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Chen QF, Chen S, Chen M, Lyu N, Zhao M. Improving the Conversion Success Rate of Hepatocellular Carcinoma: Focus on the Use of Combination Therapy with a High Objective Response Rate. J Clin Transl Hepatol 2024; 12:298-304. [PMID: 38426191 PMCID: PMC10899866 DOI: 10.14218/jcth.2023.00403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 12/03/2023] [Accepted: 12/25/2023] [Indexed: 03/02/2024] Open
Abstract
The high mortality rate in hepatocellular carcinoma (HCC) is partially due to the fact that a significant number of patients are diagnosed at an intermediate or advanced stage, with surgical treatment options unavailable. Conversion therapy, which involves both locoregional and systemic treatments, has the potential to downstage tumors in selected patients with initially unresectable HCC, thereby making surgical treatment a possibility and potentially increasing long-term survival. To optimize the conversion rate, it is necessary to maximize successful conversions and clearly define the target population for conversion treatment through a collaborative effort. In this review article, we summarize the clinical experience and evidence for conversion therapy in patients with 'potentially resectable' HCC from four perspectives: 1) defining the target population for conversion therapy, 2) selecting the appropriate conversion strategy, placing emphasis on the utilization of combination therapy that exhibits a significant objective response rate, 3) determining the timing and urgency of surgical resection, 4) promoting the adoption of a multidisciplinary team model. The authors are optimistic that with the continuous progress in treatment and a deeper understanding of HCC, the success rate of HCC conversion therapy will increase, and the overall survival of HCC patients will be prolonged.
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Affiliation(s)
- Qi-Feng Chen
- Department of Minimally Invasive Interventional Therapy, Liver Cancer Study and Service Group, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China
- State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, China
| | - Song Chen
- Department of Minimally Invasive Interventional Therapy, Liver Cancer Study and Service Group, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China
- State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, China
| | - Minshan Chen
- Department of Liver Surgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China
| | - Ning Lyu
- Department of Minimally Invasive Interventional Therapy, Liver Cancer Study and Service Group, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China
- State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, China
| | - Ming Zhao
- Department of Minimally Invasive Interventional Therapy, Liver Cancer Study and Service Group, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China
- State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, China
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Thoduka SG, Flegar L, Groeben C, Huber J, Eisenmenger N, Paulus T, Vogt K, Luster M, Abolmaali N. Trends in Selective Internal Radiation Therapy (SIRT) for Treating Hepatocellular Carcinoma, Cholangiocarcinoma, and Liver Metastasis: A Total Population Analysis from 2006 to 2021 in Germany. Curr Oncol 2023; 30:10325-10335. [PMID: 38132386 PMCID: PMC10742573 DOI: 10.3390/curroncol30120752] [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: 10/03/2023] [Revised: 11/30/2023] [Accepted: 12/04/2023] [Indexed: 12/23/2023] Open
Abstract
The aim of this study was to investigate trends in selective internal radiation therapy (SIRT) for hepatocellular carcinoma (HCC), cholangiocarcinoma (CCC), and liver metastasis in Germany. We analyzed the nationwide German hospital billing database from 2006 to 2019 for the diagnosis of HCC, CCC or liver metastasis in combination with SIRT. For analyses of SIRT on the hospital level, we used the reimbursement.INFO tool based on German hospitals' quality reports from 2008 to 2021. Linear regression analysis was performed to detect changes over time. We included a total of 14,165 SIRT procedures. The annual numbers increased from 99 in 2006 to 1605 in 2015 (p < 0.001; increase by 1521%), decreasing to 1175 cases in 2019 (p < 0.001). In 2008, 6 of 21 hospitals (28.6%) performed more than 20 SIRTs per year, which increased to 19 of 53 (35.8%) in 2021. The share of SIRT for HCC increased from 29.8% in 2006 to 44.7% in 2019 (p < 0.001) and for CCC from 0% in 2006 to 9.5% in 2019 (p < 0.001), while the share of SIRT for liver metastasis decreased from 70.2% in 2006 to 45.7% in 2019 (p < 0.001). In-hospital mortality was 0.2% after the SIRT procedure. Gastritis (2.7%), liver failure (0.4%), and sepsis (0.3%) were the most common in-hospital complications reported. We observed an increase in SIRT procedures in Germany, with the number of hospitals offering the procedure going up from 21 in 2008 to 53 in 2021. While the treatment of liver metastasis remains the most common indication, SIRT for HCC and CCC increased significantly over the last few years. The mortality and complication rates show that SIRT is a relatively safe procedure.
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Affiliation(s)
- Smita George Thoduka
- Department of Nuclear Medicine, Philipps University of Marburg, 35043 Marburg, Germany;
| | - Luka Flegar
- Department of Urology, Philipps University of Marburg, 35043 Marburg, Germany; (L.F.); (C.G.); (J.H.)
| | - Christer Groeben
- Department of Urology, Philipps University of Marburg, 35043 Marburg, Germany; (L.F.); (C.G.); (J.H.)
| | - Johannes Huber
- Department of Urology, Philipps University of Marburg, 35043 Marburg, Germany; (L.F.); (C.G.); (J.H.)
| | | | - Tobias Paulus
- Department for Diagnostic and Interventional Radiology and Nuclear Medicine, St. Josef Hospital, Ruhr-University Bochum, 44791 Bochum, Germany; (T.P.); (N.A.)
| | - Katharina Vogt
- Department of Radiology and Interventional Radiology, University Hospital Freiburg, 79110 Breisgau, Germany;
| | - Markus Luster
- Department of Nuclear Medicine, Philipps University of Marburg, 35043 Marburg, Germany;
| | - Nasreddin Abolmaali
- Department for Diagnostic and Interventional Radiology and Nuclear Medicine, St. Josef Hospital, Ruhr-University Bochum, 44791 Bochum, Germany; (T.P.); (N.A.)
