Making the Case: Intra-arterial Therapy for Less Common Metastases

Interventional oncology in breast cancer

Breast cancer (BC) is the most common cancer and one of the most important causes of death in women. Surgery is the standard therapy for breast cancer and in the last decades evolved towards a more conservative approach, with lumpectomy, followed by radiation therapy, the most common option. Unfortunately, up to 40% of women affected by BC will develop metastases and will receive systemic therapy, which improves survival and quality of life. Interventional oncology (IO), thanks to the improvement in technology and clinical experience, is gaining an important role in the field of breast cancer, both in treating the primary tumour and also in metastasis in well-selected cases. Percutaneous thermal ablation and more recently cryoablation are reported to achieve promising results in the radical treatment of small breast cancer, with optimal cosmetic outcome and a very high safety profile. Percutaneous ablation as well as intra-arterial therapies, such as chemoembolization and radioembolization, might also be indicated in metastatic BC patients. In advanced stage disease, breast cancer liver metastases (BCLM) represent the main factor affecting the overall survival. Metastatic breast disease is a systemic disease, with tumour deposits potentially spread into different organs and tissues for which systemic therapy is the standard approach. Local therapies for liver metastases might have an important role in improving survival and quality of life in well-selected patients. Clinical and technical indications with their limitations, results and potential complications in local IO treatment for BCLM, will be also described.

A 20-year scoping review of the veterinary interventional radiology and interventional endoscopy literature (2000-2019)

BACKGROUND

Interventional radiology (IR) and interventional endoscopy (IE) have broad potential for minimally invasive therapy in veterinary patients, but the scope of original peer-reviewed veterinary IR/IE research publications has not been described.

OBJECTIVES

Catalogue published applications and indications for noncardiac therapeutic IR/IE in animals and describe type and quality of veterinary IR/IE research over 20 years.

METHODS

Highly-cited veterinary journals were searched to identify articles published 2000 to 2019 involving therapeutic IR/IE applications for clinical veterinary patients. Articles were assigned a level of evidence (LOE) according to published standards. Authorship, animal data, study design, and interventions were described. Change in publication rate, study size, and LOE of IR/IE articles over time was analyzed.

RESULTS

One hundred fifty-nine of 15 512 (1%) articles were eligible, including 2972 animals. All studies were low LOE and 43% were case reports with ≤5 animals. Number of IR/IE articles per year (P < .001), proportion of journals' articles pertaining to IR/IE (P = .02), and study size (P = .04) all increased over time, but LOE (P = .07) did not. Common target body systems were urinary (40%), digestive (23%) respiratory (20%), and vascular (13%). Common indications were nonvascular luminal obstructions (47%), object retrieval (14%), and congenital anomalies (13%). Most procedures involved indwelling medical devices or embolic agents, whereas tissue resection and other procedures were less common. Procedures utilized fluoroscopy (43%), endoscopy (33%), ultrasound (8%), digital radiography (1%), or fluoroscopy in combination with other modalities (16%).

CONCLUSIONS

Treatments involving IR/IE have wide applicability in veterinary medicine but large, rigorous, and comparative studies describing these procedures are lacking.

Successful Treatment with Hepatic Arterial Infusion Chemotherapy in a Breast Cancer Patient with Multiple Liver Metastases Who Declined Systemic Therapy

Despite improvements in systemic medical therapy (ST), liver metastases (LMs) are a poor prognostic factor in metastatic breast cancer (MBC) patients. We describe a MBC patient with predominant LMs treated with hepatic arterial infusion chemotherapy (HAIC) who declined ST. Moreover, we assessed general health status during treatment using C-reactive protein (CRP)/albumin ratio (CAR) and peripheral platelet count × CRP multiplier (P-CRP), well-known indicators of systemic inflammatory response. A 64-year-old woman who underwent a total mastectomy with axillary lymph node dissection for an HR-positive, HER2-negative infiltrating ductal BC developed multiple liver, lung, lymph node, and bone metastases. She received ST including paclitaxel plus the anti-vascular endothelial growth factor antibody, bevacizumab, hormone therapy with high-dose toremifene, the oral 5-fluorouracil derivative, S-1, and eribulin. She then declined ST because of the toxicity or decreased treatment motivation thereof, and opted for HAIC with 5FU plus epirubicin followed by Taxane for 1 year and 1 month. Computed tomography revealed a partial response or stable disease in the liver and slow progression in other sites without symptoms or side effects and decreased CEA and CA15-3 levels. The CAR and P-CRP remained low. She survived for 1 year and 3 months after the start of HAIC. This case reveals that HAIC may be an option for advanced BC patients with LMs who cannot receive ST.

