Radioembolization for primary and metastatic liver cancer

Treatments and cancer: implications for radiologists

This review highlights the critical role of radiologists in personalized cancer treatment, focusing on the evaluation of treatment outcomes using imaging tools like Computed Tomography (CT), Magnetic Resonance Imaging (MRI), and Ultrasound. Radiologists assess the effectiveness and complications of therapies such as chemotherapy, immunotherapy, and ablative treatments. Understanding treatment mechanisms and consistent imaging protocols are essential for accurate evaluation, especially in managing complex cases like liver cancer. Collaboration between radiologists and oncologists is key to optimizing patient outcomes through precise imaging assessments.

Advanced targeted microsphere embolization for arteriovenous malformations: state-of-the-art and future directions

BACKGROUND

Arteriovenous malformations (AVMs) present a significant therapeutic challenge, as current treatment modalities frequently fail to achieve complete and rapid obliteration and are associated with substantial morbidity in both the short and long term. This underscores the critical need for innovative therapeutic strategies that enable efficient AVM obliteration while minimizing patient risk. The current review aims to comprehensively assess the role of ATME in AVM management, examining its clinical efficacy, associated risks and benefits, and the economic and ethical implications to provide valuable foundation for future studies and guiding development in treatment strategies for AVMs.

RESULTS

Advanced targeted microsphere embolization (ATME) has emerged as a promising therapeutic option, initially developed for the localized treatment of AVMs and unresectable tumors, including liver cancer. By providing targeted delivery, ATME offers potential advantages over conventional approaches in achieving effective local control.

CONCLUSIONS

ATME are safe and effective for vascular disease and cancer. Although evidence for microspheres in AVMs is scarce, results are promising. Future research could refine eligibility criteria, evaluate treatment techniques, and optimize ATME.

Development of Alginate-Based Biodegradable Radioactive Microspheres Labeled with Positron Emitter through Click Chemistry Reaction: Stability and PET Imaging Study

Biodegradable radioactive microspheres labeled with positron emitters hold significant promise for diagnostic and therapeutic applications in cancers and other diseases, including arthritis. The alginate-based polymeric microspheres offer advantages such as biocompatibility, biodegradability, and improved stability, making them suitable for clinical applications. In this study, we developed novel positron emission tomography (PET) microspheres using alginate biopolymer radiolabeled with gallium-68 (68Ga) through a straightforward conjugation reaction. Polyethylenimine (PEI)-decorated calcium alginate microspheres (PEI-CAMSs) were fabricated and further modified using azadibenzocyclooctyne-N-hydroxysuccinimide ester (ADIBO-NHS). Subsequently, azide-functionalized NOTA chelator (N3-NOTA) was labeled with [68Ga]Ga to obtain [68Ga]Ga-NOTA-N3, which was then reacted with the surface-modified PEI-CAMSs using strain-promoted alkyne-azide cycloaddition (SPAAC) reaction to develop [68Ga]Ga-NOTA-PEI-CAMSs, a novel PET microsphere. The radiolabeling efficiency and radiochemical stability of [68Ga]Ga-NOTA-PEI-CAMSs were determined using the radio-instant thin-layer chromatography-silica gel (radio-ITLC-SG) method. The in vivo PET images were also acquired to study the in vivo stability of the radiolabeled microspheres in normal mice. The radiolabeling efficiency of [68Ga]Ga-NOTA-PEI-CAMSs was over 99%, and the microspheres exhibited high stability (92%) in human blood serum. PET images demonstrated the stability and biodistribution of the microspheres in mice for up to 2 h post injection. This study highlights the potential of biodegradable PET microspheres for preoperative imaging and targeted radionuclide therapy. Overall, the straightforward synthesis method and efficient radiolabeling technique provide a promising platform for the development of theranostic microspheres using other radionuclides such as 90Y, 177Lu, 188Re, and 64Cu.

Applications of Yttrium-90 (90Y) in Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the most common primary liver cancer, affecting millions of people worldwide. Due to the lack of systemic radiation therapy in hepatocellular carcinoma, researchers have been investigating the use of yttrium-90 (90Y) radioembolization for local-regional tumor control since the 1960s. With the development of glass and resin 90Y microspheres and the durable local control, good long-term efficacy, and equivalent tumor responsiveness and tolerability of 90Y-selective internal irradiation compared with alternative therapies such as transarterial chemoembolization (TACE) and sorafenib, 90Y radioembolization has gradually been applied in the treatment of hepatocellular carcinoma of all stages. In this article, we summarize the latest progress of 90Y in the treatment of hepatocellular carcinoma in terms of its principle, advantages, indications, contraindications, efficacy and adverse effects.

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.

Holmium-166 Transarterial Radioembolization for the Treatment of Intrahepatic Cholangiocarcinoma: A Case Series

BACKGROUND

Transarterial radioembolization (TARE) is used to treat primary and secondary malignancies in the liver that are not amenable to curative resection. Accumulating evidence demonstrates the efficacy and safety of TARE with yttrium-90 (90Y), which is the most widely used radionuclide for TARE, and later with holmium-166 (166Ho) for various indications. However, the safety and efficacy of 166Ho TARE in patients with intrahepatic cholangiocarcinoma (ICC) remains to be studied.

METHODS

This was a retrospective case series study of seven consecutive patients with ICC who were treated with 166-Ho-TARE in our center. We recorded the clinical parameters and outcomes of the TARE procedures, the tumor response according to mRECIST, subsequent treatments, and adverse events.

RESULTS

Three out of the seven patients had a partial or complete response. Two patients had stable disease after the first TARE procedure, and two of the patients (one with a complete response, and one with stable disease) were alive at the time of analysis. No serious adverse events related to the procedure were recorded.

CONCLUSIONS

This is the first case series reporting the safety and tumor response outcomes of 166Ho-TARE for ICC. The treatment demonstrated its versatility, allowing for reaching a high tumor dose, which is important for improving tumor response and treating patients in a palliative setting, where safety and the preservation of quality of life are paramount.

Combined radiotherapy and immune checkpoint inhibition for the treatment of advanced hepatocellular carcinoma

Hepatocellular Carcinoma (HCC) is one of the most common cancers and a leading cause of cancer related death worldwide. Until recently, systemic therapy for advanced HCC, defined as Barcelona Clinic Liver Cancer (BCLC) stage B or C, was limited and ineffective in terms of long-term survival. However, over the past decade, immune check point inhibitors (ICI) combinations have emerged as a potential therapeutic option for patients with nonresectable disease. ICI modulate the tumor microenvironment to prevent progression of the tumor. Radiotherapy is a crucial tool in treating unresectable HCC and may enhance the efficacy of ICI by manipulating the tumor microenvironment and decreasing tumor resistance to certain therapies. We herein review developments in the field of ICI combined with radiotherapy for the treatment of HCC, as well as look at challenges associated with these treatment modalities, and review future directions of combination therapy.

