Yttrium-90 radioembolization for unresectable hepatic metastases of breast cancer: A systematic review

Comparison of Clinical Characteristics and Outcomes of Patients with Breast Cancer and Liver Metastases Who Have or Have Not Undergone Radioembolization

The purpose of this study was to compare characteristics and outcomes of patients with breast cancer with liver metastasis who had and had not undergone radioembolization. Medical records of patients with breast cancer with liver metastases (4,332 patients who had not undergone radioembolization and 166 patients who had) seen between January 1, 2009, and October 31, 2021, were assessed. Propensity score matching was performed. Patients who underwent radioembolization were significantly younger (47.7 years [SD ± 10.1] vs 52.3 years [SD ± 12.5]; P < .001) and underwent more systemic treatment regimens (8.6 [SD ± 4.1] vs 5.2 [SD ± 3.2]; P < .001). Median survival was longer, in unmatched (67.1 vs 40.7 months; P = .001) and matched (67.1 vs 38.0 months, P = .001) cohorts. Radioembolization was associated with superior survival (P = .002). In conclusion, patients with breast cancer with liver metastases who underwent radioembolization were significantly younger and underwent more treatment regimens. Radioembolization was associated with longer median survival.

The Objective Response and Disease Control Rates in Patients with Liver Metastastic Breast Cancer Receiving Transarterial Radioembolization: A Meta-Analysis

AIM

To meta-analyze the utility of transarterial radioembolization (TARE) in patients with liver metastatic breast cancer (BC), based on the objective response rate (ORR) and disease control rate (DCR).

METHODS

A literature search was performed retrieving studies with (1) at least 10 patients with liver metastatic BC treated with TARE and (2) adequate information to derive ORR and DCR. The ORR is the ratio between patients with liver lesions showing complete response (CR) or partial response (PR) over the total number of patients treated with TARE; the DCR is the ratio between patients with CR, PR, or stable disease (SD) over the total number of patients treated with TARE.

RESULTS

Eighteen studies (650 patients) were eligible; the ORR of TARE resulted 50.71% (95% C.I.: 40.04-61.36) and the DCR resulted 88.37% (95% C.I.: 81.89-93.57). Taking into account resin spheres (395 patients), the ORR was 60.35% (95% C.I.: 46.55-73.36) and the DCR was 92.73% (95% C.I.: 87.17-96.80%). Considering glass spheres (144 patients), the ORR was 32.38% (95% C.I.: 18.43-48.16) and the DCR was 82.69% (95% C.I.: 59.29-97.26).

CONCLUSIONS

This meta-analysis favors the use of TARE in patients with liver metastatic BC either with resin or glass spheres.

Impact of Hypoxia on Radiation-Based Therapies for Liver Cancer

Background: Hypoxia, a state of low oxygen level within a tissue, is often present in primary and secondary liver tumors. At the molecular level, the tumor cells' response to hypoxic stress induces proteomic and genomic changes which are largely regulated by proteins called hypoxia-induced factors (HIF). These proteins have been found to drive tumor progression and cause resistance to drug- and radiation-based therapies, ultimately contributing to a tumor's poor prognosis. Several imaging modalities have been developed to visualize tissue hypoxia, providing insight into a tumor's microbiology. Methods: A systematic literature search was conducted in PubMed, EMBASE, Cochrane, and Google Scholar for all reports related to hypoxia on liver tumors. All relevant studies were summarized. Results: This review will focus on the impact of hypoxia on liver tumors and review PET-, MRI-, and SPECT-based imaging modalities that have been developed to predict and assess a tumor's response to radiation therapy, with a focus on liver cancers. Conclusion: While there are numerous studies that have evaluated the impact of hypoxia on tumor outcomes, there remains a relative paucity of data evaluating and quantifying hypoxia within the liver. Novel and developing non-invasive imaging techniques able to provide functional and physiological information on tumor hypoxia within the liver may be able to assist in the treatment planning of primary and metastatic liver lesions.

Radioembolisation of liver metastases

This review aims to present contemporary data for SIRT in the treatment of secondary hepatic malignancies including colorectal, neuroendocrine, breast and uveal melanoma.

