Yttrium-90 radioembolization for colorectal cancer liver metastases: a single institution experience

Arterial Embolization Using Microspheres for Hypervascular Liver Metastases Refractory to Standard Treatments: A Multicenter Prospective Clinical Trial

PURPOSE

To evaluate the clinical utility of bland arterial embolization using microspheres in patients with hypervascular liver metastases refractory to standard treatments.

MATERIALS AND METHODS

Primary endpoints of this prospective single-arm non-comparative study were objective response and disease control rates (ORR and DCR), based on the modified Response Evaluation Criteria in Solid Tumors at 4 weeks after embolization. Secondary endpoints were ORR according to primary tumor, overall survival, progression-free survival (PFS), and safety.

RESULTS

Twenty-five patients with a median age of 66 years (range, 40-95 years) were enrolled in this study. The median maximum diameter of liver metastasis was 3.7 cm (range, 2.0-15.2 cm). Primary lesions were colorectal cancer in 12 patients (48%, 12/25), other cancer in 7 (28%, 7/25), neuroendocrine tumor in 4 (16%, 4/25), and sarcoma in 2 (8%, 2/25). ORR and DCR were 52% (13/25) and 72% (18/25) in all patients, 42% (5/12) and 75% (9/12) in colorectal cancer patients, and 62% (8/13) and 69% (9/13) in other malignant tumor patients (p = 0.43, p > 0.99). Median survival time was 19 months in all patients, 19 months in colorectal cancer patients, and 8 months (p = 0.16) in other malignant tumor patients. Median PFS time was 4 months in all patients, 4 months in colorectal cancer patients, and 6 months (p = 0.0085) in other malignant tumor patients. There were no grade-3 or -4 adverse events.

CONCLUSION

Microsphere embolization appears to be an effective and safe treatment for hypervascular liver metastases refractory to standard treatments.

Systematic review and network meta-analyses of third-line treatments for metastatic colorectal cancer

BACKGROUND

Limited treatment options are available in chemotherapy-refractory metastatic colorectal cancer (mCRC). The objective was to conduct a systematic literature review (SLR) and exploratory network meta-analysis (NMA) to compare the tolerability and effectiveness of SIRT with Y-90 resin microspheres, regorafenib, TAS-102 (trifluridine/tipiracil), and best supportive care (BSC) as third-line treatment in patients with mCRC.

METHODS

An SLR was conducted to identify studies comparing two or more of the treatments and reporting overall survival (OS), progression-free survival, tumor response, or adverse event (AE) incidence. An exploratory NMA was conducted to compare hazard ratios (HRs) for OS using Markov chain Monte Carlo (MCMC) techniques.

RESULTS

Seven studies were identified in the SLR: two double-blind randomized-controlled trials (RCT) for each drug, one open-label RCT, and two non-randomized comparative studies for SIRT. Patient selection criteria differed between studies, with SIRT studies including patients with liver-dominant colorectal metastases. Nausea and vomiting were more frequent with TAS-102 than regorafenib or SIRT; diarrhea was more common with TAS-102 and regorafenib than SIRT. The exploratory NMA suggested that all active treatments improved OS, with HRs of 0.48 (95% CrI 0.30-0.78) for SIRT with Y-90 resin microspheres, 0.63 (0.38-1.03) for TAS-102, and 0.67 (0.40-1.08) for regorafenib each compared to BSC.

CONCLUSIONS

Regorafenib, TAS-102 and SIRT using Y-90 resin microspheres are more effective than BSC in third-line treatment of mCRC; however, study heterogeneity made comparisons between active treatments challenging. SIRT is a viable treatment for third-line mCRC and its favorable AE profile should be considered in the therapeutic decision-making process.

Outcomes of Radioembolization in Patients with Chemorefractory Colorectal Cancer Liver Metastasis: a Single-Center Experience

PURPOSE

We aimed to evaluate the efficacy and outcomes of radioembolization with Yttrium-90 (Y-90) microspheres in patients with unresectable and chemorefractory colorectal cancer liver metastasis (CRCLM).