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Tzedakis S, Sebai A, Jeddou H, Garin E, Rolland Y, Bourien H, Uguen T, Sulpice L, Robin F, Edeline J, Boudjema K. Resection Postradioembolization in Patients With Single Large Hepatocellular Carcinoma. Ann Surg 2023; 278:756-762. [PMID: 37539588 DOI: 10.1097/sla.0000000000006061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the efficacy of yttrium-90 transarterial radioembolization (TARE) to convert to resection initially unresectable, single, large (≥5 cm) hepatocellular carcinoma (HCC). BACKGROUND TARE can downsize cholangiocarcinoma to resection but its role in HCC resectability remains debatable. METHODS All consecutive patients with a single large HCC treated between 2015 and 2020 in a single tertiary center were reviewed. When indicated, patients were either readily resected (upfront surgery) or underwent TARE. TARE patients were converted to resection (TARE surgery) or not (TARE-only). To further assess the effect of TARE on the long-term and short-term outcomes, a propensity score matching analysis was performed. RESULTS Among 216 patients, 144 (66.7%) underwent upfront surgery. Among 72 TARE patients, 20 (27.7%) were converted to resection. TARE-surgery patients received a higher mean yttrium-90 dose that the 52 remaining TARE-only patients (211.89±107.98 vs 128.7±36.52 Gy, P <0.001). Postoperative outcomes between upfront-surgery and TARE-surgery patients were similar. In the unmatched population, overall survival at 1, 3, and 5 years was similar between upfront-surgery and TARE-surgery patients (83.0%, 60.0%, 47% vs 94.0%, 86.0%, 55.0%, P =0.43) and compared favorably with TARE-only patients (61.0%, 16.0% and 9.0%, P <0.0001). After propensity score matching, TARE-surgery patients had significantly better overall survival than upfront-surgery patients ( P =0.021), while disease-free survival was similar ( P =0.29). CONCLUSION TARE may be a useful downstaging treatment for unresectable localized single large HCC providing comparable short-term and long-term outcomes with readily resectable tumors.
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Affiliation(s)
- Stylianos Tzedakis
- Department of Hepatobiliary and Digestive Surgery, Pontchaillou University Hospital, University of Rennes 1, Rennes, France
| | - Amine Sebai
- Department of Hepatobiliary and Digestive Surgery, Pontchaillou University Hospital, University of Rennes 1, Rennes, France
| | - Heithem Jeddou
- Department of Hepatobiliary and Digestive Surgery, Pontchaillou University Hospital, University of Rennes 1, Rennes, France
| | - Etienne Garin
- Department of Nuclear Medicine, Centre Eugène Marquis, Rennes, France
| | - Yan Rolland
- Department of Interventional Radiology, Centre Eugène Marquis, Rennes, France
| | - Heloise Bourien
- Department of Medical Oncology, Centre Eugène Marquis, Rennes, France
| | - Thomas Uguen
- Department of Hepatology, Pontchaillou University Hospital, University of Rennes 1, Rennes, France
| | - Laurent Sulpice
- Department of Hepatobiliary and Digestive Surgery, Pontchaillou University Hospital, University of Rennes 1, Rennes, France
| | - Fabien Robin
- Department of Hepatobiliary and Digestive Surgery, Pontchaillou University Hospital, University of Rennes 1, Rennes, France
| | - Julien Edeline
- Department of Medical Oncology, Centre Eugène Marquis, Rennes, France
| | - Karim Boudjema
- Department of Hepatobiliary and Digestive Surgery, Pontchaillou University Hospital, University of Rennes 1, Rennes, France
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Dhote A, Tzedakis S, Hobeika C, Marchese U, Coriat R, Nassar A, Beaufrère A, Codjia T, Goumard C, Scatton O, Dohan A, Ronot M, Terris B, Lesurtel M, Dokmak S, Cauchy F, Fuks D. Impact of induction therapy in locally advanced intrahepatic cholangiocarcinoma. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:106939. [PMID: 37268522 DOI: 10.1016/j.ejso.2023.05.014] [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: 02/26/2023] [Revised: 05/13/2023] [Accepted: 05/19/2023] [Indexed: 06/04/2023]
Abstract
INTRODUCTION After local or systemic treatment, a small number of patients with primarily unresectable intrahepatic cholangiocarcinoma (ICC) may benefit from secondary resection. This study aimed to analyze the oncological outcome of patients who underwent radical surgery after preoperative treatment. METHODS From 2000 to 2021, all patients who underwent curative-intent liver resection for ICC in three tertiary centers were selected. Patients were divided into two groups: upfront surgery (US) and preoperative treatment (POT). Oncologic data (preoperative treatment, histologic data, adjuvant chemotherapy, overall survival, and recurrence-free survival) were compared between the two groups. RESULTS Among 198 included patients, 31 (15.7%) received POT including chemotherapy (74.2%), radioembolization (12.9%), chemoembolization (9.7%), or combined radiotherapy and chemotherapy (3.2%). Major resection was performed in 156 (78.8%) patients, and 53 (26.8%) had vascular and/or biliary reconstruction. Histological findings were similar between US and POT group and were not affected by the type of POT. After a median follow-up of 23 months, recurrence rate (58.1% POT vs. 55.1% US, p = 0.760) and type were similar between groups. Recurrence-free survival at 1 and 3 years (41.9% and 22.6% vs. 46.7 and 21.6% in the POT and US, respectively, p = 0.989) and overall survival at 1 and 3 years (77.4% and 32.3% vs. 69.5% and 34.7% in the POT and US respectively, p = 0.323) were similar and independent of the POT type. CONCLUSION After POT, downstaged patients who underwent curative-intent resection for initially unresectable ICC have similar long-term outcomes as those undergoing upfront surgery.
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Affiliation(s)
- Alix Dhote
- Service De Chirurgie Digestive, Hépatobiliaire Et Endocrinienne, Hôpital Cochin, Paris, France; Université Paris-Sorbonne, Paris, France.
