Management of Liver Tumors during the COVID-19 Pandemic: The Added Value of Selective Internal Radiation Therapy (SIRT)

Abstract

Background: In the context of the coronavirus disease 2019 (COVID-19) pandemic, liver-directed therapies (LDTs) may offer minimally invasive integrative tools for tumor control. Among them, selective internal radiation therapy (SIRT) represents a safe, flexible and effective treatment. Purpose of this study is to present our experience with SIRT during the first wave of COVID-19 pandemic and provide an overview of the indications and challenges of SIRT in this scenario. Methods: We retrospectively analyzed the number of patients evaluated by Multidisciplinary Liver Tumor Board (MLTB) and who were undergoing LDTs between March and July 2020 and compared it with 2019. For patients treated with SIRT, clinical data, treatment details and the best radiological response were collected. Results: Compared to 2019, we observed a 27.5% reduction in the number of patients referred to MLTB and a 28.3% decrease in percutaneous ablations; transarterial chemoembolizations were stable, while SIRT increased by 64%. The majority of SIRT patients (75%) had primary tumors, mostly HCC. The best objective response and disease control rates were 56.7% and 72.2%, respectively. Conclusion: The first wave of the COVID-19 pandemic was characterized by an increased demand for SIRT, which represents a safe, flexible and effective treatment, whose manageability will further improve by simplifying the treatment workflow, developing user-friendly and reliable tools for personalized dosimetry and improving interdisciplinary communication.

Advances in Delivery of Selective Internal Radiation Therapy (SIRT): Economic and Logistical Effects of Same-Stay Work-Up and Procedure in the Treatment of Unresectable Liver Tumors in England

“…Despite ongoing reductions in the prevalence of COVID-19 in the UK, reducing unnecessary contacts with the healthcare system is still beneficial in terms of reducing the transmission rate of COVID-19, other airborne diseases, and nosocomial infections more broadly. In this context, SIRT is a flexible and well-tolerated treatment, allowing tumor progression to be controlled (or tumor load to be reduced) while patients are waiting for evaluation or access to other therapies; such adaptable treatment pathways are particularly beneficial during global health crises such as the COVID-19 pandemic, but are also clearly advantageous in routine practice [ 43 ]. OMT increases this aspect by enabling single-stay treatment of HCC, compared to systemic therapies or chemoembolization which generally require several hospitalizations, sometimes lasting multiple days [ 44 , 45 ].…”

“…In this context, SIRT is a flexible and well-tolerated treatment, allowing tumor progression to be controlled (or tumor Fig. 4 Overall, per-patient, healthcare resource group-based cost estimates of SIR-Spheres Y-90 resin microspheres, workup, and selective internal radiation therapy procedure with and without the order-map-treat program load to be reduced) while patients are waiting for evaluation or access to other therapies; such adaptable treatment pathways are particularly beneficial during global health crises such as the COVID-19 pandemic, but are also clearly advantageous in routine practice [43]. OMT increases this aspect by enabling single-stay treatment of HCC, compared to systemic therapies or chemoembolization which generally require several hospitalizations, sometimes lasting multiple days [44,45].…”

Impact of SARS-CoV-2 Pandemic on the Management of Patients with Hepatocellular Carcinoma

“…Often the main decision was to delay, when possible, the surgical treatment, but the American Association for the Study of Liver Diseases (AASLD) and EASL recommend continuing HCC surveillance and treatment with an acceptable delay of a maximum of two months to reduce the number of patients presenting with HCC not amenable to treatment [ 1 , 26 ]. The general agreement was to delay surgery, promoting locoregional treatment, such as ablation or trans-arterial options, considering two main causes: (a) the day of hospitalization, and (b) the need for post-operative ICU care, often busy for COVID-19 patients [ 27 , 28 ]. The delayed treatment must be considered in the non-urgent treatment of localized HCC by 2–3 months if there is no negative impact on the oncological outcomes; otherwise, large or multifocal HCC candidate for resection must have a “high surgical priority” [ 29 ].…”

“…In cases where the HCC treatment cannot be postponed, locoregional approaches, such as radiofrequency/microwave ablation and trans-arterial therapies (Transarterial chemoembolization—TACE or Transarterial radioembolization—TARE), can be used as alternative or bridging methods, until surgery can be performed. In fact, in many centers locoregional treatments did not decrease but sometimes increased, such as in Pisa [ 27 ] where TACE and TARE were alternative options for patients with delayed treatment. In patients undergoing surgery or locoregional therapy, strict monitoring should be carried out with imaging examinations every 12–16 weeks in the first year and then every 6 months to evaluate treatment response and detect possible HCC recurrence.…”

Editorial of Special Issue “Embolization Techniques: State of the Art and Future Perspectives”

“…Embolization is used with the main purpose to obtain a target vessel occlusion [ 4 ] or a significant flow reduction as in conventional chemoembolization [ 5 ], although it can be also used in the case of a vessel bifurcation to determine an obligatory flow direction, for example in case of gastroduodenal artery coil embolization to favor hepatic intra-arterial chemotherapy [ 6 ]. Embolization is routinely performed in many clinical situations including arterial/venous bleeding [ 7 ], vascular/lymphatic malformations [ 8 ], visceral/renal aneurysms [ 9 , 10 ], endoleaks [ 11 ], variceal diseases [ 12 ], pre-surgical treatments [ 13 ], oncological treatments [ 14 ], benign/hypertrophic nodules/organs [ 15 ]. Every embolic agent is characterized by points of strengths and weaknesses and can be used alone or combined with another embolic agent to increase its embolic power.…”