Minimally Invasive Treatment Options for Hepatic Uveal Melanoma Metastases

Uveal melanoma is one of the most common primary intraocular malignancies that accounts for about 85% of all ocular melanomas. The pathophysiology of uveal melanoma is distinct from cutaneous melanoma and has separate tumor profiles. The management of uveal melanoma is largely dependent on the presence of metastases, which confers a poor prognosis with a one-year survival reaching only 15%. Although a better understanding of tumor biology has led to the development of novel pharmacologic agents, there is increasing demand for minimally invasive management of hepatic uveal melanoma metastases. Multiple studies have already summarized the systemic therapeutic options available for metastatic uveal melanoma. This review covers the current research for the most prevalent locoregional treatment options for metastatic uveal melanoma including percutaneous hepatic perfusion, immunoembolization, chemoembolization, thermal ablation, and radioembolization.

Microspheres as a Carrier System for Therapeutic Embolization Procedures: Achievements and Advances

The targeted delivery of anti-cancer drugs and isotopes is one of the most pursued goals in anti-cancer therapy. One of the prime examples of such an application is the intra-arterial injection of microspheres containing cytostatic drugs or radioisotopes during hepatic embolization procedures. Therapy based on the application of microspheres revolves around vascular occlusion, complemented with local therapy in the form of trans-arterial chemoembolization (TACE) or radioembolization (TARE). The broadest implementation of these embolization strategies currently lies within the treatment of untreatable hepatocellular cancer (HCC) and metastatic colorectal cancer. This review aims to describe the state-of-the-art TACE and TARE technologies investigated in the clinical setting for HCC and addresses current trials and new developments. In addition, chemical properties and advancements in microsphere carrier systems are evaluated, and possible improvements in embolization therapy based on the modification of and functionalization with therapeutical loads are explored.

The Role of 18F-FLT PET/CT in Assessing Early Response to Transarterial Radioembolization and Chemoembolization in Patients with Primary and Metastatic Liver Tumors

Objectives

Metastases and primary malignancies are common in the liver. Local ablative applications such as transarterial chemoembolization (TACE), and transarterial radioembolization (TARE) provide minimally invasive and safe treatment in unresectable liver tumors. Early detection of response to treatment prevents unnecessary toxicity and cost in non-responder patients and provides an earlier use of other options that may be effective. This study aimed to identify the role of ¹⁸F-fluorothymidine (FLT) positron emission tomography/computed tomography (PET/CT) in the assessment of early response to TACE and TARE treatments in patients with unresectable primary and metastatic liver tumors.

Methods

This single-center study included 63 patients who underwent ¹⁸F-FLT PET/CT for response evaluation after TACE and TARE. After excluding 20 patients whose data were missing 43 TARE-receiving patients were analyzed. The compatibility of change in semi-quantitative values obtained from the ¹⁸F-FLT PET/CT images with the treatment responses detected in ¹⁸F-fluorodeoxyglucose PET/CT, CT, and MR images and survival was evaluated.

Results

There was no correlation between early metabolic, morphological response, and ¹⁸F-FLT uptake pattern, and change in standardized uptake values (SUV) which were ΔSUV_max, ΔSUV_mean, ΔSUV_peak., ΔSUV_mean, Δ SUV_peak values. There was no significant correlation between ¹⁸F-FLT uptake pattern, ΔSUV_max, ΔSUV_mean, ΔSUV_peak, and overall survival, progression-free survival (PFS) for the target lobe PFS for the whole-body. The survival distributions for the patients with >30% change in Δ SUV_max and ΔSUV_peak values were statistically significantly longer than the patients with <30% change (p<0.009 and p<0.024, respectively).

Conclusion

There was significant longer PFS for target liver lobe in patients with more than 30% decrease in ¹⁸F-FLT SUV_max and SUV_peak of the liver lesion in primary and metastatic unresectable liver tumors undergoing TARE.

Larraona G, Sangro B, Bilbao JI, Aramburu J. Computational study of a novel catheter for liver radioembolization

Radioembolization (RE) is a medical treatment for primary and secondary liver cancer that involves the transcatheter intraarterial delivery of micron-sized and radiation-emitting microspheres, with the goal of improving microsphere deposition in the tumoral bed while sparing healthy tissue. An increasing number of in vitro and in silico studies on RE in the literature suggest that the particle injection velocity, spatial location of the catheter tip and catheter type are important parameters in particle distribution. The present in silico study assesses the performance of a novel catheter design that promotes particle dispersion near the injection point, with the goal of generating a particle distribution that mimics the flow split to facilitate tumour targeting. The design is based on two factors: the direction and the velocity at which particles are released from the catheter. A series of simulations was performed with the catheter inserted at an idealised hepatic artery tree with physiologically realistic boundary conditions. Two longitudinal microcatheter positions in the first generation of the tree were studied by analysing the performance of the catheter in terms of the outlet-to-outlet particle distribution and split flow matching. The results show that the catheter with the best performance is one with side holes on the catheter wall and a closed frontal tip. This catheter promotes a flow-split-matching particle distribution, which improves as the injection crossflow increases.

Radiometal-Labeled Chitosan Microspheres as Transarterial Radioembolization Agents against Hepatocellular Carcinoma

Transarterial radioembolization (TARE) is an emerging treatment for patients with unresectable hepatocellular carcinoma (HCC). This study successfully developed radiometal-labeled chitosan microspheres (111In/177Lu-DTPA-CMS) with a diameter of 36.5 ± 5.3 μm for TARE. The radiochemical yields of 111In/177Lu-DTPA-CMS were greater than 90% with high radiochemical purities (>98%). Most of the 111In/177Lu-DTPA-CMS were retained in the hepatoma and liver at 1 h after intraarterial (i.a.) administration. Except for liver accumulation, radioactivity in each normal organ was less than 1% of the injected radioactivity (%IA) at 72 h after injection. At 10 days after injection of 177Lu-DTPA-CMS (18.6 ± 1.3 MBq), the size of the hepatoma was significantly reduced by around 81%, while that of the rats in the control group continued to grow. This study demonstrated the effectiveness of 177Lu-DTPA-CMS in the treatment of N1-S1 hepatoma. 111In/177Lu-DTPA-CMS have the potential to be a superior theranostic pair for the treatment of clinical hepatoma.