Intra-Arterial Therapies for Liver Metastatic Breast Cancer: A Systematic Review and Meta-Analysis

PURPOSE

Performing a systematic review and meta-analysis to assess the evidence of intra-arterial therapies in liver metastatic breast cancer (LMBC) patients.

METHODS

A systemic literature search was performed in PubMed, EMBASE, SCOPUS for studies regarding intra-arterial therapies in LMBC patients. Full text studies of LMBC patients (n ≥ 10) published between January 2010 and December 2020 were included when at least one outcome among response rate, adverse events or survival was available. Response rates were pooled using generalized linear mixed models. A weighted estimate of the population median overall survival (OS) was obtained under the assumption of exponentially distributed survival times.

RESULTS

A total of 26 studies (1266 patients) were included. Eleven articles reported on transarterial radioembolization (TARE), ten on transarterial chemoembolization (TACE) and four on chemo-infusion. One retrospective study compared TARE and TACE. Pooled response rates were 49% for TARE (95%CI 32-67%), 34% for TACE (95%CI 22-50%) and 19% for chemo-infusion (95%CI 14-25%). Pooled median survival was 9.2 months (range 6.1-35.4 months) for TARE, 17.8 months (range 4.6-47.0) for TACE and 7.9 months (range 7.0-14.2) for chemo-infusion. No comparison for OS was possible due to missing survival rates at specific time points (1 and 2 year OS) and the large heterogeneity.

CONCLUSION

Although results have to be interpreted with caution due to the large heterogeneity, the superior response rate of TARE and TACE compared to chemo-infusion suggests first choice of TARE or TACE in chemorefractory LMBC patients. Chemo-infusion could be considered in LMBC patients not suitable for TARE or TACE.

LEVEL OF EVIDENCE

3a.

Feasibility of Combination Intra-arterial Yttrium-90 and Irinotecan Microspheres in the VX2 Rabbit Model

PURPOSE

To evaluate the combination of 90Y radioembolization (Y90) and drug-eluting bead irinotecan (DEBIRI) microspheres in the VX2 rabbit model.

MATERIALS AND METHODS

An initial dose finding study was performed in 6 White New Zealand rabbits to identify a therapeutic but subcurative dose of Y90. In total, 29 rabbits were used in four groups: Y90 treatment (n = 8), DEBIRI treatment (n = 6), Y90 + DEBIRI treatment (n = 7), and an untreated control group (n = 8). Hepatic toxicity was evaluated at baseline, 24 h, 72 h, 1 week, and 2 weeks. MRI tumor volume (TV) and enhancing tumor volume were assessed baseline and 2 weeks. Tumor area and necrosis were evaluated on H&E for pathology.

RESULTS

Infused activities of 84.0-94.4 MBq (corresponding to 55.1-72.7 Gy) were selected based on the initial dose finding study. Infusion of DEBIRI after Y90 was technically feasible in all cases (7/7). Overall, 21/29 animals survived to 2 weeks, and the remaining animals had extrahepatic disease on necropsy. Liver transaminases were elevated with Y90, DEBIRI, and Y90 + DEBIRI compared to control at 24 h, 72 h, and 1 week post-treatment and returned to baseline by 2 weeks. By TV, Y90 + DEBIRI was the only treatment to show statistically significant reduction at 2 weeks compared to the control group (p = 0.012). The change in tumor volume (week 2-baseline) for both Y90 + DEBIRI versus control (p = 0.002) and Y90 versus control (p = 0.014) was significantly decreased. There were no statistically significant differences among groups on pathology.

