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Aliseda D, Rotellar F, Sancho L, Batidas JF, Martínez de la Cuesta A, Rodríguez-Fraile M. Surgery and radioembolization of liver tumors. Rev Esp Med Nucl Imagen Mol 2023:S2253-8089(23)00056-3. [PMID: 37321348 DOI: 10.1016/j.remnie.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 06/08/2023] [Indexed: 06/17/2023]
Abstract
Surgical resection is considered the curative treatment par excellence for patients with primary or metastatic liver tumors. However, less than 40% of them are candidates for surgery, either due to non-modifiable factors (comorbidities, age, liver dysfunction…), or to the invasion or proximity of the tumor to the main vascular requirements, the lack of a future liver remnant (FLR) adequate to maintain postoperative liver function, or criteria of tumor size and number. In these last factors, hepatic radioembolization has been shown to play a role as a presurgical tool, either by hypertrophy of the FLR or by reducing tumor size that manages to reduce tumor staging (term known as "downstaging"). To these is added a third factor, which is its ability to apply the test of time, which makes it possible to identify those patients who present progression of the disease in a short period of time (both locally and at distance), avoiding a unnecessary surgery. This paper aims to review RE as a tool to facilitate liver surgery, both through the experience of our center and the available scientific evidence.
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Affiliation(s)
- Daniel Aliseda
- Departamento de Cirugía General, Clínica Universidad de Navarra, Pamplona, Navarra, Spain
| | - Fernando Rotellar
- Departamento de Cirugía General, Clínica Universidad de Navarra, Pamplona, Navarra, Spain
| | - Lidia Sancho
- Servicio de Medicina Nuclear, Clínica Universidad de Navarra, Madrid, Spain
| | - Juan Fernando Batidas
- Servicio de Medicina Nuclear, Clínica Universidad de Navarra, Pamplona, Navarra, Spain
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2
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Casáns-Tormo I, Guijarro-Rosaleny J, Lluch-García P, Rodríguez-Parra H, Roselló-Keränen S, Asensio-Valero L. Evaluation of results after 112 radioembolizations with 90Y-microspheres. Rev Esp Med Nucl Imagen Mol 2023:S2253-8089(23)00053-8. [PMID: 37269983 DOI: 10.1016/j.remnie.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 05/07/2023] [Accepted: 05/09/2023] [Indexed: 06/05/2023]
Abstract
AIM To determine the results of radioembolization transarterial (TARE), in the treatment of liver tumors, a retrospective evaluation was performed after 112 TARE with 90Y-microspheres administered in 82 patients in a single hospital, analyzing efficacy and safety, after a follow-up greater than or equal to 1 year post-TARE in all patients, and evaluating the possible relationship between treatment response and patient survival. MATERIAL AND METHODS We have administered 57 single TARE and 55 multiple TARE in patients with hepatocellular carcinoma (53), liver metastases (25) and cholangiocarcinoma (4), with prior multidisciplinary evaluation, clinical, angiographic and gammagraphic (planar/SPECT/SPECT-CT with 99mTc-MAA), multicompartment model (MIRD equations), post-TARE screening (planar/SPECT/SPECT-CT), clinical and radiological follow-up, tumor response evaluation (mRECIST criteria) and Kaplan-Meier analysis to determine progression-free survival and overall survival (OS). RESULTS Therapeutic intention was palliative (82%) and as bridge to liver transplantation/surgical resection (17%). We obtained response (R), complete or partial, in 65.9% of cases. One year after TARE 34.7% of patients with R and 19.2% of non-R were progression-free (p: 0.003), with OS of 80% for R and 37.5% for non-R (p: 0.001). Survival analysis showed median OS of 18 months (95% CI 15.7-20.3) for R and 9 months (95% CI 6.1-11.8) for non-R (p: 0.03). We found mild (27.6%) and severe (5.3%) side effects, all of them resolved, without higher incidence after multiple TARE. CONCLUSION TARE with 90Y-microspheres, in appropriately selected patients with liver tumors, provides therapeutic efficacy and low rate of toxicity, with higher progression-free survival and OS in patients with TARE response compared to those who did not respond.
