Predictors of Survival after Yttrium-90 Radioembolization for Colorectal Cancer Liver Metastases

Meta-analysis of the prognostic value of serum carcinoembryonic antigen in patients with colorectal cancer liver metastases after hepatectomy

OBJECTIVES

Carcinoembryonic antigen (CEA) is a broad-spectrum tumor marker for differential diagnosis, monitoring, and response assessment of a variety of malignancies. This meta-analysis was aimed at evaluating whether serum CEA could predict the prognosis in patients with colorectal cancer liver metastasis (CRCLM) before and after liver resection (LR).

METHODS

PubMed, Embase, Cochrane, and Web of Science were systematically searched to retrieve literature, with a search cutoff date of 27 February 2023. Articles were strictly screened for inclusion according to pre-specified inclusion and exclusion criteria. Data were pooled and analyzed using Stata 16.0.

RESULTS

This meta-analysis included 36 studies involving a total of 11 143 CRCLM patients. The results showed that a high pre-LR serum CEA level was correlated with poor overall survival (OS: HR = 1.61, 95% CI = 1.49-1.75, P  < 0.001) and recurrence-free survival (RFS: HR = 1.27, 95% CI = 1.11-1.45, P  < 0.001) in CRCLM patients. A high post-LR serum CEA level predicted poor overall survival (OS: HR = 2.66, 95% CI = 2.10-3.38, P  < 0.001).

CONCLUSION

High preoperative and postoperative serum CEA levels in patients with CRCLM were significantly associated with poor prognosis, independent of treatment modality, mode of analysis, case origin, and cutoff value classification.

Immune Effects of Intra-Arterial Liver-Directed Therapies

Image-guided intra-arterial locoregional therapies (LRTs) such as transarterial embolization, transarterial chemoembolization, and transarterial radioembolization exhibit effects on the immune system. Understanding the humoral (cytokine, chemokine, and growth factor) and cellular (T cell, neutrophil, dendritic cell, and macrophage) mechanisms underlying the immune effects of LRT is crucial to designing rational and effective combinations of immunotherapy and interventional radiology procedures. This article aims to review the immune effects of intra-arterial LRTs and provide insight into strategies to combine LRTs with systemic immunotherapy.

Prognostic role of serum carcinoembryonic antigen in patients receiving liver resection for colorectal cancer liver metastasis: A meta-analysis

BACKGROUND

Carcinoembryonic antigen (CEA) is a broad-spectrum tumor marker for differential diagnosis, monitoring, and response assessment of a variety of malignancies.

AIM

To evaluate whether serum CEA could predict the prognosis in patients with colorectal cancer liver metastasis (CRCLM) before and after liver resection (LR).

METHODS

PubMed, Embase, Cochrane, and Web of Science were systematically searched to retrieve literature, with a search cut-off date of February 27, 2023. Articles were strictly screened for inclusion according to pre-specified inclusion and exclusion criteria. Data were pooled and analyzed using Stata 16.0.

RESULTS

This meta-analysis included 36 studies involving a total of 11143 CRCLM patients. The results showed that a high pre-LR serum CEA level was correlated with poor overall survival (OS) [hazard ratio (HR) = 1.61, 95% confidence interval (CI): 1.49-1.75, P < 0.001] and recurrence-free survival (HR = 1.27, 95%CI: 1.11-1.45, P < 0.001) in CRCLM patients. A high post-LR serum CEA level predicted poor OS (HR = 2.66, 95%CI: 2.10-3.38, P < 0.001). A comparison by treatment modality, analysis modality, patient source, and cutoff-value showed that overall, high preoperative and postoperative serum CEA levels remained correlated with a poor prognosis.

CONCLUSION

This study concluded that high pre-LR and post-LR serum CEA levels were significantly correlated with a poor prognosis in CRCLM patients.

