Effect of Thromboprophylaxis on Clinical Outcomes After COVID-19 Hospitalization

BACKGROUND

Patients hospitalized with COVID-19 have an increased incidence of thromboembolism. The role of extended thromboprophylaxis after hospital discharge is unclear.

OBJECTIVE

To determine whether anticoagulation is superior to placebo in reducing death and thromboembolic complications among patients discharged after COVID-19 hospitalization.

DESIGN

Prospective, randomized, double-blind, placebo-controlled clinical trial. (ClinicalTrials.gov: NCT04650087).

SETTING

Done during 2021 to 2022 among 127 U.S. hospitals.

PARTICIPANTS

Adults aged 18 years or older hospitalized with COVID-19 for 48 hours or more and ready for discharge, excluding those with a requirement for, or contraindication to, anticoagulation.

INTERVENTION

2.5 mg of apixaban versus placebo twice daily for 30 days.

MEASUREMENTS

The primary efficacy end point was a 30-day composite of death, arterial thromboembolism, and venous thromboembolism. The primary safety end points were 30-day major bleeding and clinically relevant nonmajor bleeding.

RESULTS

Enrollment was terminated early, after 1217 participants were randomly assigned, because of a lower than anticipated event rate and a declining rate of COVID-19 hospitalizations. Median age was 54 years, 50.4% were women, 26.5% were Black, and 16.7% were Hispanic; 30.7% had a World Health Organization severity score of 5 or greater, and 11.0% had an International Medical Prevention Registry on Venous Thromboembolism risk prediction score of greater than 4. Incidence of the primary end point was 2.13% (95% CI, 1.14 to 3.62) in the apixaban group and 2.31% (CI, 1.27 to 3.84) in the placebo group. Major bleeding occurred in 2 (0.4%) and 1 (0.2%) and clinically relevant nonmajor bleeding occurred in 3 (0.6%) and 6 (1.1%) apixaban-treated and placebo-treated participants, respectively. By day 30, thirty-six (3.0%) participants were lost to follow-up, and 8.5% of apixaban and 11.9% of placebo participants permanently discontinued the study drug treatment.

LIMITATIONS

The introduction of SARS-CoV-2 vaccines decreased the risk for hospitalization and death. Study enrollment spanned the peaks of the Delta and Omicron variants in the United States, which influenced illness severity.

CONCLUSION

The incidence of death or thromboembolism was low in this cohort of patients discharged after hospitalization with COVID-19. Because of early enrollment termination, the results were imprecise and the study was inconclusive.

PRIMARY FUNDING SOURCE

National Institutes of Health.

Cancer Diagnoses during Active Conflict: Experience from a Cancer Program in Northwest Syria

Background  Protracted conflict has destroyed Syria's health system with severe impacts on the diagnosis and treatment of chronic and high-cost diseases including cancer. Here, we review the type and (where possible) the stage of cancers diagnosed in a pathology laboratory serving Northwest Syria. Methods  We retrospectively reviewed all pathology reports which reported a diagnosis of cancer from a pathology department in Northwest Syria from January to December 2020. Results  A total of 397 new cancers were diagnosed during 2020 of which 191 were among males (48.1%) and 20 cases were in children aged 17 years or under (5%). The most common cancer in men was bladder cancer (15.7%) and skin cancers (14.7%) followed by cancers in the lymph nodes (includes primary and secondary; 9.9%.) In women, breast cancer (38.3%) followed by skin cancer skin (9.7%) and uterine cancer (8.7%) was the most common. The overall proportion of cancer diagnoses were breast cancer (20.2%), skin cancer (12.1%), cancer affecting lymph nodes (8.8%), and urinary bladder (8.3%) and colorectal cancer (7.3%). Discussion  This preliminary analysis is the first report of cancer types and demographics in areas outside of government control in Syria since the onset of the conflict. Despite limitations, it presents some indication of the burden of oncological diagnoses in this area. Further research which aims to describe and address the burden of cancer on populations under ongoing conflict and humanitarian crises remains essential, especially in Northwest Syria given ongoing attacks and severe underfunding. There is a particular need to investigate how best to apply interventions and support health systems and cancer services within conflict settings. More support and resources need to be allocated to cancer centers with long-term health partnership models. The underresourced and understaffed conditions of the hospital are significant limits to a more detailed report.

Effect of P2Y12 Inhibitors on Survival Free of Organ Support Among Non-Critically Ill Hospitalized Patients With COVID-19: A Randomized Clinical Trial

Importance

Platelets represent a potential therapeutic target for improved clinical outcomes in patients with COVID-19.

Objective

To evaluate the benefits and risks of adding a P2Y12 inhibitor to anticoagulant therapy among non-critically ill patients hospitalized for COVID-19.

Design, Setting, and Participants

An open-label, bayesian, adaptive randomized clinical trial including 562 non-critically ill patients hospitalized for COVID-19 was conducted between February 2021 and June 2021 at 60 hospitals in Brazil, Italy, Spain, and the US. The date of final 90-day follow-up was September 15, 2021.

Interventions

Patients were randomized to a therapeutic dose of heparin plus a P2Y12 inhibitor (n = 293) or a therapeutic dose of heparin only (usual care) (n = 269) in a 1:1 ratio for 14 days or until hospital discharge, whichever was sooner. Ticagrelor was the preferred P2Y12 inhibitor.

Main Outcomes and Measures

The composite primary outcome was organ support-free days evaluated on an ordinal scale that combined in-hospital death (assigned a value of -1) and, for those who survived to hospital discharge, the number of days free of respiratory or cardiovascular organ support up to day 21 of the index hospitalization (range, -1 to 21 days; higher scores indicate less organ support and better outcomes). The primary safety outcome was major bleeding by 28 days as defined by the International Society on Thrombosis and Hemostasis.