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Affiliation(s)
- I Casáns-Tormo
- Servicio de Medicina Nuclear, Hospital Clínico Universitario, Valencia, Spain.
| | - J Guijarro-Rosaleny
- Servicio de Radiodiagnóstico, Hospital Clínico Universitario, Valencia, Spain
| | - P Lluch-García
- Servicio de Medicina Digestiva, Hospital Clínico Universitario, Valencia, Spain
| | - H Rodríguez-Parra
- Servicio de Medicina Nuclear, Hospital Clínico Universitario, Valencia, Spain
| | - S Roselló-Keränen
- Servicio de Oncología Médica, Hospital Clínico Universitario, Valencia, Spain
| | - L Asensio-Valero
- Servicio de Medicina Nuclear, Hospital Clínico Universitario, Valencia, Spain
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3
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Oliván-Sasot P, Pérez-Enguix D, Bello-Arques P, Torres-Espallardo I, Falgás-Lacueva M, Yepes-Agudelo AM, Olivas-Arroyo C. Radioembolization in patients with hepatocellular carcinoma: a series of 53 cases. Radiologia (Engl Ed) 2023; 65:12-21. [PMID: 36842781 DOI: 10.1016/j.rxeng.2021.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 09/30/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To contribute our results to increase the scientific evidence about the use of radioembolization in the management of patients with hepatocellular carcinoma. MATERIAL AND METHODS This retrospective review included 53 patients with hepatocellular carcinoma treated with radioembolization at our center. Patients were classified according to the BCLC algorithm in detail according to their Child-Pugh functional status. We analyzed survival using the Kaplan-Meier method. We used Cox regression analysis to determine clinically significant parameters, including the doses administered in the parameters studied. RESULTS Patients ranged in age from 28 to 86 years (mean, 60 years). A total of 61 procedures were done. The mean activity administered was 2.8GBq (0.7-6.4GBq), with a mean dose of 229.9Gy (74-425.9Gy) administered in the tumor. Progression-free survival was 6.7 months and overall survival was 12.8 months. Differences in disease-free survival according to BCLC and Child-Pugh classification were not significant (p=0.848 and p=0.252, respectively). The clinical parameters that were significantly different with respect to overall survival were bilirubin levels (p<0.001), pretreatment transaminase levels (AST) (p=0.022), Child-Pugh subclassification (p=0.003), and dose administered in the tumor (p=0.001). Only one patient had a severe adverse reaction, developing posttreatment liver failure resulting in death. CONCLUSIONS Radioembolization is safe and efficacious in the treatment of patients with hepatocellular carcinoma. Liver function and the doses received by the tumor are key parameters for the efficacy of treatment. The increase in the scientific evidence supports the inclusion of this technique in treatment guidelines.
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Affiliation(s)
- P Oliván-Sasot
- Medicina Nuclear, Hospital de La Ribera, Alzira, Valencia, Spain.