Theragnostics in primary and secondary liver tumors: the need for a personalized approach

Primary and secondary hepatic tumors have a dramatic impact in oncology. Despite many advances in diagnosis and therapy, the management of hepatic malignancies is still challenging, ranging from various loco-regional approaches to system therapies. In this scenario, theragnostic approaches, based on the administration of a radiopharmaceuticals' pair, the first labeled with a radionuclide suitable for the diagnostic phase and the second one bound to radionuclide emitting particles for therapy, is gaining more and more importance. Selective internal radiation therapy (SIRT) with microspheres labeled with ⁹⁰Y or ¹⁶⁶Ho is widely used as a loco-regional treatment for primary and secondary hepatic tumors. While ¹⁶⁶Ho presents both gamma and beta emission and can be therefore considered a real "theragnostic" agent, for ⁹⁰Y-microspheres theragnostic approach is realized at the diagnostic phase through the utilization of macroaggregates of human albumin, labeled with ^99mTc as "biosimilar" agent respect to microspheres. The aim of the present review was to cover theragnostic applications of ⁹⁰Y/¹⁶⁶Ho-labeled microspheres in clinical practice. Furthermore, we report the preliminary data concerning the potential role of some emerging theragnostic biomarkers for hepatocellular carcinoma, such as glypican-3 (GPC3) and prostate specific membrane antigen (PSMA).

Clinical Management of Liver Cancer in India and Other Developing Nations: A Focus on Radiation Based Strategies

Hepatocellular carcinoma (HCC) is a global killer with preponderance in Asian and African countries. It poses a challenge for successful management in less affluent or developing nations like India, with large populations and limited infrastructures. This review aims to assess the available options and future directions for management of HCC applicable to such countries. While summarizing current and emerging clinical strategies for detection, staging and therapy of the disease, it highlights radioisotope- and radioactivity-based strategies as part of an overall program. Using the widely accepted Barcelona Clinic Liver Cancer (BCLC) staging system as a base, it evaluates the applicability of different therapeutic approaches and their synergistic combination(s) in the context of a patient-specific dynamic results-based strategy. It distills the conclusions of multiple HCC management-focused consensus recommendations to provide a picture of clinical strategies, especially radiation-related approaches. Additionally, it discusses the logistical and economic feasibility of these approaches in the context of the limitations of the burdened public health infrastructure in India (and like nations) and highlights possible strategies both at the clinical level and in terms of an administrative health policy on HCC to provide the maximum possible benefit to the widest swathe of the affected population.

Post Yttrium-90 Imaging

Transarterial radioembolization with yttrium-90 ( ⁹⁰ Y) is a mainstay for the treatment of liver cancer. Imaging the distribution following delivery is a concept that dates back to the 1960s. As β particles are created during ⁹⁰ Y decay, bremsstrahlung radiation is created as the particles interact with tissues, allowing for imaging with a gamma camera. Inherent qualities of bremsstrahlung radiation make its imaging difficult. SPECT and SPECT/CT can be used but suffer from limitations related to low signal-to-noise bremsstrahlung radiation. However, with optimized imaging protocols, clinically adequate images can still be obtained. A finite but detectable number of positrons are also emitted during ⁹⁰ Y decay, and many studies have demonstrated the ability of commercial PET/CT and PET/MR scanners to image these positrons to understand ⁹⁰ Y distribution and help quantify dose. PET imaging has been proven to be superior to SPECT for quantitative imaging, and therefore will play an important role going forward as we try and better understand dose/response and dose/toxicity relationships to optimize personalized dosimetry. The availability of PET imaging will likely remain the biggest barrier to its use in routine post- ⁹⁰ Y imaging; thus, SPECT/CT imaging with optimized protocols should be sufficient for most posttherapy subjective imaging.

Contrast-enhanced ultrasound (CEUS) in HCC diagnosis and assessment of tumor response to locoregional therapies

Hepatocellular carcinoma (HCC) is a global problem constituting the second leading cause of cancer deaths worldwide, thereby necessitating an accurate and cost-effective solution for managing care. Ultrasound is well poised to address this need due to its low cost, portability, safety, and excellent temporal resolution. The role of ultrasound for HCC screening has been well established and supported by multiple international guidelines. Similarly, contrast-enhanced ultrasound (CEUS) can be used for the characterization of focal liver lesions in high-risk populations, and standardized criteria for CEUS have been established by the American College of Radiology Liver Imaging Reporting & Data System (LI-RADS). Following HCC identification, CEUS can also be highly beneficial in treatment planning, delivery, and monitoring HCC response to locoregional therapies. Specific advantages of CEUS include providing real-time treatment guidance and improved diagnostic performance for the detection of residual tumor viability or recurrence, thereby identifying patients in need of retreatment substantially earlier than contrast-enhanced CT and MRI. This review provides a primer on ultrasound and CEUS for the screening and characterization of HCC, with an emphasis on assessing tumor response to locoregional therapies.

Study of the G Protein Nucleolar 2 Value in Liver Hepatocellular Carcinoma Treatment and Prognosis

LIHC (liver hepatocellular carcinoma) mostly occurs in patients with chronic liver disease. It is primarily induced by a vicious cycle of liver injury, inflammation, and regeneration that usually last for decades. The G protein nucleolar 2 (GNL2), as a protein-encoding gene, is also known as NGP1, Nog2, Nug2, Ngp-1, and HUMAUANTIG. Few reports are shown towards the specific biological function of GNL2. Meanwhile, it is still unclear whether it is related to the pathogenesis of carcinoma up to date. Here, our study attempts to validate the role and function of GNL2 in LIHC via multiple databases and functional assays. After analysis of gene expression profile from The Cancer Genome Atlas (TCGA) database, GNL2 was largely heightened in LIHC, and its overexpression displayed a close relationship with different stages and poor prognosis of carcinoma. After enrichment analysis, the data revealed that the genes coexpressed with GNL2 probably participated in ribosome biosynthesis which was essential for unrestricted growth of carcinoma. Cell functional assays presented that GNL2 knockdown by siRNA in LIHC cells MHCC97-H and SMCC-7721 greatly reduced cell proliferation, migration, and invasion ability. All in all, these findings capitulated that GNL2 could be a promising treatment target and prognosis biomarker for LIHC.