Results

Enrollment of non-critically ill patients was discontinued when the prespecified criterion for futility was met. All 562 patients who were randomized (mean age, 52.7 [SD, 13.5] years; 41.5% women) completed the trial and 87% received a therapeutic dose of heparin by the end of study day 1. In the P2Y12 inhibitor group, ticagrelor was used in 63% of patients and clopidogrel in 37%. The median number of organ support-free days was 21 days (IQR, 20-21 days) among patients in the P2Y12 inhibitor group and was 21 days (IQR, 21-21 days) in the usual care group (adjusted odds ratio, 0.83 [95% credible interval, 0.55-1.25]; posterior probability of futility [defined as an odds ratio <1.2], 96%). Major bleeding occurred in 6 patients (2.0%) in the P2Y12 inhibitor group and in 2 patients (0.7%) in the usual care group (adjusted odds ratio, 3.31 [95% CI, 0.64-17.2]; P = .15).

Conclusions and Relevance

Among non-critically ill patients hospitalized for COVID-19, the use of a P2Y12 inhibitor in addition to a therapeutic dose of heparin, compared with a therapeutic dose of heparin only, did not result in an increased odds of improvement in organ support-free days within 21 days during hospitalization.

Trial Registration

ClinicalTrials.gov Identifier: NCT04505774.

Trastuzumab for Her2/neu-positive metastatic salivary gland carcinoma: Case report and review of the literature

Salivary gland carcinomas metastasize to distant organs in 20% of salivary gland malignancies. Applying immunohistochemistry (IHC) measures, salivary gland tumors showed a wide range of oncogene markers expression, including the human epidermoid receptor 2 (Her2/neu), which could be targeted with monoclonal antibody. Treating salivary gland tumors, which have Her2/neu over-expression, with trastuzumab was reported in a few case reports. We report a 61-year-old Caucasian male, with a history of salivary gland tumor, who presented after 20 years of complete surgical resection with kidney mass. He was treated as primary renal cell carcinoma, unclassified, with nephrectomy and adjuvant clinical trail where he received placebo. Subsequently, he developed multiple hepatic lesions and retroperitoneal mesenteric lymphadenopathy; CT-guided biopsy revealed adenocarcinoma with Her2/neu, 3+ by IHC. The patient was treated successfully with trastuzumab with near-complete response.

Institutional decision to adopt Y90 as primary treatment for hepatocellular carcinoma informed by a 1,000-patient 15-year experience

Yttrium-90 transarterial radioembolization (TARE) is a locoregional therapy (LRT) for hepatocellular carcinoma (HCC). In this study, we present overall survival (OS) outcomes in a 1,000-patient cohort acquired over a 15-year period. Between December 1, 2003 and March 31, 2017, 1,000 patients with HCC were treated with TARE as part of a prospective cohort study. A comprehensive review of toxicity and survival outcomes was performed. Outcomes were stratified by baseline Child-Pugh (CP) class, United Network for Organ Sharing (UNOS), and Barcelona Clinic Liver Cancer (BCLC) staging systems. Albumin and bilirubin laboratory toxicities were compared to baseline. OS outcomes were reported using censoring and intention-to-treat methodologies. All treatments were outpatient, with a median one treatment per patient. Five hundred six (51%) were CP A, 450 (45%) CP B, and 44 (4%) CP C. Two hundred sixty-three (26%) patients were BCLC A, 152 (15%) B, 541 (54%) C, and 44 (4%) D. Three hundred sixty-eight (37%) were UNOS T1/T2, 169 (17%) T3, 147 (15%) T4a, 223 (22%) T4b, and 93 (9%) N/M. In CP A patients, censored OS for BCLC A was 47.3 (confidence interval [CI], 39.5-80.3) months, BCLC B 25.0 (CI, 17.3-30.5) months, and BCLC C 15.0 (CI, 13.8-17.7) months. In CP B patients, censored OS for BCLC A was 27 (CI, 21-30.2) months, BCLC B 15.0 (CI, 12.3-19.0) months, and BCLC C 8.0 (CI, 6.8-9.5) months. Forty-nine (5%) and 110 (11%) patients developed grade 3/4 albumin and bilirubin toxicities, respectively.

CONCLUSION

Based on our experience with 1,000 patients over 15 years, we have made a decision to adopt TARE as the first-line transarterial LRT for patients with HCC. Our decision was informed by prospective data and incrementally reported demonstrating outcomes stratified by BCLC, applied as either neoadjuvant or definitive treatment. (Hepatology 2017).

Metastatic Malignant Paraganglioma: A Case Report and Review of Literature

Metastasis is a rare presentation of non-secretory paraganglioma. Consequently, there is no standard of care for the treatment of metastatic malignant paraganglioma. The most widely used chemotherapy regimen for non-resectable cases includes cyclophosphamide, vincristine, and dacarbazine (CVD). CVD has been previously studied with variable therapeutic response. However, yttrium-90 (Y90) radioembolization has not been previously studied in the treatment of hepatic metastasis in patients diagnosed with malignant paraganglioma. This case report follows the treatment of a patient with stage IV mediastinal paraganglioma with metastasis to the liver. Treatment consisted of the CVD chemotherapy regimen and Y90 radioembolization of the hepatic lesions. After 10 cycles of CVD, the tumor size has decreased from 6.0 × 8.8 to 5.5 × 3.0 × 3.4 cm on computed tomography scan. The prominent metastatic liver lesions responded after Y90 radioembolization of both the right and left hepatic arteries. The prominent right hepatic lobe lesion has decreased in size from 2.6 × 3.4 × 3.0 cm to 2.6 × 2.8 × 2.9 cm. The prominent left hepatic lobe lesion originally measuring 1.6 cm in diameter completely resolved on follow-up imaging studies. After completion of 12 cycles of chemotherapy, the most recent positron emission testing scan determined no evidence of disease regarding both the primary mass and the hepatic lesions. This study demonstrates the first case of combination chemotherapy and Y90 radioembolization with a complete response per response evaluation criteria in solid tumors criteria. The approaches toward diagnosis and treatment corresponding to this case of malignant metastatic paraganglioma are also reviewed in this study.

Twelve-year experience of radioembolization for colorectal hepatic metastases in 214 patients: survival by era and chemotherapy

PURPOSE

The aim of this study was to analyze the safety, treatment characteristics and survival outcomes of Yttrium-90 (Y90) radioembolization for unresectable colorectal carcinoma (CRC) liver metastases refractory to standard of care therapy.

