Intra-arterial radioembolization of breast cancer liver metastases: a structured review

Mode of progression after radioembolization in patients with colorectal cancer liver metastases

Background

Radioembolization is an established treatment modality in colorectal cancer patients with liver-dominant disease in a salvage setting. Selection of patients who will benefit most is of vital importance. The aim of this study was to assess response (and mode of progression) at 3 months after radioembolization and the impact of baseline characteristics.

Methods

Three months after radioembolization with either yttrium-90 resin/glass or holmium-166, anatomic response, according to RECIST 1.1, was evaluated in 90 patients. Correlations between baseline characteristics and efficacy were evaluated. For more detailed analysis of progressive disease as a dismal clinical entity, distinction was made between intra- and extrahepatic progression, and between progression of existing metastases and new metastases.

Results

Forty-two patients (47%) had extrahepatic disease (up to five ≥ 1 cm lung nodules, and ≤ 2 cm lymph nodes) at baseline. No patients showed complete response, 5 (5.5%) patients had partial response, 16 (17.8%) had stable disease, and 69 (76.7%) had progressive disease. Most progressive patients (67/69; 97%) had new metastases (intra-hepatic N = 11, extrahepatic N = 32; or both N = 24). Significantly fewer patients had progressive disease in the group of patients presenting without extrahepatic metastases at baseline (63% versus 93%; p = 0.0016). Median overall survival in patients with extrahepatic disease was 6.5 months, versus 10 months in patients without extrahepatic disease at baseline (hazard ratio 1.79, 95%CI 1.24–2.57).

Conclusions

Response at 3-month follow-up and survival were heavily influenced by new metastases. Patients with extrahepatic disease at baseline had a worse outcome compared to patients without.

Predictors of Survival after Yttrium-90 Radioembolization of Chemotherapy-Refractory Hepatic Metastases from Breast Cancer

PURPOSE

To determine predictors of survival after transarterial radioembolization of hepatic metastases from breast cancer.

MATERIALS AND METHODS

Twenty-four patients with chemotherapy-refractory hepatic metastases from breast cancer who underwent radioembolization from 2013 to 2018 were evaluated based on various demographic and clinical factors before and after treatment. Overall survival (OS) was estimated by Kaplan-Meier method. Log-rank analysis was performed to determine predictors of prolonged OS from the time of first radioembolization and first hepatic metastasis diagnosis.

RESULTS

Median OS times were 35.4 and 48.6 months from first radioembolization and time of hepatic metastasis diagnosis, respectively. Radioembolization within 6 months of hepatic metastasis diagnosis was a positive predictor of survival from first radioembolization, with median OS of 38.9 months vs 22.1 months for others (P = .033). Estrogen receptor (ER)-positive status predicted prolonged survival (38.6 months for ER⁺ vs 5.4 months for ER^-; P = .005). The presence of abdominal pain predicted poor median OS: 12.8 months vs 38.6 months for others (P < .001). The presence of ascites was also a negative predictor of OS (1.7 months vs 35.4 months for others; P = .037), as was treatment-related grade ≥ 2 toxicity at 3 months (5.4 months vs 38.6 months for others; P = .017).

CONCLUSIONS

In patients with metastatic breast cancer, radioembolization within 6 months of hepatic metastasis diagnosis and ER⁺ status appear to be positive predictors of prolonged survival. Conversely, baseline abdominal pain, baseline ascites, and treatment-related grade ≥ 2 toxicity at 3 months after treatment appear to be negative predictors of OS.

Yttrium-90 radioembolization for unresectable hepatic metastases of breast cancer: A systematic review

BACKGROUND

Liver metastases secondary to breast cancer are associated with unfavourable prognosis. Radioembolization with ytrrium-90 is an emerging option for management of liver metastases of breast cancer when other systemic therapies have failed to achieve disease control. However, unlike the case of other liver tumours (colorectal/melanoma metastases/cholangiocarcinoma), its role in the management of breast liver metastases is yet to be elucidated.