American Radium Society Appropriate Use Criteria for the use of liver-directed therapies for nonsurgical management of liver metastases: Systematic review and guidelines

The liver is a common site of cancer metastases. Systemic therapy is widely accepted as the standard treatment for liver metastases (LM), although select patients with liver oligometastases may be candidates for potentially curative liver resection. Recent data support the role of nonsurgical local therapies such as ablation, external beam radiotherapy, embolization, and hepatic artery infusion therapy for management of LM. Additionally, for patients with advanced, symptomatic LM, local therapies may provide palliative benefit. The American Radium Society gastrointestinal expert panel, including members representing radiation oncology, interventional radiology, surgical oncology, and medical oncology, performed a systemic review and developed Appropriate Use Criteria for the use of nonsurgical local therapies for LM. Preferred Reporting Items for Systematic reviews and Meta-Analyses methodology was used. These studies were used to inform the expert panel, which then rated the appropriateness of various treatments in seven representative clinical scenarios through a well-established consensus methodology (modified Delphi). A summary of recommendations is outlined to guide practitioners on the use of nonsurgical local therapies for patients with LM.

Colorectal Cancer Liver Metastases: Genomics and Biomarkers with Focus on Local Therapies

Molecular cancer biomarkers help personalize treatment, predict oncologic outcomes, and identify patients who can benefit from specific targeted therapies. Colorectal cancer (CRC) is the third-most common cancer, with the liver being the most frequent visceral metastatic site. KRAS, NRAS, BRAF V600E Mutations, DNA Mismatch Repair Deficiency/Microsatellite Instability Status, HER2 Amplification, and NTRK Fusions are NCCN approved and actionable molecular biomarkers for colorectal cancer. Additional biomarkers are also described and can be helpful in different image-guided hepatic directed therapies specifically for CRLM. For example, tumors maintaining the Ki-67 proliferation marker after thermal ablation was shown to be particularly resilient to ablation. Ablation margin was also shown to be an important factor in predicting local recurrence, with a ≥10 mm minimal ablation margin being required to attain local tumor control, especially for patients with mutant KRAS CRLM.

The prognostic utility of preoperative neutrophil-to-lymphocyte ratio (NLR) in patients with colorectal liver metastasis: a systematic review and meta-analysis

The neutrophil-to-lymphocyte ratio is used to reflect body's inflammatory status with prognostic value in different cancers. We aimed to investigate the influence of preoperative NLR in the prognosis of CRLM patients receiving surgery using meta-analysis. Data in Cochrane Library, PubMed, Embase, and Web of Science databases created before October 2022 were recruited. Meta-analysis was carried out with RevMan 5.3 and Stata16 software, and the primary outcome indicators included overall survival (OS), and secondary outcome indicators included disease-free survival (DFS) and relapse-free survival (RFS). The pooled risk ratio (HR) and 95% confidence interval (CI) for each outcome indicator were determined using random-effects models or fixed-effects models. The pooled odds ratio (OR) and corresponding 95% confidence intervals (CI) for NLR and clinicopathological characteristics were determined with a fixed-effects model. 18 papers published between 2008 and 2022 (3184 patients in total) were included. The pooled analysis found that high preoperative NLR was correlated with poor OS (multivariate HR = 1.83, 95% CI = 1.61-2.08, p < 0.01), DFS (multivariate HR = 1.78, 95% CI = 1.16-2.71, p < 0.01) and RFS (multivariate HR = 1.46, 95% CI = 1.15-1.85, p < 0.01), but NLR was not related to clinicopathological features of CRLM patients correlation. In conclusion, NLR is an independent risk factor for poor prognosis in patients with CRLM. More large-scale clinical researches are required in the future to demonstrate the inclusion of preoperative NLR as a prognostic indicator for CRLM patients to guide postoperative adjuvant chemotherapy.

Evaluation of Inflammatory Scores in Metastatic Colorectal Cancer Patients Undergoing Transarterial Radioembolization

PURPOSE

To evaluate the correlation of neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), aspartate aminotransferase-to-lymphocyte ratio (ALRI), systemic inflammation index (SII), and lymphocyte count to oncologic outcomes in metastatic colorectal cancer (mCRC) patients undergoing transarterial radioembolization (TARE).