CONCLUSION

Intra-arterial Y90 + DEBIRI was safe and demonstrated enhanced antitumor activity in rabbit VX2 tumors. This combined approach warrants further investigation.

Sequential intra-arterial infusion of 90Y-resin microspheres and mitomycin C in chemo refractory liver metastatic breast cancer patients: a single centre pilot study

Background

The aim of the study was to evaluate the safety and feasibility of intra-arterial mitomycin C (MMC) infusion after selective internal radiation therapy (SIRT) using Yttrium-90 (⁹⁰Y) resin microspheres in liver metastatic breast cancer (LMBC) patients.

Patients and methods

The prospective pilot study included LMBC patients from 2012–2018. Patients first received infusion of ⁹⁰Y resin microspheres, after 6–8 weeks response to treatment was assessed by MRI, ¹⁸F-FDG PET/CT and laboratory tests. After exclusion of progressive disease, MMC infusion was administrated 8 weeks later in different dose cohorts; A: 6 mg in 1 cycle, B: 12 mg in 2 cycles, C: 24 mg in 2 cycles and D: maximum of 72 mg in 6 cycles. In cohort D the response was evaluated after every 2 cycles and continued after exclusion of progressive disease. Adverse events (AE) were reported according to CTCAE version 5.0.

Results

Sixteen patients received ⁹⁰Y treatment. Four patients were excluded for MMC infusion, because of extra hepatic disease progression (n = 3) and clinical and biochemical instability (n = 1). That resulted in the following number of patient per cohort; A: 2, B: 1, C: 3 and D: 6. In 4 of the 12 patients (all cohort D) the maximum dose of MMC was adjusted due biochemical toxicities (n = 2) and progressive disease (n = 2). One grade 3 AE occurred after ⁹⁰Y treatment consisting of a gastrointestinal ulcer whereby prolonged hospitalization was needed.

Conclusions

Sequential treatment of intra-arterial infusion of MMC after ⁹⁰Y SIRT was feasible in 75% of the patients when MMC was administrated in different escalating dose cohorts. However, caution is needed to prevent reflux after ⁹⁰Y SIRT in LMBC patients.

Efficacy and Safety of Intro-Arterial Chemotherapy Combined with Radiotherapy on Head and Neck Cancer: A Systematic Review and Meta-Analysis

Objectives: Intro-arterial chemotherapy combined with radiotherapy (IACRT) for the treatment of head and neck cancer (HNC) underwent a revival in recent years. Although many clinical trials have reported favorable outcomes, the effect of IACRT for HNC is still controversial. Therefore, this study was designed to evaluate the efficacy and safety of IACRT for HNC.

Methods: The relevant articles published before August 2019 were searched from PubMed, Embase, Cochrane Library, Web of Science and PMC databases. Data were extracted and the combined complete response (CR), overall survival (OS) and toxicity incidence with 95% credible interval (CI) were examined from eligible studies.

Results: Thirty-four studies comprising 1890 patients were included. IACRT achieved high CR (0.81, 95% CI: 0.76-0.86, P < 0.001), 3-year OS (0.75, 95% CI: 0.68-0.82, P < 0.001) and 5-year OS (0.68, 95% CI: 0.61-0.75, P < 0.001). The 3-year OS rate of stage III cancer (0.75, 95% CI: 0.53-0.97, P< 0.001) was higher than stage IV (0.52, 95% CI: 0.37-0.66, P = 0.025). Meanwhile, the 5-year OS of T3 cancer (0.87, 95% CI: 0.73-1.01, P = 0.028) was higher than T4 (0.53, 95% CI: 0.42-0.63, P = 0.286). Additionally, oral diseases, mucositis, leukopenia and dermatitis were the major toxicities of IACRT, which were all reversible.

Conclusion: IACRT is an efficient and safe modality for HNC, which could achieve favorable cancer response and higher survival rate with acceptable toxicities, even for advanced HNC.

Intra-arterial Mitomycin C infusion in a large cohort of advanced liver metastatic breast cancer patients: safety, efficacy and factors influencing survival

PURPOSE

The aim of this study was to determine the safety and efficacy of Mitomycin C (MMC) infusion in a large cohort of advanced liver metastatic breast cancer patients (LMBC) and to determine factors influencing overall survival (OS).