METHODS

A total of 214 patients with CRC metastases were treated with Y90 radioembolization over 12 years. Toxicity was assessed using National Cancer Institute common terminology criteria. Overall survival was analyzed from date of diagnosis of primary cancer, hepatic metastases and from the first Y90. Uni/multivariate analyses were performed. Substratification by era of chemotherapeutics was performed.

RESULTS

Most patients were male (60 %) and <65 years old (61 %). Of them, 98 % had been exposed to chemotherapy. Grade 3 lymphocyte, bilirubin, albumin, ALP and AST toxicities were observed in 39 %, 11 %, 10 %, 8 % and 4 % of patients, respectively. Grade 4 lymphocyte and ALP toxicities were observed in 5 % and 3 % of patients, respectively. Median overall survival was 43.0, 34.6, and 10.6 months from date of diagnosis of primary cancer, hepatic metastases and first Y90, respectively. Survival was significantly longer in patients: (1) who received ≤2 cytotoxic drugs (n = 104) than those who received 3 (n = 110) (15.2 vs. 7.5 months, p = 0.0001); and (2) who received no biologic agents (n = 52) compared with those that did (n = 162) (18.6 vs. 9.4 months, p = 0.0001). Multivariate analyses identified ≤2 cytotoxic agents, no exposure to biologics, ECOG 0, tumor burden <25 %, lack of extrahepatic disease and albumin >3 g/dL as independent predictors of survival.

CONCLUSION

In this largest metastatic CRC series published to date, Y90 radioembolization was found to be safe; survival varied by prior therapy. Further studies are required to further refine the role of Y90 in metastatic CRC.

Evaluation of a short-term medical mission to Syrian refugee camps in Turkey

BACKGROUND:

The escalating political and humanitarian crisis in Syria has left thousands detained, killed or displaced in neighboring countries. Given the permission and co-operation of the Turkish health authorities, a short-term medical mission to the Syrian refugee camps in the Hatay province was arranged.

MATERIALS AND METHODS:

To assess this mission's impact and potential expansion to serve other more emergently inflicted areas both inside and outside the Syrian borders, an evaluation was conducted via survey questionnaire of participating physicians.

RESULTS:

While almost all respondents found the experience worthwhile and fulfilling, medical, social and educational challenges as well as possible solutions were outlined.

CONCLUSION:

The use of several specified principles to further guide efforts towards providing service, education, relief, and awareness would result in greater effect, sustainability and growth of the mission.

Methotrexate and cetuximab for metastatic advanced head and neck squamous cell carcinoma

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Background: After the failure of first-line palliative chemotherapy in recurrent non-resectable or metastatic head and neck squamous-cell carcinoma (HNSCC), there is no standard of care second-line treatment that is proven to improve quality of life or prolong survival. Both methotrexate and cetuximab has shown a single-agent activity in advanced HNSCC. We are presenting our institutional experience in using unique combination chemotherapy with methotrexate plus cetuximab (MC). Methods: Retrospectively, single institution’s charts were reviewed from 2004-2010, all patients have documented recurrent non-resectable or metastatic HNSCC. After failing at least one line of palliative chemotherapy, patients received weekly IV methotrexate 25 mg/m2 plus IV cetuximab 400 mg/m2 loading dose at week one followed by 250 mg/m2 maintenance dose weekly. Each cycle is 4 weeks treatments. Patients who completed at least 2 cycles were included in the study. Patients can receive MC as first line if they have poor performance status. Treatment was continued until progression. Results: Total of 34 patients were included in the study, 26 male and 8 female, 18 African American and 16 Caucasian. Median patient age was 60 years old. 18, 6 and 6 patients received MC as second, third and fourth line therapy, respectively. 4 patients received MC as first line because there were not candidates for more aggressive chemotherapeutic regimens. The average received number of weekly treatments was 25 (8-69) and average number of cycles was 6 (2-17). Prior chemotherapy regimens include taxanes, platinum, 5-flurouracil, and gemcitabin. Median progression free survival was 4.9 months and overall survival was 10.7 months. Overall survival based on race was 9.9 months for Caucasians and 10.7 months for African Americans (P=0.0391). Grade I and II skin rash was observed in 41% of patients, no grade III/IV toxicities were noticed. Conclusions: Methotrexate plus cetuximab is a well tolerated regimen with a significant survival benefit. Prospective studies are warranted in order to evaluate this regimen as a second line palliative therapy for patients with advanced non-curable head and neck squamous cell carcinoma.

Methotrexate and cetuximab for metastatic advanced head and neck squamous cell carcinoma: A retrospective study

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Background: After the failure of first line palliative chemotherapy in recurrent non-resectable or metastatic head and neck squamous-cell carcinoma (HNSCC), there is no standard of care treatment that improves survival or quality of life. Both, methotrexate and cetuximab have single agent activity in metastatic HNSCC. We are presenting our institutional experience in using unique combination chemotherapy with methotrexate plus cetuximab (MC). Methods: Retrospectively, single institution’s charts were reviewed from 2004-2010, all patients have documented recurrent non-resectable or metastatic HNSCC. Patients received weekly IV methotrexate 25 mg/m2 plus IV cetuximab 250 mg/m2. Each cycle is 4 weeks treatments. Patients who completed at least 2 cycles were included. Patients can receive MC as first line if they have poor performance status. Treatment was continued until progression. Results: Total of 39 patients were included, 27 male and 12 female. Median patients’ age was 57 years old. 35 patients received methotrexate plus cetuximab (MC) after failure of prior line of palliative chemotherapy. 17, 10 and 8 patients received MC as second, third and fourth line therapy, respectively. 4 patients received MC as 1st line because they were not candidate for more aggressive therapy. The average received number of weekly treatments was 31 (8-95) and average number of cycles was 7 (2-23). Prior chemotherapy regimens include taxanes, platinum, 5-flurouracil, and gemcitabin. 13 patients received prior cetuximab as single agent or in combination. Median progression free survival was 7.1 months and overall survival was 9.8 months. Considering the line of therapy, the median survival was 6.9, 10.1, 13.5 and 9.9 months for patients received MC as 1st, 2nd , 3rd and 4th line of therapy respectively (P= 0.356). Grade 1 and 2 skin rash and hypomagnesimia were observed in 47% and 36% of patients. Conclusions: Methotrexate plus cetuximab is a well tolerated regimen with a significant survival benefit. Prospective well designed studies are warranted in order to evaluate this regimen as a second line palliative therapy for patients with advanced non-curable head and neck squamous cell carcinoma.