| | - Stylianos Tzedakis
- Service De Chirurgie Digestive, Hépatobiliaire Et Endocrinienne, Hôpital Cochin, Paris, France; Université Paris Cité, Paris, France
| | - Christian Hobeika
- Service De Chirurgie Digestive, Hépato-Bilio-Pancréatique Et Transplantation Hépatique, Hôpital Beaujon, Clichy, France; Université Paris Cité, Paris, France
| | - Ugo Marchese
- Service De Chirurgie Digestive, Hépatobiliaire Et Endocrinienne, Hôpital Cochin, Paris, France; Université Paris Cité, Paris, France
| | - Romain Coriat
- Service De Cancérologie, Hôpital Cochin, Paris, France; Université Paris Cité, Paris, France
| | - Alexandra Nassar
- Service De Chirurgie Digestive, Hépatobiliaire Et Endocrinienne, Hôpital Cochin, Paris, France; Université Paris Cité, Paris, France
| | - Aurélie Beaufrère
- Service d'Anatomie et cytologie pathologique, APHP.Nord, FHU MOSAIC, Hôpital Beaujon, Clichy, France; Université Paris Cité, Paris, France
| | - Tatiana Codjia
- Service De Chirurgie Digestive, Hépato-Bilio-Pancréatique Et Transplantation Hépatique, Hôpital Beaujon, Clichy, France; Université Paris Cité, Paris, France
| | - Claire Goumard
- Service de Chirurgie Digestive, Hépato-Bilio-pancréatique et Transplantation Hépatique, Hôpital Pitié-Salpêtrière, Paris, France; Université Paris-Sorbonne, Paris, France
| | - Olivier Scatton
- Service de Chirurgie Digestive, Hépato-Bilio-pancréatique et Transplantation Hépatique, Hôpital Pitié-Salpêtrière, Paris, France; Université Paris-Sorbonne, Paris, France
| | - Anthony Dohan
- Service De Radiologie, Hôpital Cochin, Paris, France; Université Paris Cité, Paris, France
| | - Maxime Ronot
- Service De Radiologie, Hôpital Beaujon, APHP.Nord, Clichy, France; Université Paris Cité, Paris, France
| | - Benoit Terris
- Service d'Anatomie et cytologie pathologique, Hôpital Cochin, Paris, France; Université Paris Cité, Paris, France
| | - Mickael Lesurtel
- Service De Chirurgie Digestive, Hépato-Bilio-Pancréatique Et Transplantation Hépatique, Hôpital Beaujon, Clichy, France; Université Paris Cité, Paris, France
| | - Safi Dokmak
- Service De Chirurgie Digestive, Hépato-Bilio-Pancréatique Et Transplantation Hépatique, Hôpital Beaujon, Clichy, France; Université Paris Cité, Paris, France
| | - François Cauchy
- Service De Chirurgie Digestive, Hépato-Bilio-Pancréatique Et Transplantation Hépatique, Hôpital Beaujon, Clichy, France; Université Paris Cité, Paris, France
| | - David Fuks
- Service De Chirurgie Digestive, Hépatobiliaire Et Endocrinienne, Hôpital Cochin, Paris, France; Université Paris Cité, Paris, France
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Prediction of left lobe hypertrophy after right lobe radioembolization of the liver using a clinical data model with external validation. Sci Rep 2022; 12:20718. [PMID: 36456637 PMCID: PMC9715713 DOI: 10.1038/s41598-022-25077-6] [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: 12/08/2021] [Accepted: 11/24/2022] [Indexed: 12/02/2022] Open
Abstract
In cirrhotic patients with hepatocellular carcinoma (HCC), right-sided radioembolization (RE) with Yttrium-90-loaded microspheres is an established palliative therapy and can be considered a "curative intention" treatment when aiming for sequential tumor resection. To become surgical candidate, hypertrophy of the left liver lobe to > 40% (future liver remnant, FLR) is mandatory, which can develop after RE. The amount of radiation-induced shrinkage of the right lobe and compensatory hypertrophy of the left lobe is difficult for clinicians to predict. This study aimed to utilize machine learning to predict left lobe liver hypertrophy in patients with HCC and cirrhosis scheduled for right lobe RE, with external validation. The results revealed that machine learning can accurately predict relative and absolute volume changes of the left liver lobe after right lobe RE. This prediction algorithm could help to estimate the chances of conversion from palliative RE to curative major hepatectomy following significant FLR hypertrophy.
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6
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Pouget JP. Basics of radiobiology. Nucl Med Mol Imaging 2022. [DOI: 10.1016/b978-0-12-822960-6.00137-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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7
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Theranostic radiopharmacy for the nuclear medicine and molecular imaging. Nucl Med Mol Imaging 2022. [DOI: 10.1016/b978-0-12-822960-6.00066-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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8
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Abstract
Selective internal radiation therapy represents an endovascular treatment option for patients with primary liver malignancies, in different clinical stages. Potential applications of this treatment are in early-stage hepatocellular carcinoma, as a curative option, or in combination with systemic treatments in intermediate and advanced-stages. This review, based on existing literature and ongoing trials, will focus on the future of this treatment in patients with hepatocellular carcinoma, in combination with systemic treatments, or with the use of new devices and technological developments; it will also describe new potential future indications and structural and organizational perspectives.
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Xing R, Gao J, Cui Q, Wang Q. Strategies to Improve the Antitumor Effect of Immunotherapy for Hepatocellular Carcinoma. Front Immunol 2021; 12:783236. [PMID: 34899747 PMCID: PMC8660685 DOI: 10.3389/fimmu.2021.783236] [Citation(s) in RCA: 73] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 11/09/2021] [Indexed: 12/12/2022] Open
Abstract
Hepatocellular carcinoma (HCC), one of the most fatal malignancies in the world, is usually diagnosed in advanced stages due to late symptom manifestation with very limited therapeutic options, which leads to ineffective intervention and dismal prognosis. For a decade, tyrosine kinase inhibitors (TKIs) have offered an overall survival (OS) benefit when used in a first-line (sorafenib and lenvatinib) and second-line setting (regorafenib and cabozantinib) in advanced HCC, while long-term response remains unsatisfactory due to the onset of primary or acquired resistance. Recently, immunotherapy has emerged as a promising therapy in the treatment of several solid tumors, such as melanoma and non-small cell lung cancer. Moreover, as the occurrence of HCC is associated with immune tolerance and immunosurveillance escape, there is a potent rationale for employing immunotherapy in HCC. However, immunotherapy monotherapy, mainly including immune checkpoint inhibitors (ICIs) that target checkpoints programmed death-1 (PD-1), programmed death-ligand 1 (PD-L1), and the cytotoxic T lymphocyte antigen-4 (CTLA-4), has a relatively low response rate. Thus, the multi-ICIs or the combination of immunotherapy with other therapies, like antiangiogenic drugs and locoregional therapies, has become a novel strategy to treat HCC. Combining different ICIs may have a synergistical effect attributed to the complementary effects of the two immune checkpoint pathways (CTLA-4 and PD-1/PD-L1 pathways). The incorporation of antiangiogenic drugs in ICIs can enhance antitumor immune responses via synergistically regulating the vasculature and the immune microenvironment of tumor. In addition, locoregional treatments can improve antitumor immunity by releasing the neoplasm antigens from killed tumor cells; in turn, this antitumor immune response can be intensified by immunotherapy. Therefore, the combination of locoregional treatments and immunotherapy may achieve greater efficacy through further synergistic effects for advanced HCC. This review aims to summarize the currently reported results and ongoing trials of the ICIs-based combination therapies for HCC to explore the rational combination strategies and further improve the survival of patients with HCC.