METHODS

We retrospectively analysed LMBC patients, treated with MMC infusion between 2000 and 2017. Hepatic response was measured with baseline CT scans and first available CT scan after MMC infusion by RECIST 1.1 criteria. Adverse events were registered by the CTCAE version 5.0. OS and hepatic progression free survival (hPFS) were evaluated using Kaplan-Meier estimates. After univariable analysis, a stepwise forward multivariable (MV) prediction analysis was developed to select independent pre-treatment factors associated with OS.

RESULTS

We included 176 patients with a total of 599 MMC infusions, mostly heavily pre-treated patients with a median time from diagnosis of MBC to MMC infusion of 36.9 months. RECIST evaluation of liver lesions (n = 132) showed a partial response rate of 15%, stable disease of 43% and progressive disease in 17%. Adverse events grade 3 and 4 were reported in 17.5%. Median PFS was 5.5 months and median OS was 7.8 months. Significant independent baseline predictors of worse OS included number of prior systemic chemotherapy lines, prior liver ablation, higher liver tumour burden and elevated levels of bilirubin and ALT.

CONCLUSION

MMC infusion is safe and effective in advanced LMBC patients. An increased number of prior therapies, a higher liver tumour burden and elevated levels of bilirubin and ALT were associated with a worse OS.

Treatment options for PNET liver metastases: a systematic review

BACKGROUND

Pancreatic neuroendocrine tumors (PNETs) are rare pancreatic neoplasms. About 40-80% of patients with PNET are metastatic at presentation, usually involving the liver (40-93%). Liver metastasis represents the most significant prognostic factor. The aim of this study is to present an up-to-date review of treatment options for patients with liver metastases from PNETs.

METHODS

A systematic literature search was performed using the PubMed database to identify all pertinent studies published up to May 2018.

RESULTS

The literature search evaluated all the therapeutic options for patients with liver metastases of PNETs, including surgical treatment, loco-regional therapies, and pharmacological treatment. All the different treatment options showed particular indications in different presentations of liver metastases of PNET. Surgery remains the only potentially curative therapeutic option in patients with PNETs and resectable liver metastases, even if relapse rates are high. Efficacy of medical treatment has increased with advances in targeted therapies, such as everolimus and sunitinib, and the introduction of radiolabeled somatostatin analogs. Several techniques for loco-regional control of metastases are available, including chemo- or radioembolization.

CONCLUSIONS

Treatment of patients with PNET metastases should be multidisciplinary and must be personalized according to the features of individual patients and tumors.

Liver Metastases in Pancreatic Acinar Cell Carcinoma Treated with Selective Internal Radiation Therapy with Y-90 Resin Microspheres

Background

Pancreatic acinar cell carcinoma (PACC) is a rare tumor. Surgical resection is the treatment of choice when feasible, but there are no clear recommendations for patients with advanced disease. Liver-directed therapy with Y-90 selective internal radiation therapy (SIRT) has been used to treat hepatic metastases from pancreatic tumors. We describe a case of PACC liver metastases treated with SIRT.

Case Report

59-year-old man was admitted with an infiltrative, solid lesion in pancreatic tail diagnosed as PACC. Lymph nodes in the hepatic hilum were enlarged, and many metastatic liver nodules were observed. After partial pancreatectomy, the left and right lobes of the liver were separately treated with Y-90 resin microspheres. Follow-up imaging revealed that all hepatic nodules shrank by at least 50%, and 3 nodules disappeared completely. Lipase concentration was 8407 U/L at baseline, rose to 12,705 U/L after pancreatectomy, and declined to 344 U/L after SIRT. Multiple rounds of chemotherapy in the subsequent year shrank the hepatic tumors further; disease then progressed, but a third line of chemotherapy shrank the tumors again, 16 months after SIRT treatment.

Conclusion

SIRT had a positive effect on liver metastases from PACC. In conjunction with systemic therapy, SIRT can achieve sustained disease control.