Biliary Sequelae following Radioembolization with Yttrium-90 Microspheres

Diagnosis and management of radiation cholecystitis as a complication of Y90 radioembolization for hepatocellular carcinoma

Radiation induced cholecystitis is a known but rare complication of Yttrium90 (Y90) radioembolization of hepatic tumors due to nontarget embolization. Many documented cases of radiation induced cholecystitis have been treated with cholecystectomy, which is significant given the typical patient population undergoing radioembolization tends to be of higher surgical risk. Here, we present a case of a 68 year old male who developed radiation induced cholecystitis status post hepatic radioembolization that resolved with conservative management alone. This case highlights that radiation induced cholecystitis may be successfully and safely treated conservatively.

Incidence and Risk Factors of Acute Ischemic Cholecystitis after Transarterial Chemoembolization: Correlation with Cone Beam CT Findings

Purpose

Acute cholecystitis is a complication of transarterial chemoembolization (TACE) that occasionally requires surgical intervention. We aimed to analyze the incidence and risk factors of cholecystitis requiring surgical intervention in patients with embolic material uptake on cone beam CT (CBCT) performed immediately after various TACE procedures.

Materials and Methods

After a retrospective review of 2633 TACE procedures performed over a 6-year period, 120 patients with embolic material retention in the gallbladder wall on CBCT immediately after TACE were selected. We analyzed the incidence of and risk factors for acute cholecystitis.

Results

The overall incidence of acute cholecystitis requiring surgical intervention was 0.45% (12 of 2633 TACE procedures); however, it was present in 10% (12 of 120) of procedures that showed high-density embolic material retention in the gallbladder wall on CBCT performed immediately after TACE. Acute cholecystitis requiring surgical intervention occurred in eight patients (66.7%) who underwent direct cystic arterial embolization. Surgical intervention was performed 15 days (mean) after TACE.

Conclusion

Most unintended chemolipiodol deposits in the gallbladder wall resolved without intervention or surgery. However, superselective direct cystic arterial chemoembolization was associated with a high incidence of acute cholecystitis requiring surgery, and patients who undergo this procedure should be closely monitored.

Safety and Efficacy of Selective Internal Radionuclide Therapy with 90Y Glass Microspheres in Patients with Progressive Hepatocellular Carcinoma after the Failure of Repeated Transarterial Chemoembolization

Transarterial chemoembolization (TACE) is currently the standard of care in patients with unresectable hepatocellular carcinoma (HCC), and selective internal radionuclide therapy (SIRT) with 90Y microspheres is mainly used as an alternative modality in patients considered poor candidates for TACE. Treatment with sorafenib is the recommended option for patients with progressive disease after TACE. This study aims to evaluate the safety and efficacy of SIRT with glass microspheres in patients with progressive HCC after repeated TACE who are not eligible for treatment with sorafenib. Forty-seven patients with progressive HCC after a median of three TACE sessions (range 2-14) underwent SIRT (3.5 ± 1.5 GBq; liver target dose 110-120 Gy). Toxicity was recorded 4 and 12 weeks after treatment and reported according to the Common Terminology Criteria for Adverse Events Version 5.0. Treatment response was assessed three months after SIRT using multiphase computed tomography and modified criteria in solid tumors (mRECIST). Survival analyses were performed using Kaplan-Meier curves and a Cox proportional hazards model for uni- and multivariate analyses. Significant but reversible hepatotoxicity (≥grade 3) occurred in five patients (11%). No radioembolization-induced liver disease (REILD) was observed. The number of previous TACE sessions and cumulative administered activity did not predict the incidence of post-SIRT significant hepatotoxicity. Treatment responses consisted of partial responses in 26 (55%), stable disease in 12 (26%), and progressive disease in 9 (19%) patients. The median overall survival (OS) was 11 months (95% confidence interval (CI), 9-13), and objective responses to SIRT were associated with a longer OS (p = 0.008). Significant hepatotoxicity (≥grade 3) after SIRT was a contributor to impaired survival (median OS 6 months (95% CI, 4-8) vs. 12 months (95% CI, 10-14), p < 0.001). SIRT with glass microspheres is a safe and effective salvage treatment for patients with progressive HCC refractory to TACE who are considered poor candidates for sorafenib treatment.

Safety of Radioembolization via the Cystic Artery in Patients with Hepatocellular Carcinoma and Parasitized Arterial Supply

PURPOSE

To evaluate the safety and effectiveness of radioembolization through the cystic artery supplying hepatocellular carcinoma (HCC) adjacent to the gallbladder.

MATERIALS AND METHODS

This retrospective, single-center study included 24 patients who underwent radioembolization via the cystic artery between March 2017 and October 2022. The median tumor size was 8.3 cm (range, 3.4-20.4 cm). Twenty-two (92%) patients had Child-Pugh Class A disease, and 2 (8%) patients had Class B cirrhosis. Technical issues, adverse events, and tumor response were analyzed.