AIM

The aims of this systematic review were to (1) assess the effect of radioembolization with yttrium-90 on tumour response; and (2) to estimate patient survival post radioembolization.

METHODS

The review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. A systematic literature search was performed using the PubMed and EMBASE databases from January 2007 to December 2018. The initial search yielded 265 reports which were potentially suitable for inclusion in this review. Studies published in English reporting at least one outcome of interest were considered to be suitable for inclusion. Conference abstracts; case reports, animal studies and reports not published in English were excluded from this review. Data was retrieved from each individual report on the name of primary author, year of publication, patient demographics, type of microspheres used, radiation dose delivered to tumour, duration of follow-up, disease control rate (%), tumour response, and overall patient survival.

RESULTS

The final number of studies which met the inclusion criteria was 12 involving 452 patients. There were no randomized controlled trials identified after the literature search. The age of the patients included in this review ranged from 52 to 61 years. The duration of the follow up period post-radioembolization ranged from 6 to 15.7 mo. The total number of patients with breast metastases not confined to the liver was 236 (52.2%). Cumulative analysis revealed that radioembolization with yttrium-90 conferred tumour control rate in 81% of patients. Overall survival post-radioembolization ranged from 3.6 to 20.9 mo with an estimated mean survival of 11.3 mo.

CONCLUSION

Radioembolization with ytrrium-90 appears to confer control of tumour growth rate in most patients, however its effect on patient survival need to be elucidated further. Furthermore, quality evidence in the form of randomized trials is needed in order to assess the effect of radioembolization in more depth.

Sequential intra-arterial infusion of 90Y-resin microspheres and mitomycin C in chemo refractory liver metastatic breast cancer patients: a single centre pilot study

Background

The aim of the study was to evaluate the safety and feasibility of intra-arterial mitomycin C (MMC) infusion after selective internal radiation therapy (SIRT) using Yttrium-90 (⁹⁰Y) resin microspheres in liver metastatic breast cancer (LMBC) patients.

Patients and methods

The prospective pilot study included LMBC patients from 2012–2018. Patients first received infusion of ⁹⁰Y resin microspheres, after 6–8 weeks response to treatment was assessed by MRI, ¹⁸F-FDG PET/CT and laboratory tests. After exclusion of progressive disease, MMC infusion was administrated 8 weeks later in different dose cohorts; A: 6 mg in 1 cycle, B: 12 mg in 2 cycles, C: 24 mg in 2 cycles and D: maximum of 72 mg in 6 cycles. In cohort D the response was evaluated after every 2 cycles and continued after exclusion of progressive disease. Adverse events (AE) were reported according to CTCAE version 5.0.

Results

Sixteen patients received ⁹⁰Y treatment. Four patients were excluded for MMC infusion, because of extra hepatic disease progression (n = 3) and clinical and biochemical instability (n = 1). That resulted in the following number of patient per cohort; A: 2, B: 1, C: 3 and D: 6. In 4 of the 12 patients (all cohort D) the maximum dose of MMC was adjusted due biochemical toxicities (n = 2) and progressive disease (n = 2). One grade 3 AE occurred after ⁹⁰Y treatment consisting of a gastrointestinal ulcer whereby prolonged hospitalization was needed.

Conclusions

Sequential treatment of intra-arterial infusion of MMC after ⁹⁰Y SIRT was feasible in 75% of the patients when MMC was administrated in different escalating dose cohorts. However, caution is needed to prevent reflux after ⁹⁰Y SIRT in LMBC patients.