| | - D Pérez-Enguix
- Radiología Intervencionista, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - P Bello-Arques
- Medicina Nuclear, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | | | - M Falgás-Lacueva
- Medicina Nuclear, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - A M Yepes-Agudelo
- Medicina Nuclear, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - C Olivas-Arroyo
- Radiofarmacia, Hospital Universitario y Politécnico La Fe, Valencia, Spain
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4
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Triviño-Ibáñez EM, Pardo Moreno P, Ciampi Dopazo JJ, Ramos-Font C, Ruiz Villaverde G, González-Flores E, Navarro Vergara PF, Rashki M, Gómez-Río M, Rodríguez-Fernández A. Biomarkers associated with survival and favourable outcome of radioembolization with yttrium-90 glass microspheres for colon cancer liver metastases: Single centre experience. Rev Esp Med Nucl Imagen Mol 2021; 41:231-238. [PMID: 34454892 DOI: 10.1016/j.remnie.2021.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 05/22/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To determine the therapeutic effectiveness and safety of transarterial radioembolization (TARE) with Yttrium-90 in patients with colorectal cancer (CRC) liver metastases and to evaluate the prognostic value of different biomarkers. MATERIAL AND METHODS This prospective longitudinal study enrolled consecutive patients with CRC liver metastases treated with TARE between November 2015 and june 2020. The therapeutic response at three and six months (RECIST1.1 criteria) and the relationship of biomarkers with therapeutic response, by calculating objective tumor response rates (ORR) and disease control (DCR), and overall survival (OS) and progression-free (PFS). RESULTS Thirty TAREs were performed in 23 patients (mean age, 61.61 ± 9.13 years; 56.5% male). At three months, the objective response rate (ORR) was 16.7% and the disease control rate (DCR) 53.3%. At six months, the disease progressed in 80%. The ORR and DCR were significantly associated with age at diagnosis (P = 0.047), previous bevacizumab treatment (P = 0.008), pre-TARE haemoglobin (P = 0.008), NLR (P = 0.040), pre-TARE albumin (P = 0.012), pre-TARE ALT (P = 0.023) and tumour-absorbed dose > 115 Gy (P = 0.033). Median overall survival (OS) was 12 months (95% CI, 4.75-19.25 months) and median progression-free survival (PFS) 3 months (95% CI, 2.41-3.59). OS was significantly associated with primary tumour resection (P = 0.019), KRAS mutation (HR: 5.15; P = 0.024), pre-TARE haemoglobin (HR: 0.50; p = 0.009), pre-TARE NLR (HR: 1.65; P = 0.005) and PLR (HR: 1.01; P = 0.042). CONCLUSION TARE prognosis and therapeutic response were predicted by different biomarkers, ranging from biochemical parameters to tumour dosimetrics.
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Affiliation(s)
- E M Triviño-Ibáñez
- Servicio de Medicina Nuclear, Hospital Universitario Virgen de las Nieves, Granada, Spain; IBS, Granada Bio-Health Research Institute, Granada, Spain.
| | - P Pardo Moreno
- Servicio de Radiodiagnóstico, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - J J Ciampi Dopazo
- Servicio de Radiodiagnóstico, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - C Ramos-Font
- Servicio de Medicina Nuclear, Hospital Universitario Virgen de las Nieves, Granada, Spain; IBS, Granada Bio-Health Research Institute, Granada, Spain
| | - G Ruiz Villaverde
- Servicio de Radiodiagnóstico, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - E González-Flores
- Servicio de Oncología Médica, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - P F Navarro Vergara
- Servicio de Radiodiagnóstico, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - M Rashki
- Servicio de Medicina Nuclear, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - M Gómez-Río
- Servicio de Medicina Nuclear, Hospital Universitario Virgen de las Nieves, Granada, Spain; IBS, Granada Bio-Health Research Institute, Granada, Spain
| | - A Rodríguez-Fernández
- Servicio de Medicina Nuclear, Hospital Universitario Virgen de las Nieves, Granada, Spain; IBS, Granada Bio-Health Research Institute, Granada, Spain
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5
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Triviño-Ibáñez EM, Pardo Moreno P, Ciampi Dopazo JJ, Ramos-Font C, Ruiz Villaverde G, González-Flores E, Navarro Vergara PF, Rashki M, Gómez-Río M, Rodríguez-Fernández A. Biomarkers associated with survival and favourable outcome of radioembolization with yttrium-90 glass microspheres for colon cancer liver metastases: Single centre experience. Rev Esp Med Nucl Imagen Mol 2021; 41:S2253-654X(21)00129-3. [PMID: 34294586 DOI: 10.1016/j.remn.2021.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 05/21/2021] [Accepted: 05/22/2021] [Indexed: 11/30/2022]
Abstract