Generation of annotated multimodal ground truth datasets for abdominal medical image registration

PURPOSE

Sparsity of annotated data is a major limitation in medical image processing tasks such as registration. Registered multimodal image data are essential for the diagnosis of medical conditions and the success of interventional medical procedures. To overcome the shortage of data, we present a method that allows the generation of annotated multimodal 4D datasets.

METHODS

We use a CycleGAN network architecture to generate multimodal synthetic data from the 4D extended cardiac-torso (XCAT) phantom and real patient data. Organ masks are provided by the XCAT phantom; therefore, the generated dataset can serve as ground truth for image segmentation and registration. Realistic simulation of respiration and heartbeat is possible within the XCAT framework. To underline the usability as a registration ground truth, a proof of principle registration is performed.

RESULTS

Compared to real patient data, the synthetic data showed good agreement regarding the image voxel intensity distribution and the noise characteristics. The generated T1-weighted magnetic resonance imaging, computed tomography (CT), and cone beam CT images are inherently co-registered. Thus, the synthetic dataset allowed us to optimize registration parameters of a multimodal non-rigid registration, utilizing liver organ masks for evaluation.

CONCLUSION

Our proposed framework provides not only annotated but also multimodal synthetic data which can serve as a ground truth for various tasks in medical imaging processing. We demonstrated the applicability of synthetic data for the development of multimodal medical image registration algorithms.

Timeline of Translational Formulation Technologies for Cancer Therapy: Successes, Failures, and Lessons Learned Therefrom

Over the past few decades, the field of cancer therapy has seen a significant change in the way in which formulations are designed and developed, resulting in more efficient products that allow us to ultimately achieve improved drug bioavailability, efficacy, and safety. However, although many formulations have entered the market, many others have fallen by the wayside leaving the scientific community with several lessons to learn. The successes (and failures) achieved with formulations that have been approved in Europe and/or by the FDA for the three major types of cancer therapy (peptide-based therapy, chemotherapy, and radiotherapy) are reviewed herein, covering the period from the approval of the first prolonged-release system for hormonal therapy to the appearance of the first biodegradable microspheres intended for chemoembolization in 2020. In addition, those products that have entered phase III clinical trials that have been active over the last five years are summarized in order to outline future research trends and possibilities that lie ahead to develop clinically translatable formulations for cancer treatment.

Short-term Safety and Quality of Life Outcomes Following Radioembolization in Primary and Secondary Liver Tumours: a Multi-centre Analysis of 200 Patients in France

PURPOSE

Radioembolization has emerged as a treatment modality for patients with primary and secondary liver tumours. This observational study CIRT-FR (CIRSE Registry for SIR-Spheres Therapy in France) aims to evaluate real-life clinical practice on all patients treated with transarterial radioembolization (TARE) using SIR-Spheres yttrium-90 resin microspheres in France. In this interim analysis, safety and quality of life data are presented. Final results of the study, including secondary effectiveness outcomes, will be published later. Overall, CIRT-FR is aiming to support French authorities in the decision making on reimbursement considerations for this treatment.

METHODS

Data on patients enrolled in CIRT-FR from August 2017 to October 2019 were analysed. The interim analysis describes clinical practice, baseline characteristics, safety (adverse events according to CTCTAE 4.03) and quality of life (according to EORTC QLQ C30 and HCC module) aspects after TARE.

RESULTS

This cohort included 200 patients with hepatocellular carcinoma (114), metastatic colorectal cancer (mCRC; 38) and intrahepatic cholangiocarcinoma (33) amongst others (15). TARE was predominantly assigned as a palliative treatment (79%). 12% of patients experienced at least one adverse event in the 30 days following treatment; 30-day mortality was 1%. Overall, global health score remained stable between baseline (66.7%), treatment (62.5%) and the first follow-up (66.7%).

CONCLUSION

This interim analysis demonstrates that data regarding safety and quality of life generated by randomised-controlled trials is reflected when assessing the real-world application of TARE.

TRIAL REGISTRATION

Clinical Trials.gov NCT03256994.

"Primum Non Nocere" in Interventional Oncology for Liver Cancer: How to Reduce the Risk for Complications?

Interventional oncology represents a relatively new clinical discipline based upon minimally invasive therapies applicable to almost every human organ and disease. Over the last several decades, rapidly evolving research developments have introduced a newer generation of treatment devices, reagents, and image-guidance systems to expand the armamentarium of interventional oncology across a wide spectrum of disease sites, offering potential cure, control, or palliative care for many types of cancer patients. Due to the widespread use of locoregional procedures, a comprehensive review of the methodologic and technical considerations to optimize patient selection with the aim of performing a safe procedure is mandatory. This article summarizes the expert discussion and report from the Mediterranean Interventional Oncology Live Congress (MIOLive 2020) held in Rome, Italy, integrating evidence-reported literature and experience-based perceptions as a means for providing guidance on prudent ways to reduce complications. The aim of the paper is to provide an updated guiding tool not only to residents and fellows but also to colleagues approaching locoregional treatments.

DNA Damage-Inducing Anticancer Therapies: From Global to Precision Damage

DNA damage-inducing therapies are of tremendous value for cancer treatment and function by the direct or indirect formation of DNA lesions and subsequent inhibition of cellular proliferation. Of central importance in the cellular response to therapy-induced DNA damage is the DNA damage response (DDR), a protein network guiding both DNA damage repair and the induction of cancer-eradicating mechanisms such as apoptosis. A detailed understanding of DNA damage induction and the DDR has greatly improved our knowledge of the classical DNA damage-inducing therapies, radiotherapy and cytotoxic chemotherapy, and has paved the way for rational improvement of these treatments. Moreover, compounds targeting specific DDR proteins, selectively impairing DNA damage repair in cancer cells, form a promising novel therapy class that is now entering the clinic. In this review, we give an overview of the current state and ongoing developments, and discuss potential avenues for improvement for DNA damage-inducing therapies, with a central focus on the role of the DDR in therapy response, toxicity and resistance. Furthermore, we describe the relevance of using combination regimens containing DNA damage-inducing therapies and how they can be utilized to potentiate other anticancer strategies such as immunotherapy.

Transarterial Radioembolization for Hepatocellular Carcinoma and Hepatic Metastases: Clinical Aspects and Dosimetry Models

Transarterial radioembolization (TARE) with Yttrium-90 (⁹⁰Y) microspheres is a liver-directed therapy for primary and metastatic disease. This manuscript provides a review of the clinical literature on TARE indications and efficacy with overviews of patient-selection and toxicity. Current dosimetry models used in practice are safe, relatively simple, and easy for clinicians to use. Planning currently relies on the imperfect surrogate, ^99mTc macroaggregated albumin. Post-therapy quantitative imaging (⁹⁰Y SPECT/CT or ⁹⁰Y PET/CT) of microspheres can be used to calculate the macroscopic in vivo absorbed dose distribution. Similar to the evolution of other brachytherapy dose calculations, TARE is moving toward more patient-specific dosimetry that includes calculating and reporting nonuniform dose distributions throughout tumors and normal uninvolved liver.