New Frontiers in the Role of Locoregional Therapies in Breast Cancer: Proceedings from the Society of Interventional Radiology Foundation Research Consensus Panel

Emerging evidence regarding the effectiveness of locoregional therapies (LRTs) for breast cancer has prompted investigation of the potential role of interventional radiology (IR) in the care continuum of patients with breast cancer. The Society of Interventional Radiology Foundation invited 7 key opinion leaders to develop research priorities to delineate the role of LRTs in both primary and metastatic breast cancer. The objectives of the research consensus panel were to identify knowledge gaps and opportunities pertaining to the treatment of primary and metastatic breast cancer, establish priorities for future breast cancer LRT clinical trials, and highlight lead technologies that will improve breast cancer outcomes either alone or in combination with other therapies. Potential research focus areas were proposed by individual panel members and ranked by all participants according to each focus area's overall impact. The results of this research consensus panel present the current priorities for the IR research community related to the treatment of breast cancer to investigate the clinical impact of minimally invasive therapies in the current breast cancer treatment paradigm.

Study Protocol: Efficacy and Safety of Radioembolization (REM) as an Early Modality (EM) Therapy for Metastatic Breast Cancer (BR) to the Liver with Y90 (REMEMBR Y90)

PURPOSE

The primary objective of the REMEMBR Y90 study is to evaluate the efficacy of Yttrium-90 (Y90) radioembolization in patients with breast cancer metastases to the liver as a 2nd or 3rd line treatment option with systemic therapy by assessing liver-specific and overall progression-free survival. Secondary objectives include quality of life, overall survival benefit, and toxicity in relation to patients' tumor biology.

MATERIALS AND METHODS

This trial is a multi-center, prospective, Phase 2, open-label, IRB-approved, randomized control trial in the final phases of activation. Eligible patients include those over 18 years of age with metastatic breast cancer to the liver with liver-only or liver-dominant disease, and history of tumor progression on 1-2 lines of chemotherapy. 60 patients will be randomized to radioembolization with chemotherapy versus chemotherapy alone. Permissible regimens include capecitabine, eribulin, vinorelbine, and gemcitabine within 2 weeks of enrollment for every patient. Patients receiving radioembolization will receive lobar or segmental treatment within 1-6 weeks of enrollment depending on their lesion. After final radioembolization, patients will receive clinical and imaging follow-up every 12-16 weeks for two years, including contrast-enhanced computed tomography or magnetic resonance imaging of the abdomen and whole-body positron emission tomography/computed tomography.

DISCUSSION

This study seeks to elucidate the clinical benefit and toxicity of Y90 in patients with metastatic breast cancer to the liver who are receiving minimal chemotherapy. Given previous data, it is anticipated that the use of Y90 and chemotherapy earlier in the metastatic disease course would improve survival outcomes and reduce toxicity.

LEVEL OF EVIDENCE

Level 1b, Randomized Controlled Trial.

TRIAL REGISTRATION NUMBER

NCT05315687 on clinicaltrials.gov.

Radioembolization, Principles and indications

Radioembolization is the selective application of radionuclide-loaded microspheres into liver arteries for the therapy of liver tumours and metastases. In this review, we focused on therapy planning and dosimetry, as well as the main indications of 90Y-glass and resin microspheres and 166Ho-microspheres.

Transarterial Yttrium-90 Glass Microsphere Radioembolization of Chemotherapy-Refractory Breast Cancer Liver Metastases: Results of a Single Institution Retrospective Study

Purpose

Our purpose was to retrospectively evaluate the safety and efficacy of transarterial hepatic radioembolization (TARE) treatment with yttrium-90 labeled glass microspheres in patients with chemotherapy-refractory breast cancer with liver-dominant metastatic disease.

Methods and Materials

This retrospective single-institution study evaluated 31 female patients (mean age of 59.6 ± 13.2 years) who were treated with TARE. All patients received and progressed on systemic chemotherapy before TARE. Twenty-one patients also had extrahepatic metastases, including 13 patients who had metastases in bones only besides the liver. Survival data were analyzed by Kaplan-Meier method and compared using log-rank test. Imaging response to treatment was determined by Response Evaluation Criteria in Solid Tumors.