METHODS

This single-center study included 43 patients (34 male, 9 female) who underwent radioembolization with Y-90 for unresectable, chemorefractory CRCLM between September 2008 and July 2014. Overall survival (OS), liver progression-free survival (LPFS), overall response rate (ORR), local disease control rate (LDCR), and relations of these parameters with patient disease characteristics were evaluated. OS and LPFS rates were compared according to microspheres. Survival rates were calculated with Kaplan-Meier method, and potential prognostic variables were evaluated on univariate analyses.

RESULTS

Post-procedural median OS was 12.8 months. LPFS was 5.6 months. ORR was 33%, LDCR was 67% on 3rd month follow-up. Low tumor burden (< 25%) was associated with higher median OS after radioembolization (< 25 vs > 25-50% p < 0.0001 and < 25 vs > 50% p = 0.005). Patients with left colon tumors exhibited significantly longer median OS after metastasis than right colon tumors (p = 0.046). Extrahepatic disease and synchronicity showed poorer survival parameters; however, the difference was not significant (p = 0.1 and p = 0.3, respectively). In subgroup analyses, the distribution of patient number and characteristics showed heterogeneity as number of patients with low tumor burden was higher in resin Y-90 group. Resin Y-90 group exhibited significantly higher median OS and LPFS compared to glass Y-90 group (16.5 vs. 7 months, p = 0.001; 6.73 vs. 3.38 months, p = 0.023, respectively).

CONCLUSION

Radioembolization is a safe local-regional treatment option in chemorefractory, inoperable CRCLM. Radioembolization at earlier stages may lead to more favorable results especially with lower tumor burden patients.

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.

The development, commercialization, and clinical context of yttrium-90 radiolabeled resin and glass microspheres

Selective internal radiation therapy has emerged as a well-accepted therapeutic for primary and metastatic hepatic malignancies. This therapeutic modality requires the combined efforts of multiple medical disciplines to ensure the safe delivery of yttrium-90 (90Y)-labeled microspheres. The development of this therapy followed decades of clinical research involving tumor vascularity and microsphere development. Today, it is essential that treating physicians have a thorough understanding of hepatic tumor vascularity and 90Y microsphere characteristics before undertaking this complex intervention. This review explores the contributions of early investigators of this therapy, as well as the development, US Food and Drug Administration approval, manufacturing process, and attributes of the 2 commercially available 90Y radiolabeled microsphere device to clarify the key physical differences between the products.

Administered activity and outcomes of glass versus resin (90)Y microsphere radioembolization in patients with colorectal liver metastases

BACKGROUND

Given the differences in size, specific activity, and dosing methods for glass yttrium-90 microspheres ((90)Y-glass) and resin (90)Y microspheres ((90)Y-resin), these therapies may expose the liver to different amounts of radiation, thereby affecting their efficacy and tolerability. We aimed to compare the prescribed activity of (90)Y-glass and (90)Y-resin for real-world patients undergoing selective internal radiation therapy (SIRT) for liver-dominant metastatic colorectal cancer (mCRC) and to assess efficacy and safety outcomes in these patients.

METHODS

We examined the records of 28 consecutive patients with unresectable colorectal liver metastases treated with SIRT between June 2008 and May 2011 at our institution. Using baseline CT and MR images, we calculated a projected activity as if we had used the other product and compared it to the actual prescribed activity of (90)Y-glass and (90)Y-resin for each SIRT treatment per manufacturer guidelines. Progression and adverse events were evaluated at follow up visits. Survival was analyzed by the Kaplan-Meier method.

RESULTS

For (90)Y-glass treatments with a mean prescribed (90)Y activity of 1.77 GBq, the mean projected (90)Y-resin activity was 0.84 GBq. For (90)Y-resin treatments with a mean prescribed (90)Y activity of 1.05 GBq, the mean projected (90)Y-glass activity was 2.48 GBq. The median survival was 9.3 months versus 18.2 months for (90)Y-glass and (90)Y-resin, respectively (P=0.292). During the second year after SIRT, the hazard ratio of death for patients treated with (90)Y-glass versus (90)Y-resin was 4.0 (95% CI: 1.3, 12.3; P=0.017). No significant difference in progression, adverse events or liver toxicity was observed.