Selective Internal Radiation Therapy for Liver Metastasis of Papillary Thyroid Carcinoma

Papillary carcinoma of thyroid (PTC) is the most common neoplasm of the thyroid gland that usually invades lymphatics rather than blood vessels. Hematogenous metastasis of PTC is rare, and distant metastasis to the liver is even rarer. Selective internal radiation therapy with Y microspheres is a well-recognized technique in the treatment of liver metastases. Herein, we present a case of PTC with radioactive iodine-negative hepatic metastasis detected by F-FDG PET/CT and treated with selective internal radiation therapy.

Transcatheter arterial chemoembolization combined with radiofrequency or microwave ablation for hepatocellular carcinoma: a review

Hepatocellular carcinoma (HCC) is the sixth most common type of malignancy. Several therapies are available for HCC and are determined by stage of presentation, patient clinical status and liver function. Local–regional treatment options, including transcatheter arterial chemoembolization, radiofrequency ablation or microwave ablation, are safe and effective for HCC but are accompanied by limitations. The synergistic effects of combined transcatheter arterial chemoembolization and radiofrequency ablation/microwave ablation may overcome these limitations and improve the therapeutic outcome. The purpose of this article is to review the current literature on these combined therapies and examine their efficacy, safety and influence on the overall and recurrence-free survival in patients with HCC.

Preparation and evaluation of 188 Re sulfide colloidal nanoparticles loaded biodegradable poly (L-lactic acid) microspheres for radioembolization therapy

Radioembolization with radioactive microspheres has been an effective method for the treatment of liver lesions. The aim of this study was to prepare carrier-free ¹⁸⁸ Re loaded poly (L-lactic acid) (PLLA) microspheres through ¹⁸⁸ Re sulfide colloidal nanoparticles (¹⁸⁸ Re-SC nanoparticles). The formation of ¹⁸⁸ Re-SC nanoparticles was confirmed by ultraviolet-visible spectrophotometry. The labeling yield of ¹⁸⁸ Re-SC nanoparticles was verified using the RTLC method. Effects of synthesis parameters on morphology and size of prepared ¹⁸⁸ Re-sulfide colloidal-PLLA microspheres (¹⁸⁸ Re-SC-PLLA microspheres) were studied by scanning electron microscopy. In vitro stability of ¹⁸⁸ Re-SC-PLLA microspheres was investigated in normal saline at room temperature and in human serum at 37°C. In vivo distribution studies and gamma camera imaging were performed in healthy BALB/c mice. The microspheres could be prepared with sizes between 13 and 48 μm (modal value 29 μm) and radiolabeling efficiency >99%. After incubation, the microspheres were found stable in vitro up to 72 hours. The biodistribution after intravenous injection in healthy BALB/c mice showed high accumulation in lung as a first capture pathway organ for microsphere followed by great retention over 48 hours for these microspheres. These data show that ¹⁸⁸ Re-SC-PLLA microspheres are suitable candidate for clinical studies.

Uncomplicated 90Y Selective Internal Radio Therapy in a Patient With Hepatocellular Carcinoma After Arterial and Portal Vein Embolizations

Selective internal radio therapy (SIRT) with Y-glass microspheres was performed in a cirrhotic patient with hepatocellular carcinoma (Barcelona Clinic Liver Cancer stage C) after arterial coil embolization for treatment of intratumoral hemorrhage and planned preoperative right portal vein embolization. Three technetium Tc macro-albumin-aggregate injections were needed to optimize intralesional uptake without extrahepatic deposition. The consecutive SIRT treatment was uncomplicated with a remarkable result.

90Y radioembolization dosimetry using a simple semi-quantitative method in intrahepatic cholangiocarcinoma: Glass versus resin microspheres

INTRODUCTION

There are two different types of ⁹⁰Y Microspheres, glass and resin, in the market for ⁹⁰Y radioembolization (⁹⁰Y-RE). This study aimed to investigate the dose of radiation delivered through glass vs. resin-based ⁹⁰Y-RE to intrahepatic cholangiocarcinoma (ICC).

METHODS

In this retrospective study, 10 patients with ICC underwent ⁹⁰Y-RE, five underwent glass (Glass group) and other 5 resin (Resin group) microspheres. Technetium-99m macro-aggregated albumin (Tc-99m MAA) shunt study was performed two weeks before ⁹⁰Y-RE. Within 2 h from ⁹⁰Y-RE, Bremsstrahlung SPECT/CT was obtained. Regions of interest (ROIs) were segmented around the targeted tumor and the liver. Tumor and liver volumes, corresponding radioactive counts, and tumor to liver count ratio were calculated using MIM software and compared between Glass and Resin groups.

RESULTS

Mean hepatopulmonary shunt fraction was 7.1 vs. 6.2% for the Glass and Resin groups (p = 0.83), with no extrahepatic activity. There was no difference in the activity and tumor uptake of administered Tc-99m MAA between both groups (p = 0.71 and p = 0.63). Mean administered activity of ⁹⁰Y in the Glass group was higher than the Resin group (73.2 ± 24.3 vs. 44.5 ± 18.2 mCi, p < 0.001). The tumor ⁹⁰Y uptake was significantly higher in the Glass group compared to the Resin group (41.3% vs. 33.5%, p < 0.001), corresponding to the mean tumor dose of 205.7 ± 19.7 vs. 128.9 ± 10.6 Gy, respectively (p < 0.001). The tumor to normal liver parenchyma ⁹⁰Y dose ratio was significantly higher in the Glass group compared to the Resin group, 4.9 ± 0.7 versus 2.4 ± 0.3 respectably (p < 0.001).

CONCLUSIONS

Both ⁹⁰Y glass and resin-based microsphere ⁹⁰Y-RE are feasible and safe in patients with ICC, while ⁹⁰Y glass microsphere delivers higher dose of ⁹⁰Y to the targeted tumors.

ADVANCES IN KNOWLEDGE

While both ⁹⁰Y glass and resin-based microsphere yttrium-90 radioembolization are feasible and safe treatment options for in patients with intrahepatic cholangiocarcinoma, ⁹⁰Y glass microsphere delivers higher dose of ⁹⁰Y to the targeted tumors.