Local Treatment of Breast Cancer Liver Metastasis

Breast cancer represents a leading cause of death worldwide. Despite the advances in systemic therapies, the prognosis for patients with breast cancer liver metastasis (BCLM) remains poor. Especially in case of failure or cessation of systemic treatments, surgical resection for BCLMs has been considered as the treatment standard despite a lack of robust evidence of benefit. However, due to the extent and location of disease and physical condition, the number of patients with BCLM who are eligible for surgery is limited. Palliative locoregional treatments of liver metastases (LM) include transarterial embolization (TAE), transarterial chemoembolization (TACE), and selective internal radiotherapy (SIRT). Percutaneous thermal ablation methods, such as radiofrequency ablation (RFA) and microwave ablation (MWA), are considered potentially curative local treatment options. They are less invasive, less expensive and have fewer contraindications and complication rates than surgery. Because conventional ultrasound- and computed tomography-guided single-probe thermal ablation is limited by tumor size, multi-probe stereotactic radiofrequency ablation (SRFA) with intraoperative image fusion for immediate, reliable judgment has been developed in order to treat large and multiple tumors within one session. This review focuses on the different minimally invasive local and locoregional treatment options for BCLM and attempts to describe their current and future role in the multidisciplinary treatment setting.

Intra-arterial Mitomycin C infusion in a large cohort of advanced liver metastatic breast cancer patients: safety, efficacy and factors influencing survival

PURPOSE

The aim of this study was to determine the safety and efficacy of Mitomycin C (MMC) infusion in a large cohort of advanced liver metastatic breast cancer patients (LMBC) and to determine factors influencing overall survival (OS).

METHODS

We retrospectively analysed LMBC patients, treated with MMC infusion between 2000 and 2017. Hepatic response was measured with baseline CT scans and first available CT scan after MMC infusion by RECIST 1.1 criteria. Adverse events were registered by the CTCAE version 5.0. OS and hepatic progression free survival (hPFS) were evaluated using Kaplan-Meier estimates. After univariable analysis, a stepwise forward multivariable (MV) prediction analysis was developed to select independent pre-treatment factors associated with OS.

RESULTS

We included 176 patients with a total of 599 MMC infusions, mostly heavily pre-treated patients with a median time from diagnosis of MBC to MMC infusion of 36.9 months. RECIST evaluation of liver lesions (n = 132) showed a partial response rate of 15%, stable disease of 43% and progressive disease in 17%. Adverse events grade 3 and 4 were reported in 17.5%. Median PFS was 5.5 months and median OS was 7.8 months. Significant independent baseline predictors of worse OS included number of prior systemic chemotherapy lines, prior liver ablation, higher liver tumour burden and elevated levels of bilirubin and ALT.

CONCLUSION

MMC infusion is safe and effective in advanced LMBC patients. An increased number of prior therapies, a higher liver tumour burden and elevated levels of bilirubin and ALT were associated with a worse OS.

Long-term radiological and histological outcomes following selective internal radiation therapy to liver metastases from breast cancer

Liver metastasis from breast cancer is associated with poor prognosis and is a major cause of early morbidity and mortality. When liver resection is not feasible, minimally invasive directed therapies are considered to attempt to prolong survival. Selective internal radiation therapy (SIRT) with yttrium-90 microspheres is a liver-directed therapy that can improve local control of liver metastases from colorectal cancer. We present a case of a patient with a ductal breast adenocarcinoma, who developed liver and bone metastasis despite extensive treatment with systemic chemotherapies. Following SIRT to the liver, after an initial response, the patient ultimately progressed in the liver after 7 months. Liver tumor histology obtained 20 months after the SIRT intervention demonstrated the presence of the resin microspheres in situ. This case report demonstrates the long-term control that may be achieved with SIRT to treat liver metastases from breast cancer that is refractory to previous chemotherapies, and the presence of microspheres in situ long-term.

Pretreatment albumin may aid in patient selection for intrahepatic Y-90 microsphere transarterial radioembolization (TARE) for malignancies of the liver

Background

Hepatic malignancies are common including primary malignancies and metastases. Transarterial radioembolization (TARE) is an important treatment option. We reviewed safety and efficacy of (TARE) in our patients to identify factors that may impact treatment outcomes in a heterogeneous population.

Methods

All patients that received TARE at the Medical University of South Carolina from March 2006 through May of 2014 were included. Kaplan-Meier estimates on overall survival (OS) from date of first procedure are reported. Potential prognostic factors for OS were evaluated using log rank tests and Cox proportional hazards models.

