1
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DePietro DM, Li X, Shamimi-Noori SM. Chemoembolization Beyond Hepatocellular Carcinoma: What Tumors Can We Treat and When? Semin Intervent Radiol 2024; 41:27-47. [PMID: 38495263 PMCID: PMC10940046 DOI: 10.1055/s-0043-1777716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Liver metastases are the most common malignancy found in the liver and are 20 to 40 times more common than primary hepatic tumors, including hepatocellular carcinoma. Patients with liver metastases often present with advanced disease and are not eligible for curative-intent surgery or ablative techniques. The unique hepatic arterial blood supply of liver metastases allows interventional radiologists to target these tumors with transarterial therapies. Transarterial chemoembolization (TACE) has been studied in the treatment of liver metastases originating from a variety of primary malignancies and has demonstrated benefits in terms of hepatic progression-free survival, overall survival, and symptomatic relief, among other benefits. Depending on the primary tumor from which they originate, liver metastases may have different indications for TACE, may utilize different TACE regimens and techniques, and may result in different post-procedural outcomes. This review offers an overview of TACE techniques and specific considerations in the treatment of liver metastases, provides an in-depth review of TACE in the treatment of liver metastases originating from colorectal cancer, neuroendocrine tumor, and uveal melanoma, which represent some of the many tumors beyond hepatocellular carcinoma that can be treated by TACE, and summarizes data regarding when one should consider TACE in their treatment algorithms.
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Affiliation(s)
- Daniel M. DePietro
- Division of Interventional Radiology, Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Xin Li
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Susan M. Shamimi-Noori
- Division of Interventional Radiology, Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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2
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Sajan A, Fordyce S, Sideris A, Liou C, Toor Z, Filtes J, Krishnasamy V, Ahmad N, Reis S, Brejt S, Baig A, Khan S, Caplan M, Sperling D, Weintraub J. Minimally Invasive Treatment Options for Hepatic Uveal Melanoma Metastases. Diagnostics (Basel) 2023; 13:diagnostics13111836. [PMID: 37296688 DOI: 10.3390/diagnostics13111836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 05/01/2023] [Accepted: 05/12/2023] [Indexed: 06/12/2023] Open
Abstract
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.
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Affiliation(s)
- Abin Sajan
- Department of Radiology, Columbia University Medical Center, 622 West 168th Street, New York, NY 10032, USA
| | - Samuel Fordyce
- Department of Radiology, Columbia University Medical Center, 622 West 168th Street, New York, NY 10032, USA
| | - Andrew Sideris
- Department of Radiology, Columbia University Medical Center, 622 West 168th Street, New York, NY 10032, USA
| | - Connie Liou
- Department of Radiology, Columbia University Medical Center, 622 West 168th Street, New York, NY 10032, USA
| | - Zeeshan Toor
- Department of Radiology, Columbia University Medical Center, 622 West 168th Street, New York, NY 10032, USA
| | - John Filtes
- Department of Radiology, Columbia University Medical Center, 622 West 168th Street, New York, NY 10032, USA
| | - Venkatesh Krishnasamy
- Department of Radiology, Columbia University Medical Center, 622 West 168th Street, New York, NY 10032, USA
| | - Noor Ahmad
- Department of Radiology, Columbia University Medical Center, 622 West 168th Street, New York, NY 10032, USA
| | - Stephen Reis
- Department of Radiology, Columbia University Medical Center, 622 West 168th Street, New York, NY 10032, USA
| | - Sidney Brejt
- Department of Radiology, Columbia University Medical Center, 622 West 168th Street, New York, NY 10032, USA
| | - Asad Baig
- Department of Radiology, Columbia University Medical Center, 622 West 168th Street, New York, NY 10032, USA
| | - Shaheer Khan
- Department of Medicine, Columbia University Medical Center, 161 Fort Washington Avenue, New York, NY 10032, USA
| | - Michael Caplan
- Department of Medicine, Columbia University Medical Center, 161 Fort Washington Avenue, New York, NY 10032, USA
| | - David Sperling
- Department of Radiology, Columbia University Medical Center, 622 West 168th Street, New York, NY 10032, USA
| | - Joshua Weintraub
- Department of Radiology, Columbia University Medical Center, 622 West 168th Street, New York, NY 10032, USA
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3
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Varelas AI, Kővári B, Bruckner E, Lauwers GY, Langner C. Metachronous double-hit by arterial chemoembolization (TACE) with fotemustine inducing dysplasia-like atypia in the gallbladder and stomach - a diagnostic pitfall. Histopathology 2022; 81:128-130. [PMID: 35319109 PMCID: PMC9325052 DOI: 10.1111/his.14653] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 03/10/2022] [Accepted: 03/21/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Ana I Varelas
- Department of Pathology, Francisco Gentil Portuguese Institute of Oncology, Porto, Portugal.,Diagnostic and Research Institute of Pathology, Diagnostic and Research Centre for Molecular BioMedicine, Medical University of Graz, Graz, Austria
| | - Bence Kővári
- H. Lee Moffitt Cancer Centre & Research Institute, Tampa, Florida, USA.,Department of Pathology, University of Szeged, Albert Szent-Györgyi Medical School, Szeged, Hungary
| | - Elisabeth Bruckner
- Department of Internal Medicine, Landeskrankenhaus Hartberg, Hartberg, Austria
| | - Gregory Y Lauwers
- H. Lee Moffitt Cancer Centre & Research Institute, Tampa, Florida, USA
| | - Cord Langner
- Diagnostic and Research Institute of Pathology, Diagnostic and Research Centre for Molecular BioMedicine, Medical University of Graz, Graz, Austria
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4
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Rantala ES, Hernberg MM, Piperno-Neumann S, Grossniklaus HE, Kivelä TT. Metastatic uveal melanoma: The final frontier. Prog Retin Eye Res 2022; 90:101041. [PMID: 34999237 DOI: 10.1016/j.preteyeres.2022.101041] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 12/31/2021] [Accepted: 01/03/2022] [Indexed: 12/11/2022]
Abstract
Treatment of primary intraocular uveal melanoma has developed considerably, its driver genes are largely unraveled, and the ways to assess its risk for metastases are very precise, being based on an international staging system and genetic data. Unfortunately, the risk of distant metastases, which emerge in approximately one half of all patients, is unaltered. Metastases are the leading single cause of death after uveal melanoma is diagnosed, yet no consensus exists regarding surveillance, staging, and treatment of disseminated disease, and survival has not improved until recently. The final frontier in conquering uveal melanoma lies in solving these issues to cure metastatic disease. Most studies on metastatic uveal melanoma are small, uncontrolled, retrospective, and do not report staging. Meta-analyses confirm a median overall survival of 10-13 months, and a cure rate that approaches nil, although survival exceeding 5 years is possible, estimated 2% either with first-line treatment or with best supportive care. Hepatic ultrasonography and magnetic resonance imaging as surveillance methods have a sensitivity of 95-100% and 83-100%, respectively, to detect metastases without radiation hazard according to prevailing evidence, but computed tomography is necessary for staging. No blood-based tests additional to liver function tests are generally accepted. Three validated staging systems predict, each in defined situations, overall survival after metastasis. Their essential components include measures of tumor burden, liver function, and performance status or metastasis free interval. Age and gender may additionally influence survival. Exceptional mutational events in metastases may make them susceptible to checkpoint inhibitors. In a large meta-analysis, surgical treatment was associated with 6 months longer median overall survival as compared to conventional chemotherapy and, recently, tebentafusp as first-line treatment at the first interim analysis of a randomized phase III trial likewise provided a 6 months longer median overall survival compared to investigator's choice, mostly pembrolizumab; these treatments currently apply to selected patients. Promoting dormancy of micrometastases, harmonizing surveillance protocols, promoting staging, identifying predictive factors, initiating controlled clinical trials, and standardizing reporting will be critical steppingstones in reaching the final frontier of curing metastatic uveal melanoma.
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Affiliation(s)
- Elina S Rantala
- Ocular Oncology Service, Department of Ophthalmology, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 4 C, PL 220, FI-00029, HUS, Helsinki, Finland.
| | - Micaela M Hernberg
- Comprehensive Cancer Center, Department of Oncology, Helsinki University Hospital and University of Helsinki, Paciuksenkatu 3, PL 180, FI-00029, HUS, Helsinki, Finland.
| | | | - Hans E Grossniklaus
- Section of Ocular Oncology, Emory Eye Center, 1365 Clifton Road B, Atlanta, GA, 30322, USA.
| | - Tero T Kivelä
- Ocular Oncology Service, Department of Ophthalmology, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 4 C, PL 220, FI-00029, HUS, Helsinki, Finland.
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5
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Carr MJ, Sun J, Cohen JB, Liu J, Serdiuk AA, Stewart SR, Doobay N, Duclos A, Seal DA, Choi J, Zager JS. Over 12 Years Single Institutional Experience Performing Percutaneous Hepatic Perfusion for Unresectable Liver Metastases. Cancer Control 2021; 27:1073274820983019. [PMID: 33372814 PMCID: PMC8480350 DOI: 10.1177/1073274820983019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Patients with unresectable hepatic metastases, from uveal or ocular melanoma, are challenging to treat with an overall poor prognosis. Although over the past decade significant advances in systemic therapies have been made, metastatic disease to the liver, especially from uveal melanoma, continues to be a poor prognosis. Percutaneous hepatic perfusion (PHP) is a safe, viable treatment option for these patients. PHP utilizes high dose chemotherapy delivered directly to the liver while minimizing systemic exposure and can be repeated up to 6 times. Isolation of the hepatic vasculature with a double-balloon catheter allows for high concentration cytotoxic therapy to be administered with minimal systemic adverse effects. A detailed description of the multidisciplinary treatment protocol used at an institution with over 12 years of experience is discussed and recommendations are given. A dedicated team of a surgical or medical oncology, interventional radiology, anesthesiology and a perfusionist allows PHP to be repeatedly performed as a safe treatment strategy for unresectable hepatic metastases.
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Affiliation(s)
- Michael J Carr
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - James Sun
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Jonathan B Cohen
- Department of Anesthesiology, Moffitt Cancer Center, Tampa, FL, USA.,Department of Oncological Sciences, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Jinhong Liu
- Department of Anesthesiology, Moffitt Cancer Center, Tampa, FL, USA.,Department of Oncological Sciences, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Andrew A Serdiuk
- Department of Anesthesiology, Moffitt Cancer Center, Tampa, FL, USA.,Department of Oncological Sciences, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Stephen R Stewart
- Certified Clinical Perfusionist, Moffitt Cancer Center, Tampa, FL, USA
| | - Navin Doobay
- Department of Anesthesiology, Moffitt Cancer Center, Tampa, FL, USA
| | - Andrew Duclos
- Department of Anesthesiology, Moffitt Cancer Center, Tampa, FL, USA
| | - David A Seal
- Department of Anesthesiology, Moffitt Cancer Center, Tampa, FL, USA
| | - Junsung Choi
- Department of Oncological Sciences, University of South Florida Morsani College of Medicine, Tampa, FL, USA.,Department of Diagnostic Imaging and Interventional Radiology, Moffitt Cancer Center, Tampa, FL, USA. Sun is now with the Department of Surgery, University Hospitals, Cleveland Medical Center, Cleveland, OH, USA
| | - Jonathan S Zager
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL, USA.,Department of Oncological Sciences, University of South Florida Morsani College of Medicine, Tampa, FL, USA
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6
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Höppener DJ, Grünhagen DJ, Eggermont AMM, van der Veldt AAM, Verhoef C. An Overview of Liver Directed Locoregional Therapies. Surg Oncol Clin N Am 2021; 30:103-123. [PMID: 33220800 DOI: 10.1016/j.soc.2020.09.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
An overview of all liver-directed locoregional therapies, including surgical resection for melanoma liver metastases (MLMs), is provided. MLM patients are divided by their primary melanoma location; cutaneous, uvea (eye), and mucosal melanoma. If patients with isolated cutaneous MLMs are considered for surgical resection, treatment with systemic therapy should be part of the treatment course. For uveal MLMs, complete surgical or ablative treatment of all MLMs suggests superior results compared with other liver-directed or systemic therapies, based on current evidence, no recommendations for any liver-directed regional therapy in the treatment of mucosal MLMs can be made.
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Affiliation(s)
- Diederik J Höppener
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Dirk J Grünhagen
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Alexander M M Eggermont
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, the Netherlands
| | - Astrid A M van der Veldt
- Department of Medical Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Cornelis Verhoef
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands.
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7
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Carle X, Gastaud L, Salleron J, Tardy MP, Caujolle JP, Thyss A, Thariat J, Chevallier P. Optimizing the treatment of liver metastases from uveal melanomas with transarterial chemoembolization using melphalan and calibrated microspheres. Bull Cancer 2020; 107:1274-1283. [PMID: 33183739 DOI: 10.1016/j.bulcan.2020.09.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 09/14/2020] [Accepted: 09/27/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Patients with liver metastasis from uveal melanoma have a poor prognosis. Efficacy and safety of hepatic transarterial chemoembolization (TACE) using melphalan and microspheres was evaluated. MATERIALS AND METHODS Monocentric retrospective study of all consecutive patients treated by TACE using melphalan and 250μm calibrated microspheres between 2004 and 2016. Radiological response was assessed according to RECIST 1.1, modified (m)-RECIST and EASL on contrast-enhanced computed tomography (CT) or magnetic resonance imaging (MRI). The primary endpoint was overall survival (OS). Liver metastasis response, hepatic, extrahepatic and global progression free survival (PFS) complications were evaluated with the common terminology criteria for adverse events version 4.0 (CTCAE 4.0) and survival factors were secondary endpoints. RESULTS Thirty-four patients underwent 138 TACE (4; 4.1 sessions; range 1-9). Median OS was 16.5 months (mean 21.6 months). Liver metastasis response combining partial and complete response was 42.4%, 97%, 97% with RECIST 1.1, mRECIST, EASL, respectively. There were 58 severe (CTCAE≥3) but manageable complications in 28 patients, except for 1 toxic death. CONCLUSION For patients with liver metastases from uveal melanoma ineligible for local treatments, TACE using melphalan may be performed as first line therapy in metastatic miliary disease from uveal melanomas with careful supportive care.
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Affiliation(s)
- Xavier Carle
- University Hospital Archet 2, Department of Diagnostic and Interventional Radiology, 151 Route de Saint-Antoine, 06200 Nice, France
| | - Lauris Gastaud
- Antoine-Lacassagne Centre, Cancer Research Center, Department of Oncology, 133, avenue de Valombrose, 06189 Nice, France
| | - Julia Salleron
- Lorraine Institute of Oncology, Department of Biostatistics, 6 avenue de Bourgogne, 54519 Vandoeuvre-lès-Nancy, France
| | - Magali Pascale Tardy
- Antoine-Lacassagne Centre, Cancer Research Center, Department of Oncology, 133, avenue de Valombrose, 06189 Nice, France
| | - Jean-Pierre Caujolle
- University Hospital Pasteur 2, Department of Ophtalmology, 30, voie Romaine, 06001 Nice, France
| | - Antoine Thyss
- Antoine-Lacassagne Centre, Cancer Research Center, Department of Oncology, 133, avenue de Valombrose, 06189 Nice, France
| | - Juliette Thariat
- Francois-Baclesse Centre, Cancer Research Center, Department of Oncology, 3, avenue du Général Harris, 14000 Caen, France
| | - Patrick Chevallier
- University Hospital Archet 2, Department of Diagnostic and Interventional Radiology, 151 Route de Saint-Antoine, 06200 Nice, France.
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8
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Rodriguez-Vidal C, Fernandez-Diaz D, Fernandez-Marta B, Lago-Baameiro N, Pardo M, Silva P, Paniagua L, Blanco-Teijeiro MJ, Piñeiro A, Bande M. Treatment of Metastatic Uveal Melanoma: Systematic Review. Cancers (Basel) 2020; 12:E2557. [PMID: 32911759 PMCID: PMC7565536 DOI: 10.3390/cancers12092557] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 09/02/2020] [Accepted: 09/04/2020] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION More than 50% of patients with uveal melanoma end up developing metastases. Currently, there is no standard first-line treatment that facilitates proper management of the metastatic disease. METHODS A systematic review of the last 40 years in PubMed with an exhaustive and strict selection of studies was conducted, in which the unit of measurement was overall survival (OS) expressed in Kaplan-Meier curves or numerically. RESULTS After the selection process, 110 articles were included. Regional therapies, such as intra-arterial liver chemotherapy (OS: 2, 9-22 months), isolated liver perfusion (OS: 9, 6-27, 4 months), or selective internal radiation therapy (OS: 18 months in monotherapy and 26 months in combination with other therapies) showed some superiority when compared to systemic therapies, such as chemotherapy (OS: 4, 6-17 months), immunotherapy (OS: 5-19, 1 month), immunosuppression (OS: 11 months), or targeted therapy (OS: 6-12 months), without being significant. CONCLUSIONS The results of this review suggest that there are no important differences in OS when comparing the different current treatment modalities. Most of the differences found seem to be explained by the heterogenicity of the different studies and the presence of biases in their design, rather than actual extensions of patient survival.
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Affiliation(s)
- Cristina Rodriguez-Vidal
- Department of Ophthalmology, University Hospital of Cruces, Cruces Plaza S/N, 48903 Barakaldo-Vizcaya, Spain;
| | - Daniel Fernandez-Diaz
- Department of Ophthalmology, University Hospital of Santiago de Compostela, Ramon Baltar S/N, 15706 Santiago de Compostela, Spain; (D.F.-D.); (B.F.-M.); (M.J.B.-T.); (A.P.)
- Tumores Intraoculares en el Adulto, Instituto de Investigación Sanitaria de Santiago (IDIS), 15706 Santiago de Compostela, Spain; (M.P.); (P.S.)
| | - Beatriz Fernandez-Marta
- Department of Ophthalmology, University Hospital of Santiago de Compostela, Ramon Baltar S/N, 15706 Santiago de Compostela, Spain; (D.F.-D.); (B.F.-M.); (M.J.B.-T.); (A.P.)
| | - Nerea Lago-Baameiro
- Grupo Obesidómica, Instituto de Investigación Sanitaria de Santiago (IDIS), 15706 Santiago de Compostela, Spain;
| | - María Pardo
- Tumores Intraoculares en el Adulto, Instituto de Investigación Sanitaria de Santiago (IDIS), 15706 Santiago de Compostela, Spain; (M.P.); (P.S.)
- Grupo Obesidómica, Instituto de Investigación Sanitaria de Santiago (IDIS), 15706 Santiago de Compostela, Spain;
| | - Paula Silva
- Tumores Intraoculares en el Adulto, Instituto de Investigación Sanitaria de Santiago (IDIS), 15706 Santiago de Compostela, Spain; (M.P.); (P.S.)
- Fundación Pública Galega de Medicina Xenómica, Clinical University Hospital, SERGAS, 15705 Santiago de Compostela, Spain
| | - Laura Paniagua
- Department of Ophthalmology, University Hospital of Coruña, Praza Parrote s/n, 15006 A Coruña, Spain;
| | - María José Blanco-Teijeiro
- Department of Ophthalmology, University Hospital of Santiago de Compostela, Ramon Baltar S/N, 15706 Santiago de Compostela, Spain; (D.F.-D.); (B.F.-M.); (M.J.B.-T.); (A.P.)
- Tumores Intraoculares en el Adulto, Instituto de Investigación Sanitaria de Santiago (IDIS), 15706 Santiago de Compostela, Spain; (M.P.); (P.S.)
| | - Antonio Piñeiro
- Department of Ophthalmology, University Hospital of Santiago de Compostela, Ramon Baltar S/N, 15706 Santiago de Compostela, Spain; (D.F.-D.); (B.F.-M.); (M.J.B.-T.); (A.P.)
- Tumores Intraoculares en el Adulto, Instituto de Investigación Sanitaria de Santiago (IDIS), 15706 Santiago de Compostela, Spain; (M.P.); (P.S.)
| | - Manuel Bande
- Department of Ophthalmology, University Hospital of Santiago de Compostela, Ramon Baltar S/N, 15706 Santiago de Compostela, Spain; (D.F.-D.); (B.F.-M.); (M.J.B.-T.); (A.P.)
- Tumores Intraoculares en el Adulto, Instituto de Investigación Sanitaria de Santiago (IDIS), 15706 Santiago de Compostela, Spain; (M.P.); (P.S.)
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9
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Meijer TS, Burgmans MC, de Leede EM, de Geus-Oei LF, Boekestijn B, Handgraaf HJM, Hilling DE, Lutjeboer J, Vuijk J, Martini CH, van Erkel AR, van der Meer RW, Tijl FGJ, Speetjens FM, Kapiteijn E, Vahrmeijer AL. Percutaneous Hepatic Perfusion with Melphalan in Patients with Unresectable Ocular Melanoma Metastases Confined to the Liver: A Prospective Phase II Study. Ann Surg Oncol 2020; 28:1130-1141. [PMID: 32761328 PMCID: PMC7801354 DOI: 10.1245/s10434-020-08741-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Indexed: 12/13/2022]
Abstract
Background Ocular melanoma is the most common primary intraocular malignancy and has a very poor prognosis once liver metastases occur. The
aim of this study was to prospectively assess the efficacy and safety of percutaneous hepatic perfusion with melphalan (M-PHP) using the new second-generation
(GEN 2) hemofiltration system in patients with ocular melanoma metastases confined to the liver. Methods Prospective, single-center, single-arm, phase II study including patients with unresectable ocular melanoma metastases confined to the liver. Treatment consisted of two M-PHP procedures at 6–8 weeks interval. Procedures were performed using the CHEMOSAT (GEN 2) system with 3 mg/kg
melphalan. Primary endpoints were overall response rate (ORR) and best overall response (BOR). Secondary endpoints included overall survival (OS), progression-free survival (PFS), hepatic PFS (hPFS), and safety. Results Sixty-four M-PHP procedures were performed in 35 patients between February 2014 and June 2017. The ORR was 72%. BOR was as follows: complete response in 3%, partial response in 69%, stable disease in 13%, and progressive disease in 16%. There was no treatment-related mortality. Fourteen serious adverse events occurred. At a median follow-up of 19.1 months (range 5.6–69.5), median OS was 19.1 months and was significantly longer in responders than in nonresponders (27.5 vs. 11.9 months, p < 0.001). The 1- and 2-year OS was 77% and 43%, respectively. PFS and hPFS were 7.6 and 11.2 months, respectively. Conclusions M-PHP using the GEN 2 filter can achieve a high ORR and prolonged survival in patients with liver-only ocular melanoma metastases.
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Affiliation(s)
- T Susanna Meijer
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands.
| | - Mark C Burgmans
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Eleonora M de Leede
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Lioe-Fee de Geus-Oei
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands.,Biomedical Photonic Imaging Group, University of Twente, Enschede, The Netherlands
| | - Bas Boekestijn
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Denise E Hilling
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Jacob Lutjeboer
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jaap Vuijk
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Christian H Martini
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Arian R van Erkel
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Fred G J Tijl
- Department of Extra Corporal Circulation, Leiden University Medical Center, Leiden, The Netherlands
| | - Frank M Speetjens
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ellen Kapiteijn
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
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10
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Arulananda S, Parakh S, Palmer J, Goodwin M, Andrews MC, Cebon J. A pilot study of intrahepatic yttrium-90 microsphere radioembolization in combination with intravenous cisplatin for uveal melanoma liver-only metastases. Cancer Rep (Hoboken) 2020; 2:e1183. [PMID: 32721131 DOI: 10.1002/cnr2.1183] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 03/22/2019] [Accepted: 04/03/2019] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Metastatic uveal melanoma is a highly aggressive disease with no standard of care treatment option. A large proportion of patients have liver-only metastatic disease which raises the question if liver-directed therapy can be efficacious in this subpopulation. AIMS The study aims to evaluate the safety and efficacy of radiosensitizing chemotherapy in combination with yttrium-90 microspheres in patients with uveal melanoma with liver-only metastases. METHODS AND RESULTS This single arm, open labeled, non-randomized study enrolled 10 patients with liver-only metastatic uveal melanoma between November 2012 and January 2018. Eligible patients received intrahepatic yttrium-90 microspheres followed by intravenous cisplatin (20 mg/m2) for 5 days. Ten patients were enrolled, but nine patients received treatment who were included in the final analysis with a median follow-up of 30 months (range 7 to 44). Five (50%) were female, five (50%) had an elevated lactate dehydrogenase (LDH), and one (10%) had prior anti-PD-1 therapy. The combination was well tolerated with no greater than or equal to grade 3 toxicity observed. The liver objective response rate (ORR) was 33% (3/9), the median progression-free survival (PFS) in the liver was 3 months (95% CI, 3-NA), and the extrahepatic PFS was 3 months (95% CI, 3-NA). Seventy-eight percent (7/9) received an immune checkpoint inhibitor on disease progression, with no responses seen. The median overall survival (OS) was 10 months (95% CI, 7-NA). CONCLUSION The combination of cisplatin with yttrium-90 microspheres was well tolerated; however, it was associated with intrahepatic disease control of relatively short duration. No responses were seen in patients treated with immune checkpoint inhibitors post radioembolization.
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Affiliation(s)
- Surein Arulananda
- Medical Oncology Unit, Austin Health, Heidelberg, Victoria, Australia.,Cancer Immuno-Biology Laboratory, Olivia Newton-John Cancer Research Institute, Heidelberg, Victoria, Australia.,School of Cancer Medicine, La Trobe University, Bundoora, Victoria, Australia
| | - Sagun Parakh
- Medical Oncology Unit, Austin Health, Heidelberg, Victoria, Australia.,Cancer Immuno-Biology Laboratory, Olivia Newton-John Cancer Research Institute, Heidelberg, Victoria, Australia.,School of Cancer Medicine, La Trobe University, Bundoora, Victoria, Australia
| | - Jodie Palmer
- Cancer Immuno-Biology Laboratory, Olivia Newton-John Cancer Research Institute, Heidelberg, Victoria, Australia
| | - Mark Goodwin
- Department of Radiology, Austin Hospital, Heidelberg, Victoria, Australia
| | - Miles C Andrews
- Medical Oncology Unit, Austin Health, Heidelberg, Victoria, Australia.,Cancer Immuno-Biology Laboratory, Olivia Newton-John Cancer Research Institute, Heidelberg, Victoria, Australia.,School of Cancer Medicine, La Trobe University, Bundoora, Victoria, Australia.,Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Jonathan Cebon
- Medical Oncology Unit, Austin Health, Heidelberg, Victoria, Australia.,Cancer Immuno-Biology Laboratory, Olivia Newton-John Cancer Research Institute, Heidelberg, Victoria, Australia.,School of Cancer Medicine, La Trobe University, Bundoora, Victoria, Australia
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11
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Rowcroft A, Loveday BPT, Thomson BNJ, Banting S, Knowles B. Systematic review of liver directed therapy for uveal melanoma hepatic metastases. HPB (Oxford) 2020; 22:497-505. [PMID: 31791894 DOI: 10.1016/j.hpb.2019.11.002] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 10/29/2019] [Accepted: 11/04/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Uveal melanoma (UM) is a rare malignancy with a propensity for metastasis to the liver. Systemic chemotherapy is typically ineffective in these patients with liver metastases and overall survival is poor. There are no evidence-based guidelines for management of UM liver metastases. The aim of this study was to review the evidence for management of UM liver metastases. METHODS A systematic review of English literature publications was conducted across Ovid Medline, Ovid MEDLINE and Cochrane CENTRAL databases until April 2019. The primary outcome was overall survival, with disease free survival as a secondary outcome. RESULTS 55 studies were included in the study, with 2446 patients treated overall. The majority of these studies were retrospective, with 17 of 55 including comparative data. Treatment modalities included surgery, isolated hepatic perfusion (IHP), hepatic artery infusion (HAI), transarterial chemoembolization (TACE), selective internal radiotherapy (SIRT) and Immunoembolization (IE). Survival varied greatly between treatments and between studies using the same treatments. Both surgery and liver-directed treatments were shown to have benefit in selected patients. CONCLUSION Predominantly retrospective and uncontrolled studies suggest that surgery and locoregional techniques may prolong survival. Substantial variability in patient selection and study design makes comparison of data and formulation of recommendations challenging.
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Affiliation(s)
- Alistair Rowcroft
- Department of Surgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Benjamin P T Loveday
- Department of Surgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Benjamin N J Thomson
- Department of Surgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Department of Surgery, University of Melbourne, Melbourne, Australia
| | - Simon Banting
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Brett Knowles
- Department of Surgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.
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12
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Wessely A, Steeb T, Erdmann M, Heinzerling L, Vera J, Schlaak M, Berking C, Heppt MV. The Role of Immune Checkpoint Blockade in Uveal Melanoma. Int J Mol Sci 2020; 21:ijms21030879. [PMID: 32013269 PMCID: PMC7037664 DOI: 10.3390/ijms21030879] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 01/27/2020] [Accepted: 01/27/2020] [Indexed: 12/25/2022] Open
Abstract
Uveal melanoma (UM) represents the most common intraocular malignancy in adults and accounts for about 5% of all melanomas. Primary disease can be effectively controlled by several local therapy options, but UM has a high potential for metastatic spread, especially to the liver. Despite its clinical and genetic heterogeneity, therapy of metastatic UM has largely been adopted from cutaneous melanoma (CM) with discouraging results until now. The introduction of antibodies targeting CTLA-4 and PD-1 for immune checkpoint blockade (ICB) has revolutionized the field of cancer therapy and has achieved pioneering results in metastatic CM. Thus, expectations were high that patients with metastatic UM would also benefit from these new therapy options. This review provides a comprehensive and up-to-date overview on the role of ICB in UM. We give a summary of UM biology, its clinical features, and how it differs from CM. The results of several studies that have been investigating ICB in metastatic UM are presented. We discuss possible reasons for the lack of efficacy of ICB in UM compared to CM, highlight the pitfalls of ICB in this cancer entity, and explain why other immune-modulating therapies could still be an option for future UM therapies.
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Affiliation(s)
- Anja Wessely
- Department of Dermatology, Universitätsklinikum Erlangen, Friedrich Alexander University, Ulmenweg 18, 91054 Erlangen, Germany; (A.W.); (T.S.); (M.E.); (L.H.); (J.V.); (C.B.)
| | - Theresa Steeb
- Department of Dermatology, Universitätsklinikum Erlangen, Friedrich Alexander University, Ulmenweg 18, 91054 Erlangen, Germany; (A.W.); (T.S.); (M.E.); (L.H.); (J.V.); (C.B.)
| | - Michael Erdmann
- Department of Dermatology, Universitätsklinikum Erlangen, Friedrich Alexander University, Ulmenweg 18, 91054 Erlangen, Germany; (A.W.); (T.S.); (M.E.); (L.H.); (J.V.); (C.B.)
| | - Lucie Heinzerling
- Department of Dermatology, Universitätsklinikum Erlangen, Friedrich Alexander University, Ulmenweg 18, 91054 Erlangen, Germany; (A.W.); (T.S.); (M.E.); (L.H.); (J.V.); (C.B.)
| | - Julio Vera
- Department of Dermatology, Universitätsklinikum Erlangen, Friedrich Alexander University, Ulmenweg 18, 91054 Erlangen, Germany; (A.W.); (T.S.); (M.E.); (L.H.); (J.V.); (C.B.)
| | - Max Schlaak
- Department of Dermatology and Allergy, University Hospital, LMU Munich, Frauenlobstr. 9-11, 80337 Munich, Germany;
| | - Carola Berking
- Department of Dermatology, Universitätsklinikum Erlangen, Friedrich Alexander University, Ulmenweg 18, 91054 Erlangen, Germany; (A.W.); (T.S.); (M.E.); (L.H.); (J.V.); (C.B.)
| | - Markus Vincent Heppt
- Department of Dermatology, Universitätsklinikum Erlangen, Friedrich Alexander University, Ulmenweg 18, 91054 Erlangen, Germany; (A.W.); (T.S.); (M.E.); (L.H.); (J.V.); (C.B.)
- Correspondence: ; Tel.: +49-9131-85-35747
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13
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Abbott AM, Doepker MP, Kim Y, Perez MC, Gandle C, Thomas KL, Choi J, Shridhar R, Zager JS. Hepatic Progression-free and Overall Survival After Regional Therapy to the Liver for Metastatic Melanoma. Am J Clin Oncol 2018; 41:747-753. [PMID: 28059929 PMCID: PMC7771287 DOI: 10.1097/coc.0000000000000356] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVES Regional therapy for metastatic melanoma to the liver represents an alternative to systemic therapy. Hepatic progression-free survival (HPFS), progression-free survival (PFS), and overall survival (OS) were evaluated. MATERIALS AND METHODS A retrospective review of patients with liver metastases from cutaneous or uveal melanoma treated with yttrium-90 (Y90), chemoembolization (CE), or percutaneous hepatic perfusion (PHP) was conducted. RESULTS Thirty patients (6 Y90, 10 PHP, 12 CE, 1 PHP then Y90, 1 CE then PHP) were included. Multivariate analysis showed improved HPFS for PHP versus Y90 (P=0.004), PHP versus CE (P=0.02) but not for CE versus Y90. PFS was also significantly different: Y90 (54 d), CE (52 d), PHP (245 d), P=0.03. PHP treatment and lower tumor burden were significant predictors of prolonged PFS on multivariate analysis. Median OS from time of treatment was longest, but not significant, for PHP at 608 days versus Y90 (295 d) and CE (265 d), P=0.24. Only PHP treatment versus Y90 and lower tumor burden had improved OS on multivariate analysis (P=0.03, 0.03, respectively). CONCLUSIONS HPFS and PFS were significantly prolonged in patients treated with PHP versus CE or Y90. Median OS in PHP patients was over double that seen in Y90 or CE patients but was significant only between PHP and Y90.
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Affiliation(s)
- Andrea M. Abbott
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL
| | | | - Youngchul Kim
- Department of Biostatistics and Bioinformatics, Moffitt Cancer Center, Tampa, FL
| | - Matthew C. Perez
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL
| | - Cassandra Gandle
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL
| | | | - Junsung Choi
- Department of Interventional Radiology, Moffitt Cancer Center, Tampa, FL
| | - Ravi Shridhar
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL
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Abstract
Melanomas affecting different components of the uvea occur with differing frequencies and clinical presentations. Uveal melanoma is diagnosed via funduscopic exam and ancillary tests. These lesions may present with visual findings or incidental findings on physical exam. Metastasis occurs in approximately half of all patients with primary uveal melanoma. The liver is the most common site of metastasis. Enucleation was at one time considered the definitive local treatment for primary uveal melanoma, but has been largely replaced by other therapeutic procedures that aim to prevent metastasis while preserving vision. Unfortunately, metastasis of uveal melanoma almost always proves to be fatal. The current treatment of metastatic uveal melanoma is limited by the intrinsic resistance of uveal melanoma to conventional systemic therapies. Advancements in molecular biology have resulted in the identification of a number of promising prognostic and therapeutic targets. Early detection and therapy are important factors in disease survival. It is imperative that the treating physician be familiar with the clinical features of uveal melanoma and distinguish it from mimickers in order to ensure effective and timely treatment.
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Affiliation(s)
| | - Priya Durairaj
- Department of Ocular Oncology, The Princess Margaret Hospital, Toronto, ON, Canada
| | - Jensen Yeung
- Department of Medicine (Dermatology), University of Toronto, Toronto, ON, Canada
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15
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Long-term survival in a patient with unresectable liver metastases from uveal melanoma treated with transarterial chemoembolization with irinotecan eluting beads - case report and review of literature. Contemp Oncol (Pozn) 2017; 21:244-248. [PMID: 29180934 PMCID: PMC5701586 DOI: 10.5114/wo.2017.70115] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 07/09/2017] [Indexed: 01/01/2023] Open
Abstract
Introduction Treatment of unresectable liver metastases (LM) from uveal melanoma (UM) remains a major clinical challenge. Systemic chemotherapy and chemoimmunotherapy regimens extrapolated from cutaneous melanoma are considered to be ineffective in therapy of metastases from uveal melanoma. Studies suggest that the progression of hepatic metastases rather than the primary tumor or metastases in other organs determines survival. Case report We report a case of transarterial chemoembolization of 57-year-old man diagnosed with unresectable liver metastases from uveal melanoma with irinotecan eluting beads. Therapy resulted in long progression free survival and overall survival, 41 months and 45 months after diagnosis of metastatic disease respectively. Patient did not experience any major side effects of the therapy. Follow-up CTs indicate stable disease in mRECIST criteria and partial response in CHOI criteria. Conclusions Transarterial chemoembolization with drug eluting beads loaded with irinotecan may be an effective treatment of unresectable liver metastases from uveal melanoma.
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16
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Eigentler TK, Mühlenbein C, Follmann M, Schadendorf D, Garbe C. S3-Leitlinie Diagnostik, Therapie und Nachsorge des Melanoms - Update 2015/2016, Kurzversion 2.0. J Dtsch Dermatol Ges 2017; 15:e1-e41. [DOI: 10.1111/ddg.13247] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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17
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Jia Z, Jiang G, Zhu C, Wang K, Li S, Qin X. A systematic review of yttrium-90 radioembolization for unresectable liver metastases of melanoma. Eur J Radiol 2017. [PMID: 28624008 DOI: 10.1016/j.ejrad.2017.05.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE To assess the effectiveness of yttrium-90 (90Y) radioembolization in the treatment of unresectable liver metastases of melanoma. METHODS PubMed and EMBASE were systemically searched for all English language studies related to 90Y radioembolization for unresectable liver metastases of melanoma, including clinical trials, observational studies, and abstracts from conferences, published between January 1991 and March 2016. RESULTS A total of 12 reports (7 observational studies and 5 abstracts from conferences) involving 255 patients were included in the analysis. The primary sites of melanoma were cutaneous (n=22; 8.6%), ocular (n=197; 77.3%), rectal (n=3; 1.2%), and unknown (n=33; 12.9%). The median disease control rate at 3 months was 73.6% (range, 58.3%-88.9%). Among the 207 patients for whom tumor response at 3 months was reported, complete response was seen in 1.0% (2/207), partial response was seen in 19.3% (40/207), stable disease was seen in 46.9% (97/207), and progressive disease was seen in 32.9% (68/207). The median survival was 10 months (range, 7-13.4 months), and the median 1-year survival rate was 34.6% (range, 23%-80%). Complications of 90Y radioembolization were reported in 13 cases. The most common side effects were fatigue (median, 36.1%), abdominal pain (median, 17.8%), and nausea (median, 15.0%). CONCLUSIONS 90Y radioembolization is a promising alternative therapy for the treatment of unresectable liver metastases of melanoma, with encouraging effects on disease control and survival. Some complications can occur, and side effects are frequent but mild.
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Affiliation(s)
- Zhongzhi Jia
- Department of Interventional Radiology, No. 2 People's Hospital of Changzhou, Nanjing Medical University, Chang Zhou, 213003, China
| | - Guomin Jiang
- Department of Interventional Radiology, No. 2 People's Hospital of Changzhou, Nanjing Medical University, Chang Zhou, 213003, China
| | - Chunfu Zhu
- Department of General Surgery, No. 2 People's Hospital of Changzhou, Nanjing Medical University, Changzhou, 213003, China
| | - Kai Wang
- Department of Interventional Radiology, No. 2 People's Hospital of Changzhou, Nanjing Medical University, Chang Zhou, 213003, China
| | - Shaoqin Li
- Department of Interventional Radiology, No. 2 People's Hospital of Changzhou, Nanjing Medical University, Chang Zhou, 213003, China
| | - Xihu Qin
- Department of General Surgery, No. 2 People's Hospital of Changzhou, Nanjing Medical University, Changzhou, 213003, China.
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18
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Efficacy and toxicity of transarterial chemoembolization therapy using cisplatin and gelatin sponge in patients with liver metastases from uveal melanoma in an Asian population. Int J Clin Oncol 2017; 22:577-584. [DOI: 10.1007/s10147-017-1095-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 01/20/2017] [Indexed: 11/25/2022]
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19
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Klingenstein A, Schaumberger MM, Freeman WR, Folberg R, Mueller AJ, Schaller UC. MuSIC report III: tumour microcirculation patterns and development of metastasis in long-term follow-up of melanocytic uveal tumours. Acta Ophthalmol 2016; 94:175-81. [PMID: 26426375 DOI: 10.1111/aos.12836] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 07/22/2015] [Indexed: 12/21/2022]
Abstract
PURPOSE To statistically determine differences in microcirculation patterns between nevi and uveal melanomas and the influence of these patterns on metastatic potential in the long-term follow-up of 112 patients with melanocytic uveal tumours. In vivo markers indicating malignancy and metastatic potential have implications for treatment decision. METHODS Primary diagnosis and work-up included clinical examination, fundus photography, standardized A and B scan echography as well as evaluation of tumour microcirculation patterns via confocal fluorescein and indocyanine green angiography (ICGA). Patient data were collected from the patient files, the tumour registry or personal contact. Statistical analysis was performed with spss 22.0 using chi-square, Fisher's exact test and Kaplan-Meier survival analysis. RESULTS Forty-three uveal melanocytic lesions remained untreated and were retrospectively classified as benign nevi, whereas 69 lesions were malignant melanomas (T1: 32, T2: 28, T3: 6 and T4: 3). 'Silent' and 'arcs without branching' were found significantly more often in nevi (p = 0.001 and p = 0.010), whereas 'parallel with cross-linking' and 'networks' were significantly more frequent in melanomas (p = 0.022 and p = 0.029). The microcirculation pattern 'parallel with cross-linking' proved significantly more frequent in patients who developed metastases (p = 0.001). CONCLUSIONS Certain microcirculation patterns may guide us in differentiating uveal nevi from malignant melanomas. A non-invasive prognostic marker can be of great value for borderline lesions in which cytology is less likely taken. 'Parallel with cross-linking' did not only indicate malignancy, but it was also associated with later tumour metastasis.
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Affiliation(s)
| | | | | | - Robert Folberg
- Department of Biomedical Sciences; Oakland University William Beaumont School of Medicine; Rochester MI USA
| | | | - Ulrich C Schaller
- Department of Ophthalmology; Ludwig-Maximilians University; Munich Germany
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20
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Vogl TJ, Emam A, Naguib NN, Eichler K, Zangos S. How Effective Are Percutaneous Liver-Directed Therapies in Patients with Non-Colorectal Liver Metastases? VISZERALMEDIZIN 2015; 31:406-13. [PMID: 26889144 PMCID: PMC4748795 DOI: 10.1159/000440677] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The purpose of this review is to demonstrate the clinical indications, technical developments, and outcome of liver-directed therapies in interventional oncology of non-colorectal liver metastases. METHODS Liver-directed therapies are classified into vascular transarterial techniques such as chemoperfusion (TACP), chemoembolization (TACE), radioembolization (selective internal radiation therapy (SIRT)), and chemosaturation, as well as thermal ablation techniques like microwave ablation (MWA), radiofrequency ablation (RFA), laser-induced thermotherapy (LITT), cryotherapy, and irreversible electroporation (IRE). The authors searched the database PubMed using the following terms: 'image-guided tumor ablation', 'thermal ablation therapies', 'liver metastases of uveal melanoma', 'neuroendocrine carcinoma', 'breast cancer', and 'non-colorectal liver metastases'. RESULTS Various combinations of the above-mentioned therapy protocols are possible. In neuroendocrine carcinomas, oligonodular liver metastases are treated successfully via thermal ablation like RFA, LITT, or MWA, and diffuse involvement via TACE or SIRT. Although liver involvement in breast cancer is a systemic disease, non-responding nodular metastases can be controlled via RFA or LITT. In ocular or cutaneous melanoma, thermal ablation is rarely considered as an interventional treatment option, as opposed to TACE, SIRT, or chemosaturation. Rarely liver-directed therapies are used in pancreatic cancer, most likely due to problems such as biliary digestive communications after surgery and the risk of infections. Rare indications for thermal ablation are liver metastases of other primary cancers like non-small cell lung, gastric, and ovarian cancer. CONCLUSION Interventional oncological techniques play a role in patients with liver-dominant metastases.
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Affiliation(s)
- Thomas J. Vogl
- Institute for Diagnostic and Interventional Radiology, University Hospital Frankfurt, Johann Wolfgang Goethe University, Frankfurt am Main, Germany
| | - Ahmed Emam
- Institute for Diagnostic and Interventional Radiology, University Hospital Frankfurt, Johann Wolfgang Goethe University, Frankfurt am Main, Germany
| | - Nagy N. Naguib
- Institute for Diagnostic and Interventional Radiology, University Hospital Frankfurt, Johann Wolfgang Goethe University, Frankfurt am Main, Germany
- Department of Diagnostic and Interventional Radiology, University of Alexandria, Alexandria, Egypt
| | - Katrin Eichler
- Institute for Diagnostic and Interventional Radiology, University Hospital Frankfurt, Johann Wolfgang Goethe University, Frankfurt am Main, Germany
| | - Stefan Zangos
- Institute for Diagnostic and Interventional Radiology, University Hospital Frankfurt, Johann Wolfgang Goethe University, Frankfurt am Main, Germany
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Wei IH, