Combination of yttrium-90 radioembolization with stereotactic body radiation therapy in the treatment of portal vein tumor thrombosis

Abstract

Portal vein tumor thrombosis (PVTT) from cancer involving the liver carries a dismal prognosis, with median overall survival (OS) ranging from 2 to 5 months. While treatment with yttrium-90 ( 90 Y) radioembolization alone may improve outcomes, overall prognosis remains poor. We hypothesize that the combination of 90 Y radioembolization to the parenchymal component of the tumor and stereotactic body radiation therapy (SBRT) to the vascular component is a safe and effective means of improving outcomes. Materials and Methods: A single center retrospective review identified 12 patients with cancers involving the liver who received both 90 Y radioembolization and SBRT to the PVTT between May 2015 to August 2020. Primary endpoint was the 90-day toxicity rate by the Common Terminology Criteria for Adverse Events version 5.0. Secondary endpoints were the best response rate based on the Response Evaluation Criteria in Solid Tumors v1.1, local control rate, portal vein (PV) patency rate, and median OS. Results: Patients received a median 90 Y dose of 104.3 Gy (range, 83.3 to 131.7 Gy) and a median 5-fraction SBRT dose of 32.5 Gy (range, 27.5 to 50 Gy). There were no late toxicities reported, and only 7 acute grade 1 toxicities reported: elevation of liver function tests (17%), nausea (17%), fatigue (17%), and esophagitis (8%). Local control was 83%. 58% of patients had a patent PV after treatment. With a median follow-up time of 28 months, 1-year OS was 55% with a median OS of 14 months. Conclusion: Combination 90 Y radioembolization and SBRT appears to be safe and effective in the treatment of PVTT. Larger prospective studies are warranted to better evaluate this combination treatment approach.

Stereotactic body radiation therapy (SBRT) following Yttrium-90 (90Y) selective internal radiation therapy (SIRT): a feasibility planning study using 90Y delivered dose

“…This approach makes use of the fact that SIRT is inherently sparing of healthy tissue due to preferential uptake of 90 Y in lesions relative to healthy liver and the limited range of the beta particles. There are prior studies reporting the combination of 90 Y SIRT and EBRT delivered to the liver in the same patients, with no major toxicities noted (Abbott et al 2020, Liu et al 2021. However, to our knowledge this is the first study to propose direct usage of delivered 90 Y dose maps, with predicted tumor responses, to create EBRT plans that dynamically conform to SIRT underdosed tumor regions.…”

AAPM Medical Physics Practice Guideline 14.a: Yttrium‐90 microsphere radioembolization

“…2,3 The possibility of using combined therapies has also been recommended in the literature. 4,5 There is a large body of prospective and retrospective literature demonstrating both safety and efficacy of radioembolization for the management of primary 2,[6][7][8] and metastatic 3,9,10 liver cancers. The literature for colorectal liver metastases, especially patients with liver only, or liver dominant disease, is particularly extensive.…”

“…The procedure for requesting this change process is detailed in the NRC guidance document. 4 authorization to submit notification of the new AU to the NRC instead of an amendment request, provided conditions detailed for this situation in the NRC licensing document are met.…”

“…The therapeutic ratio effectively improves intrahepatic tumor control while minimizing the relative risk of radioembolization‐induced liver disease (REILD) even for patients with extensive tumor burden 2,3 . The possibility of using combined therapies has also been recommended in the literature 4,5 …”

Local and Regional Therapies for Hepatocellular Carcinoma and Future Combinations

“…As mentioned above, the combination of TARE and TACE is scarcely investigated. The combination of TARE and SBRT in patients with portal vein infiltration seems to be safe and led to an improved prognosis [118,119]. However, these results are currently of experimental character and have been reported only for a very limited number of patients.…”