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Affiliation(s)
- Rui Xing
- Department of Oncology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Jinping Gao
- Department of Oncology, North War Zone General Hospital, Shenyang, China
| | - Qi Cui
- Department of Cold Environmental Medicine, College of High Altitude Military Medicine, Third Military Medical University (Army Medical University), Chongqing, China
| | - Qian Wang
- Department of Oncology, Shengjing Hospital of China Medical University, Shenyang, China
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Moslim MA, Jeyarajah DR. Narrative review of the role of yttrium-90 selective internal radiation therapy in the surgical management of colorectal liver metastases. J Gastrointest Oncol 2021; 12:2438-2446. [PMID: 34790404 DOI: 10.21037/jgo-21-96] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 06/08/2021] [Indexed: 11/06/2022] Open
Abstract
The management of colorectal liver metastasis (CRLM) is complicated and benefits from a multidisciplinary team approach. Liver-directed therapy has been emerging as a modality for better progression-free control. In its early years, selective internal radiation therapy (SIRT) with yttrium-90 (Y-90) was confined as an end-of-line therapy. However, literature has supported other roles including: a first-line treatment for CRLM alone or in combination with systemic chemotherapy; an adjunct to second or third-line chemotherapy; and a salvage treatment for chemo-refractory disease. Although future liver remnant (FLR) hypertrophy may take 3-12 months, the SIRT effect on loco-regional disease control has rendered it to be a useful tool in some pathologies with certain strategic goals. This paper reviews the use of SIRT with Y-90 in a surgical treatment pathway. This includes: (I) an element of multidisciplinary treatment of low-volume CRLMs, (II) convert an R1 to R0 resection by sterilizing the margins of tumor near critical structures, and (III) radiation lobectomy to induce contralateral hypertrophy in order to aid in a safer resection. There are many opportunities to validate the role of SIRT as a first-line therapy along with surgical resection including an umbrella clinical trial design.
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11
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Sun HC, Zhu XD. Downstaging Conversion Therapy in Patients With Initially Unresectable Advanced Hepatocellular Carcinoma: An Overview. Front Oncol 2021; 11:772195. [PMID: 34869008 PMCID: PMC8636437 DOI: 10.3389/fonc.2021.772195] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 10/28/2021] [Indexed: 12/12/2022] Open
Abstract
The high mortality rate associated with hepatocellular carcinoma (HCC) is partly due to the high proportion of patients who present with advanced stage disease at diagnosis, for whom there are limited treatment options. For selected patients with initially unresectable HCC, locoregional and/or systemic treatments can result in tumor downstaging and consequently provide opportunities for surgical intervention and the potential for long-term survival. Therefore, the key aim of 'conversion therapy' is to reduce tumor burden so that patients become amenable to surgical resection. Various therapies have been investigated as candidates for downstaging patients with potentially resectable HCC including transarterial chemoembolization, transarterial radioembolization with yttrium-90 microspheres, radiotherapy, systemic therapies and combination or multimodality treatment approaches. However, downstaging conversion therapy remains controversial and there are several challenges such as defining the criteria used to identify the population of patients who are 'potentially resectable', the criteria used to define successful downstaging, and the optimum treatment approach to maximize the success of downstaging therapy. In this review article, we summarize clinical experience and evidence of downstaging conversion treatment in patients identified as having 'potentially resectable' HCC.
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Affiliation(s)
- Hui-Chuan Sun
- Department of Liver Surgery and Transplantation, Liver Cancer Institute and Zhongshan Hospital, Fudan University, Shanghai, China
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12
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Kwan J, Pua U. Review of Intra-Arterial Therapies for Colorectal Cancer Liver Metastasis. Cancers (Basel) 2021; 13:cancers13061371. [PMID: 33803606 PMCID: PMC8003062 DOI: 10.3390/cancers13061371] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/14/2021] [Accepted: 03/15/2021] [Indexed: 12/12/2022] Open
Abstract
Simple Summary Colorectal cancer liver metastasis occurs in more than 50% of patients with colorectal cancer and is thought to be the most common cause of death from this cancer. The mainstay of treatment for inoperable liver metastasis has been combination systemic chemotherapy with or without the addition of biological targeted therapy with a goal for disease downstaging, for potential curative resection, or more frequently, for disease control. For patients with dominant liver metastatic disease or limited extrahepatic disease, liver-directed intra-arterial therapies including hepatic arterial chemotherapy infusion, chemoembolization and radioembolization are alternative treatment strategies that have shown promising results, most commonly in the salvage setting in patients with chemo-refractory disease. In recent years, their role in the first-line setting in conjunction with concurrent systemic chemotherapy has also been explored. This review aims to provide an update on the current evidence regarding liver-directed intra-arterial treatment strategies and to discuss potential trends for the future. Abstract The liver is frequently the most common site of metastasis in patients with colorectal cancer, occurring in more than 50% of patients. While surgical resection remains the only potential curative option, it is only eligible in 15–20% of patients at presentation. In the past two decades, major advances in modern chemotherapy and personalized biological agents have improved overall survival in patients with unresectable liver metastasis. For patients with dominant liver metastatic disease or limited extrahepatic disease, liver-directed intra-arterial therapies such as hepatic arterial chemotherapy infusion, chemoembolization and radioembolization are treatment strategies which are increasingly being considered to improve local tumor response and to reduce systemic side effects. Currently, these therapies are mostly used in the salvage setting in patients with chemo-refractory disease. However, their use in the first-line setting in conjunction with systemic chemotherapy as well as to a lesser degree, in a neoadjuvant setting, for downstaging to resection have also been investigated. Furthermore, some clinicians have considered these therapies as a temporizing tool for local disease control in patients undergoing a chemotherapy ‘holiday’ or acting as a bridge in patients between different lines of systemic treatment. This review aims to provide an update on the current evidence regarding liver-directed intra-arterial treatment strategies and to discuss potential trends for the future.
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13
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Modern therapeutic approaches for the treatment of malignant liver tumours. Nat Rev Gastroenterol Hepatol 2020; 17:755-772. [PMID: 32681074 DOI: 10.1038/s41575-020-0314-8] [Citation(s) in RCA: 113] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/05/2020] [Indexed: 02/06/2023]
Abstract
Malignant liver tumours include a wide range of primary and secondary tumours. Although surgery remains the mainstay of curative treatment, modern therapies integrate a variety of neoadjuvant and adjuvant strategies and have achieved dramatic improvements in survival. Extensive tumour loads, which have traditionally been considered unresectable, are now amenable to curative treatment through systemic conversion chemotherapies followed by a variety of interventions such as augmentation of the healthy liver through portal vein occlusion, staged surgeries or ablation modalities. Liver transplantation is established in selected patients with hepatocellular carcinoma but is now emerging as a promising option in many other types of tumour such as perihilar cholangiocarcinomas, neuroendocrine or colorectal liver metastases. In this Review, we summarize the available therapies for the treatment of malignant liver tumours, with an emphasis on surgical and ablative approaches and how they align with other therapies such as modern anticancer drugs or radiotherapy. In addition, we describe three complex case studies of patients with malignant liver tumours. Finally, we discuss the outlook for future treatment, including personalized approaches based on molecular tumour subtyping, response to targeted drugs, novel biomarkers and precision surgery adapted to the specific tumour.