Radioembolization results in longer time-to-progression and reduced toxicity compared with chemoembolization in patients with hepatocellular carcinoma

BACKGROUND & AIMS

Chemoembolization is one of several standards of care treatment for hepatocellular carcinoma (HCC). Radioembolization with Yttrium-90 microspheres is a novel, transarterial approach to radiation therapy. We performed a comparative effectiveness analysis of these therapies in patients with HCC.

METHODS

We collected data from 463 patients who were treated with transarterial locoregional therapies (chemoembolization or radioembolization) over a 9-year period. We excluded patients who were not appropriate for comparison and analyzed data from 245 (122 who received chemoembolization and 123 who received radioembolization). Patients were followed for signs of toxicity; all underwent imaging analysis at baseline and follow-up time points. Overall survival was the primary outcome measure. Secondary outcomes included safety, response rate, and time-to-progression. Uni- and multivariate analyses were performed.

RESULTS

Abdominal pain and increased transaminase activity were more frequent following chemoembolization (P < .05). There was a trend that patients treated with radioembolization had a higher response rate than with chemoembolization (49% vs 36%, respectively, P = .104). Although time-to-progression was longer following radioembolization than chemoembolization (13.3 months vs 8.4 months, respectively, P = .046), median survival times were not statistically different (20.5 months vs 17.4 months, respectively, P = .232). Among patients with intermediate-stage disease, survival was similar between groups that received chemoembolization (17.5 months) and radioembolization (17.2 months, P = .42).

CONCLUSIONS

Patients with HCC treated by chemoembolization or radioembolization with Yttrium-90 microspheres had similar survival times. Radioembolization resulted in longer time-to-progression and less toxicity than chemoembolization. Post hoc analyses of sample size indicated that a randomized study with > 1000 patients would be required to establish equivalence of survival times between patients treated with these two therapies.

Does multidetector CT attenuation change in colon cancer liver metastases treated with 90Y help predict metabolic activity at FDG PET?

PURPOSE

To evaluate the correlation between change in attenuation and tumor metabolic activity assessed by using fluorodeoxyglucose (FDG) positron emission tomography (PET) in colon cancer liver metastases treated with yttrium 90 ((90)Y) radioembolization.

MATERIALS AND METHODS

This Health Insurance Portability and Accountability Act-compliant retrospective study was approved by the institutional review board; patient informed consent was waived. Unresectable chemorefractory colon cancer liver metastases treated with (90)Y radioembolization in 28 patients were evaluated at pre- and posttreatment multidetector computed tomographic (CT) and FDG PET scans. Maximum cross-sectional diameter, volume, and overall attenuation of target lesions were calculated. The percentage change (%Delta) in these parameters after treatment was calculated and correlated with the standardized uptake value (SUV) analysis at FDG PET. The accuracy of the radiologic parameters in helping predict response to treatment at FDG PET was assessed. Data were analyzed by using the Student t, Wilcoxon matched pair, Mann-Whitney, Spearman rank correlation, and chi(2) tests. The significance level was set at .05.

RESULTS

Seventy-four metastatic lesions in 10 women and 18 men (mean age, 61.5 years +/- 14.3 [standard deviation]) were evaluated. Mean follow-up interval for multidetector CT after treatment was 30 days. A significant reduction in maximum cross-sectional diameter, volume, and attenuation was observed from pre- to posttreatment multidetector CT (P < .05). The %Delta in attenuation had higher correlation with %Delta in SUV (r = 0.61) than diameter (r = 0.39) or volume (r = 0.49) and also predicted the metabolic activity at FDG PET with higher sensitivity (P < .001). By using a threshold level of a reduction in attenuation of 15% or greater, attenuation showed 84.2% sensitivity and 83.3% specificity in predicting response at FDG PET evaluation.

CONCLUSION

Changes in attenuation of colon cancer liver metastases treated with (90)Y radioembolization correlate highly with metabolic activity at FDG PET and may be useful as an early surrogate marker for assessing treatment response.

Radioembolization for hepatocellular carcinoma using Yttrium-90 microspheres: a comprehensive report of long-term outcomes

BACKGROUND & AIMS

Hepatocellular carcinoma (HCC) has limited treatment options; long-term outcomes following intra-arterial radiation are unknown. We assessed clinical outcomes of patients treated with intra-arterial yttrium-90 microspheres (Y90).

METHODS

Patients with HCC (n = 291) were treated with Y90 as part of a single-center, prospective, longitudinal cohort study. Toxicities were recorded using the Common Terminology Criteria version 3.0. Response rate and time to progression (TTP) were determined using World Health Organization (WHO) and European Association for the Study of the Liver (EASL) guidelines. Survival by stage was assessed. Univariate/multivariate analyses were performed.

RESULTS

A total of 526 treatments were administered (mean, 1.8; range, 1-5). Toxicities included fatigue (57%), pain (23%), and nausea/vomiting (20%); 19% exhibited grade 3/4 bilirubin toxicity. The 30-day mortality rate was 3%. Response rates were 42% and 57% based on WHO and EASL criteria, respectively. The overall TTP was 7.9 months (95% confidence interval, 6-10.3). Survival times differed between patients with Child-Pugh A and B disease (A, 17.2 months; B, 7.7 months; P = .002). Patients with Child-Pugh B disease who had portal vein thrombosis (PVT) survived 5.6 months (95% confidence interval, 4.5-6.7). Baseline age; sex; performance status; presence of portal hypertension; tumor distribution; levels of bilirubin, albumin, and alpha-fetoprotein; and WHO/EASL response rate predicted survival.

CONCLUSIONS

Patients with Child-Pugh A disease, with or without PVT, benefited most from treatment. Patients with Child-Pugh B disease who had PVT had poor outcomes. TTP and overall survival varied by patient stage at baseline. These data can be used to design future Y90 trials and to describe Y90 as a potential treatment option for patients with HCC.

Yttrium-90 radioembolization for liver malignancies: prognostic factors associated with survival

PURPOSE

To identify key prognostic clinical and imaging variables in patients undergoing yttrium-90 radioembolization ((90)Y) for liver malignancies.

