<sup>90</sup>Y radiation lobectomy: Outcomes following surgical resection in patients with hepatic tumors and small future liver remnant volumes

Lewandowski, Robert J.; Donahue, Larry; Chokechanachaisakul, Attasit; Kulik, Laura; Mouli, S.; Caicedo, Juan C.; Abécassis, Michaël; Fryer, Jonathan P.; Salem, Riad; Baker, Talia

doi:10.1002/jso.24269

Cited by 97 publications

(66 citation statements)

References 31 publications

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“…Limited therapy after progression permits the attribution of survival outcome solely to RS without confounders. Finally, the time to progression of 2.4 years (29 months) is comparable to the Prospective Randomized Trial of Radioembolization and Chemoembolization in HCC (or PREMIERE) trial, where greater than 26 months of time to progression was validated in a randomized setting (32). Also, the mean follow-up that are Child-Pugh class A BCLC stage 0 or A was evaluated.…”

Section: Vascular and Interventional Radiology: Radiation Segmentectomentioning

confidence: 93%

Radiation Segmentectomy: Potential Curative Therapy for Early Hepatocellular Carcinoma

Lewandowski¹,

Gabr²,

Abouchaleh³

et al. 2018

Radiology

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187

115

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Purpose:To report long-term outcomes of radiation segmentectomy (RS) for early hepatocellular carcinoma (HCC). The authors hypothesized that outcomes are comparable to curative treatments for patients with solitary HCC less than or equal to 5 cm and preserved liver function. Materials and Methods:This retrospective study included 70 patients (median age, 71 years; range, 22-96 years) with solitary HCC less than or equal to 5 cm not amenable to percutaneous ablation who underwent RS (dose of .190 Gy) between 2003 and. Patients who underwent subsequent curative liver transplantation were excluded to eliminate this confounding variable affecting survival. Radiologic response of time to progression and median overall survival were estimated by using the Kaplan-Meier method per the guidelines of the European Association for the Study of the Liver (EASL) and the World Health Organization (WHO). Results:Seventy patients were treated with RS over 14 years. Sixty-three patients (90%) showed response by using EASL criteria, of which 41 (59%) showed complete response. Fifty patients (71%) achieved response by using WHO criteria, of which 11 (16%) achieved complete response. Response rates at 6 months were 86% and 49% by using EASL and WHO criteria, respectively. Median time to progression was 2.4 years (95% confidence interval: 2.1, 5.7), with 72% of patients having no target lesion progression at 5 years. Median overall survival was 6.7 years (95% confidence interval: 3.1, 6.7); survival probability at 1, 3, and 5 years was 98%, 66%, and 57%, respectively. Overall survival probability at 1, 3, and 5 years was 100%, 82%, and 75%, respectively, in patients with baseline tumor size less than or equal to 3 cm (n = 45) and was significantly longer than in patients with tumors greater than 3 cm (P = .026). In our study, we review our longterm outcomes (.10 years) of patients with HCC less than or equal to 5 cm not amenable to resection, radiofrequency ablation, or transplantation who underwent RS. We hypothesize that this approach could be considered potentially curative based on the same rationale as resection, radiofrequency ablation, and transplantation. Conclusion Materials and MethodsR.J.L. and R.S. are advisors to BTG International. There was no funding for this analysis and all authors had control of the data and information submitted for publication. Our study was approved by the institutional review board and was compliant with the Health Insurance Portability and Accountability Act. All patients provided written informed consent prior to receiving treatment after selecting RS over chemoembolization. We searched our prospectively acquired database of HCC (10) for patients treated with 90 Y radioembolization from December 2003 to 2016 (14 years). Inclusion criteria were as follows: solitary HCC less than or equal to 5 cm, preserved liver function (Child-Pugh class A), and no vascular invasion or extrahepatic metastases (7). Patients who underwent transplantation or resection were excluded to mitigate the potential confo...

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Section: Vascular and Interventional Radiology: Radiation Segmentectomentioning

confidence: 93%

Radiation Segmentectomy: Potential Curative Therapy for Early Hepatocellular Carcinoma

Lewandowski¹,

Gabr²,

Abouchaleh³

et al. 2018

Radiology

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187

115

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“…Neoadjuvant RL offers a unique advantage by delivering ablative transarterial brachytherapy in addition to generating FLR hypertrophy. The majority of patients in this series received RL doses greater than 200 Gy, higher than prior reported doses of 120-150 Gy in prior studies (23)(24)(25). Higher hepatic doses and concurrent systemic therapy were well-tolerated in these first line patients without significant clinical toxicity (grade I C-D complications) or hepatic dysfunction.…”

Section: Discussionmentioning

confidence: 71%

“…Two out of four patients progressed after resection at 3 months and may have benefited from longer surveillance. Unlike PVE, patients in this study had a minimal time to resection of 3 months (25). This increased observational period may circumvent an unnecessary resection should there be FLR disease progression that cannot be addressed (7,26).…”

Section: A B a Bmentioning

confidence: 99%

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Neoadjuvant transarterial radiation lobectomy for colorectal hepatic metastases: a small cohort analysis on safety, efficacy, and radiopathologic correlation