OBJETIVE To determine the therapeutic effectiveness and safety of transarterial radioembolization (TARE) with Yttrium-90 in patients with colorectal cancer (CRC) liver metastases and to evaluate the prognostic value of different biomarkers. MATERIAL AND METHODS This prospective longitudinal study enrolled consecutive patients with CRC liver metastases treated with TARE between November 2015 and june 2020. The therapeutic response at three and six months (RECIST1.1 criteria) and the relationship of biomarkers with therapeutic response, by calculating objective tumor response rates (ORR) and disease control (DCR), and overall survival (OS) and progression-free (PFS). RESULTS Thirty TAREs were performed in 23 patients (mean age, 61,61±9,13 years; 56,5% male). At three months, the objective response rate (ORR) was 16,7% and the disease control rate (DCR) 53,3%. At six months, the disease progressed in 80%. The ORR and DCR were significantly associated with age at diagnosis (P=.047), previous bevacizumab treatment (P=.008), pre-TARE haemoglobin (P=.008), NLR (P=.040), pre-TARE albumin (P=.012), pre-TARE ALT (P=.023) and tumour-absorbed dose>115Gy (P=.033). Median overall survival (OS) was 12 months (95% CI, 4.75-19.25 months) and median progression-free survival (PFS) 3 months (95% CI, 2.41-3.59). OS was significantly associated with primary tumour resection (P=.019), KRAS mutation (HR: 5.15; P=.024), pre-TARE haemoglobin (HR: .50; p=.009), pre-TARE NLR (HR: 1.65; P=.005) and PLR (HR: 1.01; P=.042). CONCLUSION TARE prognosis and therapeutic response were predicted by different biomarkers, ranging from biochemical parameters to tumour dosimetrics.
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Affiliation(s)
- E M Triviño-Ibáñez
- Servicio de Medicina Nuclear, Hospital Universitario Virgen de las Nieves, Granada, España; IBS, Granada Bio-Health Research Institute, Granada, España.
| | - P Pardo Moreno
- Servicio de Radiodiagnóstico, Hospital Universitario Virgen de las Nieves, Granada, España
| | - J J Ciampi Dopazo
- Servicio de Radiodiagnóstico, Hospital Universitario Virgen de las Nieves, Granada, España
| | - C Ramos-Font
- Servicio de Medicina Nuclear, Hospital Universitario Virgen de las Nieves, Granada, España; IBS, Granada Bio-Health Research Institute, Granada, España
| | - G Ruiz Villaverde
- Servicio de Radiodiagnóstico, Hospital Universitario Virgen de las Nieves, Granada, España
| | - E González-Flores
- Servicio de Oncología Médica, Hospital Universitario Virgen de las Nieves, Granada, España
| | - P F Navarro Vergara
- Servicio de Radiodiagnóstico, Hospital Universitario Virgen de las Nieves, Granada, España
| | - M Rashki
- Servicio de Medicina Nuclear, Hospital Universitario Virgen de las Nieves, Granada, España
| | - M Gómez-Río
- Servicio de Medicina Nuclear, Hospital Universitario Virgen de las Nieves, Granada, España; IBS, Granada Bio-Health Research Institute, Granada, España
| | - A Rodríguez-Fernández
- Servicio de Medicina Nuclear, Hospital Universitario Virgen de las Nieves, Granada, España; IBS, Granada Bio-Health Research Institute, Granada, España
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6
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Oliván-Sasot P, Pérez-Enguix D, Bello-Arques P, Torres-Espallardo I, Falgás-Lacueva M, Yepes-Agudelo AM, Olivas-Arroyo C. Radioembolization in patients with hepatocellular carcinoma: a series of 53 cases. Radiologia (Engl Ed) 2020; 65:S0033-8338(20)30143-0. [PMID: 33257052 DOI: 10.1016/j.rx.2020.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 09/10/2020] [Accepted: 09/30/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To contribute our results to increase the scientific evidence about the use of radioembolization in the management of patients with hepatocellular carcinoma. MATERIAL AND METHODS This retrospective review included 53 patients with hepatocellular carcinoma treated with radioembolization at our center. Patients were classified according to the BCLC algorithm in detail according to their Child-Pugh functional status. We analyzed survival using the Kaplan-Meier method. We used Cox regression analysis to determine clinically significant parameters, including the doses administered in the parameters studied. RESULTS Patients ranged in age from 28 to 86 years (mean, 60 years). A total of 61 procedures were done. The mean activity administered was 2.8 GBq (0.7-6.4 GBq), with a mean dose of 229.9Gy (74-425.9Gy) administered in the tumor. Progression-free survival was 6.7 months and overall survival was 12.8 months. Differences in disease-free survival according to BCLC and Child-Pugh classification were not significant (p=0.848 and p=0.252, respectively). The clinical parameters that were significantly different with respect to overall survival were bilirubin levels (p<0.001), pretreatment transaminase levels (AST) (p=0.022), Child-Pugh subclassification (p=0.003), and dose administered in the tumor (p=0.001). Only one patient had a severe adverse reaction, developing posttreatment liver failure resulting in death. CONCLUSIONS Radioembolization is safe and efficacious in the treatment of patients with hepatocellular carcinoma. Liver function and the doses received by the tumor are key parameters for the efficacy of treatment. The increase in the scientific evidence supports the inclusion of this technique in treatment guidelines.
