Transarterial radioembolization with yttrium‐90 of unresectable primary hepatic malignancy in children

Abstract

Background Primary malignant liver tumors are rare, accounting for 1% to 2% of all childhood cancers. When chemotherapy fails, transarterial radioembolization with yttrium‐90 (TARE‐Y90) may offer an alternative therapy as a bridge to surgical resection or liver transplant or for palliation. Methods We conducted a retrospective review of 10 pediatric patients with histologically confirmed primary liver malignancy who received treatment with TARE‐Y90. Results The median age at treatment was 5.5 years (range, 2–18 years). Median patient survival from initial diagnosis was 12.5 months (range, 10–28 months), and median patient survival after TARE‐Y90 was 4 months (range, 2–20 months). Retreatment was well tolerated in three of 10 patients, with these patients demonstrating the longest survival times (range, 17–20 months). One patient was transplanted 6 weeks after TARE‐Y90. By RECIST 1.1 criteria of all target lesions, eight of nine patients had stable disease, and one of nine had progressive disease. By mRECIST criteria (requiring postcontrast arterial phase imaging), two of seven patients had a partial response, four of seven had stable disease, and one of seven had progressive disease. Conclusion TARE‐Y90 of unresectable primary liver malignancy is both technically feasible and demonstrates an anticancer effect, and retreatment is well tolerated. TARE‐Y90 could be considered as adjunctive therapy in pediatric patients with unresectable hepatic malignancies and could be used as a bridge to surgical resection or liver transplant. More research is required to determine the efficacy of this treatment in children and to define the clinical scenarios where benefit is likely to be optimized.

Successful use of transarterial radioembolization with yttrium‐90 (TARE‐Y90) in two children with hepatoblastoma

“…TARE‐Y90 can be used as a component of a curative treatment approach in children with primary HB 5,6 . In both reported cases, one with chemorefractory initial disease and one with chemoresponsive initial disease, the use of Y90 resulted in significant decline of AFP (95% and 98%, respectively), significant tumor shrinkage (58% and 49%, respectively), and hypertrophy of the future liver remnant that allowed for conventional hepatectomy rather than liver transplantation 12,14‐16 .…”

“…This therapy offers a novel approach to increase survival and decrease OLT in pediatric liver tumor patients 3 . Minimal pediatric data exist concerning the use of TARE‐Y90, mostly in patients with relapsed disease, with almost no data on TARE‐Y90 use as part of primary pediatric liver tumor curative therapy 5,6 …”

Interventional Oncology for Hepatic Malignancy in Children

“…In smaller children, it is important to modify the geometric mean for the lung weight of the child when calculating the lung-shunt fraction. This can be done by measuring the mean density of the lungs, based on Hounsfield units, and measuring lung volumes on CT. 69 After the pretreatment angiogram, TARE treatment is usually performed within 1 to 2 weeks using either resin-or glassbased microspheres, with dose calculations performed by an authorized user of Y-90. Immediate posttreatment, nuclear medicine single-photon emission CT (SPECT) is performed of the chest and abdomen to assess the distribution of Y-90 microspheres.…”

“…[70][71][72] Two case series from Cincinnati Children's Hospital exist in the literature, with one cohort consisting of 2 patients and another involving 10 patients, which includes the two patients from the aforementioned study. 69,73 Median age at TARE treatment was 5.5 years, and 70% were male. Diagnoses included FL-HCC (three patients), conventional HCC (three patients), HB (two patients), and HCN-NOS (two patients).…”

Endovascular approaches in pediatric interventional oncology

“…In selected settings, there may be role for preoperative portal vein embolization to promote hypertrophy of the liver prior to partial hepatectomy by radioembolization. At the time of this publication, only 12 patients treated with radioembolization for liver tumors has been reported (Hawkins et al 2013;Aguado et al 2019). Potential indications of radioembolization in children may include patients with nonresectable liver malignancies such as hepatoblastoma, hepatocellular carcinoma or metastases as palliation or with curative intent or as a bridge to liver transplantation (Lungren et al 2018).…”