MATERIALS AND METHODS

Patients with liver malignancies that progressed despite standard-of-care therapy were treated with (90)Y from 2002 to 2006. Baseline functional status, laboratory values, and diagnostic imaging were assessed before therapy. Imaging follow-up was performed 1 month after treatment and subsequently at 3-month intervals. Patients were followed for survival from the time of their first (90)Y treatment.

RESULTS

Patients with follow-up imaging after radioembolization (N = 130) were included in this analysis. Primary malignancies included colon, neuroendocrine, and others. The following clinical variables had a significant effect on survival on multivariate analysis: Eastern Cooperative Oncology Group (ECOG) performance status (PS) greater than 0 (hazard ratio [HR], 7.98; 95% CI, 3.98-16), hepatic tumor burden of 51%-75% (HR, 2.46; 95% CI, 1.01-6.02), bilirubin level greater than 1.3 mg/dL (HR, 2.60; 95% CI, 1.27-5.34), hepatic metastases from breast cancer (HR, 2.51; 95% CI, 1.13-5.61), response on imaging based on World Health Organization (WHO) criteria (HR, 0.48; 95% CI, 0.24-0.94), and lymphocyte depression (HR, 0.56; 95% CI, 0.31-0.96). Among patients with colorectal cancer metastases to the liver, the HR for survival on univariate analysis for responders compared with nonresponders (per WHO criteria) was 0.26 (95% CI, 0.10-0.69).

CONCLUSIONS

Cancer-related symptoms (ie, ECOG PS > 0), hepatic tumor burden greater than 50%, increased bilirubin levels, and hepatic metastases from breast cancer were found to be negative prognostic factors. Tumor response to therapy and lymphocyte depression were associated with favorable prognosis. Additionally, WHO response was identified to be a favorable prognostic factor in patients with colorectal cancer metastases. These findings may be useful when counseling patients regarding prognosis of their hepatic disease.

Radioembolization of colorectal hepatic metastases using yttrium-90 microspheres

BACKGROUND

: The objective of the current study was to determine the safety and efficacy of Yttrium-90 (Y90) microsphere treatment in patients with liver-dominant colorectal metastases.

METHODS

: Seventy-two patients with unresectable hepatic colorectal metastases were treated at a targeted absorbed dose of 120 Gray (Gy). Safety and toxicity were assessed using version 3 of the National Cancer Institute Common Terminology Criteria. Response was assessed by anatomic imaging and positron emission tomography (PET). Survival from the diagnosis of hepatic metastases and first treatment were estimated using the Kaplan-Meier method. Substratification analyses were performed.

RESULTS

: The median dose delivered was 118 Gy. Treatment-related toxicities included fatigue (61%), nausea (21%), and abdominal pain (25%). Grade 3 and 4 bilirubin toxicities were observed in 9 of 72 patients (12.6%). The tumor response rate was 40.3%. The median time to hepatic progression was 15.4 months, and the median response duration was 15 months. The PET response rate was 77%. Overall survival from the first Y90 treatment was 14.5 months. Tumor replacement (< or =25% vs >25%) was associated with significantly greater median survival (18.7 months vs 5.2 months). The presence of extrahepatic disease was associated negatively with overall survival (7.9 months vs 21 months). Overall survival from the date of initial hepatic metastases was 34.6 months. A subset analysis of patients who had an Eastern Cooperative Oncology Group performance status of 0 demonstrated a median survival of 42.8 months and 23.5 months from the time of hepatic metastases and Y90 treatment, respectively.

CONCLUSIONS

: Y90 liver therapy appears to provide sustained disease stabilization with acceptable toxicity. Asymptomatic patients with preserved liver function at the time of Y90 appeared to benefit most from treatment. Cancer 2009. (c) 2009 American Cancer Society.

Transcatheter intraarterial perfusion: MR monitoring of chemoembolization for hepatocellular carcinoma--feasibility of initial clinical translation

PURPOSE

To prospectively test the hypothesis that intraprocedural transcatheter intraarterial perfusion (TRIP) magnetic resonance (MR) imaging can be used to successfully measure reductions in perfusion to the targeted hepatocellular carcinoma (HCC) and the adjacent surrounding liver tissue during MR-interventional radiology (IR)-monitored transcatheter arterial chemoembolization (TACE).

MATERIALS AND METHODS

This HIPAA-compliant prospective study was approved by the institutional review board. An MR-IR unit was used to perform TACE in 10 patients with HCC (seven male, three female; eight younger than 69 years, two older than 69 years). Intraprocedural reductions in tumor perfusion before and after TACE were monitored with TRIP MR imaging. Time-signal intensity curves were derived, and semiquantitative spatially resolved area under the time-signal intensity curve maps of tumor perfusion before and after TACE were produced. Mean perfusion values before and after TACE for liver tumors and adjacent liver tissue were compared by using a mixed-model analysis, with alpha = .05.

RESULTS

Perfusion reductions were measured successfully with TRIP MR imaging in 18 separate tumors during 13 treatment sessions. Perfusion maps showed significant perfusion reductions for tumors (P < .013) but not for adjacent nontumorous liver tissue (P = .21). For tumors, the mean perfusion value was 193 arbitrary units (AU) +/- 223 (standard deviation) before TACE and 45.3 AU +/- 91.9 after TACE, with a mean reduction in baseline perfusion of 74.6% +/- 24.8. For adjacent liver tissue, the mean perfusion value was 124 AU +/- 93.5 before TACE and 93.2 AU +/- 72.3 after TACE, with a mean reduction in baseline perfusion of 24.2% +/- 14.5.

CONCLUSION

TRIP MR imaging can be used to detect intraprocedural changes in perfusion to HCC and surrounding liver parenchyma during MR-IR-monitored TACE.

Unresectable chemorefractory liver metastases: radioembolization with 90Y microspheres--safety, efficacy, and survival

PURPOSE

To prospectively evaluate the safety, efficacy, and survival of patients with chemorefractory liver metastases who have been treated with yttrium 90 ((90)Y) glass microspheres.