CONCLUSIONS

Using manufacturer recommended guidelines, (90)Y-resin delivers significantly less activity than (90)Y-glass to patients with liver-dominant mCRC undergoing SIRT with no significant difference in adverse events and a trend toward improved survival.

Hepatic imaging response to radioembolization with yttrium-90-labeled resin microspheres for tumor progression during systemic chemotherapy in patients with colorectal liver metastases

BACKGROUND

To assess response and the impact of imaging artifacts following radioembolization with yttrium-90-labeled resin microspheres ((90)Y-RE) based on the findings from a central independent review of patients with liver-dominant metastatic colorectal cancer (mCRC).

METHODS

Patients with mCRC who received (90)Y-RE (SIR-Spheres(®); Sirtex Medical, Sydney, Australia) at nine US institutions between July 2002 and December 2011 were included in the analysis. Tumor response was assessed at baseline and 3 months using either the Response Evaluation Criteria in Solid Tumors (RECIST) version 1.0 or 1.1. For each lesion, known artifacts affecting the interpretation of response (peri-tumoral edema and necrosis) were documented. Survivals (Kaplan-Meier analyses) were compared in responders [partial response (PR)] and non-responders [stable (SD) or progressive disease (PD)].

RESULTS

Overall, 195 patients (mean age 62 years) received (90)Y-RE after a median of 2 (range, 1-6) lines of prior chemotherapy. Using RECIST 1.0 and RECIST 1.1, 7.6% and 6.9% of patients were partial responders, 47.3% and 48.1% had SD, and 55.0% and 55.0% PD, respectively. RECIST 1.0 and RECIST 1.1 showed excellent agreement {Kappa =0.915 [95% confidence interval (CI): 0.856-0.975]}. Peri-tumoral edema was documented in 32.8%, necrosis in 48.1% and both in 57.3% of cases (using RECIST 1.0). Although baseline characteristics were similar in responders and non-responders (P>0.05), responders survived significantly longer in an analysis according to RECIST 1.0: PR median (95% CI) 25.2 (range, 9.2-49.4) months vs. SD 15.8 (range, 9.3-21.1) months vs. PD 7.1 (range, 6.0-9.5) months (P<0.0001).

CONCLUSIONS

RECIST 1.0 and RECIST 1.1 imaging responses provide equivalent interpretations in the assessment of hepatic tumors following (90)Y-RE. Radiologic lesion responses at 3 months must be interpreted with caution due to the significant proportion of patients with peri-tumoral edema and necrosis, which may lead to an under-estimation of PR/SD. Nevertheless, 3-month radiologic responses were predictive of prolonged survival.

Phase II trial of selective internal radiation therapy and systemic chemotherapy for liver-predominant metastases from pancreatic adenocarcinoma

BACKGROUND

This prospective, open-label phase II study assessed the impact of liver-directed therapy with selective internal radiation therapy (SIRT) and systemic chemotherapy on progression-free survival (PFS) in liver-dominant metastatic pancreatic adenocarcinoma.

METHODS

Patients received yttrium-90-labelled ((90)Y) resin microspheres (SIR-Spheres; Sirtex Medical Limited, Sydney, Australia) as a single procedure on day 2 of the first weekly cycle of 5-fluorouracil (5FU; 600 mg/m(2)) with the option to switch to gemcitabine (1000 mg/m(2)) after 8 weeks of 5FU. Statistical analysis was conducted using Microsoft Excel (Microsoft Corporation, Redmond, Washington, USA). The primary endpoint of the study was PFS in the liver, with a median of ≥ 16 weeks defined as the threshold for clinical significance. PFS and overall survival (OS) were summarised by the Kaplan-Meier method using non-parametric estimates of the survivor function.

RESULTS

Fourteen eligible patients were enrolled; ten had primary tumour in situ and eight had liver-only metastases. Patients received a median (90)Y activity of 1.1 GBq and 8 weekly doses of 5FU; seven patients received a median of two doses of gemcitabine. Disease control in the liver was 93% (two confirmed partial responses [PR], one unconfirmed PR, ten stable disease). Median reduction in cancer antigen 19-9 was 72%. Median PFS was 5.2 months in the liver, which met the primary endpoint of the study, and 4.4 months at any site. PFS was prolonged in those with a resected primary compared with patients with primary in situ (median 7.8 vs. 3.4 months; p = 0.017). Median OS was 5.5 months overall and 13.6 months in patients with a resected primary. Grade 3/4 adverse events occurred in eight (57%) patients during days 0-60. There was one sudden death and another patient who died from possible treatment-related liver failure 7.0 months after SIRT.