Results

Median overall survival (OS) from the TARE was 13 months (95% confidence interval, 9.1-16.9 months). The survival probability at 1, 2, and 3 years was 60.1%, 36.7%, and 24.5%, respectively. The median hepatic progression-free survival was 7 months (95% confidence interval, 6.1-7.9 months). There was no 30-day mortality and 3 patients (9.4%) had grade 3 toxicity. Estrogen receptor (ER) positive status predicted prolonged survival (14 months for ER+ vs 9 months for ER-; P = .028). Patients who had bone-only extrahepatic disease had higher OS than patients with extraosseous metastases (23 vs 8 months, P = .02). At the 3-month follow-up the radiographic objective response rate was 46.6% and disease control rate was 70%.

Conclusions

The treatment of patients with liver-dominant chemotherapy-refractory breast cancer metastases with TARE using yttrium-90 labeled glass microspheres is safe and led to promising hepatic disease control and OS especially in patients with ER+ tumors and in patients without extrahepatic extraosseous metastases.

The global status of research in breast cancer liver metastasis: a bibliometric and visualized analysis

This study aimed to investigate the distribution laws and research frontiers of international literature, so as to present a holistic bibliometric evaluation of the studies on breast cancer liver metastasis(BCLM). Data were collected from the Web of Science Core Collection database, including publications, year, country, journal, author and keywords. The software VOSviewer and CiteSpace were used for bibliometric coupling, co-authorship, co-citation and co-occurrence analysis. In total, 1,031 publications were analyzed from 2004 to 2020 on BCLM. The year with the highest number of publications was 2006, with 103 papers. The United States, followed by China and Germany were the leading countries on BCLM, accounting for 59% of the whole. The journals that published about BCLM were mainly located in Q1/Q2. Keywords co-occurrence analysis divides BCLM into five clusters:'basic research', 'auxiliary diagnosis and therapy', 'liver resection', 'clinical trial' and 'prognosis'. Main treatment therapies were the latest focus. Burst detection indicated that the trends in BCLM concentrated on subtype and SEER. There is apparently brighter perspective for BCLM research in the coming years, especially in liver resection, subtype and bioinformatics. The consequence of our study as the exclusive scientific evaluation offered an integral overview of BCLM, particularly for research focus and future directions, which can further accurately guide scholars on diagnosis, treatment, and personalized prevention.

Successful treatment with yttrium-90 microspheres in a metastatic breast cancer patient and sclerosing cholangitis

Breast cancer is the most common malignancy occurring in women worldwide. More than 90% of patients present with localized disease are treated with curative intent; however, recurrence can occur with development of metastatic lesions. Frequently associated with extra-hepatic lesions, localized treatments (surgery or stereotaxic body radiotherapy) are rarely proposed in liver lesions. ⁹⁰Y radioembolization has extensively been evaluated in colorectal cancer, but its role in breast cancer with isolated liver metastases remains largely unknown. Pre-existing liver diseases are known risk factors for ⁹⁰Y induced liver toxicity. Not considered as an excluding factor for this treatment, data are limited regarding its safe use with cholangitis. We report a successful control of liver metastases by ⁹⁰Y radioembolization in a breast cancer patient.

Breast cancer is the most common malignancy occurring in women worldwide. Metastasis-directed therapies are more and more often offered to patients in order to delay systemic treatments; however, their role in improving survival remains unknown. Trans-arterial radioembolization with ⁹⁰Y appears to be an interesting strategy in breast cancer with isolated liver metastases, even if its survival benefit remains largely unknown. Safety of trans-arterial radioembolization also remains under investigated in patients with previous liver disease. We report a successful control of liver metastases by ⁹⁰Y radioembolization in a breast cancer patient.

Selective internal radiation therapy in the management of primary and metastatic disease in the liver

Selective internal radiation therapy is a type of brachytherapy used to provide targeted radiotherapy, most commonly to treat primary or metastatic disease within the liver. This review outlines current clinical practice, dosimetric considerations, the pre-treatment workup and safety considerations before treatment. It also examines the clinical evidence for its use in patients with both primary and metastatic disease within the liver.