MATERIALS AND METHODS

All patients undergoing TARE for mCRC were retrospectively reviewed at a single academic institution. A receiver operating characteristics (ROC) curve analysis was performed using a landmark survival point of 12 months, with an area under the curve (AUC) calculated. A cutoff point was determined by Youden's index and used to separate patients for OS and PFS analysis. Cox proportional-hazards models which included pertinent clinical factors were also created to evaluate PFS and OS.

RESULTS

In total, 41 patients who underwent 66 TARE treatments were included. A correlation was seen between post-treatment ALRI < 45 (HR: 0.38 (95%CI: 0.17-0.86), p = 0.02) and PFS. Patients with a pretreatment ALRI score < 20 had a significantly longer OS (HR: 0.49 (95%CI: 0.19-0.88), p = 0.02) as did those with a post-treatment lymphocyte count > 1.1 10⁹/L (HR: 0.27 (95%CI: 0.11-0.68), p = 0.005). In multivariate analysis of PFS, post-treatment lymphocyte count (HR: 8.46 (95%CI: 1.14-62.89), p = 0.044) was the only significantly associated inflammatory marker and presence of extrahepatic disease (HR:8.46 (95%CI: 1.14-62.89, p = 0.044) also correlated. Multivariate analysis of OS showed that pretreatment PLR (HR:1.01 (95%CI:1.-1.03), p = 0.02) and post-treatment NLR (HR:0.33 (95%CI:0.14-0.76), p = 0.009), PLR (HR:0.98 (95%CI:0.97-1), p = 0.046), SII (HR:1.04 (95%CI:1.01-1.08), p = 0.014), and lymphocyte count (HR:0.07 (95%CI:0.01-0.16), p = 0.003) were significantly associated.

CONCLUSION

Inflammatory markers may be associated with OS and PFS in mCRC patients undergoing TARE.

Neutrophil-to-lymphocyte ratio as a prognostic factor for survival in patients with colorectal liver metastases: A systematic review

BACKGROUND

The inflammatory response to tumor has been proven to be closely related to the prognosis of colorectal cancer. Neutrophil to lymphocyte ratio (NLR) is a widely available inflammatory biomarker that may have prognostic value for patients with colorectal liver metastasis (CRLM).

AIM

To assess the role of NLR as a prognostic factor of survival and tumor recurrence in patients with CRLM.

METHODS

A systematic literature search of PubMed, Cochrane Library and clinicaltrials.gov was conducted by two independent researchers in order to minimize potential errors and bias. Conflicts were discussed and settled between three researchers. Studies including patients undergoing different types of medical interventions for the treatment of CRLM and evaluating the correlation between pretreatment NLR and disease-free survival (DFS) and overall survival (OS) were included in the review. Nineteen studies, involving 3283 patients matched our inclusion criteria.

RESULTS

In the studies included, NLR was measured before the intervention and the NLR thresholds ranged between 1.9 and 7.26. Most studies used 5 as the cut-off value. Liver metastases were treated with hepatectomy with or without chemotherapy regimens in 13 studies and with radiofrequency ablation, radioembolization, chemoembolization or solely with chemotherapy in 6 studies. High NLR was associated with decreased OS and DFS after liver resection or other medical intervention. Moreover, high NLR was associated with poor chemosensitivity. On the contrary, CRLM patients with low pretreatment NLR demonstrated improved OS and DFS. NLR could potentially be used as a predictive factor of survival and tumor recurrence in patients with CRLM treated with interventions of any modality, including surgery, chemotherapy and ablative techniques.

CONCLUSION

NLR is an inflammatory biomarker that demonstrates considerable prognostic value. Elevated pretreatment NLR is associated with poor OS and DFS in patients with CRLM who are submitted to different treatments.