MATERIALS AND METHODS

Institutional review boards from two institutions approved the HIPAA-compliant study; all patients provided informed consent. One hundred thirty-seven patients underwent 225 administrations of (90)Y microspheres by using intraarterial infusion. Primary sites (origins) included colon, breast, neuroendocrine, pancreas, lung, cholangiocarcinoma, melanoma, renal, esophageal, ovary, adenocarcinoma of unknown primary, lymphoma, gastric, duodenal, bladder, angiosarcoma, squamous cell carcinoma, thyroid, adrenal, and parotid. Patients underwent evaluation of baseline and follow-up liver function and tumor markers and computed tomographic or magnetic resonance imaging. Patients were observed for survival from first treatment. Median survival (in days) and corresponding 95% confidence intervals were computed by using the Kaplan-Meier method. The log-rank statistic was used for statistical significance testing of survival distributions between various subgroups of patients.

RESULTS

There were 66 men and 71 women. All patients were treated on an outpatient basis. Median age was 61 years. The mean number of treatments was 1.6. The median activity and dose infused were 1.83 GBq and 112.8 Gy, respectively. Clinical toxicities included fatigue (56%), vague abdominal pain (26%), and nausea (23%). At follow-up imaging, according to World Health Organization criteria, there was a 42.8% response rate (2.1% complete response, 40.7% partial response). There was a biologic tumor response (any decrease in tumor size) of 87%. Overall median survival was 300 days. One-year survival was 47.8%, and 2-year survival was 30.9%. Median survival was 457 days for patients with colorectal tumors, 776 days for those with neuroendocrine tumors, and 207 days for those with noncolorectal, nonneuroendocrine tumors.

CONCLUSION

(90)Y hepatic treatments are well tolerated with acceptable toxicities; tumor response and median survival are promising.

Technical aspects of radioembolization with 90Y microspheres

Embolotherapy with radioactive microspheres, radioembolization, is gaining clinical acceptance as a therapeutic option for patients with liver malignancies. Knowledge of the anatomic variants in the mesenteric system is critical to safely administer this therapy. The purpose of this review is to provide a thorough discussion and detailed presentation of the technical aspects of radioembolization specifically as it pertains to the implantation devices. Normal vascular anatomy, commonly encountered variants, and factors involved in changes to regional perfusion in the presence of liver tumors are discussed. In addition, the basic principles described in this manuscript apply to all liver-directed transarterial therapies, such as chemoembolization and/or drug-eluting microspheres.

Multimodality imaging following 90Y radioembolization: a comprehensive review and pictorial essay

Radioembolization with yttrium 90 (90Y) microspheres represents an emerging transarterial therapy for the treatment of liver malignancies that continues to generate interest in the medical community. The classic indication of treatment response is a reduction in tumor size; however, parenchymal changes (eg, necrosis, lack of enhancement, specific findings at positron emission tomography and functional magnetic resonance imaging) and other benign findings (pleural effusions, perivascular edema, contralateral hypertrophy, ring enhancement, perihepatic fluid, fibrosis) may occur following treatment, requiring proper image interpretation. With classic imaging findings and surrogates (time to progression, duration of response, disease-free interval), response rates range from 20% to 80% in patients treated for hepatocellular carcinoma or metastatic disease to the liver. Complications of 90Y radioembolization include cholecystitis, abscess, and bilomas and should be recognized early in the imaging follow-up of these patients. Radiologists who are involved in the posttreatment assessment of patients undergoing 90Y radioembolization should be familiar with the imaging findings and potential imaging pitfalls associated with this therapy.

A comparison of chemoembolization endpoints using angiographic versus transcatheter intraarterial perfusion/MR imaging monitoring

PURPOSE

Transcatheter arterial chemoembolization (TACE) is an established treatment for unresectable liver cancer. This study was conducted to test the hypothesis that angiographic endpoints during TACE are measurable and reproducible by comparing subjective angiographic versus objective magnetic resonance (MR) endpoints of TACE.

MATERIALS AND METHODS

The study included 12 consecutive patients who presented for TACE for surgically unresectable HCC or progressive hepatic metastases despite chemotherapy. All procedures were performed with a dedicated imaging system. Angiographic series before and after TACE were reviewed independently by three board-certified interventional radiologists. A subjective angiographic chemoembolization endpoint (SACE) classification scheme, modified from an established angiographic grading system in the cardiology literature, was designed to assist in reproducibly classifying angiographic endpoints. Reproducibility in SACE classification level was compared among operators, and MR imaging perfusion reduction was compared with SACE levels for each observer.

RESULTS

Twelve patients successfully underwent 15 separate TACE sessions. SACE levels ranged from I through IV. There was moderate agreement in SACE classification (kappa = 0.46 +/- 0.12). There was no correlation between SACE level and MR perfusion reduction (r = 0.16 for one operator and 0.02 for the other two).

CONCLUSIONS

Angiographic endpoints during TACE vary widely, have moderate reproducibility among operators, and do not correlate with functional MR imaging perfusion endpoints. Future research should aim to determine ideal angiographic and functional MR imaging endpoints for TACE according to outcome measures such as imaging response, pathologic response, and survival.

Safety and efficacy of 90Y radiotherapy for hepatocellular carcinoma with and without portal vein thrombosis

This study was undertaken to present data from a phase 2 study in which patients with unresectable hepatocellular carcinoma (HCC) with and without portal vein thrombosis underwent radioembolization with Yttrium ((90)Y) microspheres. Patients treated were stratified by Okuda, Child-Pugh, baseline bilirubin, tumor burden, Eastern Cooperative Oncology Group (ECOG), presence of cirrhosis and portal vein thrombosis (PVT) (none, branch, and main). Clinical and biochemical data were obtained at baseline and at 4-week intervals following treatment for up to 6 months. Tumor response was obtained using computed tomography (CT). Patients were followed for survival. One hundred eight patients were treated during the study period. Thirty-seven (34%) patients had PVT, 12 (32%) of which involved the main PV. The cumulative dose for those with and without PVT was 139.7 Gy and 131.9 Gy, respectively. The partial response rate using world Health Organization (WHO) criteria was 42.2%. Using European Association for the Study of the Liver (EASL), the response rate was 70%. Kaplan-Meier survival varied depending on location of PVT and presence of cirrhosis. The adverse event (AE) rates were highest in patients with main PVT and cirrhosis. There were no cases of radiation pneumonitis.