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14
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Mafeld S, Littler P, Hayhurst H, Manas D, Jackson R, Moir J, French J. Liver Resection After Selective Internal Radiation Therapy with Yttrium-90: Safety and Outcomes. J Gastrointest Cancer 2020; 51:152-158. [PMID: 30911980 PMCID: PMC7000505 DOI: 10.1007/s12029-019-00221-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction Selective internal radiotherapy (SIRT) with yttrium-90 (Y-90) is an intra-arterial therapy for hepatic malignancy in patients who are unsuitable for surgical resection. This treatment is considered palliative, although some patients can demonstrate a response that is adequate to facilitate surgical resection with curative intent. Methods All patients who underwent liver resection post SIRT were reviewed. Data gathered included patient demographics, tumor type, surgical details, and post-operative outcomes. Results Twelve patients underwent SIRT followed by liver resection (7 males and 5 females). Pathologies were hepatocellular carcinoma (n = 5), metastatic colorectal cancer (n = 5), and neuroendocrine tumor (n = 2). Lesional response (size, volume, and RECIST (response evaluation criteria in solid tumors)) was calculated and where appropriate functional liver remnant (FLR) is presented. Mean FLR increase was 264cm3 (range − 123 to 909), and all cases demonstrated a partial response according to RECIST with a mean largest lesion volume reduction of 475cm3 (range 14–1632). No post-SIRT complications were noted. Hepatectomy occurred at a mean of 322 days from SIRT treatment. Ninety-day morbidity was 67% (n = 6), complications post-surgery were analyzed according to the Clavien-Dindo classification scale; a total of 15 events occurred in 6 patients. Ninety-day mortality of 11% (n = 1). Conclusion In selected cases, liver resection is possible post SIRT. As this can represent a potentially curative option, it is important to reconsider resection in the follow-up of patients undergoing SIRT. Post-operative complications are noted following major and extended liver resection. Therefore, further studies are needed to improve patient selection.
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Affiliation(s)
- Sebastian Mafeld
- Department of Interventional Radiology, Freeman Hospital, Freeman Road, High Heaton, Newcastle upon Tyne, NE7 7DN, UK.
| | - Peter Littler
- Department of Interventional Radiology, Freeman Hospital, Freeman Road, High Heaton, Newcastle upon Tyne, NE7 7DN, UK
| | - Hannah Hayhurst
- Department of Hepatobiliary Surgery, Freeman Hospital, Newcastle upon Tyne, NE7 7DN, UK
| | - Derek Manas
- Department of Hepatobiliary Surgery, Freeman Hospital, Newcastle upon Tyne, NE7 7DN, UK
| | - Ralph Jackson
- Department of Interventional Radiology, Freeman Hospital, Freeman Road, High Heaton, Newcastle upon Tyne, NE7 7DN, UK
| | - John Moir
- Department of Hepatobiliary Surgery, Freeman Hospital, Newcastle upon Tyne, NE7 7DN, UK
| | - Jeremy French
- Department of Hepatobiliary Surgery, Freeman Hospital, Newcastle upon Tyne, NE7 7DN, UK
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15
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Riby D, Mazzotta AD, Bergeat D, Verdure L, Sulpice L, Bourien H, Lièvre A, Rolland Y, Garin E, Boudjema K, Edeline J. Downstaging with Radioembolization or Chemotherapy for Initially Unresectable Intrahepatic Cholangiocarcinoma. Ann Surg Oncol 2020; 27:3729-3737. [PMID: 32472411 DOI: 10.1245/s10434-020-08486-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Indexed: 12/22/2022]
Abstract
OBJECTIVE The aim of this retrospective study was to compare the outcomes of patients resected for intrahepatic cholangiocarcinoma (ICC) with upfront surgery or after downstaging treatment. METHODS All consecutive patients with ICC between January 1997 and November 2017 were included in a single-center database and retrospectively reviewed. Patients were divided into two groups: upfront resection or resection after downstaging using either chemotherapy alone or selective internal radiation therapy (SIRT) combined with chemotherapy. Survival rates of patients who underwent upfront surgery for ICC were compared with those of patients who underwent surgery after downstaging therapy. RESULTS A total of 169 patients resected for ICC were included: 137 underwent upfront surgery and 32 received downstaging treatment because their tumor was initially unresectable (13 received chemotherapy, 19 received SIRT). Median OS was not different between the two groups: 32.3 months [95% confidence interval (CI) 23.9-40.7] with primary surgery versus 45.9 months (95% CI 32.3-59.4) with downstaging treatment (p = 0.54, log-rank test). In a multivariable Cox regression model, downstaging treatment was not associated with a better or worse prognosis; however, delivery of SIRT as a downstaging treatment was associated with a significant benefit in multivariable analysis (hazard ratio 0.34, 95% CI 0.14-0.84; p = 0.019). CONCLUSIONS Overall survival of patients resected after downstaging treatment was not different compared with the OS of patients resected upfront. Patients should therefore again be discussed with the surgeon following medical treatment. SIRT may be an efficient neoadjuvant therapy in patients with resectable ICC, in order to improve surgical results.
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Affiliation(s)
- Diane Riby
- Departement of Medical Oncology, Centre Eugène Marquis, Rennes, France
| | - Alessandro D Mazzotta
- Departement of Hepatobiliary and Digestive Surgery, CHU Rennes, University of Rennes, Rennes, France
| | - Damien Bergeat
- Departement of Hepatobiliary and Digestive Surgery, CHU Rennes, University of Rennes, Rennes, France
| | - Lucas Verdure
- Departement of Hepatobiliary and Digestive Surgery, CHU Rennes, University of Rennes, Rennes, France
| | - Laurent Sulpice
- Departement of Hepatobiliary and Digestive Surgery, CHU Rennes, University of Rennes, Rennes, France
| | - Heloise Bourien
- Departement of Medical Oncology, Centre Eugène Marquis, Rennes, France
| | - Astrid Lièvre
- Departement of Hepatogastroenterology, CHU Rennes, University of Rennes, Rennes, France
| | - Yan Rolland
- Departement of Interventional Radiology, Centre Eugène Marquis, Rennes, France
| | - Etienne Garin
- Departement of Nuclear Medicine, Centre Eugène Marquis, Rennes, France
| | - Karim Boudjema
- Departement of Hepatobiliary and Digestive Surgery, CHU Rennes, University of Rennes, Rennes, France.