IMPLICATIONS FOR PATIENT CARE

Both of ⁹⁰Y glass and resin-based microsphere can be safely and feasibly used for treatment of intrahepatic cholangiocarcinoma, difference in dose of ⁹⁰Y delivered to the targeted tumors should be clinically considered while choosing the microsphere type.

Yttrium-90 microsphere radioembolization in unresectable intrahepatic cholangiocarcinoma

Intrahepatic cholangiocarcinoma is increasing in frequency worldwide, but radical surgical treatment is practicable in 30–40% of cases. The median survival without therapy is about 8 months, increased to 12 months in combination with systemic chemotherapy. Therefore, locoregional therapies, such as, radiofrequency ablation or transarterial chemoembolization have been employed. Radioembolization with yttrium-90 microspheres (90Y-TARE) is a novel intrarterial treatment which could be included in the armamentarium of treatment options, having shown higher median survival (up to 22 months) and low complication rates. Evidence-based algorithms for staging and allocation to treatment should be defined in the future, after robust results obtained through randomized controlled trials, thus establishing the exact role and timing of 90Y-TARE in the treatment protocol of unresectable intrahepatic cholangiocarcinoma.

A Review and Update of Treatment Options and Controversies in the Management of Hepatocellular Carcinoma

OBJECTIVE

To review the current management, outline recent advances and address controversies in the management of hepatocellular carcinoma (HCC).

SUMMARY OF BACKGROUND DATA

The treatment of HCC is multidisciplinary involving hepatologists, surgeons, medical oncologists, radiation oncologists, radiologists, interventional radiologists, and other disciplines. Each of these disciplines brings its unique perspective and differing opinions that add to controversies in the management of HCC.

METHODS

A focused literature review was performed to identify recent studies on the management of HCC and thereby summarize relevant information on the various therapeutic modalities and controversies involved in the treatment of HCC.

RESULTS

The main treatment algorithms continue to rely on hepatic resection or transplantation with controversies involving patients harboring early stage disease and borderline hepatic function. The other treatment strategies include locoregional therapies, radiation, and systemic therapy used alone or in combination with other treatment modalities. Recent advances in locoregional therapies, radiation, and systemic therapies have provided better therapeutic options with curative intent potential for some locoregional therapies. Further refinements in combination therapies such as algorithms consisting of locoregional therapies and systemic or radiation therapies are likely to add additional options and improve survival.

CONCLUSIONS

The management of HCC has witnessed significant strides with advances in existing options and introduction of several new treatment modalities of various combinations. Further refinements in these treatment options combined with enrollment in clinical trials are essential to improve the management and outcomes of patients with HCC.

Differences in Radiation Activity Between Glass and Resin 90Y Microspheres in Treating Unresectable Hepatic Cancer

The purpose of this study was to compare the difference in prescribed radiation activity between glass and resin yttrium-90 (Y) microspheres for radioembolization of unresectable hepatocellular carcinoma (HCC) or liver metastases at a tertiary care teaching institution. The authors performed a retrospective analysis on 126 patients with primary HCC and hepatic metastatic disease from extrahepatic primary cancers who underwent radioembolization with glass or resin particles between 2008 and 2013 at their institution. Radiation activity estimates for prescribed treatments, as well as for the alternate embolization particles, were calculated using commonly employed formulae for both glass and resin particles for all treatments. A total of 217 treatments were performed on 126 patients, with 136 (62.7%) using glass particles and 81 (37.3%) using resin particles. Forty-six (36.5%) patients had metastatic colorectal cancer (CRC), 51 (40.5%) had primary HCC, while 11 (8.7%) had neuroendocrine carcinoma, and 18 (14.3%) had metastases from other primary tumors. The average prescribed activity was 2.66 GBq for glass treatments and 1.06 GBq for resin treatments across all cancer types. When the alternative treatment activity was calculated, activities were projected to decrease by an average of 1.52 GBq per treatment if resin microspheres were used instead of glass microspheres (-52.5%), while activities were projected to increase by an average of 1.57 GBq per treatment if glass microspheres were used instead of resin microspheres (148.9%; p < 0.001). Similar results were seen within each malignancy type and all projected changes were statistically significant (p < 0.001). In conclusion, prescribed radiation activity for radioembolization of unresectable hepatic cancer was significantly lower for resin compared to glass microspheres.

Intraarterial Liver-Directed Therapies: The Role of Interventional Oncology

BACKGROUND

Since the early 1990s, the minimally invasive image-guided therapies used in interventional oncology to treat hepatocellular carcinoma have continued to evolve. Additionally, the range of applications has been expanded to the treatment of hepatic metastases from colorectal cancer, neuroendocrine tumors, cholangiocarcinoma, breast cancer, melanoma, and sarcoma.

METHODS

We searched the literature to identify publications from 1990 to the present on various image-guided intraarterial therapies and their efficacy, as well as their role in the management of primary and secondary liver malignancies.

RESULTS

Chemoembolization and radioembolization are considered a standard of care in treating, delaying progression of disease, and downstaging to bridge to liver transplantation. Progression-free survival and overall survival outcomes are promising in patients with colorectal cancer and neuroendocrine tumors with liver metastases. Applications in the treatment of hepatic metastases from cholangiocarcinoma, breast cancer, melanoma, and sarcoma also show potential.

CONCLUSION

Interventional oncology and its image-guided intraarterial therapies continue to gain recognition as treatment options for primary and secondary liver cancers. Growing evidence supports their role as a standard of care alongside medical oncology, surgery, and radiation oncology.

[Selective internal radioembolization in nonresectable hepatocellular carcinoma]

INTRODUCTION

The role of selective internal radioembolization (SIRT) in the treatment of hepatocellular carcinoma (HCC) is currently unclear.

MATERIALS AND METHODS

We investigated 52 patients with nonresectable HCC in cirrhosis who underwent SIRT at the Department of General, Visceral and Vascular Surgery in co-operation with the Department of Nuclear Medicine and the Institute of Diagnostic and Interventional Radiology between April 2011 and October 2015.