CONCLUSIONS

SIRT and chemotherapy appears to be an effective treatment for liver metastases from pancreatic cancer, likely to be of most benefit in selected patients with a resected primary tumour and liver only disease. Significant toxicity was observed and the safety of this approach in patients with metastatic pancreatic cancer will need to be confirmed in subsequent studies. Further study is warranted with SIRT and modern chemotherapies.

TRIAL REGISTRATION

ACTRN12606000015549.

Evaluation of the delivered activity of yttrium-90 resin microspheres using sterile water and 5 % glucose during administration

BACKGROUND

The purpose of this study is to evaluate the impact of switching from sterile water to 5 % glucose (G5W) for the administration of yttrium-90 ((90)Y)-resin microspheres on the total activity of (90)Y administered (expressed as a proportion of the prescribed/calculated activity), as well as the number of cases of stasis and the reported incidence of discomfort during the selective internal radiation therapy (SIRT) procedure.

METHODS

In December 2013, we switched from sterile water to G5W for the administration of SIRT using (90)Y resin microspheres in all patients. This retrospective observational single-center case series describes our experience in the months preceding and after the switch. Apart from the change in administration medium, the protocol for SIRT was otherwise identical.

RESULTS

One hundred and four SIRT procedures were performed on 78 patients (45 male, mean age: 63 years, range: 31-87 years) with either unresectable hepatocellular carcinoma, cholangiocarcinoma, or chemorefractory liver-dominant metastatic cancer. Compared with sterile water, the whole prescribed activity was administered in significantly more procedures with G5W: 85 vs. 22 %; p < 0.0001. A significantly higher proportion of the calculated activity was administered with G5W: 96.1 ± 11.0 % vs. 77.4 ± 24.3 % (p < 0.0001). G5W procedures were also associated with a significantly lower incidence of stasis (28 vs. 11 % procedures; p = 0.02) and mild-to-moderate upper abdominal pain during the procedure (1.8 vs. 44 % procedures; p < 0.0001).

CONCLUSIONS

Replacing sterile water with isotonic G5W during administration favorably impacts on the safety of SIRT, eliminates and/or minimizes flow reductions and stasis/reflux during administration of (90)Y resin microspheres, improves percentage activity delivered, and reduces peri-procedural pain.

Survival and tolerability of liver radioembolization: a comparison of elderly and younger patients with metastatic colorectal cancer

AIM

To evaluate the outcomes among elderly (≥70 years) and younger patients (<70 years) with liver-dominant metastatic colorectal cancer (mCRC) who received radioembolization (RE) as salvage therapy.

METHODS

A retrospective review of 107 consecutive patients with unresectable mCRC treated with RE after failing first- and second-line chemotherapy.

RESULTS

From 2002 to 2012, 44 elderly and 63 younger (<70 years) patients received RE. Patients had similar previous extensive chemotherapy and liver-directed interventions. Using modified Response Evaluation Criteria in Solid Tumors (mRECIST) criteria, either a stable or a partial radiographical response was seen in 65.8% of the younger compared with 76.5% of the elderly patients. RE was equally well tolerated in both groups and common procedure-related adverse events were predominantly grade 1-2 and of short duration. No significant difference was found with regard to overall median survival between younger [8.4 months; 95% confidence interval (CI) = 6.2-10.6] or elderly patients (8.2 months; 95% CI = 5.9-10.5, P = 0.667). The presence of extrahepatic disease at the time of RE was associated with a significantly worse median survival in both groups.

CONCLUSION

Radioembolization appears to be as well tolerated and effective for the elderly as it is for younger patients with mCRC. Age alone should not be a discriminating factor for the use of radioembolization in the management of mCRC patients.