Results

In the 114 patients that received TARE at our institution, median follow-up was 6.4 months (range, 0-86 months) with the following histologies: colorectal (CR) n=55, hepatocellular (HC) n=20, cholangiocarcinoma (CC) n=16, neuroendocrine (NE) n=12, breast (BR) n=6, other n=5. At least 1 line of prior systemic therapy was noted in 79% of patients. Median OS was significantly better with NE and BR histology, and in those with normal albumin levels. With an albumin >3.4 median OS was 10.3 months, but was only 3.1 months with an albumin <3 g/dL. Grade ≥2 toxicity was observed in 22 patients (19.3%) including 9 (7.9%) with Grade 3 and 1 (0.9%) with Grade 4 toxicity.

Conclusions

TARE is a relatively safe and effective treatment for intrahepatic malignancies. Patients with NE and BR histology as well as those with better hepatic synthetic function were associated with significantly better survival. Our data suggest that patients with albumin below 3 g/dL may not derive significant benefit from TARE.

Technical Advances in Image Guidance of Radionuclide Therapy

Internal radiation therapy with radionuclides (i.e., radionuclide therapy) owes its success to the many advantages over other, more conventional, treatment options. One distinct advantage of radionuclide therapies is the potential to use (part of) the emitted radiation for imaging of the radionuclide distribution. The combination of diagnostic and therapeutic properties in a set of matched radiopharmaceuticals (sometimes combined in a single radiopharmaceutical) is often referred to as theranostics and allows accurate diagnostic imaging before therapy. The use of imaging benefits treatment planning, dosimetry, and assessment of treatment response. This paper focuses on a selection of advances in imaging technology relevant for image guidance of radionuclide therapy. This involves developments in nuclear imaging modalities, as well as other anatomic and functional imaging modalities. The quality and quantitative accuracy of images used for guidance of radionuclide therapy is continuously being improved, which in turn may improve the therapeutic outcome and efficiency of radionuclide therapies.

The value of intravoxel incoherent motion model-based diffusion-weighted imaging for outcome prediction in resin-based radioembolization of breast cancer liver metastases

Purpose

To evaluate prognostic values of clinical and diffusion-weighted magnetic resonance imaging-derived intravoxel incoherent motion (IVIM) parameters in patients undergoing primary radioembolization for metastatic breast cancer liver metastases.

Subjects and methods

A total of 21 females (mean age 54 years, range 43–72 years) with liver-dominant metastatic breast cancer underwent standard liver magnetic resonance imaging (1.5 T, diffusion-weighted imaging with b-values of 0, 50, and 800 s/mm²) before and 4–6 weeks after radioembolization. The IVIM model-derived estimated diffusion coefficient D’ and the perfusion fraction f’ were evaluated by averaging the values of the two largest treated metastases in each patient. Kaplan–Meier and Cox regression analyses for overall survival (OS) were performed. Investigated parameters were changes in f’- and D’-values after therapy, age, sex, Eastern Cooperative Oncology Group (ECOG) status, grading of primary tumor, hepatic tumor burden, presence of extrahepatic disease, baseline bilirubin, previous bevacizumab therapy, early stasis during radioembolization, chemotherapy after radioembolization, repeated radioembolization and Response Evaluation Criteria in Solid Tumors (RECIST) response at 6-week follow-up.

Results

Median OS after radioembolization was 6 (range 1.5–54.9) months. In patients with therapy-induced decreasing or stable f’-values, median OS was significantly longer than in those with increased f’-values (7.6 [range 2.6–54.9] vs 2.6 [range 1.5–17.4] months, P<0.0001). Longer median OS was also seen in patients with increased D’-values (6 [range 1.6–54.9] vs 2.8 [range 1.5–17.4] months, P=0.008). Patients with remission or stable disease (responders) according to RECIST survived longer than nonresponders (7.2 [range 2.6–54.9] vs 2.6 [range 1.5–17.4] months, P<0.0001). An ECOG status ≤1 resulted in longer median OS than >1 (7.6 [range 2.6–54.9] vs 1.7 [range 1.5–4.5] months, P<0.0001). Pretreatment IVIM parameters and the other clinical characteristics were not associated with OS. Classification by f’-value changes and ECOG status remained as independent predictors of OS on multivariate analysis, while RECIST response and D’-value changes did not predict survival.