Shah

Zendejas-Ruiz

Thornton

et al. 2017

J. Gastrointest. Oncol.

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Colorectal cancer patients have a high incidence of liver metastasis (ml-CRC). Surgical resection is the gold standard for treatment of hepatic metastasis but only a small percent of patients are traditional candidates based on disease extent and adequate size of the future liver remnant (FLR). Interventions such as portal vein embolization (PVE) and associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) are performed to increase FLR for operative conversion. Limitations to PVE include intrahepatic disease progression, portal vascular invasion, and utilization with concurrent chemotherapy. ALPPS is associated with a high morbidly and mortality. Radiation lobectomy (RL) with yttrium-90 (Y-90) delivers transarterial ablative brachytherapy to the future hepatectomy site which generates FLR hypertrophy similar or greater than PVE. Early results indicate that RL is safe, effective, and may offer unique benefits by providing cytoreduction of hepatic metastases which extends FLR hypertrophy time and allows FLR surveillance to gauge disease biology. A retrospective analysis of four patients with ml-CRC treated with RL prior to hepatectomy was performed to evaluate initial safety, efficacy, FLR hypertrophy, and radiopathologic correlation. Adverse events after RL and hepatectomy were evaluated. Imaging findings were analyzed for efficacy defined as FLR hypertrophy and disease control. Radiopathologic correlation was performed after histologic analysis. RL was well tolerated without major adverse events or hepatic decompensation. FLR hypertrophy ranged from 24.9% to 119% at mean follow-up of three months. The majority of complications were related to surgical instrumentation of the FLR due to upstaging at time of surgery. Hepatectomy specimen histology demonstrated complete pathologic response in 50% of patients, 50% radiopathologic concordance rate, and no significant hepatic fibrosis. Initial experience with neoadjuvant RL for ml-CRC is safe and provides both durable disease control and FLR hypertrophy with concurrent chemotherapy. A 50% complete pathologic response rate raises the possibility of definitive chemoradiation in poor surgical candidates. Prospective investigation is required.

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“…However, it is important to consider the feasibility and safety of surgery after SIRT, and to determine the impact of concomitant chemotherapy. A preliminary study of 13 patients who underwent SIRT followed by lobectomy found the approach to be an effective method to induce hypertrophy of the future liver remnant (FLR) prior to resection (89). The median time to resection in this study was 86 days (30-210 days); and with PVE the median time to resection was 37 days (21-84 days) (90).…”

Section: Sirt and Surgerymentioning

confidence: 71%

Safety of selective internal radiation therapy (SIRT) with yttrium-90 microspheres combined with systemic anticancer agents: expert consensus

Kennedy

Brown

Feilchenfeldt

et al. 2017

J. Gastrointest. Oncol.

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Selective internal radiation therapy (SIRT) with microspheres labelled with the β-emitter yttrium-90 (Y-90) enables targeted delivery of radiation to hepatic tumors. SIRT is primarily used to treat inoperable primary or metastatic liver tumors. Eligible patients have usually been exposed to a variety of systemic anticancer therapies, including cytotoxic agents, targeted biologics, immunotherapy and peptide receptor radionuclide therapy (PRRT). All these treatments have potential interactions with SIRT; however, robust evidence on the safety of these potential combinations is lacking. This paper provides current clinical experiences and expert consensus guidelines for the use of SIRT in combination with the anticancer treatment agents likely to be encountered in clinical practice. It was agreed by the expert panel that precautions need to be taken with certain drugs, but that, in general, systemic therapies do not necessarily have to be stopped to perform SIRT. The authors recommend stopping vascular endothelial growth factor inhibitors 4-6 weeks before SIRT, and restart after the patient has recovered from the procedure. It may also be prudent to stop potent radiosensitizers such as gemcitabine therapy 4 weeks before SIRT, and restart treatment at least 2-4 weeks later. Data from phase III studies combining SIRT with fluorouracil (5FU) or folinic acid/5FU/oxaliplatin (FOLFOX) suggest that hematological toxicity is more common from the combination than it is from chemotherapy without SIRT. There is no evidence to suggest that chemotherapy increases SIRT-specific gastro-intestinal or liver toxicities.

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⁹⁰Y radiation lobectomy: Outcomes following surgical resection in patients with hepatic tumors and small future liver remnant volumes

Cited by 97 publications

References 31 publications

Radiation Segmentectomy: Potential Curative Therapy for Early Hepatocellular Carcinoma

Radiation Segmentectomy: Potential Curative Therapy for Early Hepatocellular Carcinoma

Neoadjuvant transarterial radiation lobectomy for colorectal hepatic metastases: a small cohort analysis on safety, efficacy, and radiopathologic correlation

Safety of selective internal radiation therapy (SIRT) with yttrium-90 microspheres combined with systemic anticancer agents: expert consensus

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90Y radiation lobectomy: Outcomes following surgical resection in patients with hepatic tumors and small future liver remnant volumes

Cited by 97 publications

References 31 publications

Radiation Segmentectomy: Potential Curative Therapy for Early Hepatocellular Carcinoma

Radiation Segmentectomy: Potential Curative Therapy for Early Hepatocellular Carcinoma

Neoadjuvant transarterial radiation lobectomy for colorectal hepatic metastases: a small cohort analysis on safety, efficacy, and radiopathologic correlation

Safety of selective internal radiation therapy (SIRT) with yttrium-90 microspheres combined with systemic anticancer agents: expert consensus

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⁹⁰Y radiation lobectomy: Outcomes following surgical resection in patients with hepatic tumors and small future liver remnant volumes