Multiradiographic Diagnosis of Primary Hepatocellular Carcinoma and Evaluation of Its Postoperative Observation after Interventional Treatment

Objective

To investigate the focal imaging performance of MRI and CT multiphase dynamic enhancement scan examination in primary liver cancer patients, analyze its clinical diagnostic value, and provide a basis for early diagnosis of the disease.

Methods

236 patients with primary liver cancer admitted to our hospital from May 2019 to November 2021 were randomly divided into two groups, the control group was given MRI multiphase dynamic enhancement scan diagnostic method, and the observation group was given CT scan combined with the MRI diagnostic method. The patients' examination results and pathological examination results were compared and analyzed, and the therapeutic effects of patients in the two groups after interventional treatment were compared.

Results

After the imaging and pathological examinations of patients in both groups, it was found that the diagnostic accuracy of patients in the observation group and the therapeutic effect after interventional treatment were significantly better than those in the control group.

Conclusions

Compared with CT multiphase dynamic enhancement scan, MRI multiphase dynamic enhancement scan can show multidirectional and multiangle lesions in primary hepatocellular carcinoma patients, with better characteristics of blood supply to hepatocellular carcinoma and a higher accuracy rate.

Combining Transarterial Radioembolization (TARE) and CT-Guided High-Dose-Rate Interstitial Brachytherapy (CT-HDRBT): A Retrospective Analysis of Advanced Primary and Secondary Liver Tumor Treatment

Simple Summary

Clinical management of advanced stages of primary and secondary liver tumors remains challenging. Combining different treatment approaches to create the most effective therapy for patients is, however, often necessary. With this study we aim to analyze the efficacy and safety of a combined intrahepatic treatment of transarterial radioembolization and CT-guided high-dose-rate interstitial brachytherapy. Our study showed that patients not responding to systemic chemotherapy or suffering from tumor relapse after surgical resection might benefit from a combined minimal-invasive treatment.

Abstract

Purpose: Treatment of patients with primary and secondary liver tumors remains challenging. This study analyzes the efficacy and safety of transarterial radioembolization (TARE) combined with CT-guided high-dose-rate interstitial brachytherapy (CT-HDRBT) for the treatment of primary and secondary liver tumors. Patients and Methods: A total of 77 patients (30 female) with various liver malignancies were treated. Primary endpoints were median overall survival (OS) and time to untreatable progression (TTUP). Additionally, subgroup analyses were performed in consideration of diagnosis and procedure sequence. Median OS and TTUP prediction were estimated using Kaplan–Meier analysis and hazard ratios (HR) were calculated using a multivariate Cox proportional hazard model. Results: A total of 115 CT-HDRBT and 96 TARE procedures were performed with no significant complications recorded. Median OS and TTUP were 29.8 (95% CI 18.1–41.4) and 23.8 (95% CI 9.6–37.9) months. Median OS for hepatocellular carcinoma (HCC)-, cholangiocarcinoma carcinoma (CCA) and colorectal cancer (CRC) patients was 29.8, 29.6 and 34.4 months. Patients starting with TARE had a median OS of 26.0 (95% CI 14.5–37.5) compared to 33.7 (95% CI 21.6–45.8) months for patients starting with CT-HDRBT. Hazard ratio of 1.094 per month was shown for patients starting with CT-HDRBT. Conclusion: Combining TARE and CT-HDRBT is effective and safe for the treatment of advanced stage primary and secondary liver tumors. Our data indicate that early TARE during the disease progression may have a positive effect on survival.

Survival Advantage of Yttrium-90 Radioembolization to Systemic Therapy in Patients with Hepatic Metastases from Colorectal Cancer in the Salvage Setting: Results of a Matched Pair Study

RATIONALE AND OBJECTIVES

Patients with hepatic metastases from colorectal cancer have a poor prognosis in the salvage setting. This study assessed the survival benefit of adding transarterial ⁹⁰Y radioembolization in the salvage setting to systemic therapy.