Conclusion

Following radioembolization of breast cancer liver metastases, early changes in the IVIM model-derived perfusion fraction f’ and baseline ECOG score were predictive of patient outcome, and may thus help to guide treatment strategy.

Sonographic Detection of Metastatic Breast Cancer in the Liver

Sonography is an effective imaging modality for detecting the presence of breast cancer that has metastasized to other organs. Early determination of the presence of these metastatic lesions has proved essential in improving the survival of patients with this disease. This case study presents a patient who was diagnosed with breast cancer, treated, and considered cancer free 9 months prior to the sonogram presented. Within these 9 months, the breast cancer had metastasized to the liver, where it was initially detected on a right upper quadrant sonogram, evaluated further by computed tomography, and definitively diagnosed by histopathology following core needle biopsy.

(90)Y-glass microspheres for hepatic neoplasia

Unresectable liver cancer presents a major problem in the treatment of solid tumors. Transarterial radioembolization is a modern approach toward primary and secondary liver malignancies. The mechanism of action is independent from other therapies that are based on ischemia or chemotoxicity. (90)Y-resin and (90)Y-glass microspheres are commercially available for transarterial radioembolization. Available data on the use of (90)Y-glass microspheres in hepatocellular carcinoma and metastatic disease indicate that this treatment is safe and effective. In hepatocellular carcinoma the results compare well with chemoembolization and might be considered more often. Current data in metastatic disease are promising, but there is a strong need for prospective randomized trials to identify the role of transarterial radioembolization with (90)Y-glass microspheres in metastatic liver disease.

Yttrium-90 radioembolization stops progression of targeted breast cancer liver metastases after failed chemotherapy

PURPOSE

To determine, in an open-label, retrospective report, the safety and effectiveness of locoregional therapy with yttrium-90 ((90)Y) radioembolization for patients with progressing breast cancer liver metastases (BCLMs) despite multi-agent chemotherapy.

MATERIALS AND METHODS

Seventy-five patients with progressing BCLMs and stable extrahepatic disease were treated with radioembolization at a single institution. Retrospective review of a prospectively collected database was performed to evaluate clinical and biochemical toxicities, tumor response, overall survival (OS), and time to progression. Radiologic response assessments included Response Evaluation Criteria In Solid Tumors in primary index lesions and metabolic activity on positron emission tomography (PET). Univariate and multivariate analyses were performed.

RESULTS

The mortality rate at 30 days was 4% (n = 3). Clinical toxicity and hyperbilirubinemia of grade 3 or worse occurred in 7.6% (n = 5) and 5.9% of patients (n = 4), respectively. Partial response (PR) was seen in 35.3% of patients (n = 24), stable disease (SD) in 63.2% (n = 43), and progressive disease in 1.5% (n = 1). PET imaging was available in 25 patients, and 21 (84%) had a complete response, PR, or SD. The median OS was 6.6 months (95% confidence interval [CI], 5.0-9.2 mo). The hazard ratio (HR) for OS on multivariate analysis was 0.39 (95% CI, 0.23-0.66) for tumor burden less than 25% compared with greater burden. Elevated bilirubin levels were shown to reduce OS. The HR for hepatic progression was 0.22 (95% CI, 0.05-0.98) for solitary versus multifocal disease.

CONCLUSIONS

Locoregional therapy with (90)Y radioembolization is safe and stops or delays the progression of targeted chemorefractory BCLMs. Adverse prognosticators were identified.

Tumor growth kinetics versus RECIST to assess response to locoregional therapy in breast cancer liver metastases

RATIONALE AND OBJECTIVES

The aim of our study was to evaluate changes in growth kinetics of breast cancer liver metastasis in response to locoregional therapy and compare them to Response Evaluation Criteria in Solid Tumors (RECIST).