| | - Julien Edeline
- Departement of Medical Oncology, Centre Eugène Marquis, Rennes, France
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16
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Jeyarajah DR, Doyle MBM, Espat NJ, Hansen PD, Iannitti DA, Kim J, Thambi-Pillai T, Visser BC. Role of yttrium-90 selective internal radiation therapy in the treatment of liver-dominant metastatic colorectal cancer: an evidence-based expert consensus algorithm. J Gastrointest Oncol 2020; 11:443-460. [PMID: 32399284 DOI: 10.21037/jgo.2020.01.09] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Surgical resection of colorectal liver metastases is associated with greater survival compared with non-surgical treatment, and a meaningful possibility of cure. However, the majority of patients are not eligible for resection and may require other non-surgical interventions, such as liver-directed therapies, to be converted to surgical eligibility. Given the number of available therapies, a general framework is needed that outlines the specific roles of chemotherapy, surgery, and locoregional treatments [including selective internal radiation therapy (SIRT) with Y-90 microspheres]. Using a data-driven, modified Delphi process, an expert panel of surgical oncologists, transplant surgeons, and hepatopancreatobiliary (HPB) surgeons convened to create a comprehensive, evidence-based treatment algorithm that includes appropriate treatment options for patients stratified by their eligibility for surgical treatment. The group coined a novel, more inclusive phrase for targeted locoregional tumor treatment (a blanket term for resection, ablation, and other emerging locoregional treatments): local parenchymal tumor destruction therapy. The expert panel proposed new nomenclature for 3 distinct disease categories of liver-dominant metastatic colorectal cancer that is consistent with other tumor types: (I) surgically treatable (resectable); (II) surgically untreatable (borderline resectable); (III) advanced surgically untreatable (unresectable) disease. Patients may present at any point in the algorithm and move between categories depending on their response to therapy. The broad intent of therapy is to transition patients toward individualized treatments where possible, given the survival advantage that resection offers in the context of a comprehensive treatment plan. This article reviews what is known about the role of SIRT with Y-90 as neoadjuvant, definitive, or palliative therapy in these different clinical situations and provides insight into when treatment with SIRT with Y-90 may be appropriate and useful, organized into distinct treatment algorithm steps.
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Affiliation(s)
| | | | - N Joseph Espat
- Department of Surgery, Roger Williams Medical Center, Boston University School of Medicine, Providence, RI, USA
| | - Paul D Hansen
- HPB Surgery, Providence Portland Center, Portland, OR, USA
| | - David A Iannitti
- HPB Surgery, Atrium Health, Carolinas Medical Center, Charlotte, NC, USA
| | - Joseph Kim
- Department of Surgery, University of Kentucky, Lexington, KY, USA
| | - Thavam Thambi-Pillai
- Department of Surgery, University of South Dakota Sanford School of Medicine, Sioux Falls, SD, USA
| | - Brendan C Visser
- Department of Surgery, Stanford University Medical Center, CA, USA
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17
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Edeline J, Touchefeu Y, Guiu B, Farge O, Tougeron D, Baumgaertner I, Ayav A, Campillo-Gimenez B, Beuzit L, Pracht M, Lièvre A, Le Sourd S, Boudjema K, Rolland Y, Boucher E, Garin E. Radioembolization Plus Chemotherapy for First-line Treatment of Locally Advanced Intrahepatic Cholangiocarcinoma: A Phase 2 Clinical Trial. JAMA Oncol 2020; 6:51-59. [PMID: 31670746 DOI: 10.1001/jamaoncol.2019.3702] [Citation(s) in RCA: 153] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Importance Patients with unresectable intrahepatic cholangiocarcinoma (ICC) have a poor prognosis. Selective internal radiotherapy (SIRT) is a promising treatment option for hepatic tumors, but no prospective studies of combination SIRT with chemotherapy have been published to our knowledge. Objective To determine the response rate after SIRT combined with chemotherapy in patients with unresectable ICC. Design, Setting, and Participants This phase 2 clinical trial, the Yttrium-90 Microspheres in Cholangiocarcinoma (MISPHEC) trial, included patients with unresectable ICC who have never received chemotherapy or intra-arterial therapy and were treated at 7 centers which had experience with SIRT between November 12, 2013, and June 21, 2016. Statistical analysis was performed from March 31, 2017, to June 17, 2019. Interventions Concomitant first-line chemotherapy with cisplatin, 25 mg/m2, and gemcitabine, 1000 mg/m2 (gemcitabine reduced to 300 mg/m2 for the cycles just before and after SIRT), on days 1 and 8 of a 21-day cycle for 8 cycles. Selective internal radiotherapy was administered during cycle 1 (1 hemiliver disease) or cycles 1 and 3 (disease involving both hemilivers) using glass Y90 microspheres. Main Outcomes and Measures Response rate at 3 months according to Response Evaluation Criteria in Solid Tumors (RECIST) 1.1. Secondary end points were toxic effects, progression-free survival, overall survival, disease control rate, and response rate according to Choi criteria. Results Of 41 patients included in the study, 26 (63%) were male, with a mean (SD) age of 64.0 (10.7) years. Response rate according to RECIST was 39% (90% CI, 26%-53%) at 3 months according to local review and was confirmed at 41% as best response by central review; disease control rate was 98%. According to Choi criteria, the response rate was 93%. After a median follow-up of 36 months (95% CI, 26-52 months), median progression-free survival was 14 months (95% CI, 8-17 months), with progression-free survival rates of 55% at 12 months and 30% at 24 months. Median overall survival was 22 months (95% CI, 14-52 months), with overall survival rates of 75% at 12 months and 45% at 24 months. Of 41 patients, 29 (71%) had grades 3 to 4 toxic effects; 9 patients (22%) could be downstaged to surgical intervention, with 8 (20%) achieving R0 (microscopic-free margins) surgical resection. After a median of 46 months (95% CI, 31 months to not reached) after surgery, median relapse-free survival was not reached among patients who underwent resection. Conclusions and Relevance Combination chemotherapy and SIRT had antitumor activity as first-line treatment of unresectable ICC, and a significant proportion of patients were downstaged to surgical intervention. A phase 3 trial is ongoing.