MATERIALS AND METHODS

In this retrospective, matched-pair study, 21 patients who underwent radioembolization plus systemic therapy were matched with a cohort of 173 patients who received systemic chemotherapy alone in the salvage setting, defined as progression on at least two different regimens of systemic chemotherapy. Patients were matched one-to-one on Eastern Cooperative Oncology Group Performance Status, presence of extrahepatic disease, and presence of tumor KRAS mutation. Radioembolization patients underwent treatment using standard dosimetry to either a hepatic lobe or the whole liver. Survival data was analyzed using Kaplan-Meier analysis.

RESULTS

Patients who underwent radioembolization plus systemic therapy vs. those who had systemic therapy alone had similar demographics and exposure to prior systemic chemotherapies. Median survival from the date of primary diagnosis was 38 (95% CI 26 to 50) v 25 (95% CI 15 to 35) months in radioembolization with systemic therapy vs. systemic therapy alone (p = 0.17). Median survival from the date of hepatic metastases was 31 (95% CI 23.8 to 38.2) v 20 months (95% CI 10.2 to 29.8) in radioembolization with systemic therapy vs. systemic therapy alone (p = 0.03).

CONCLUSION

The addition of radioembolization to systemic therapy in patients with metastatic colorectal cancer to the liver may improve survival in the salvage setting.

Role of Resin Microsphere Y90 Dosimetry in Predicting Objective Tumor Response, Survival and Treatment Related Toxicity in Surgically Unresectable Colorectal Liver Metastasis: A Retrospective Single Institution Study

Simple Summary

Colorectal liver metastases are difficult to treat, with only a minority of patients eligible for surgical resection. Yttrium-90 selective internal radiation therapy is an alternative treatment currently used for patients who have progressed on chemotherapy. A technique called dosimetry allows clinicians to analyze how much radiation was delivered to target lesions post-treatment. The aim of this study is to evaluate the relationship of various dosimetric parameters with objective tumor response, overall survival, and treatment related toxicity with the potential goal of optimizing Yttrium-90 treatment in this patient population. Additionally, other potential predictors of survival outcomes, including clinical and demographic factors, were also evaluated. We found that delivering a mean tumor dose ≥100 Gy when using resin microspheres was significantly associated with objective tumor response and prolonged overall survival. In this study, no mean non-tumoral liver dose threshold was found to predict treatment related toxicity.

Abstract

Purpose: To Evaluate the correlation between tumor dosimetric parameters with objective tumor response (OR) and overall survival (OS) in patients with surgically unresectable colorectal liver metastasis (CRLM) undergoing resin-based Ytrrium-90 selective internal radiation therapy (Y90 SIRT). Materials and Methods: 45 consecutive patients with CRLM underwent resin-based Y90 SIRT in one or both hepatic lobes (66 treated lobes total). Dose volume histograms were created with MIM Sureplan^® v.6.9 using post-treatment SPECT/CT. Dosimetry analyses were based on the cumulative volume of the five largest tumors in each treatment session and non-tumoral liver (NTL) dose. Receiver operating characteristic (ROC) curve was used to evaluate tumor dosimetric factors in predicting OR by Response Evaluation Criteria for Solid Tumors at 3 months post-Y90. Additionally, ROC curve was used to evaluate non-tumoral liver dose as a predictor of grade ≥ 3 liver toxicity and radioembolization induced liver disease (REILD) 3 months post Y90. To minimize for potential confounding demographic and clinical factors, univariate and multivariate analysis of survival with mean tumor dose as one of the factors were also performed. Kaplan-Meier estimation was used for OS analysis from initial Y90 SIRT. Results: 26 out of 45 patients had OR with a median OS of 17.2 months versus 6.8 months for patients without OR (p < 0.001). Mean tumor dose (TD) of the five largest tumors was the strongest predictor of OR with an area under the curve of 0.73 (p < 0.001). Minimum TD, and TD to 30%, 50%, and 70% of tumor volume also predicted OR (p’s < 0.05). Mean TD ≥ 100 Gy predicted a significantly prolonged median OS of 19 vs. 11 months for those receiving TD < 100 Gy (p = 0.016). On univariate analysis, mean TD < 100 Gy, presence of any genomic mutation, presence of MAPK pathway mutation, bilobar hepatic metastases and diffuse metastatic disease (>10 lesions per liver lobe) were found to be predictors of shorter median OS. On multivariate analysis, mean TD < 100 Gy, presence of any genomic mutation, and diffuse hepatic metastatic disease were found to be independent predictors of shorter OS. Overall, six (13.3%) patients developed grade ≥ 3 liver toxicity post Y90 of whom two (4.4%) patients developed REILD. No dose threshold predicting grade ≥ 3 liver toxicity or REILD was identified. Conclusions: Mean TD ≥ 100 Gy in patients with unresectable CRLM undergoing resin-based Y90 SIRT predicts OR and prolonged OS.