MATERIALS AND METHODS

This Health Insurance Portability and Accountability Act-compliant retrospective study was Institutional Review Board approved. Thirty-four chemorefractory breast cancer liver metastases from 21 patients treated with yttrium-90 ((90)Y) were evaluated. Pre- and posttreatment computed tomography (CT) scans were used to calculate tumor growth kinetics. The growth parameter analyzed was reciprocal of doubling time (RDT). RDT range for stable disease (SD) was defined by the measurement error rate. A negative RDT below the SD range defined response and was categorized as either partial response (PR) or complete response, whereas a positive RDT value above the SD range indicated progressive disease (PD). Comparison was made to tumor response classification according to percentage change in the lesion's maximal diameter per RECIST. Lin's concordance correlation coefficient, Bland-Altman plot, Wilcoxon signed rank test, and Student t test were used for analysis. Significance was set at 0.05.

RESULTS

RDT range for SD ranged from -0.46 to +2.17. Six lesions with PR based on RECIST showed PR based on their volumetric growth rate (mean RDT of -17.3 ± 2.6). Similarly, one lesion with PD according to RECIST was categorized as PD based on its growth kinetics (RDT of 10.2). However, 14 (51.85%) lesions classified as SD by RECIST had PR according to growth kinetics (mean RDT of -7.8), six (22.22%) lesions were categorized as SD (mean RDT of 0.8), whereas seven (25.93%) lesions showed PD (mean RDT of 4.5). Growth kinetic parameters were significantly different for lesions with PR when compared to lesions with PD (P < .0001).

CONCLUSIONS

In patients with breast cancer liver metastases undergoing locoregional therapy, RECIST categorization may not be an accurate reflection of treatment response.

Hepatic radioembolization as a bridge to liver surgery

Treatment of oncologic disease has improved significantly in the last decades and in the future a vast majority of cancer types will continue to increase worldwide. As a result, many patients are confronted with primary liver cancers or metastatic liver disease. Surgery in liver malignancies has steeply improved and curative resections are applicable in wider settings, leading to a prolonged survival. Simultaneously, radiofrequency ablation (RFA) and liver transplantation (LTx) have been applied more commonly in oncologic settings with improving results. To minimize adverse events in treatments of liver malignancies, locoregional minimal invasive treatments have made their appearance in this field, in which radioembolization (RE) has shown promising results in recent years with few adverse events and high response rates. We discuss several other applications of RE for oncologic patients, other than its use in the palliative setting, whether or not combined with other treatments. This review is focused on the role of RE in acquiring patient eligibility for radical treatments, like surgery, RFA, and LTx. Inducing significant tumor reduction can downstage patients for resection or, through attaining stable disease, patients can stay on the LTx waiting list. Hereby, RE could make a difference between curative of palliative intent in oncologic patient management. Prior to surgery, the future remnant liver volume might be inadequate in some patients. In these patients, forming an adequate liver reserve through RE leads to prolonged survival without risking post-operative liver failure and minimizing tumor progression while inducing hypertrophy. In order to optimize results, developments in procedures surrounding RE are equally important. Predicting the remaining liver function after radical treatment and finding the right balance between maximum tumor irradiation and minimizing the chance of inducing radiation-related complications are still challenges.

Beyond hepatocellular carcinoma and colorectal metastasis: the expanding applications of radioembolization

As a relatively safe outpatient procedure, radioembolization can potentially be used to treat any type of tumor within the liver, primary or metastatic. The safety and effectiveness of radioembolization in the treatment of hepatocellular carcinoma (HCC) and metastatic colorectal cancer (mCRC) has led many groups to explore its application in other malignancies. Moreover, other organs, such as the lungs and kidneys, have been explored as targets for therapy. Although the most data for radioembolization is related to HCC and mCRC, there is increasing experience and data regarding metastatic disease to the liver for other primary tumors. We review the current state of liver-directed therapy with radioembolization outside of HCC and mCRC, including metastatic neuroendocrine, breast, and melanoma, as well as limited experiences with other primary malignancies. Applications of radioembolization related to these other cancers and new trends and future directions will be discussed. With increasing use and availability of radioembolization, it promises to serve an expanding role in the repertoire of tools available for treating and managing oncologic disease.