RESULTS

Infusion of radioactive microspheres was performed from the main cystic artery (n = 6), the deep cystic artery (n = 9), and small feeders from the cystic artery (n = 9). The cystic artery supplied the primary index tumor in 21 patients. The median radiation activity delivered via the cystic artery was 0.19 GBq (range, 0.02-0.43 GBq). The median total radiation activity administered was 4.1 GBq (range, 0.9-10.8 GBq). There was no case of symptomatic cholecystitis requiring invasive intervention. One patient experienced abdominal pain during injection of radioactive microspheres via the cystic artery. Eleven (46%) patients received pain medication during or within 2 days of the procedure. Twelve (50%) patients had gallbladder wall thickening on a 1-month follow-up computed tomography scan. Based on follow-up imaging, 23 (96%) patients showed an objective response (complete or partial response) of the tumor supplied by the cystic artery.

CONCLUSION

Radioembolization via the cystic artery may be safe in patients with HCC partially supplied by the cystic artery.

Hepatic Abscess following Yttrium-90 Radioembolization in Patients with Surgical Bilioenteric Anastomosis or Compromised Sphincter of Oddi: A Tertiary Cancer Center Experience

Purpose: We describe our experience with the development of hepatobiliary infection in patients with prior surgical, percutaneous, or endoscopic biliary interventions who are receiving transarterial radioembolization (TARE) with yttrium-90 (⁹⁰Y) for primary or metastatic hepatobiliary lesions. Methods: Records of 15 patients with a history of prior biliary intervention and liver malignancy subsequently treated with TARE at the participating medical center from November 2009 to September 2015 were reviewed. The primary endpoint was the development of a hepatic abscess or cholangitis in a patient after radioembolization. Results: A total of 15 patients comprising 9 men and 6 women, with a median age of 49 years (range 30-73), underwent 17 TARE with ⁹⁰Y procedures. Of the 15 patients, 2 (13.3%) of them developed a hepatobiliary infection. A single patient (6.6%) developed a hepatobiliary abscess. Conclusion: Our study shows a low incidence rate of hepatic abscess following TARE in patients with prior biliary intervention.

Intraarterial Therapies for the Management of Hepatocellular Carcinoma

Image-guided locoregional therapies play a crucial role in the management of patients with hepatocellular carcinoma (HCC). Transarterial therapies consist of a group of catheter-based treatments where embolic agents are delivered directly into the tumor via their supplying arteries. Some of the transarterial therapies available include bland embolization (TAE), transarterial chemoembolization (TACE), drug-eluting beads-transarterial chemoembolization (DEB-TACE), selective internal radioembolization therapy (SIRT), and hepatic artery infusion (HAI). This article provides a review of pre-procedural, intra-procedural, and post-procedural aspects of each therapy, along with a review of the literature. Newer embolotherapy options and future directions are also briefly discussed.

MRI features of treated hepatocellular carcinoma following locoregional therapy: a pictorial review

Hepatocellular carcinoma (HCC) is a leading cause of cancer death worldwide and within the United States. Liver transplant or partial liver resection is the definitive treatment of choice for HCC; however, the majority of cases are detected in advanced stages due to its early-stage asymptomatic nature, often precluding surgical treatment. Locoregional therapy plays an essential role in HCC management, including curative intent, as a bridge to transplant, or in some cases palliative therapy. Radiologists play a critical role in assessing tumor response following treatment to guide further management that may potentially impact transplantation eligibility; therefore, it is important for radiologists to have an understanding of different locoregional therapies and the variations of imaging response to different therapies. In this review article, we outline the imaging response to ablative therapy (AT), transarterial chemoembolization (TACE), selective internal radiation therapy (SIRT), and stereotactic body radiation therapy (SBRT). We will also briefly discuss the basic concepts of these locoregional therapies. This review focuses on the imaging features following locoregional treatment for hepatocellular carcinoma following AT, TACE, SIRT, and SBRT.

Current Approach to Planning Angiography and MAA Administration

Transarterial radioembolization of primary and secondary hepatic malignancies utilizing yttrium-90 microspheres is a commonly performed treatment by interventional radiologists. Traditionally performed as a two-part procedure, a diagnostic angiography is performed 1 to 3 weeks prior to treatment with the injection of technetium-99m-macroaggregated albumin followed by planar scintigraphy in the nuclear medicine department. Careful attention must be paid to the details during the diagnostic angiography to ensure the delivery of a safe and optimal dose to the diseased liver and to minimize radiation-induced damage to both unaffected liver and adjacent structures. In this article, we will review the steps and considerations that must be made during the angiography planning and discuss current and future areas of research.