Liver-directed therapies in metastatic colorectal cancer

Colorectal cancer (CRC) is a major health concern in the United States (US) with over 140,000 new cases diagnosed in 2012. The most common site for CRC metastases is the liver. Hepatic resection is the treatment of choice for colorectal liver metastases (CLM), with a 5-year survival rate ranging from 35% to 58%. Unfortunately, only about 20% of patients are eligible for resection. There are a number of options for extending resection to more advanced patients including systemic chemotherapy, portal vein embolization (PVE), two stage hepatectomy, ablation and hepatic artery infusion (HAI). There are few phase III trials comparing these treatment modalities, and choosing the right treatment is patient dependent. Treating hepatic metastases requires a multidisciplinary approach and knowledge of all treatment options as there continues to be advances in management of CLM. If a patient can undergo a treatment modality in order to increase their potential for future resection this should be the primary goal. If the patient is still deemed unresectable then treatments that lengthen disease-free and overall-survival should be pursued. These include chemotherapy, ablation, HAI, chemoembolization, radioembolization (RE) and stereotactic radiotherapy.

Radioembolization of hepatic lesions from a radiobiology and dosimetric perspective

Radioembolization (RE) of liver cancer with ⁹⁰Y-microspheres has been applied in the last two decades with notable responses and acceptable toxicity. Two types of microspheres are available, glass and resin, the main difference being the activity/sphere. Generally, administered activities are established by empirical methods and differ for the two types. Treatment planning based on dosimetry is a prerogative of few centers, but has notably gained interest, with evidence of predictive power of dosimetry on toxicity, lesion response, and overall survival (OS). Radiobiological correlations between absorbed doses and toxicity to organs at risk, and tumor response, have been obtained in many clinical studies. Dosimetry methods have evolved from the macroscopic approach at the organ level to voxel analysis, providing absorbed dose spatial distributions and dose–volume histograms (DVH). The well-known effects of the external beam radiation therapy (EBRT), such as the volume effect, underlying disease influence, cumulative damage in parallel organs, and different tolerability of re-treatment, have been observed also in RE, identifying in EBRT a foremost reference to compare with. The radiobiological models – normal tissue complication probability and tumor control probability – and/or the style (DVH concepts) used in EBRT are introduced in RE. Moreover, attention has been paid to the intrinsic different activity distribution of resin and glass spheres at the microscopic scale, with dosimetric and radiobiological consequences. Dedicated studies and mathematical models have developed this issue and explain some clinical evidences, e.g., the shift of dose to higher toxicity thresholds using glass as compared to resin spheres. This paper offers a comprehensive review of the literature incident to dosimetry and radiobiological issues in RE, with the aim to summarize the results and to identify the most useful methods and information that should accompany future studies.

Perfusion CT best predicts outcome after radioembolization of liver metastases: a comparison of radionuclide and CT imaging techniques

OBJECTIVE

To determine the best predictor for the response to and survival with transarterial radioembolisation (RE) with (90)yttrium microspheres in patients with liver metastases.

METHODS

Forty consecutive patients with liver metastases undergoing RE were evaluated with multiphase CT, perfusion CT and (99m)Tc-MAA SPECT. Arterial perfusion (AP) from perfusion CT, HU values from the arterial (aHU) and portal venous phase (pvHU) CT, and (99m)Tc-MAA uptake ratio of metastases were determined. Morphologic response was evaluated after 4 months and available in 30 patients. One-year survival was calculated with Kaplan-Meier curves.

RESULTS

We found significant differences between responders and non-responders for AP (P < 0.001) and aHU (P = 0.001) of metastases, while no differences were found for pvHU (P = 0.07) and the (99m)Tc-MAA uptake ratio (P = 0.40). AP had a significantly higher specificity than aHU (P = 0.003) for determining responders to RE. Patients with an AP >20 ml/100 ml/min had a significantly (P = 0.01) higher 1-year survival, whereas an aHU value >55 HU did not discriminate survival (P = 0.12). The Cox proportional hazard model revealed AP as the only significant (P = 0.02) independent predictor of survival.

CONCLUSION

Compared to arterial and portal venous enhancement and the (99m)Tc-MAA uptake ratio of liver metastases, the AP from perfusion CT is the best predictor of morphologic response to and 1-year survival with RE.