The prognostic utility of pre-treatment neutrophil-to-lymphocyte-ratio (NLR) in colorectal cancer: A systematic review and meta-analysis

Background

Inflammation is a hallmark of cancer, and systemic markers of inflammation are increasingly recognised as negative prognostic factors for clinical outcome. Neutrophil‐to‐lymphocyte ratio (NLR) is readily available from routine blood testing of patients diagnosed with cancer.

Methods

Peer‐reviewed publications from PubMed/MEDLINE, Web of Science and EMBASE were identified according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analysis (PRISMA) guidelines. Hazard ratios (HR) for overall survival (OS) and surrogate endpoints (SE; comprising disease‐, recurrence‐ and progression‐free survival) were pooled using a random effects model. Additional analysis was carried out to further investigate NLR as an independent prognostic factor and account for heterogeneity.

Results

Seventy‐one eligible papers comprising 32,788 patients were identified. High NLR was associated with poor clinical outcomes. Significant publication bias was observed, and larger studies also adjusted for more covariates. Correcting for publication bias in multivariate studies brought our best estimate for true effect size to HR = 1.57 (95% CI 1.39–1.78; p < 0.0001) for OS and to HR = 1.38 (95% CI 1.16–1.64; p = 0.0003) for SE.

Conclusions

NLR is confirmed as an easily available prognostic biomarker in colorectal cancer, despite the limitations of some studies previously reporting this finding. As such, it should be routinely collected in prospective clinical trials. While more standardised and rigorous large‐scale studies are needed before high NLR can be fully assessed as an independent predictor of CRC progression and outcome, the data suggest that it may be used to highlight individuals with tumour‐promoting inflammatory context.

Yttrium-90 Hepatic Radioembolization for Advanced Chemorefractory Metastatic Colorectal Cancer: Survival Outcomes Based on Right- Versus Left-Sided Primary Tumor Location