Biliary-Caval Fistula following Y90 Radioembolization

The safety of radioembolization with yttrium-90 ( ⁹⁰ Y) is well documented and major complications are rare. Previous studies have demonstrated that biliary complications following ⁹⁰ Y, including bile duct injury and hepatic abscess formation, occur at an increased rate in patients who have had prior biliary surgery and interventions. This article reviews a case of a patient who developed recurrent cholangitis and sepsis as well as a biliary-caval fistula following radioembolization. Additionally, we review current data regarding biliary complications following radioembolization in patients with prior biliary intervention.

Radiation Segmentectomy

Radiation segmentectomy is an yttrium-90 transarterial radioembolization treatment where a high radiation dose is administered to a small volume of liver to achieve a high tumoricidal dose to a target with anatomic surgical precision while sparing surrounding parenchyma. This therapeutic modality is often used to treat hepatocellular carcinoma, and recent studies have demonstrated that radiation segmentectomy is an effective treatment as a neoadjuvant to transplant, resection, or as a standalone treatment. This article provides a review of radiation segmentectomy, indications for treatment, recent outcome data, and guidelines for postprocedural management.

Review of Use of Y90 as a Bridge to Liver Resection and Transplantation in Hepatocellular Carcinoma

BACKGROUND

The incidence of hepatocellular carcinoma (HCC) has been rising, and 80% of HCCs are unresectable at the time of presentation. In recent years, Yttrium-90 (Y90) radioembolization has arisen as a potential tool to treat the primary HCC tumor while also inducing contralateral liver hypertrophy to increase future liver remnant volumes. The goal of this multidisciplinary review is to summarize the contemporary evidence on the safety, efficacy, and utility of Y90 as a bridge to liver resection and transplant in patients with HCC.

METHODS

A narrative review was conducted of the recent literature regarding the utilization of Y90 as a therapy prior to liver resection or transplant in patients with HCC. A specific emphasis was placed on articles published in the last 10 years.

RESULTS

Y90 radioembolization has demonstrated a high safety profile and increasing utility in bridging and downstaging patients with HCC who subsequently undergo liver resection or transplant. The continuous advancements in treatment strategies and radiation dosimetry have paved the way for the incorporation of Y90 in all stages of HCC with different intents, including downstaging and bridging.

CONCLUSIONS

Y90 radioembolization can be safely used in the HCC population to bridge patients to resection or transplantation, induce future liver remnant growth, and select for less aggressive tumor biology prior to surgery.

Hepatic necrosis following yttrium-90 radioembolization for hepatocellular carcinoma in a patient with a recent history of external radiotherapy

Hepatobiliary complications from yttrium-90 (⁹⁰Y) radioembolization have been described previously but are often clinically inconsequential. This report describes the case of a patient in whom a large area of hepatic necrosis occurred after the patient underwent both stereotactic body radiotherapy and glass-based⁹⁰Y radioembolization for the management of hepatocellular carcinoma. This case suggests that⁹⁰Y microspheres can cause severe local hepatic injury when administered after external radiotherapy.

Treatment response assessment following transarterial radioembolization for hepatocellular carcinoma

Transarterial radioembolization with yttrium-90 microspheres is an established therapy for hepatocellular carcinoma. Post-procedural imaging is important for the assessment of both treatment response and procedural complications. A variety of challenging treatment-specific imaging phenomena complicate imaging assessment, such as changes in tumoral size, tumoral and peritumoral enhancement, and extrahepatic complications. A review of the procedural steps, emerging variations, and timelines for post-treatment tumoral and extra-tumoral imaging changes are presented, which may aid the reporting radiologist in the interpretation of post-procedural imaging. Furthermore, a description of post-procedural complications and their significance is provided.

Role of Radioembolization in the Management of Liver-Dominant Metastatic Renal Cell Carcinoma: A Single-Center, Retrospective Study

PURPOSE

The management of Renal cell carcinoma (RCC) patients with liver metastases is challenging. Liver-directed therapy, such as Transarterial radioembolization (TARE), is a reasonable option for these patients; however, its safety and efficacy are not well characterized. This study evaluated the safety and efficacy of TARE in patients with liver-dominant metastatic RCC.

MATERIALS AND METHODS

This is a retrospective, single-center study. Thirty-eight patients' medical records were reviewed who underwent TARE between January 1, 2009, and December 31, 2019, in a tertiary cancer center. Two were excluded from further analysis. Thirty-six patients received 51 TARE treatments. Median follow-up time was 18.2 months. Imaging data were evaluated using mRECIST or RECIST 1.1 criteria. Toxicities, treatment responses, liver progression-free survival (LPFS), and median overall survival (OS) were calculated. Univariate and multivariate analyses were conducted to reveal predictors of OS.