CONCLUSION

The use of minimally embolic (90)Y glass microspheres to treat patients with HCC complicated by branch/lobar PVT may be clinically indicated and appears to have a favorable toxicity profile. Further investigation is warranted in patients with main PVT.

90Y radioembolization of metastatic breast cancer to the liver: toxicity, imaging response, survival

PURPOSE

To present data from patients with breast cancer liver metastases who underwent radioembolization with yttrium (90Y) microspheres.

MATERIALS AND METHODS

Using standard 90Y lobar treatment protocol, 27 female patients with progressing liver metastases on standard of care polychemotherapy were treated under an open-label phase 2 protocol. After treatment, we assessed (a) tumor response using computed tomography and/or positron emission tomography, (b) biochemical toxicity, and (c) survival.

RESULTS

The mean age of the patients was 52. Seventeen (63%) patients received 20 left lobe treatments (median radiation dose, 123 Gy; mean, 119 Gy), and 20 (74%) patients received 22 right lobe treatments (median radiation dose, 121 Gy; mean, 109 Gy) to the treatment site. No significant dose-difference was noted between the two lobes (P=.69). Tumor response on 90-day follow-up computed tomography showed (a) complete and partial response in nine (39.1%) patients, (b) stable disease in 12 (52.1%) patients, and (c) progressive disease in 2 (8.8%) patients. Positive tumor response on positron emission tomography was noted in 17 (63%) patients. Three of 27 (11%) patients (Eastern Cooperation Oncology Group 1, 2, or 3) showed bilirubin toxicity of grade 3, all of which were attributed to disease progression. Median survival for Eastern Cooperation Oncology Group 0 versus 1, 2, or 3 patients was 6.8 months and 2.6 months, respectively (P=.24) and for patients with tumor burden<25% versus >25% was 9.4 and 2.0 months, respectively (P=.46).

CONCLUSIONS

Radioembolization with 90Y brachytherapy device may be a viable therapeutic option for the treatment of breast cancer liver metastases in patients who have progressed or failed on standard of care polychemotherapy.

Radioembolization with 90Y microspheres: angiographic and technical considerations

The anatomy of the mesenteric system and the hepatic arterial bed has been demonstrated to have a high degree of variation. This is important when considering pre-surgical planning, catheterization, and trans-arterial hepatic therapies. Although anatomical variants have been well described, the characterization and understanding of regional hepatic perfusion in the context of radioembolization have not been studied with great depth. The purpose of this review is to provide a thorough discussion and detailed presentation of the angiographic and technical aspects of radioembolization. Normal vascular anatomy, commonly encountered variants, and factors involved in changes to regional perfusion in the presence of liver tumors are discussed. Furthermore, the principles described here apply to all liver-directed transarterial therapies.

Radioembolization with Yttrium-90 microspheres: review of an emerging treatment for liver tumors

Understanding the effect of radiation on tissue, the principles of dosimetry and fractionation have led to the acceptance and adoption of radiation as a standard treatment option for cancer. Delivered in staged and scheduled aliquots, radiation will break nucleic strands and cause cellular death. In general, radiation therapies are delivered using external techniques (external beam and intensity-modulated therapy). One of the limitations of such external techniques is that of nontarget radiation. That is, despite best efforts to collimate and reflect radiation beams to a small target, nontarget radiation and a dose to areas outside the tumor remains a distinct possibility. With the advent of radioembolization using Yttrium-90 microspheres (90Y), the radiation source is delivered optimally through a novel mechanism: directly into the blood vessel providing flow to the tumor. This revolutionary approach capitalizes on the basic principles of tumor hypervascularity, concentrating radiation within that tumor, while at the same time minimizing the risks of nontarget radiation. This review elaborates on this technology.

Yttrium-90 microspheres (TheraSphere) treatment of unresectable hepatocellular carcinoma: downstaging to resection, RFA and bridge to transplantation

PURPOSE

To present the clinical data of 35 patients with T3 unresectable hepatocellular carcinoma (HCC) that were treated with (90)Y with the specific intent of downstaging to resection, radiofrequency ablation (RFA) candidate, United Network for Organ Sharing (UNOS) stage T2 or liver transplantation.

MATERIALS AND METHODS

One hundred fifty patients with unresectable HCC were treated with (90)Y microspheres. Of these, 35 patients were UNOS stage T3 at the time of treatment. Patients were followed for clinical toxicities, alterations in model for end-stage-liver disease (MELD) score, tumor response, downstaging to RFA, resection, transplantation, and survival.

RESULTS

Nineteen of 34 patients (56%) were successfully downstaged from T3 to T2 following treatment. 11 of 34 (32%) patients treated were downstaged to target lesions measuring 3.0 cm or less. Twenty-three of 35 (66%) were downstaged to either T2 status, lesion < 3.0 cm (RFA candidate), or resection. Seventeen of 34 (50%) had an objective tumor response by WHO criteria. Eight patients (23%) were successfully downstaged and underwent OLT following treatment. 1, 2, and 3-year survival was 84%, 54%, and 27%, respectively. Median survival by Kaplan-Meier analysis for the entire cohort was 800 days.

CONCLUSION

These data suggest that intra-arterial (90)Y microspheres can be used as a bridge to transplantation, surgical resection, or RFA.

Treatment of unresectable hepatocellular carcinoma with use of 90Y microspheres (TheraSphere): safety, tumor response, and survival

PURPOSE

To present safety and efficacy results obtained in treatment of a cohort of patients with unresectable hepatocellular carcinoma (HCC) with use of 90Y microspheres (TheraSphere).

PATIENTS AND METHODS

Forty-three consecutive patients with HCC were treated with 90Y microspheres over a 4-year period. Patients were treated by liver segment or lobe on one or more occasions based on tumor distribution, liver function, and vascular flow dynamics. Patients were followed for adverse events, objective tumor response, and survival. Patients were stratified into three risk groups according to method of treatment and risk stratification (group 0, segmental; group 1, lobar low-risk; group 2, lobar high-risk) and Okuda and Child-Pugh scoring systems.