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Affiliation(s)
- P Oliván-Sasot
- Medicina Nuclear, Hospital de La Ribera, Alzira, Valencia, España.
| | - D Pérez-Enguix
- Radiología intervencionista, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - P Bello-Arques
- Medicina Nuclear, Hospital Universitario y Politécnico La Fe, Valencia, España
| | | | - M Falgás-Lacueva
- Medicina Nuclear, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - A M Yepes-Agudelo
- Medicina Nuclear, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - C Olivas-Arroyo
- Radiofarmacia, Hospital Universitario y Politécnico La Fe, Valencia, España
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7
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Bilbao JI, Páramo M, Madrid JM, Benito A. Hepatocellular carcinoma treatment: ablation and arterial embolization. Radiologia (Engl Ed) 2017; 60:156-166. [PMID: 29108656 DOI: 10.1016/j.rx.2017.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 09/09/2017] [Accepted: 09/11/2017] [Indexed: 02/08/2023]
Abstract
Percutaneous and endovascular techniques take an important role in the therapeutic management of patients with hepatocarcinoma. Different techniques of percutaneous ablation, especially indicated in tumors up to 2cm diameter offer, at least, similar results to surgical resection. Taking advantage of double hepatic vascularization and exclusive tumor nutrition by the artery, several endovascular techniques of treating the tumor have been developed. Intra-arterial administration of embolizing particles, alone or charged with drug (chemoembolization), will produce ischemia and consequent necrosis with excellent results in selected patients. Certain types of particles may exclusively be carriers of a therapeutic agent when they incorporate a radioisotope that facilitates the direct intratumoral selective irradiation (radioembolization). This technique has demonstrated its efficacy in lesions not susceptible to be treated with other methods and should be considered, together with ablation and chemoembolization, in the therapeutic algorithms of hepatocarcinoma.
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Affiliation(s)
- J I Bilbao
- Servicio de Radiología, Clínica Universidad de Navarra, Pamplona, España.
| | - M Páramo
- Servicio de Radiología, Clínica Universidad de Navarra, Pamplona, España
| | - J M Madrid
- Servicio de Radiología, Clínica Universidad de Navarra, Pamplona, España
| | - A Benito
- Servicio de Radiología, Clínica Universidad de Navarra, Pamplona, España
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8
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Armengol C, Sarrias MR, Sala M. Hepatocellular carcinoma: Present and future. Med Clin (Barc) 2017; 150:390-397. [PMID: 29096967 DOI: 10.1016/j.medcli.2017.08.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 08/17/2017] [Accepted: 08/21/2017] [Indexed: 12/19/2022]
Abstract
Hepatocellular carcinoma (HCC) is the sixth most common cancer worldwide with over 740,000 new cases per year and the third leading cause of cancer-related death, with a growing incidence in recent years. This tumor usually arises in patients with an underlying chronic liver disease. The management of this tumor has improved over the past 2 decades: patients at risk are included in a surveillance program, a prognostic staging system has been created and, finally, new treatments particularly aimed at patients with advanced HCC have been developed. This fact has resulted in a greater interest in this tumor and several scientific societies have developed clinical practice guidelines for the management of patients with this disease. In this article, we review the current and future prospects of this tumor.