RESULTS

Median OS from TARE was 19.3 months (95% CI, 22.6-47.4) and from diagnosis of liver metastases was 36.5 months (95% CI: 26.4-49.8). Mild, grade 1 or 2, biochemical toxicity developed in 27 patients (75%). Grade 3-4 toxicity was noted in two patients (5.5%). The objective response rate was 89%; the disease control rate was 94% (21 complete response, 11 partial response, two stable disease, and two progressive disease). Univariate and multivariate analyses showed longer survival in patients who had objective response, lower lung shunt fraction, and better baseline liver function.

CONCLUSIONS

TARE is safe and effective and led to promising overall survival in patients with liver-dominant metastatic RCC.

LEVEL OF EVIDENCE

Level 3, retrospective cohort study.

Does significantly elevated lung shunt fraction (LSF >20%) promote extrahepatic progression in patients with hepatocellular carcinoma treated with radioembolization?

PURPOSE

Radioembolization with yttrium-90 (Y-90) is an effective locoregional therapy for primary and metastatic liver tumors, but its use is restricted or contraindicated for patients with elevated lung shunt fraction (LSF) because of an increased risk of developing pulmonary adverse events, including but not limited to radiation pneumonitis. Elevated LSF is also thought to be correlated with liver tumor progression and metastases.

METHODS

In this retrospective cohort study, we examine rates of metastasis development, rates of adverse events and overall survival (OS) in 23 patients with hepatocellular carcinoma (HCC) and elevated LSF >20% on Tc-99 m macroaggregated albumin scan treated with Y-90 radioembolization at our institution from 2005 to 2016. To minimize confounding variables, patients with baseline extrahepatic metastases or portal vein tumor thrombosis were excluded. Kaplan-Meier estimates were performed for OS and time to development of metastases.

RESULTS

No patient developed clinical and imaging signs of radiation pneumonitis. Median intention to treat OS from day of radioembolization was 21.3 months; median censored OS was 14.7 months. Five out of 23 patients (22%) developed at least one metastasis during follow-up, for an incidence of 20 per 1000 patient-years (compared to the historical rate of 6 per 1000 patient-years for HCC patients in general).

CONCLUSION

HCC patients with LSF >20% treated with Y-90 radioembolization have acceptable toxicities and appear to have a rate of extrahepatic tumor development (22%) higher than expected for patients with HCC.

Interventional Oncology Approach to Hepatic Metastases

Metastatic liver disease is one of the major causes of cancer-related morbidity and mortality. Locoregional therapies offered by interventional oncologists alleviate cancer-related morbidity and in some cases improve survival. Locoregional therapies are often palliative in nature but occasionally can be used with curative intent. This review will discuss important factors to consider prior to palliative and curative intent treatment of metastatic liver disease with locoregional therapy. These factors include those specific to the tumor, liver function, liver reserve, differences between treatment modalities, and patient-specific considerations.

Benign Biliary Stricture after Yttrium-90 Radioembolization for Hepatocellular Carcinoma

PURPOSE

To determine the frequency and possible causative factors of benign biliary stricture after radioembolization in patients with hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

This retrospective study comprised 232 patients with HCC who underwent yttrium-90 radioembolization between October 2015 and September 2019. Benign biliary stricture was defined as biliary ductal dilatation of segmental or lobar biliary ducts on follow-up images. Clinical and radiologic characteristics were compared using χ² test or independent t test.

RESULTS

Mean target perfused tissue dose was 224.6 Gy ± 106.8 (median, 205.7 Gy; range, 47.0-694.7 Gy). Of 232 patients, 15 (6.5%) had benign biliary stricture, which was detected from 3 weeks to 10.3 months (mean, 3.9 months; median, 3.2 months). Whereas 5 patients did not have any symptoms or signs associated with benign biliary stricture, 10 patients had cholangitis and/or laboratory abnormality requiring biliary drainage procedures and intravenous antibiotic therapy. Selective radioembolization through a caudate artery was performed in 55 (23.7%) patients. The incidence of benign biliary stricture was 16.4% (9/55) and 3.4% (6/177) in patients with and without selective radioembolization through a caudate artery, respectively (P = .002).

CONCLUSIONS

Benign biliary stricture following yttrium-90 radioembolization may be common among patients receiving selective treatment via a caudate artery.

Pathophysiology and Imaging Findings of Bile Duct Necrosis: A Rare but Serious Complication of Transarterial Therapy for Liver Tumors

Simple Summary

Bile duct necrosis (BDN) is rare but serious complication of transarterial therapy for liver tumors. During development of BDN, ischemia of the peribiliary vascular plexus (PBP) induces the disruption of the bile duct epithelial protection mechanism, causing necrosis of the surrounding tissue by the detergent action of exuded bile acids, and eventually a biloma forms. Once BDN starts, persistent tissue damage to the surrounding bile duct is induced by imbibed bile acids, and portal vein thrombosis may also be observed. On CT images, BDN shows similar findings to intrahepatic bile duct dilatation, and, therefore, it is sometimes misdiagnosed. Clinicians should be aware that although BDN and biloma can usually be treated conservatively, in the presence of symptoms such as moderate or severe infection or interval growth of the biloma, prompt treatment is essential to avoid lethal abscess formation and sepsis.

