dose with fewer particles, likely reducing embolic effects. Glass microspheres thus may be more suitable when early stasis or reflux is a concern, in the setting of hepatocellular carcinoma with portal vein invasion, and for radiation segmentectomy. Because resin microspheres have a lower activity per particle, more particles are needed to deliver a particular radiation dose. Resin microspheres thus may be preferable for larger tumors and those with high arterial flow. In addition, resin microspheres have been approved by the U.S. Food and Drug Administration for colorectal liver metastases, whereas institutional review board approval is required before glass microspheres can be used under a compassionate-use or research protocol. Finally, radiation segmentectomy involves delivering a calculated lobar activity of ⁹⁰Y microspheres selectively to treat a tumor involving 1 or 2 liver segments. This technique administers a very high radiation dose and effectively causes the ablation of tumors that are too large or are in a location considered unsafe for thermal ablation. The selective delivery spares surrounding normal liver, reducing the risk of liver failure.

Assessing Intra-arterial Complications of Planning and Treatment Angiograms for Y-90 Radioembolization

PURPOSE

To report hepatic arterial-related complications encountered during planning and treatment angiograms for radioembolization and understand any potential-associated risk factors.

MATERIALS AND METHODS

518 mapping or treatment angiograms for 180 patients with primary or metastatic disease to the liver treated by Yttrium-90 radioembolization between 2/2010 and 12/2015 were retrospectively reviewed. Intra-procedural complications were recorded per SIR guidelines. Patient demographics, indication for treatment, prior exposure to chemotherapeutic agents, operator experience, and disease burden were reviewed. Technical variables including type of radioembolic (glass vs. resin microspheres), indication for angiography (mapping vs. treatment), variant anatomy, and attempts at coil embolization were also assessed.

RESULTS

Thirteen (13/518, 2.5%) arterial-related complications occurred in 13 patients. All but two complications resulted during transcatheter coil embolization to prevent non-target embolization. Complications included coil migration (n = 6), arterial dissection (n = 2), focal vessel perforation (n = 2), arterial thrombus (n = 2), and vasospasm prohibiting further arterial sub-selection (n = 1). Transarterial coiling was identified as a significant risk factor of complications on both univariate and multivariate regression analysis (odds ratio 7.8, P = 0.004). Usage of resin microspheres was also a significant risk factor (odds ratio 9.5, P = 0.042). No other technical parameters or pre-procedural variables were significant after adjusting for confounding on multivariate analysis (P > 0.05).

CONCLUSION

Intra-procedural hepatic arterial complications encountered during radioembolization were infrequent but occurred mainly during coil embolization to prevent non-target delivery to extra-hepatic arteries.

Radioembolization with 90Y glass microspheres for the treatment of unresectable metastatic liver disease from chemotherapy-refractory gastrointestinal cancers: final report of a prospective pilot study

BACKGROUND

This prospective pilot single-institution study was undertaken to document the feasibility, safety, and efficacy of radioembolization of liver-dominant metastatic gastrointestinal cancer using ⁹⁰Y glass microspheres.

METHODS

Between June 2010 and October 2013, 42 adult patients (26 men, 16 women; median age 60 years) with metastatic chemotherapy-refractory unresectable colorectal (n=21), neuroendocrine (n=11), intrahepatic bile duct (n=7), pancreas (n=2), and esophageal (n=1) carcinomas underwent 60 lobar or segmental administrations of ⁹⁰Y glass microspheres. Data regarding clinical and laboratory adverse events (AE) were collected prospectively for up to 5.5 years after radioembolization. Radiographic responses were evaluated using Response Evaluation Criteria in Solid Tumors (RECIST), version 1.1. Time to maximum response, response duration, progression-free survival (PFS) (hepatic and extrahepatic), and overall survival (OS) were measured.

RESULTS

Median target dose and activity were 109.4 Gy and 2.6 GBq per treatment session, respectively. Majority of clinical AE were grade 1 or 2 in severity. Patients with colorectal cancer had hepatic objective response rate (ORR) of 25% and a hepatic disease control rate (DCR) of 80%. Median PFS and OS were 1.0 and 4.4 months, respectively. Patients with neuroendocrine tumors (NET) had hepatic ORR and DCR of 73% and 100%, respectively. Median PFS was 8.9 months for this cohort. DCR and median PFS and OS for patients with cholangiocarcinoma were 86%, 1.1 months, and 6.7 months, respectively.

CONCLUSIONS

⁹⁰Y glass microspheres device has a favorable safety profile, and achieved prolonged disease control of hepatic tumor burden in a subset of patients, including all patients enrolled in the neuroendocrine cohort.