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Affiliation(s)
- Julien Edeline
- Department of Medical Oncology, Centre Eugène Marquis, Rennes, France.,Université Rennes, IndianaSERM, IndianaRA, Centre de Lutte contre le Cancer Eugène Marquis, Institut NUMECAN (Nutrition Metabolisms and Cancer), Rennes, France
| | | | - Boris Guiu
- Centre Hospitalier Universitaire Montpellier, Montpellier, France
| | - Olivier Farge
- Centre Hospitalier Universitaire Beaujon, Clichy, France
| | - David Tougeron
- Centre Hospitalier Universitaire Poitiers, Poitiers, France
| | | | - Ahmet Ayav
- Centre Hospitalier Universitaire Nancy, Nancy, France
| | - Boris Campillo-Gimenez
- Department of Medical Oncology, Centre Eugène Marquis, Rennes, France.,INSERM, LTSI U1099, Université Rennes 1, Rennes, France
| | - Luc Beuzit
- Radiology, Centre Hospitalier Universitaire Pontchaillou, Rennes, France
| | - Marc Pracht
- Department of Medical Oncology, Centre Eugène Marquis, Rennes, France
| | - Astrid Lièvre
- Gastroenterology, Centre Hospitalier Universitaire Pontchaillou, Rennes, France.,Univ Rennes, Inserm, Regional Cancer Center Eugène Marquis, Chemistry Oncogenesis Stress Signaling-UMR1242, Rennes, France
| | - Samuel Le Sourd
- Department of Medical Oncology, Centre Eugène Marquis, Rennes, France
| | - Karim Boudjema
- Hepatobiliary Surgery, Centre Hospitalier Universitaire Pontchaillou, Rennes, France
| | - Yan Rolland
- Radiology, Centre Eugène Marquis, Rennes, France
| | - Eveline Boucher
- Department of Medical Oncology, Centre Eugène Marquis, Rennes, France
| | - Etienne Garin
- Nuclear Medicine, Centre Eugène Marquis, Rennes, France
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18
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Tustumi F, Ernani L, Coelho FF, Bernardo WM, Junior SS, Kruger JAP, Fonseca GM, Jeismann VB, Cecconello I, Herman P. Preoperative strategies to improve resectability for hepatocellular carcinoma: a systematic review and meta-analysis. HPB (Oxford) 2018; 20:1109-1118. [PMID: 30057123 DOI: 10.1016/j.hpb.2018.06.1798] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 06/14/2018] [Accepted: 06/16/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Preoperative strategies to increase the future liver remnant are useful methods to improve resectability rates for patients with hepatocellular carcinoma (HCC). The aim of this study was to perform a systematic review and meta-analysis of the main strategies used for this purpose. METHODS A systematic review was performed in PubMed, EMBASE, Cochrane and Scielo/LILACS. The procedures included for analysis were portal vein embolization or ligation (PVE/PVL), sequential transarterial embolization and PVE (TACE + PVE), radioembolization (RE) and associated liver partition and portal vein ligation for staged hepatectomy (ALPPS). Perioperative morbidity and mortality, post-hepatectomy liver failure (PHLF), and survival rates were evaluated. RESULTS A total of 46 studies were included in the systematic review (1284 patients). Resection rate was higher in TACE + PVE (90%; N = 315) when compared to PVE/PVL (75%; N = 254; P = <0.001) and similar to ALPPS (84%; N = 43; P = 0.374) and RE (100%; N = 28; P = 0.14). ALPPS was associated with higher PHLF and perioperative mortality rates when compared to PVE/PVL and TACE + PVE. ALPPS and RE showed higher risk of major complications than PVE/PVL and TACE + PVE. CONCLUSION Preoperative strategies to increase liver volume are effective in achieving resectability of HCC. TACE + PVE is as safe as PVL/PVE providing higher OS. ALPPS is associated with a higher risk of PHLF, major complications, and mortality. RE despite the small experience seems to present similar resection rate and OS as TACE + PVE with higher rate of major complications.
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Affiliation(s)
- Francisco Tustumi
- Department of Gastroenterology, Digestive Surgery Division, Sao Paulo School of Medicine, Brazil.
| | - Lucas Ernani
- Department of Gastroenterology, Digestive Surgery Division, Sao Paulo School of Medicine, Brazil
| | - Fabricio F Coelho
- Department of Gastroenterology, Digestive Surgery Division, Sao Paulo School of Medicine, Brazil
| | - Wanderley M Bernardo
- Department of Gastroenterology, Digestive Surgery Division, Sao Paulo School of Medicine, Brazil
| | - Sérgio S Junior
- Department of Gastroenterology, Digestive Surgery Division, Sao Paulo School of Medicine, Brazil
| | - Jaime A P Kruger
- Department of Gastroenterology, Digestive Surgery Division, Sao Paulo School of Medicine, Brazil
| | - Gilton M Fonseca
- Department of Gastroenterology, Digestive Surgery Division, Sao Paulo School of Medicine, Brazil
| | - Vagner B Jeismann
- Department of Gastroenterology, Digestive Surgery Division, Sao Paulo School of Medicine, Brazil
| | - Ivan Cecconello
- Department of Gastroenterology, Digestive Surgery Division, Sao Paulo School of Medicine, Brazil
| | - Paulo Herman
- Department of Gastroenterology, Digestive Surgery Division, Sao Paulo School of Medicine, Brazil
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19
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Falciform Ligament Artery Uptake on 99mTc MAA Planning Scan Before 90Y SIRT Confirmed by Retrospective SPECT/MRI Fusion. Clin Nucl Med 2018; 43:522-523. [PMID: 29742611 DOI: 10.1097/rlu.0000000000002099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Selective internal radiation therapy using Y spheres is a treatment option for patients with primary or secondary liver cancer. To avoid complications, screening using Tc macroaggregated albumin is performed to identify lung shunting and extrahepatic depositions. For the latter, deposition after the anterior abdominal wall is frequently attributed to a patent falciform artery, although the vessel itself is rarely visible on SPECT/CT scans. We demonstrate that retrospective SPECT/MRI fusion clearly attributes the nuclide accumulation to a patent falciform artery. During selective internal radiation therapy, ice packs were placed on the anterior abdominal wall, resulting in a complication-free treatment.