Abstract

Bile duct necrosis (BDN) with biloma formation is a type of ischemic bile duct injury that is one of the serious complications associated with transarterial therapies, such as transcatheter chemoembolization therapy (TACE), and radioembolization for hepatocellular carcinoma (HCC) and hepatic arterial infusion chemotherapy (HAIC) for metastatic liver cancer from colorectal carcinoma. In terms of the occurrence of BDN and subsequent biloma formation, ischemic injury to the peribiliary vascular plexus (PBP), the supporting vessel of bile duct epithelium, is thought to be intimately associated. In this paper, we first describe the anatomy, blood supply, and function of the intrahepatic bile duct, and then illustrate the pathophysiology of BDN, and finally present the imaging findings of BDN. Under the process of BDN formation, ischemia of the PBP induces the disruption of the bile duct epithelial protection mechanism that causes coagulation and fibrinoid necrosis of the surrounding tissue by the detergent action of exuded bile acids, and eventually a biloma forms. Once BDN occurs, persistent tissue damage to the surrounding bile duct is induced by imbibed bile acids, and portal vein thrombosis may also be observed. On pre-contrast and contrast-enhanced computed tomography (CT), BDN shows similar findings to intrahepatic bile duct dilatation, and, therefore, it is sometimes misdiagnosed. Differentiation of imaging findings on CT and ultrasound (US)/magnetic resonance (MR) imaging/MR cholangiopancreatography (MRCP) is important for correct diagnosis of BDN.

Expected and Unexpected Imaging Findings after 90Y Transarterial Radioembolization for Liver Tumors

Transarterial radioembolization (TARE), also called radioembolization or selective internal radiation therapy, is an interventional radiology technique used to treat primary liver tumors and liver metastases. The aim of this therapy is to deliver tumoricidal doses of radiation to liver tumors while selecting a safe radiation dose limit for nontumoral liver and lung tissue. Hence, correct treatment planning is essential to obtaining good results. However, this treatment invariably results in some degree of irradiation of normal liver parenchyma, inducing different radiologic findings that may affect follow-up image interpretation. When evaluating treatment response, the treated area size, tumor necrosis, devascularization, and changes seen at functional MRI must be taken into account. Unlike with other interventional procedures, with TARE, it can take several months for the tumor response to become evident. Ideally, responding lesions will show reduced size and decreased enhancement 3-6 months after treatment. In addition, during follow-up, there are many imaging findings related to the procedure itself (eg, peritumoral edema, inflammation, ring enhancement, hepatic fibrosis, and capsular retraction) that can make image interpretation and response evaluation difficult. Possible complications, either hepatic or extrahepatic, also can occur and include biliary injuries, hepatic abscess, radioembolization-induced liver disease, and radiation pneumonitis or dermatitis. A complete understanding of these possible posttreatment changes is essential for correct radiologic interpretations during the follow-up of patients who have undergone TARE. ^©RSNA, 2019.

Comparison between liver transplantation and resection for hilar cholangiocarcinoma: A systematic review and meta-analysis

BACKGROUND

Hilar cholangiocarcinoma (hCCA) is a rare and aggressive malignancy with R0 resection being currently the only option for long-term survival. With the improvement in the outcomes of liver transplantation (LT), the indications for LT have expanded to include other malignant tumors, such as hCCA. The aim of the present analysis is to demonstrate and critically evaluate the outcomes of LT compared to resection with curative intent in patients with hCCA.

METHODS

We systematically searched the literature for articles published up to May 2018. The following algorithm was applied ((hilar cholangiocarcinoma) OR (perihilar cholangiocarcinoma) OR klatskin$ OR (bile duct neoplasm) OR cholangiocarcinoma) AND (transplant$ OR graft$).

RESULTS

Neoadjuvant treatment with chemotherapy and radiation therapy was far more common in the LT group, with very few patients having received preoperative therapy in the resection group (p = 0.0005). Moreover, length of hospital stay was shorter after LT than after resection (p<0.00001). In contrast, no difference was found between the two treatment methods concerning postoperative mortality (p = 0.57). There was a trend towards longer overall survival after LT in comparison with resection. This was not obvious in the first year postoperatively, however, the advantage of LT over resection became obvious at 3 years after the operation (p = 0.02).