RESULTS

In five patients, SIRT was employed for bridging to liver transplantation. In patients who had undergone pre-treatment with SIRT, histological examination of the explanted livers showed extensive tumor necrosis in the targeted areas with only minor remnant vital tissue at the margins. Four of the patients who underwent SIRT as local bridging treatment are tumor-free after transplantation. In the 47 palliatively treated patients, a total of 76 radioembolizations were performed. The observed 1‑ and 2‑year survival rates in these patients were 58 and 29 %, respectively, after the first SIRT. In the multivariate analysis of the observed survival, AFP before the first SIRT >30ng/ml, time interval of <12 months between the initial diagnosis and the first SIRT, largest tumor diameter >5 cm and portal vein thrombosis were independent negative prognostic factors. In the multi-variate analysis, the time to progression was independently influenced only by the AFP level before the first SIRT. In addition to standard treatment with transarterial chemoembolization (TACE), SIRT is feasible in nonresectable HCC, in particular with portal vein thrombosis, with identical results, less interventions and few side effects.

Radioembolization as a Salvage Therapy for Heavily Pretreated Patients With Colorectal Cancer Liver Metastases: Factors That Affect Outcomes

BACKGROUND

In this study we assessed the efficacy and factors that affect outcomes of radioembolization (RE) using yttrium-90 resin microspheres in patients with unresectable and chemorefractory colorectal cancer liver metastases (CLM).

PATIENTS AND METHODS

After an institutional review board waiver of approval, a review of a Health Insurance Portability and Accountability Act-registered, prospectively created and maintained database was performed. Data on patient demographic and disease characteristics, RE treatment parameters, and additional treatments were evaluated for significance in predicting overall survival (OS) and liver progression-free survival (LPFS). Complications were evaluated according to the National Cancer Institute Common Terminology Criteria for adverse events.

RESULTS

From September 2009 to September 2013, 53 patients underwent RE at a median of 35 months after CLM diagnosis. Median OS was 12.7 months. Multivariate analysis showed that carcinoembryonic antigen levels at the time of RE ≥ 90 ng/mL (P = .004) and microscopic lymphovascular invasion of the primary (P = .002) were independent predictors of decreased OS. Median LPFS was 4.7 months. At 4 to 8 and 12 to 16 weeks after RE, most patients (80% and 61%, respectively) according to Response Evaluation Criteria in Solid Tumors (RECIST) had stable disease; additional evaluation using PET Response Criteria in Solid Tumors (PERCIST) led to reclassification in 77% of these cases (response or progression). No deaths were noted within the first 30 days. Within the first 90 days after RE, 4 patients (8%) developed liver failure and 5 patients (9%) died, all with evidence of disease progression.

CONCLUSION

RE in the salvage setting was well-tolerated, and permitted the administration of additional therapies and led to a median OS of 12.7 months. Evaluation using PERCIST was more likely than RECIST to document response or progression compared with the baseline assessment before RE.

Radioembolization with Yttrium-90 microspheres in hepatocellular carcinoma: Role and perspectives

Transarterial radioembolization (TARE) is a form of brachytherapy in which intra-arterially injected yttrium-90-loaded microspheres serve as a source for internal radiation purposes. On the average, it produces disease control rates exceeding 80% and it is a consolidated therapy for hepatocellular carcinoma (HCC); however, current data are all based on retrospective series or non-controlled prospective studies since randomized controlled trials comparing it with the other liver-directed therapies for intermediate and locally advanced stage HCC are still underway. The data available show that TARE provides similar or even better survival rates when compared to transarterial chemoembolization (TACE). First-line TARE is best indicated for both intermediate-stage patients (staged according to the barcelona clinic liver cancer staging classification) who have lesions which respond poorly to TACE due to multiple tumors or a large tumor burden, and for locally advanced-stage patients with solitary tumors, and segmental or lobar portal vein tumor thrombosis. In addition, emerging data have suggested the use of TARE in patients who are classified slightly beyond the Milan criteria regarding radical treatment for downstaging purposes. As a second-line treatment, TARE can also be applied in patients progressing to TACE or sorafenib; a large number of phase II/III trials are ongoing with the purpose of evaluating the best association with systemic therapies. Transarterial radioembolization is very well tolerated and has a low rate of complications which are mainly related to unintended non-target tissue irradiation, including the surrounding liver parenchyma. The complications can be additionally reduced by accurate patient selection and a strict pre-treatment evaluation including dosimetry and assessment of the vascular anatomy. Since a correct treatment algorithm for potential TARE candidates is not clear and standardized, this comprehensive review analyzes the best selection criteria for patients who really benefit from TARE and also the new advances of this therapy, which can be a very important weapon against HCC.

Radioembolization with Yttrium-90 microspheres in hepatocellular carcinoma: Role and perspectives

Transarterial radioembolization (TARE) is a form of brachytherapy in which intra-arterially injected yttrium-90-loaded microspheres serve as a source for internal radiation purposes. On the average, it produces disease control rates exceeding 80% and it is a consolidated therapy for hepatocellular carcinoma (HCC); however, current data are all based on retrospective series or non-controlled prospective studies since randomized controlled trials comparing it with the other liver-directed therapies for intermediate and locally advanced stage HCC are still underway. The data available show that TARE provides similar or even better survival rates when compared to transarterial chemoembolization (TACE). First-line TARE is best indicated for both intermediate-stage patients (staged according to the barcelona clinic liver cancer staging classification) who have lesions which respond poorly to TACE due to multiple tumors or a large tumor burden, and for locally advanced-stage patients with solitary tumors, and segmental or lobar portal vein tumor thrombosis. In addition, emerging data have suggested the use of TARE in patients who are classified slightly beyond the Milan criteria regarding radical treatment for downstaging purposes. As a second-line treatment, TARE can also be applied in patients progressing to TACE or sorafenib; a large number of phase II/III trials are ongoing with the purpose of evaluating the best association with systemic therapies. Transarterial radioembolization is very well tolerated and has a low rate of complications which are mainly related to unintended non-target tissue irradiation, including the surrounding liver parenchyma. The complications can be additionally reduced by accurate patient selection and a strict pre-treatment evaluation including dosimetry and assessment of the vascular anatomy. Since a correct treatment algorithm for potential TARE candidates is not clear and standardized, this comprehensive review analyzes the best selection criteria for patients who really benefit from TARE and also the new advances of this therapy, which can be a very important weapon against HCC.