KEY POINTS

• Perfusion CT allows for calculation of the liver arterial perfusion. • Arterial perfusion of liver metastases differs between responders and non-responders to RE. • Arterial perfusion can be used to select patients responding to RE.

Incidence and treatment of local site recurrences following RFA of colorectal liver metastases

BACKGROUND

Patients with colorectal liver metastases (CRLM) who are ineligible for curative surgery are potential candidates for radiofrequency ablation (RFA). Although RFA has emerged as a well accepted and documented treatment modality, there are still some reservations because of initially high rates of local site recurrences (LSR). The aim of the present study was to evaluate LSR levels following RFA treatment, with a specific focus on re-treatment and survival.

PATIENTS AND METHODS

All patients ineligible for curative resection of CRLM and undergoing RFA alone or in combination with resection were prospectively included from July 2000 to December 2010 and retrospectively analyzed. Patients with untreatable extrahepatic disease were excluded. FDG PET-CT was conducted at 3-6 month intervals after RFA. Patients with LSR were evaluated for re-treatment.

RESULTS

A total of 132 patients were treated with RFA, which was combined with resection in 64 patients. A total of 290 lesions were ablated, with a mean number of 2.19 per patient and a mean size of 2.2 cm. Median survival was 41 months, with a 3- and 5-year survival of, respectively, 60 and 30.8 %. Following initial RFA, 39 patients developed an LSR in 40 ablated lesions, and local recurrence was strongly related to lesion size. Re-treatment could be performed in 26/39 patients, of whom eight remained disease-free.

CONCLUSIONS

Radiofrequency ablation can be applied to CRLM of less than 3 cm with curative intent. In the absence of extensive intrahepatic or extrahepatic disease, renewed treatment of local recurrences should be considered and is often successful.

A systematic review on the safety and efficacy of yttrium-90 radioembolization for unresectable, chemorefractory colorectal cancer liver metastases

INTRODUCTION

The management of unresectable, chemorefractory colorectal cancer liver metastases (CRCLM) is a clinical dilemma. Yttrium-90 (Y90) radioembolization is a potentially safe and effective treatment for patients with CRCLM who have failed conventional chemotherapy regimens.

METHODS

A systematic review of clinical studies before November 2012 was performed to examine the radiological response, overall survival and progression-free survival of patients who underwent Y90 radioembolization of unresectable CRCLM refractory to systemic therapy. The secondary objectives were to evaluate the safety profile of this treatment and identify prognostic factors for overall survival.

RESULTS

Twenty studies comprising 979 patients were examined. Patients had failed a median of 3 lines of chemotherapy (range 2-5). After treatment, the average reported value of patients with complete radiological response, partial response and stable disease was 0% (range 0-6%), 31% (range 0-73%) and 40.5% (range 17-76%), respectively. The median time to intra-hepatic progression was 9 months (range 6-16). The median overall survival was 12 months (range 8.3-36). The overall acute toxicity rate ranged from 11 to 100% (median 40.5 %). Most cases of acute toxicity were mild (Grade I or II) (median 39%; range 7-100%) which resolved without intervention. The number of previous lines of chemotherapy (≥ 3), poor radiological response to treatment, extra-hepatic disease and extensive liver disease (≥ 25%) were the factors most commonly associated with poorer overall survival.

CONCLUSION

Y90 radioembolization is a safe and effective treatment of CRCLM in the salvage setting and should be more widely utilized.

Selective Interarterial Radiation Therapy (SIRT) in Colorectal Liver Metastases: How Do We Monitor Response?

Radioembolisation is a way of providing targeted radiotherapy to colorectal liver metastases. Results are encouraging but there is still no standard method of assessing the response to treatment. This paper aims to review the current experience assessing response following radioembolisation. A literature review was undertaken detailing radioembolisation in the treatment of colorectal liver metastases comparing staging methods, criteria, and response. A search was performed of electronic databases from 1980 to November 2011. Information acquired included year published, patient numbers, resection status, chemotherapy regimen, criteria used to stage disease and assess response to radioembolisation, tumour markers, and overall/progression free survival. Nineteen studies were analysed including randomised controlled trials, clinical trials, meta-analyses, and case series. There is no validated modality as the method of choice when assessing response to radioembolisation. CT at 3 months following radioembolisation is the most frequently modality used to assess response to treatment. PET-CT is increasingly being used as it measures functional and radiological aspects. RECIST is the most frequently used criteria. Conclusion. A validated modality to assess response to radioembolisation is needed. We suggest PET-CT and CEA pre- and postradioembolisation at 3 months using RECIST 1.1 criteria released in 2009, which includes criteria for PET-CT, cystic changes, and necrosis.