Clinical Application of Trans-Arterial Radioembolization in Hepatic Malignancies in Europe: First Results from the Prospective Multicentre Observational Study CIRSE Registry for SIR-Spheres Therapy (CIRT)

Purpose

To address the lack of prospective data on the real-life clinical application of trans-arterial radioembolization (TARE) in Europe, the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) initiated the prospective observational study CIRSE Registry for SIR-Spheres® Therapy (CIRT).

Materials and Methods

Patients were enrolled from 1 January 2015 till 31 December 2017. Eligible patients were adult patients treated with TARE with Y90 resin microspheres for primary or metastatic liver tumours. Patients were followed up for 24 months after treatment, whereas data on the clinical context of TARE, overall survival (OS) and safety were collected.

Results

Totally, 1027 patients were analysed. 68.2% of the intention of treatment was palliative. Up to half of the patients received systemic therapy and/or locoregional treatments prior to TARE (53.1%; 38.3%). Median overall survival (OS) was reported per cohort and was 16.5 months (95% confidence interval (CI) 14.2–19.3) for hepatocellular carcinoma, 14.6 months (95% CI 10.9–17.9) for intrahepatic cholangiocarcinoma. For liver metastases, median OS for colorectal cancer was 9.8 months (95% CI 8.3–12.9), 5.6 months for pancreatic cancer (95% CI 4.1–6.6), 10.6 months (95% CI 7.3–14.4) for breast cancer, 14.6 months (95% CI 7.3–21.4) for melanoma and 33.1 months (95% CI 22.1–nr) for neuroendocrine tumours. Statistically significant prognostic factors in terms of OS include the presence of ascites, cirrhosis, extra-hepatic disease, patient performance status (Eastern Cooperative Oncology Group), number of chemotherapy lines prior to TARE and tumour burden. Thirty-day mortality rate was 1.0%. 2.5% experienced adverse events grade 3 or 4 within 30 days after TARE.

Conclusion

In the real-life clinical setting, TARE is largely considered to be a part of a palliative treatment strategy across indications and provides an excellent safety profile.

Level of evidence

Level 3.

Trial registration

ClinicalTrials.gov NCT02305459.

Electronic supplementary material

The online version of this article (10.1007/s00270-020-02642-y) contains supplementary material, which is available to authorized users.

Liver Metastases-directed Therapy in the Management of Oligometastatic Breast Cancer

INTRODUCTION

In the context of metastatic breast cancer, dissemination to the liver is a frequent occurrence. We aimed to evaluate the outcome and toxicity of metastatic breast cancer with liver oligometastases treated with metastases-directed therapies (MDTs), including surgery, stereotactic body radiation therapy, or thermal ablation (radiofrequency or microwaves).

PATIENTS AND METHODS

We included patients with diagnosis of 1 to 5 liver metastases. Selection criteria included also age > 18 years; Eastern Cooperative Oncology Group performance status 0 to 2; absence of extra-hepatic disease or other controlled metastatic sites. Endpoints were liver progression-free survival (LPFS), progression-free survival (PFS), and overall survival.

RESULTS

A total of 72 patients were included. Previous local treatments were performed in 13 (18.1%) patients, whereas systemic therapy was used in 81.9% of cases. Treatment of choice was stereotactic body radiation therapy in 54 (75%) patients followed by surgery (13 patients; 18%) and thermal ablation (5 patients; 7%). With a median follow-up of 26.2 months, LPFS at 1 and 2 years was 52.4% and 38.8%, respectively. The number of metastases predicted LPFS (hazard ratio [HR], 1.70; P = .004). Rates of PFS were 38.7% and 22% at 1 and 2 years, respectively. Systemic therapy before MDT (HR, 2.89; P = .016) was correlated with PFS. Overall survival at 1 and 2 years was 95.5% and 76.9%, respectively. Human epidermal growth factor receptor 2 status correlated with survival (HR, 1.82; P = .010).

CONCLUSION

Combination of systemic therapy with liver MDT in oligometastatic breast cancer results in durable disease control in a significant proportion of patients. Tumor biology, prior treatment, and extent of disease may be useful to guide the decision to add MDT to standard therapy.