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Affiliation(s)
- Carolina Armengol
- Unidad de Hepatología, Servicio de Aparato Digestivo, Institut de Recerca Germans Trias i Pujol (IGTP), Hospital Germans Trias i Pujol, Badalona, Barcelona, España; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Badalona, Barcelona, España; Childhood Liver Oncology group (c-LOG), Program of Predictive and Personalized Medicine of Cancer (PMPPC), Institut de Recerca Germans Trias i Pujol (IGTP), Badalona, Barcelona, España
| | - Maria Rosa Sarrias
- Unidad de Hepatología, Servicio de Aparato Digestivo, Institut de Recerca Germans Trias i Pujol (IGTP), Hospital Germans Trias i Pujol, Badalona, Barcelona, España; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Badalona, Barcelona, España; Innate Immunity Group, Germans Trias i Pujol Health Sciences Institute (IGTP), Badalona, Barcelona, España
| | - Margarita Sala
- Unidad de Hepatología, Servicio de Aparato Digestivo, Institut de Recerca Germans Trias i Pujol (IGTP), Hospital Germans Trias i Pujol, Badalona, Barcelona, España; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Badalona, Barcelona, España.
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9
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Abstract
The two intraarterial techniques used in the treatment of hepatocellular carcinoma (HCC) are the transarterial chemoembolization (TACE) and radioembolization (RE). TACE includes various procedures whose objective is to expose tumor cells to a chemotherapy agent and induce acute ischemia in the tumor. The survival benefit obtained by adding a chemotherapy agent or lipiodol to simple particle embolization has not been demonstrated in 2 meta-analyses, which suggests that the antitumor effect is primarily ischemic. RE is a form of brachytherapy that consists of an intraarterial injection of microspheres loaded with yttrium 90 as the source of radiation, a pure beta emitter with a mean tissue penetration of 2mm. TACE is performed in several sessions every 4-8 weeks, while RE is generally a single procedure. The guidelines adopted by the main research societies support the use of TACE for the palliative treatment of patients with intermediate stage HCC. This is a level 1 recommendation based on the positive results of 2 randomized clinical trials and 3 meta-analyses and on several uncontrolled studies with thousands of patients with unresectable HCC. Survival in clinical practice studies is heterogeneous due to the heterogeneity of the treated population. The survival rate varies from 8% to 26% at 5 years, and the median is 16-40 months in the early stage and 15-27 months in the intermediate stage. TACE with drug-eluting beads (DEB-TACE) has not shown superiority versus conventional TACE in terms of improved survival or tumor response, but it decreases the severe chemotherapy-related adverse events. One of its advantages is the standardization of the procedure, while its primary disadvantage is the onset of biliary complications when used nonselectively. There is level 2 evidence to support the use of RE in HCC, evidence that comes from patient cohorts with consistent results and case-control studies. The treated population includes mainly patients with unresectable tumors, who are considered suboptimal candidates for TACE or are progressing toward this condition, and those for whom TACE was directly contraindicated by the presence of portal vein thrombosis. Consequently, these patients tend to have large or extensively bilobar tumors and other factors for a poor prognosis. The overall survival reported for patients in the intermediate and advanced stages is 16-18 months and 7-17 months, respectively. A number of retrospective studies have reported comparable survival for patients treated with TACE and RE in the same institution; however, these results should be interpreted as a generator of ideas and not as an equivalent efficacy test. Although the combination of systemic agents such as sorafenib with intraarterial techniques is attractive, the results to date are not encouraging. In the only available randomized trial that compared the combination of a continuous regimen of sorafenib started before the first session of DEB-TACE versus DEB-TACE alone, neither the time to progression nor the overall survival were significantly different between the 2 groups. TACE and RE are contraindicated in cases of decompensated cirrhosis. TACE is also contraindicated for patients with considerable tumor burden in whom the procedure cannot be performed selectively and in patients with portal vein invasion.
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Affiliation(s)
- Bruno Sangro
- Unidad de Hepatología, Clínica Universidad de Navarra, Pamplona, España; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD).
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