CONCLUSIONS

In non-disseminated unresectable tumors, LT seems to have a non-inferior survival. In the same patients, neoadjuvant chemoradiotherapy and/or strict selection criteria may contribute to superior survival outcomes compared to curative-intent resection. Due to the scarcity of level 1 evidence, it remains unclear whether LT should be increasingly considered for technically resectable early stage hCCA.

Yttrium-90 Complications: Prevention and Management

Radioembolization has become a more prevalent treatment for both primary and secondary liver of the liver. Radioembolization is a relatively safe procedure with major complications being rare. Understanding how to identify the potential complications and their treatment can help make the procedure even safer and mitigate the risk of severe life threatening complications. In this article, we will review the most common complications, how to identify them, and how manage them.

Liver-Directed Therapies for Hepatocellular Carcinoma and Intrahepatic Cholangiocarcinoma

Hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (IHC) are primary liver cancers where all or most of the tumor burden is usually confined to the liver. Therefore, locoregional liver-directed therapies can provide an opportunity to control intrahepatic disease with minimal systemic side effects. The English medical literature and clinical trials were reviewed to provide a synopsis on the available liver-directed percutaneous therapies for HCC and IHC. Locoregional liver-directed therapies provide survival benefit for patients with HCC and IHC compared to best medical treatment and have lower comorbid risks compared to surgical resection. These treatment options should be considered, especially in patients with unresectable disease.

Current and Future Treatment of Hepatocellular Carcinoma: An Updated Comprehensive Review

Hepatocellular carcinoma (HCC) is among the leading causes of cancer-related mortality. The principal treatment is surgical resection or liver transplantation, depending on whether the patient is a suitable transplant candidate. However, in most patients with HCC the diagnosis is often late, thereby excluding the patients from definitive surgical resection. Medical treatment includes sorafenib, which is the most commonly used systemic therapy; although, it has been shown to only minimally impact patient survival by several months. Chemotherapy and radiotherapy are generally ineffective. Due to the poor prognosis of patients with HCC, newer treatments are needed with several being in development, either in pre-clinical or clinical studies. In this review article, we provide an update on the current and future medical and surgical management of HCC.

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.

Radioembolisation of hepatocellular carcinoma: a primer

Transarterial radioembolisation (TARE) has gained increasing acceptance as an additional/alternative locoregional treatment option for hepatocellular carcinoma, and colorectal hepatic metastases that present beyond potentially curative options. This is a catheter-based transarterial selective internal brachytherapy that involves injection of radioactive microspheres (usually Y-90) that are delivered selectively to the liver tumours. Owing to the combined radioactive and microembolic effect, the findings at follow-up imaging are significantly different from that seen with other transarterial treatment options. Considering increasing confidence among clinicians, refinement in techniques and increasing number of ongoing trials, TARE is expected to gain further acceptance and become an important tool in the armamentarium for the treatment of liver malignancies. So it is imperative that all radiologists involved in the management of liver malignancies are well versed with TARE to facilitate appropriate discussion at multidisciplinary meetings to direct further management. In this article, we provide a comprehensive review on various aspects of radioembolisation with Y-90 for hepatocellular carcinoma including the patient selection, treatment planning, radiation dosimetry and treatment, side effects, follow-up imaging and future direction.

Hepatic artery and biliary complications in liver transplant recipients with radioembolization bridging treatment for hepatocellular carcinoma

BACKGROUND

Locoregional bridging treatments are commonly applied in patients with hepatocellular carcinoma (HCC) prior to liver transplantation to prevent tumor progression during waiting time. It remains unknown whether pre-transplant radioembolization treatment may increase the prevalence of hepatic artery and biliary complications post-transplant.

METHODS

We performed a retrospective review of 173 consecutive patients with HCC who underwent liver transplantation at our transplant center between January 2007 and December 2016.

RESULTS

Radioembolization bridging treatment was applied in 42 patients while 131 patients received other or no forms of bridging treatment. The overall prevalence of intra-operative and early post-operative hepatic artery complications was 9.5% in the radioembolization group and 9.2% in the control group (P = 1.000). Biliary complications were significantly less frequent in the radioembolization group (4.8% vs 17.6%, P = .0442). In multivariable analysis, radioembolization was not significantly associated with an increased risk of arterial complications. Considering biliary complications, radioembolization bridging treatment was the only factor significantly associated with decreased odds (OR 0.187 (0.039, 0.892), P = .036).

CONCLUSIONS

Radioembolization is not associated with higher odds of hepatic artery complications following liver transplantation. There may even be a protective effect regarding biliary complications. Radioembolization as a bridge to transplantation may effectively be applied without compromising successful liver transplantation.