Initial outcome after selective intraarterial radionuclide therapy with yttrium-90 microspheres as salvage therapy for unresectable metastatic liver disease

PURPOSE

The aim of the study was to retrospectively evaluate the potential benefit on survival outcomes of selective intraarterial radionuclide therapy (SIRT) with Yttrium-90 microspheres as a salvage therapy in liver metastasis of different tumors.

MATERIAL AND METHODS

Sixty-one patients who had unresectable liver metastases from colorectal carcinoma (n=23), neuroendocrine tumor (NET; n=12), cholangiocarcinoma (n=9), and others (n=17) received yttrium-90 microspheres. All patients were treated in a salvage setting with an 11-month mean follow-up. Early metabolic treatment response was evaluated by 18F-Fluorodeoxyglucose positron emission tomography (FDG PET-CT) in the sixth week after treatment.

RESULTS

Of the 61 patients, 32 were alive at the end of the study; median overall survival (OS) was 17.0 ± 2.5 months (95% confidence interval: 11.9-22.0). A subset analysis of colorectal and noncolorectal groups demonstrated median OS rates of 14.0 ± 5.8 and 17.0 ± 4.8 months, respectively (p=0.543). The mean OS for patients with NET and cholangiocarcinoma was 29.0 ± 3.1 months and 17.7 ± 3.2 months, respectively (p=0.010). According to the early metabolic treatment response, the mean OS of responder and nonresponder groups was 32.0 ± 5.6 months and 11.4 ± 2.1 months, respectively (p=0.054). Eastern Cooperative Oncology Group performance status <1 (p=0.018) and chemotherapy-naive patients (p=0.008) showed significant correlation with survival.

CONCLUSION

SIRT is an effective treatment option for patients with metastatic liver disease in a salvage setting with acceptable toxicity.

Intra-arterial therapies for metastatic colorectal cancer

Intra-arterial therapies for unresectable hepatic metastases from colorectal cancer include radioembolization (RE) with yttrium-90 microspheres, transarterial chemoembolization (TACE), hepatic arterial infusion, and percutaneous hepatic perfusion using an organ isolation system. In this article, we discuss our approach toward treatment selection, followed by details of how RE and TACE are performed at our institution.

Added value of FDG-PET imaging in the diagnostic workup for yttrium-90 radioembolisation in patients with colorectal cancer liver metastases

OBJECTIVE

Yttrium-90 radioembolisation (Y90-RE) is recommended for unresectable, chemorefractory liver-dominant disease; however, the incidence of extrahepatic disease (EHD) is high. FDG-PET may have additional value to CT in demonstrating EHD. Our aim was to evaluate the added diagnostic value of FDG-PET to abdominal CT and study the influence of FDG-PET findings on treatment decisions.

METHODS

All consecutive patients with colorectal cancer liver metastases (CRCLM) referred for Y90-RE were included. Patients who underwent both CT and FDG-PET in the diagnostic workup were selected. Imaging reports were scrutinised for documented sites of EHD, and changes of management due to FDG-PET findings were determined.

RESULTS

A total of 42 patients were included. Findings on CT and FDG-PET matched in 20 patients (no EHD, n = 15; identical EHD, n = 5). In 4 patients, lesions detected on CT were not FDG-avid, and in 18 patients, FDG-PET showed more lesions than CT (P < 0.05). In 7/42 patients (17 %) a change of management was made based on the additional FDG-PET findings, i.e. exclusion from Y90-RE treatment (n = 6) and change in treatment plan (whole liver rather than segmental treatment, n = 1).

CONCLUSIONS

In patients with CRCLM referred for Y90-RE, FDG-PET showed significantly more EHD and led to a considerable change of management.