RESULTS

Based on follow-up data from 43 treated patients, 20 patients (47%) had an objective tumor response based on percent reduction in tumor size and 34 patients (79%) had a tumor response when percent reduction and/or tumor necrosis were used as a composite measure of tumor response. There was no statistical difference among the three risk groups with respect to tumor response. Survival times from date of diagnosis were different among the risk groups (P < .0001). Median survival times were 46.5 months, 16.9 months, and 11.1 months for groups 0, 1, and 2, respectively. Median survival times of 24.4 months and 12.5 months by Okuda scores of I and II, respectively, were achieved (mean, 25.8 months vs 13.1). Patients had median survival times of 20.5 months and 13.8 months according to Child class A and class B/C disease, respectively (mean, 22.7 months vs 13.6 months). Patients classified as having diffuse disease exhibited decreased survival and reduced tumor response. There were no life-threatening adverse events related to treatment.

CONCLUSIONS

Use of 90Y microspheres (TheraSpheres) provides a safe and effective method of treatment for a broad spectrum of patients presenting with unresectable HCC. Further investigation is warranted.

Effect of cyclothiazide on spontaneous miniature excitatory postsynaptic currents in rat hippocampal pyramidal cells

Spontaneous miniature excitatory postsynaptic currents (mEPSCs) were recorded from the CA1 region of slices using the whole-cell patch-clamp technique. Cyclothiazide (0.1 mM), a complete blocker of desensitization of (S)-alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) channels, was applied to determine the changes in amplitude and kinetics of mEPSCs occurring with complete suppression of desensitization. The amplitude of mEPSC (A) was not affected significantly by cyclothiazide, but both the rise (taur) and the decay time (taud) were consistently increased (from 2.3 to 6.5 ms and from 9.9 to 22.2 ms respectively). The amplitude dependence of both taud and taur became much greater, but there was no upward shift of the best-fitting lines. The slopes of the control best-fitting lines were (+/-SD; ms/pA; n=5) 0.39+/-0.05 for taud:A and 0.12+/-0.07 for taur:A, but, in the presence of cyclothiazide, the corresponding slopes were much steeper (2.1+/-0.60 and 0.68+/-0. 21; holding potential was -50 mV and temperature 32 degreesC). These changes, which were slow to develop, suggest that cyclothiazide blocks AMPA receptor channel desensitization, whilst having no effect on the closing rate of AMPA channels. Judging by the extent of change, the speed of diffusion of glutamate in the synaptic cleft is probably similar to that in water. In conclusion, this study provides evidence that: (1) under control conditions, desensitization of AMPA channels plays a major role in shaping the time course of synaptic currents in CA1; and (2) cyclothiazide prolongs their time course solely by abolishing desensitization.

Migration of epithelium during phenytoin-dependent gingival overgrowth in mice

A small cavity was made in the mesiopalatal area of the maxillary first molar adjacent to the gingiva. Mice were maintained on 40 mg/kg phenytoin (or on diluent for control) by daily intraperitoneal injections. After 9 weeks, light microscopic observations revealed that in experimental mice, epithelial cells migrated towards the cavity and covered it. In controls, epithelial cell migration towards the cavity did not occur. For scanning electron microscopic (SEM) studies, specimens were fixed in 4% glutaraldehyde in 0.1 M phosphate buffer, pH 7.2, for 2 hours, dehydrated, critical point dried and coated with gold. The surface of the outer gingival epithelium of experimental and of control mice showed a honeycomb arrangement of the microridges suggesting their keratinized nature. Epithelial cells lining the cavity showed well marked macroridges along their borders. Parallel microridges were observed on the upper surface of these cells suggesting that they were non-keratinized. It was concluded that the migrating epithelial cells, that covered the cavity during phenytoin-dependent gingival overgrowth, were of the non-keratinized type.

Immunologic properties of purified epidermal Langerhans cells. Distinct requirements for stimulation of unprimed and sensitized T lymphocytes

Langerhans cells (LC) are Ia+ leukocytes that account for less than 2% of the cells in murine epidermal isolates. We purified LC by cell sorting to study their capacity to stimulate antigen-specific responses from unprimed and sensitized T cells. Sorting was performed after 12 or 72 h of epidermal culture, since our earlier work had indicated that LC became immunologically active during that time interval. At 12 and 72 h, the LC were uniformly and equally rich in the Ia glycoproteins that are recognized by helper T cells. At both time points, LC were comparable in their capacity to stimulate sensitized helper T lymphocytes, and would cluster the T cells in an antigen-dependent fashion at 4 degrees C. However, 12-h LC did not sensitize T cells, as indicated by their inactivity in stimulating the primary MLR or antibody response, and they were unable to cluster T cells in an antigen-independent fashion at 37 degrees C. The latter properties were acquired during 72 h of culture. As a result, the function of 72-h LC fully resembled that of lymphoid dendritic cells. We propose that the maturation of stimulatory function within the dendritic cell lineage represents an important control point in the induction phase of cell-mediated immunity.

Induction of immunoglobulin synthesis in corticosteroid-treated blood lymphocytes of a patient with acquired agammaglobulinemia

Coculture experiments between lymphocytes of a 17-year-old immunodeficient male, DL, and a group of normal subjects, assaying pokeweed mitogen (PWM)-stimulated Ig secretion as a measure of B-cell function, revealed immunoregulatory abnormalities. Initial studies disclosed that DL had corticosteroid-sensitive T suppressor (Ts) cells capable of blocking Ig secretion by both HLA-identical and HLA-nonidentical cells in coculture. Cocultures of DL's peripheral blood mononuclear cells could be induced to secrete Ig in large amounts after certain maneuvers--the most informative of which involved mixing prednisolone-treated DL mononuclear cells with any normal T lymphocytes except those from DL himself. When these same experimental manipulations were performed individually, i.e., prednisolone treatment of cultured DL cells to remove Ts activity, or mixing equal numbers of normal T cells with untreated DL mononuclear cells, Ig was not produced. The data indicated that the T-cell abnormalities in DL included an excess of Ts cells and a deficiency to T helper (Th) cells. When repeat studies were performed later in the clinical course, during which interval a number of clinical interventions were attempted, it was found that the patient's cells were no longer corticosteroid sensitive and, further, they suppressed only HLA-identical cells.