Radioembolization with Yttrium-90 microspheres in hepatocellular carcinoma: Role and perspectives

Transarterial radioembolization (TARE) is a form of brachytherapy in which intra-arterially injected yttrium-90-loaded microspheres serve as a source for internal radiation purposes. On the average, it produces disease control rates exceeding 80% and it is a consolidated therapy for hepatocellular carcinoma (HCC); however, current data are all based on retrospective series or non-controlled prospective studies since randomized controlled trials comparing it with the other liver-directed therapies for intermediate and locally advanced stage HCC are still underway. The data available show that TARE provides similar or even better survival rates when compared to transarterial chemoembolization (TACE). First-line TARE is best indicated for both intermediate-stage patients (staged according to the barcelona clinic liver cancer staging classification) who have lesions which respond poorly to TACE due to multiple tumors or a large tumor burden, and for locally advanced-stage patients with solitary tumors, and segmental or lobar portal vein tumor thrombosis. In addition, emerging data have suggested the use of TARE in patients who are classified slightly beyond the Milan criteria regarding radical treatment for downstaging purposes. As a second-line treatment, TARE can also be applied in patients progressing to TACE or sorafenib; a large number of phase II/III trials are ongoing with the purpose of evaluating the best association with systemic therapies. Transarterial radioembolization is very well tolerated and has a low rate of complications which are mainly related to unintended non-target tissue irradiation, including the surrounding liver parenchyma. The complications can be additionally reduced by accurate patient selection and a strict pre-treatment evaluation including dosimetry and assessment of the vascular anatomy. Since a correct treatment algorithm for potential TARE candidates is not clear and standardized, this comprehensive review analyzes the best selection criteria for patients who really benefit from TARE and also the new advances of this therapy, which can be a very important weapon against HCC.

Hepatocellular carcinoma and multidrug resistance: Past, present and new challenges for therapy improvement

Hepatocellular carcinoma (HCC) is the most frequent form of liver cancer and the third most common cause of cancer-related death in the world. The main risk factor worldwide for this type of malignancy is chronic hepatitis caused by hepatitis B virus and hepatitis C virus infections. Advances in early detection and treatment have improved life expectancy of patients with HCC. However, this disorder remains as a disease with poor prognosis. In fact, epidemiological studies have revealed that there is an 8-mo median survival rate in patients, approximately 20% of whom survive one year while only 5% remain alive after three years. Additionally, HCC is particularly difficult to treat because of its high recurrence rate, and its resistance to conventional chemotherapy is due, among other mechanisms, to several members of the ATP-Binding Cassette protein family involved in drug transport being overexpressed. Fortunately, there is evidence that these patients may benefit from alternative molecular-targeted therapies. This manuscript intends to provide further insight into the etiology and molecular mechanisms related to HCC development and the latest therapeutic approaches to treat this malignancy. The development of effective delivery systems of antitumor drugs able to target the liver parenchyma is also assessed. Finally, the prospects in the development of more efficient drug therapies to overcome multidrug resistance are also examined.

Evaluation of Liver Stiffness After Radioembolization by Real-Time ShearWave™ Elastography: Preliminary Study

PURPOSE

To evaluate the effect of ShearWave(™) elastography (SWE) for the assessment of liver fibrosis after radioembolization (RE) in patients with liver malignancies.

MATERIALS AND METHODS

We prospectively examined the effects of SWE before and after RE in 17 adult patients, from June 2012 to September 2013. All patients underwent SWE within 1 month before and 3 months (96.3 ± 22.9 days) after RE. Measurements were taken in segments III, IV, V, and VI (lateral/medial left lobe and anterior/posterior right lobe, respectively). Liver stiffness was studied in the 39 treated segments.

RESULTS

The mean stiffness of liver tissue according to the pre-RE SWE measurements was not different from the post-RE SWE measurements in the segments that did not undergo RE. Conversely, segments treated with RE were significantly stiffer according to the post-RE SWE measurements (mean SWE 17.4 kPa) than according to the baseline measurements (7.0 kPa) (p < 0.001). Patients with hepatocellular carcinoma and preexisting infection with hepatitis B and C viruses had higher pre-embolization stiffness, and the post-embolization stiffness of the treated segments in these patients was higher than that in the remainder of the study population.

CONCLUSION

These data suggest that SWE measurements of liver stiffness increase as early as the third month after RE. SWE could be used as a noninvasive complementary imaging method for preliminary assessment of liver fibrosis before and after RE.

SIR-Spheres yttrium-90 radioembolization for the treatment of unresectable liver cancers

Transarterial radioembolization with yttrium-90 resin microspheres (SIR-Spheres; Sirtex Medical Limited, Sydney, Australia) is a liver-directed therapy that is gaining recognition as a treatment option for liver-dominant primary and metastatic cancers. The incidence of complications is low and can be further reduced by patient selection and rigorous pretreatment assessment. Ideal candidates for radioembolization have preserved liver function without ascites or encephalopathy, Child-Pugh score <7 and limited lung shunting. Phase III randomized controlled trials (RCTs) against other liver-directed therapies are lacking for intermediate-stage hepatocellular carcinoma. However, preliminary data from a recent RCT has suggested that radioembolization has a similar time-to-progression and comparable toxicity to selective chemoembolization. Phase II/III RCTs are now ongoing to evaluate the combination of radioembolization with systemic therapies in advanced-stage hepatocellular carcinoma and metastatic liver-dominant colorectal cancer in order to expand the treatment opportunities for patients with cancers in the liver.

Impaired hepatic Gd-EOB-DTPA enhancement after radioembolisation of liver malignancies

INTRODUCTION

To evaluate the uptake of the liver-specific magnetic resonance imaging (MRI) contrast agent gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA) by functional liver parenchyma after radioembolisation (RE) of hepatic malignancies.

METHODS

Uptake of Gd-EOB-DTPA prior to RE versus 60+/-24d and 126+/-32d after RE was compared in a group of 33 patients with primary or secondary hepatic malignancies. In patients who underwent single-lobe treatment, left and right lobes were compared 59+/-24 days after RE. Gd-EOB-DTPA uptake was determined as follows: ratio of mean signal intensity in liver parenchyma to muscle in Gd-EOB-DTPA-enhanced T1-weighted MRI was subtracted from ratio of mean intensity in liver parenchyma to muscle in unenhanced T1-weighted MRI.

RESULTS

Gd-EOB-DTPA uptake in liver parenchyma was 0.845+/-0.29 before RE, 0.615+/-0.38 (P = 0.0022) at day 60+/-24, and 0.739+/-0.30 at day 126+/-32 after RE. In cases of single-lobe treatment, Gd-EOB-DTPA uptake was 0.581+/-0.256 for treated and 0.828+/-0.32 (P = 0.0164) for untreated hepatic lobes.

CONCLUSIONS

Uptake of Gd-EOB-DTPA by liver parenchyma is impaired after RE, indicating dysfunction of the local hepatic system. These findings suggest that Gd-EOB-DTPA-enhanced MRI has the potential to be used for monitoring liver damage after RE.