Prevention and treatment of complications of selective internal radiation therapy: Expert guidance and systematic review

Selective internal radiation therapy (or radioembolization) by intra-arterial injection of radioactive yttrium-90-loaded microspheres is increasingly used for the treatment of patients with liver metastases or primary liver cancer. The high-dose beta-radiation penetrates an average of only 2.5 mm from the source, thus limiting its effects to the site of delivery. However, the off-target diversion of yttrium-90 microspheres to tissues other than the tumor may lead to complications. The most prominent of these complications include radiation gastritis and gastrointestinal ulcers, cholecystitis, radiation pneumonitis, and radioembolization-induced liver disease, which may occur despite careful pretreatment planning. Thus, selective internal radiation therapy demands an expert multidisciplinary team approach in order to provide comprehensive care for patients. This review provides recommendations to multidisciplinary teams on the optimal medical processes in order to ensure the safe delivery of selective internal radiation therapy. Based on the best available published evidence and expert opinion, we recommend the most appropriate strategies for the prevention, early diagnosis, and management of potential radiation injury to the liver and to other organs. (Hepatology 2017;66:969-982).

Medication-associated gastrointestinal tract injury

Medication-associated gastrointestinal (GI) tract injury has been known for centuries for some medications. The more recently introduced biologicals are a class of drugs that constantly increases, and as such, the spectrum of GI tract side effects is steadily growing. This review covers not only long-known GI tract side effects of drugs but also those more recently described. A comprehensive but concise list of medications used in daily practice and associated with GI tract injury is presented.

Novel implications in the treatment of hepatocellular carcinoma

Worldwide hepatocellular carcinoma remains one of the leading causes of cancer-related death, associated with a poor prognosis due to late diagnosis in the majority of cases. Physicians at care are frequently confronted with patients who are ineligible for curative treatment such as liver resection, transplantation or radiofrequency ablation. Besides established palliative locoregional therapies, such as ablation or chemoembolization, new treatment options, such as microwave ablation, drug-eluting bead transarterial chemoembolization or selective internal radiation therapy, are emerging; however, data from randomized controlled trials are still lacking. In order to achieve optimal tumor control, patients should receive tailored treatment concepts, considering their tumor burden, liver function and performance status, instead of strictly assigning patients to treatment modalities following algorithms that may be partly very restrictive. Palliative locoregional pretreatment might facilitate downstaging to ensure later curative resection or transplantation. In addition, the combined utilization of different locoregional treatment options or systemic co-treatment has been the subject of several trials. In cases where local tumor control cannot be achieved, or in the scenario of extrahepatic spread, sorafenib remains the only approved systemic therapy option. Alternative targeted therapies, such as immune checkpoint inhibitors have shown encouraging preliminary results, while data from phase III studies are pending.

Transarterial Therapy for Colorectal Liver Metastases

Until recently, hepatic arterial therapies (HAT) had been used for colorectal liver metastases after failure of first-, second-, and third-line chemotherapies. HAT has gained greater acceptance in patients with liver-dominant colorectal metastases after failure of surgery or systemic chemotherapy. The current data demonstrate that HAT is a safe and effective option for preoperative downsizing, optimizing the time to surgery, limiting non-tumor-bearing liver toxicity, and improving overall survival after surgery in patients with colorectal liver-only metastases. The aim of this review is to present the current data for HAT in liver-only and liver-dominant colorectal liver metastases.

Transarterial radioembolization for hepatocellular carcinoma: a review

Hepatocellular carcinoma (HCC) is the most common type of liver cancer and is the second cause of death due to malignancy in the world. The treatment of HCC is complex and includes potentially curative and palliative approaches. However, both curative and palliative treatments for HCC are often associated with a not-completely favorable safety/efficacy ratio. Therefore, other treatment options appear necessary in clinical practice. Transarterial radioembolization has shown a promising efficacy in terms of disease control and is associated with a good safety profile. This review discusses the use of transarterial radioembolization in HCC, with a focus on the clinical aspects of this therapeutic strategy.

Consensus for Radiotherapy in Hepatocellular Carcinoma from The 5th Asia-Pacific Primary Liver Cancer Expert Meeting (APPLE 2014): Current Practice and Future Clinical Trials

A consensus meeting to develop practice guidelines and to recommend future clinical trials for radiation therapy (RT), including external beam RT (EBRT), and selective internal RT (SIRT) in hepatocellular carcinoma (HCC) was held at the 5th annual meeting of the Asia-Pacific Primary Liver Cancer Expert consortium. Although there is no randomized phase III trial evidence, the efficacy and safety of RT in HCC has been shown by prospective and retrospective studies using modern RT techniques. Based on these results, the committee came to a consensus on the utility and efficacy of RT in the management of HCC according to each disease stage as follows: in early and intermediate stage HCC, if standard treatment is not compatible, RT, including EBRT and SIRT can be considered. In locally advanced stage HCC, combined EBRT with transarterial chemoembolization or hepatic arterial infusion chemotherapy, and SIRT can be considered. In terminal stage HCC, EBRT can be considered for palliation of symptoms and reduction of morbidity caused by the primary tumor or its metastases. Despite the currently reported benefits of RT in HCC, the committee agreed that there is a compelling need for large prospective studies, including randomized phase III trial evidence evaluating the role of RT. Specifically studies evaluating the efficacy and safety of sequential combination of EBRT and SIRT are strongly recommended.