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20
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Abstract
The treatment of malignancies has undergone dramatic changes in the past few decades. Advances in drug delivery techniques and nanotechnology have allowed for new formulations of old drugs, so as to improve the pharmacokinetics, to enhance accumulation in solid tumors, and to reduce the significant toxic effects of these important therapeutic agents. Here, we review the published clinical data in cancer therapy of several major drug delivery systems, including targeted radionuclide therapy, antibody-drug conjugates, liposomes, polymer-drug conjugates, polymer implants, micelles, and nanoparticles. The clinical outcomes of these delivery systems from various phases of clinical trials are summarized. The success and limitations of the drug delivery strategies are discussed based on the clinical observations. In addition, the challenges in applying drug delivery for efficacious cancer therapy, including physical barriers, tumor heterogeneity, drug resistance, and metastasis, are discussed along with future perspectives of drug delivery in cancer therapy. In doing so, we intend to underscore that efficient delivery of cancer therapeutics to solid malignancies remains a major challenge in cancer therapy, and requires a multidisciplinary approach that integrates knowledge from the diverse fields of chemistry, biology, engineering, and medicine. The overall objective of this review is to improve our understanding of the clinical fate of commonly investigated drug delivery strategies, and to identify the limitations that must be addressed in future drug delivery strategies, toward the pursuit of curative therapies for cancer.
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Affiliation(s)
- Zheng-Rong Lu
- Case Center for Biomolecular Engineering, Department of Biomedical Engineering , Case Western Reserve University , Cleveland , Ohio 44106 , United States
| | - Peter Qiao
- Case Center for Biomolecular Engineering, Department of Biomedical Engineering , Case Western Reserve University , Cleveland , Ohio 44106 , United States
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21
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Vouche M, Degrez T, Bouazza F, Delatte P, Galdon MG, Hendlisz A, Flamen P, Donckier V. Sequential tumor-directed and lobar radioembolization before major hepatectomy for hepatocellular carcinoma. World J Hepatol 2017; 9:1372-1377. [PMID: 29359022 PMCID: PMC5756728 DOI: 10.4254/wjh.v9.i36.1372] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2017] [Revised: 11/20/2017] [Accepted: 12/05/2017] [Indexed: 02/06/2023] Open
Abstract
Preoperative radioembolization may improve the resectability of liver tumor by inducing tumor shrinkage, atrophy of the embolized liver and compensatory hypertrophy of non-embolized liver. We describe the case of a cirrhotic Child-Pugh A patient with a segment IV hepatocellular carcinoma requiring a left hepatectomy. Preoperative angiography demonstrated 2 separated left hepatic arteries, for segment IV and segments II-III. This anatomic variant allowed sequential radioembolizations, delivering high-dose 90Yttrium (160 Gy) to the tumor, followed 28 d later by lower dose (120 Gy) to segments II-III. After 3 mo, significant tumor response and atrophy of the future resected liver were obtained, allowing uneventful left hepatectomy. This case illustrates that, when anatomic disposition permits it, sequential radioembolizations, delivering different 90Yttrium doses to the tumor and the future resected liver, could represent a new strategy to prepare major hepatectomy in cirrhotic patients, allowing optimal tumoricidal effect while reducing the toxicity of the global procedure.
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Affiliation(s)
- Michael Vouche
- Department of Radiology, Institut Jules Bordet, Université Libre de Bruxelles, Brussels 1000, Belgium
| | - Thierry Degrez
- Department of Gastroenterology, CHR Sambre et Meuse, Namur 5000, Belgium
| | - Fikri Bouazza
- Department of Abdominal Surgery, Institut Jules Bordet, Université Libre de Bruxelles, Brussels 1000, Belgium
| | - Philippe Delatte
- Department of Radiology, Institut Jules Bordet, Université Libre de Bruxelles, Brussels 1000, Belgium
| | - Maria Gomez Galdon
- Department of Pathology, Institut Jules Bordet, Université Libre de Bruxelles, Brussels 1000, Belgium
| | - Alain Hendlisz
- Department of Digestive Oncology, Institut Jules Bordet, Université Libre de Bruxelles, Brussels 1000, Belgium
| | - Patrick Flamen
- Department of Nuclear Medicine, Institut Jules Bordet, Université Libre de Bruxelles, Brussels 1000, Belgium
| | - Vincent Donckier
- Department of Abdominal Surgery, Institut Jules Bordet, Centre de Chirurgie Hépato-Biliaire de l’ULB (CCHB-ULB), Université Libre de Bruxelles, Brussels1000, Belgium
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22
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Cucchetti A, Cappelli A, Mosconi C, Zhong JH, Cescon M, Pinna AD, Golfieri R. Improving patient selection for selective internal radiation therapy of intra-hepatic cholangiocarcinoma: A meta-regression study. Liver Int 2017; 37:1056-1064. [PMID: 28177190 DOI: 10.1111/liv.13382] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 01/30/2017] [Indexed: 01/27/2023]
Abstract
BACKGROUND & AIMS Selective internal radiation therapy (SIRT) is emerging as a potential therapy for unresectable intra-hepatic cholangiocarcinoma (iCCA) able to prolong life-expectancy. Aim of this study was to collect available literature meta-analyse data and results and investigate sources of heterogeneity through a meta-regression approach before suggesting SIRT as a valuable option. METHODS A systematic review of studies published until 1 September 2016 in PubMed and Scopus databases was performed. Patient survival was the primary outcome measure. Meta-analysis was performed using a random-effects model. Meta-regression was applied to investigate relationships existing between clinical and tumour features and the primary outcome. RESULTS Nine observational studies were included in the analysis involving 224 patients. The 1-, 2- and 3-year pooled survival estimates were 55.7%, 33.1% and 20.2%. Clinical and tumour characteristics showed medium-to-considerable heterogeneity (I2 >50%). Meta-regression analysis showed that determinants of best survivals were the presence of mass-forming iCCA type (median survival=19.9 months vs 8.1 months for the infiltrative type; P=.002) that also accounted for most of the heterogeneity between included studies (residual I2 =0); SIRT as first-line therapy (median survival=24 months vs 11.5 months for non-naïve patients; P=.048) and the adoption of concomitant chemotherapy (median survival 19.5 months vs 5.5 months in patients not receiving chemotherapy; P=.042). CONCLUSIONS There is considerable heterogeneity between studies highlighting that indications for SIRT are extremely varied. To ameliorate SIRT results naïve patients with mass-forming iCCA should be selected as the best candidates with the possibility of adding concomitant standard chemotherapy.
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Affiliation(s)
- Alessandro Cucchetti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Alberta Cappelli
- Radiology Unit, Department of Digestive Disease and Internal Medicine, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Cristina Mosconi
- Radiology Unit, Department of Digestive Disease and Internal Medicine, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Jian-Hong Zhong
- Department of Hepatobiliary Surgery, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, China
| | - Matteo Cescon
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Antonio D Pinna
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Rita Golfieri
- Radiology Unit, Department of Digestive Disease and Internal Medicine, Sant'Orsola-Malpighi Hospital, Bologna, Italy
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