Inflammatory markers and long term hematotoxicity of holmium-166-radioembolization in liver-dominant metastatic neuroendocrine tumors after initial peptide receptor radionuclide therapy

Development of an immunosuppressed orthotopic hepatocellular carcinoma rat model for the evaluation of chemo- and radioembolization therapies

Hepatocellular carcinoma (HCC) is widely known to be chemo-resistant and presents with significant liver disease resulting in low tolerability to systemic chemotherapy. As a counter measure, more targeted therapies such as trans-arterial chemoembolization (TACE) and trans-arterial radioembolization (TARE) have been developed. To further optimize these therapies, animal models are critical in elucidating the molecular events in disease progression and test new treatment options. The present study focuses on the development of a hepatoma bearing rat model. N1S1 rat hepatoma cells were transfected by a lentiviral method and injected into the liver of Sprague Dawley (SD) and Rowett Nude (RNU) rats. Longitudinal tumor growth was observed by bioluminescence imaging (BLI) and liver/tumor histology. In both models, tumors were visible within 4 days post cell inoculation. Tumor take rates were 52 % and 73 % for male and female SD rats, respectively, and 100 % for male RNU rats. By day 12 and 15 post inoculation, we recorded complete tumor regression in male and female SD rats. Liver histology showed advanced fibrosis in the tumor regressed SD rats, whilst RNU rats exhibited the characteristic sheet pattern of Novikoff tumor with mild liver fibrosis. Increased CD3 and TUNEL staining observed in SD rat livers may be key factors for tumor regression. Our data reveal that the immunocompetent SD rats are not recommended as a model for therapeutic investigations. The immunosuppressed RNU rats, however, are characterized by consistent and reliable tumor growth and thus a desirable model for future therapeutic investigations.

Intra-arterial peptide-receptor radionuclide therapy for neuro-endocrine tumour liver metastases: an in-patient randomised controlled trial (LUTIA)

PURPOSE

Peptide receptor radionuclide therapy (PRRT) using [177Lu]Lu-DOTATATE has been shown to effectively prolong progression free survival in grade 1-2 gastroenteropancreatic neuroendocrine tumours (GEP-NET), but is less efficacious in patients with extensive liver metastases. The aim was to investigate whether tumour uptake in liver metastases can be enhanced by intra-arterial administration of [177Lu]Lu-DOTATATE into the hepatic artery, in order to improve tumour response without increasing toxicity.

METHODS

Twenty-seven patients with grade 1-2 GEP-NET, and bi-lobar liver metastases were randomized to receive intra-arterial PRRT in the left or right liver lobe for four consecutive cycles. The contralateral liver lobe and extrahepatic disease were treated via a "second-pass" effect and the contralateral lobe was used as the control lobe. Up to three metastases (> 3 cm) per liver lobe were identified as target lesions at baseline on contrast-enhanced CT. The primary endpoint was the tumour-to-non-tumour (T/N) uptake ratio on the 24 h post-treatment [177Lu]Lu-SPECT/CT after the first cycle. This was calculated for each target lesion in both lobes using the mean uptake. T/N ratios in both lobes were compared using paired-samples t-test.

FINDINGS

After the first cycle, a non-significant difference in T/N uptake ratio was observed: T/NIA = 17·4 vs. T/Ncontrol = 16·2 (p = 0·299). The mean increase in T/N was 17% (1·17; 95% CI [1·00; 1·37]). Of all patients, 67% (18/27) showed any increase in T/N ratio after the first cycle.

CONCLUSION

Intra-arterial [177Lu]Lu-DOTATATE is safe, but does not lead to a clinically significant increase in tumour uptake.

The Evolving Role of Radioembolization in the Treatment of Neuroendocrine Liver Metastases

Simple Summary

This review provides basic insights into radioembolization, also known as selective internal radiation therapy, in patients suffering from neuroendocrine liver metastases. Radioembolization is a treatment that uses radioactive beads that are implanted intra-arterially to locally irradiate liver tumors. The available literature on radioembolization in neuroendocrine liver metastases show promising results in terms of efficacy and toxicity and will be discussed in more detail. However, data in the field of NELM need clarification, and this review also discusses the caveats, challenges and new insights when considering radioembolization in neuroendocrine liver metastases.

Abstract

At diagnosis, 21–50% of neuroendocrine tumors already have distant metastases, of which the liver is most commonly affected. Unfortunately, the presence of neuroendocrine liver metastases (NELM) is the most incriminating factor for survival. At NELM diagnosis, 60–70% of patients suffer from bilobar multifocal disease, making them ineligible for surgical resection. With limited systemic options, a clinical need for liver-directed treatments exists. Trans-arterial (bland) embolization, chemoembolization and radioembolization have been increasingly used in the treatment of NELM. In recent years, radioembolization (also known as selective internal radiation therapy) has gained attention due to promising tumor reductive results, limited toxicities and increasing scientific evidence. This review provides basic insights into radioembolization as a technique, a summary of available literature on radioembolization in NELM, and discusses caveats, challenges and new insights when considering radioembolization in NELM.