Yttrium-90 Selective Internal Radiation Therapy with Glass Microspheres for Hepatocellular Carcinoma: Current and Updated Literature Review

Hepatocellular carcinoma is the most common primary liver cancer and it represents the majority of cancer-related deaths in the world. More than 70% of patients present at an advanced stage, beyond potentially curative options. Ytrrium-90 selective internal radiation therapy (Y90-SIRT) with glass microspheres is rapidly gaining acceptance as a potential therapy for intermediate and advanced stage primary hepatocellular carcinoma and liver metastases. The technique involves delivery of Y90 infused glass microspheres via the hepatic arterial blood flow to the appropriate tumor. The liver tumor receives a highly concentrated radiation dose while sparing the healthy liver parenchyma due to its preferential blood supply from portal venous blood. There are two commercially available devices: TheraSphere® and SIR-Spheres®. Although, Y90-SIRT with glass microspheres improves median survival in patients with intermediate and advanced hepatocellular carcinoma and has the potential to downstage hepatocellular carcinoma so that the selected candidates meet the transplantable criteria, it has not gained widespread acceptance due to the lack of large randomized controlled trials. Currently, there are various clinical trials investigating the use of Y90-SIRT with glass microspheres for treatment of hepatocellular carcinoma and the outcomes of these trials may result in the incorporation of Y90-SIRT with glass microspheres into the treatment guidelines as a standard therapy option for patients with intermediate and advanced stage hepatocellular carcinoma.

Current status of transarterial radioembolization

Unresectable primary and secondary liver malignancies present a major problem in the treatment of solid tumors. Transarterial radioembolization (TARE) is an increasingly used technique for treating various types of malignant liver tumors. This approach is appealing, as the mechanism of action is independent from other loco-regional treatments and potentially complementary to systemic therapies. There are two commercially available products in use for TARE: ⁹⁰Y-resin and ⁹⁰Y-glass microspheres. Currently available data indicates TARE so be safe and effective in hepatocellular carcinoma (HCC) and metastatic liver disease. In HCC the results compare well with chemoembolization, while the role of TARE in combination with kinase inhibitors has yet to be established. Current data on TARE in metastatic liver disease is promising, but there is a strong need for prospective randomized trials comparing TARE and modern chemotherapeutic regimen to support the growing role of TARE in metastatic liver disease.

Radioembolization: Is Prophylactic Embolization of Hepaticoenteric Arteries Necessary? A Systematic Review

PURPOSE

To study the effectiveness of prophylactic embolization of hepaticoenteric arteries to prevent gastrointestinal complications during radioembolization.

METHODS

A PubMed, Embase and Cochrane literature search was performed. We included studies assessing both a group of patients with and without embolization.

RESULTS

Our search revealed 1401 articles of which title and abstract were screened. Finally, eight studies were included investigating 1237 patients. Of these patients, 456 received embolization of one or more arteries. No difference was seen in the incidence of gastrointestinal complications in patients with prophylactic embolization of the gastroduodenal artery (GDA), right gastric artery (RGA), cystic artery (CA) or hepatic falciform artery (HFA) compared to patients without embolization. Few complications were reported when microspheres were injected distal to the origin of these arteries or when reversed flow of the GDA was present. A high risk of confounding by indication was present because of the non-randomized nature of the included studies.

CONCLUSION

It is advisable to restrict embolization to those hepaticoenteric arteries that originate distally or close to the injection site of microspheres. There is no conclusive evidence that embolization of hepaticoenteric arteries influences the risk of complications.

Evidence-based medical oncology and interventional radiology paradigms for liver-dominant colorectal cancer metastases

Colorectal cancer metastasizes predictably, with liver predominance in most cases. Because liver involvement has been shown to be a major determinant of survival in this population, liver-directed therapies are increasingly considered even in cases where there is (limited) extrahepatic disease. Unfortunately, these patients carry a known risk of recurrence in the liver regardless of initial therapy choice. Therefore, there is a demand for minimally invasive, non-surgical, personalized cancer treatments to preserve quality of life in the induction, consolidation, and maintenance phases of cancer therapy. This report aims to review evidence-based conceptual, pharmacological, and technological paradigm shifts in parenteral and percutaneous treatment strategies as well as forthcoming evidence regarding next-generation systemic, locoregional, and local treatment approaches for this patient population.