BACKGROUND. Primary colon cancer location affects survival of patients with metastatic colorectal cancer (mCRC). Outcomes based on primary tumor location after salvage hepatic radioembolization with ⁹⁰Y resin microspheres are not well studied. OBJECTIVE. The objectives of this study are to assess the survival outcomes of patients with advanced chemorefractory mCRC treated with ⁹⁰Y radioembolization, as stratified by primary tumor location, and to explore potential factors that are predictive of survival. METHODS. A total of 99 patients who had progressive mCRC liver metastases while receiving systemic therapy and who were treated with ⁹⁰Y radioembolization at a single center were retrospectively analyzed. For 89 patients, tumor response on the first imaging follow-up examination (CT or MRI performed at a mean [± SD] of 1.9 ± 0.9 months after ⁹⁰Y radioembolization) was evaluated using RECIST. Overall survival (OS), OS after ⁹⁰Y radioembolization, and hepatic progression-free survival (PFS) were calculated using the Kaplan-Meier method. Outcomes and associations of outcomes with tumor response were compared between patients with left- and right-sided tumors. RESULTS. A total of 74 patients had left-sided colon cancer, and 25 patients had right-sided colon cancer. Median OS from the time of mCRC diagnosis was 37.2 months, median OS after ⁹⁰Y radioembolization was 5.8 months, and median hepatic PFS was 3.3 months. Based on RECIST, progressive disease on first imaging follow-up was observed in 38 patients (43%) after ⁹⁰Y radioembolization and was associated with shorter OS after ⁹⁰Y radioembolization compared with observation of disease control on first imaging follow-up (4.0 vs 10.5 months; p < .001). Patients with right-sided primary tumors showed decreased median OS after ⁹⁰Y radioembolization compared with patients with left-sided primary tumors (5.4 vs 6.2 months; p = .03). Right- and left-sided primary tumors showed no significant difference in RECIST tumor response, hepatic PFS, or extrahepatic disease progression (p > .05). Median survival after ⁹⁰Y radioembolization was significantly lower among patients with progressive disease than among those with disease control in the group with left-sided primary tumors (4.2 vs 13.9 months; p < .001); however, this finding was not observed in the group with right-sided primary tumors (3.3 vs 7.2 months; p = .05). CONCLUSION. Right-sided primary tumors were independently associated with decreased survival among patients with chemorefractory mCRC after ⁹⁰Y radioembolization, despite these patients having a similar RECIST tumor response, hepatic PFS, and extrahepatic disease progression compared with patients with left-sided primary tumors. CLINICAL IMPACT. Primary colon cancer location impacts outcomes after salvage ⁹⁰Y radioembolization and may help guide patient selection.

Feasibility and Safety of CT-Guided High-Dose-Rate Brachytherapy Combined with Transarterial Chemoembolization Using Irinotecan-Loaded Microspheres for the Treatment of Large, Unresectable Colorectal Liver Metastases

PURPOSE

To evaluate feasibility and safety of combined irinotecan chemoembolization and CT-guided high-dose-rate brachytherapy (HDRBT) in patients with unresectable colorectal liver metastases > 3 cm in diameter.

MATERIALS AND METHODS

This prospective study included 23 patients (age, 70 y ± 11.3; 16 men) with 47 liver metastases (size, 62 mm ± 18.7). Catheter-related adverse events were reported per Society of Interventional Radiology classification, and treatment toxicities were reported per Common Terminology Criteria for Adverse Events. Liver-related blood values were analyzed by Wilcoxon test, with P < .05 as significant. Time to local tumor progression, progression-free survival (PFS), and overall survival (OS) were estimated by Kaplan-Meier method.

RESULTS

No catheter-related major or minor complications were recorded. Significant differences vs baseline levels of aspartate aminotransferase (AST), alanine aminotransferase (ALT; both P < .001), γ-glutamyltransferase (GGT; P = .013), and hemoglobin (P = .014) were recorded. After therapy, 11 of 23 patients (47.8%) presented with new grade I/II toxicities (bilirubin, n = 3 [13%]; AST, n = 16 [70%]; ALT, n = 18 [78%]; ALP, n = 12 [52%] and hemoglobin, n = 15 [65%]). Moreover, grade III/IV toxicities developed in 10 (43.5%; 1 grade IV): AST, n = 6 (26%), grade III, n = 5; grade IV, n = 1; ALT, n = 3 (13%); GGT, n = 7 (30%); and hemoglobin, n = 1 (4%). However, all new toxicities resolved within 3 months after therapy without additional treatment. Median local tumor control, PFS, and OS were 6, 4, and 8 months, respectively.

CONCLUSIONS

Combined irinotecan chemoembolization and CT-guided HDRBT is safe and shows a low incidence of toxicities, which were self-resolving.

Prognostic factors in patients treated with transarterial radioembolization for unresectable and chemorefractory colorectal cancer with liver metastases

Background: Transarterial radioembolization (TARE) is used to treat unresectable colorectal cancer with liver metastases (CRCLM). This study aimed to assess survival after TARE and to identify potential prognostic factors in this patient population. Methods: Patients with unresectable and chemorefractory CRCLM treated with TARE at our institution between February 2006 and September 2015 were included in the study. Survival rate, hepatic tumor response, and potential prognostic factors were analyzed. Results: In the 43 study patients, the mean follow-up was 15.0 ± 14.2 months, with a median survival of 13.0 months and 1-, 2-, 3-, 4-, and 5-year survival rates of 52.1%, 24.9%, 21.4%, 21.4%, and 7.1%, respectively. The mean activity of yttrium-90 administered was 1.55 ± 0.28 GBq for the disease-controlled group and 1.19 ± 0.27 GBq for the progressive disease group (p= 0.031). Survival was correlated with Child-Pugh class (p< 0.001), hepatic tumor response (p= 0.001), and baseline carcinoembryonic antigen (CEA) level (p= 0.013). Conclusion: Child-Pugh class B, low degree of hepatic tumor response, and normal baseline CEA levels are prognostic factors for poorer survival after TARE in patients with unresectable and chemorefractory CRCLM. Hepatic tumor response is related to radiation activity delivered to the liver.

Targeted Radionuclide Therapy: New Advances for Improvement of Patient Management and Response

Compared to external beam radiotherapy, targeted radionuclide therapy (TRT) allows for systemic radiation treatment of metastatic lesions. Published work on recent strategies to improve patient management and response to TRT through individualising patient treatment, modifying treatment pharmacokinetics and increasing anticancer potency are discussed in this review, with a special focus on the application of clinically evaluated radiolabelled ligands and peptides in the treatment of neuroendocrine and prostate cancers.

Factors Affecting Oncologic Outcomes of 90Y Radioembolization of Heavily Pre-Treated Patients With Colon Cancer Liver Metastases

INTRODUCTION

The purpose of this study was to identify predictors of overall (OS) and liver progression-free survival (LPFS) following Yttrium-90 radioembolization (RAE) of heavily pretreated patients with colorectal cancer liver metastases (CLM), as well as to create and validate a predictive nomogram for OS.

MATERIALS AND METHODS

Metabolic, anatomic, laboratory, pathologic, genetic, primary disease, and procedure-related factors, as well as pre- and post-RAE therapies in 103 patients with CLM treated with RAE from September 15, 2009 to March 21, 2017 were analyzed. LPFS was defined by Response Evaluation Criteria In Solid Tumors 1.1 and European Organization for Research and Treatment of Cancer criteria. Prognosticators of OS and LPFS were selected using univariate Cox regression, adjusted for clustering and competing risk analysis (for LPFS), and subsequently tested in multivariate analysis (MVA). The nomogram was built using R statistical software and internally validated using bootstrap resampling.

RESULTS

Patients received RAE at a median of 30.9 months (range, 3.4-161.7 months) after detection of CLM. The median OS and LPFS were 11.3 months (95% confidence interval, 7.9-15.1 months) and 4 months (95% confidence interval, 3.3-4.8 months), respectively. Of the 40 parameters tested, 6 were independently associated with OS in MVA. These baseline parameters included number of extrahepatic disease sites (P < .001), carcinoembryonic antigen (P < .001), albumin (P = .005), alanine aminotransferase level (P < .001), tumor differentiation level (P < .001), and the sum of the 2 largest tumor diameters (P < .001). The 1-year OS of patients with total points of < 25 versus > 80 was 90% and 10%, respectively. Bootstrap resampling showed good discrimination (optimism corrected c-index = 0.745) and calibration (mean absolute prediction error = 0.299) of the nomogram. Only baseline maximum standardized uptake value was significant in MVA for LPFS prediction (P < .001; SHR = 1.06).

CONCLUSION

The developed nomogram included 6 pre-RAE parameters and provided good prediction of survival post-RAE in heavily pretreated patients. Baseline maximum standardized uptake value was the single significant predictor of LPFS.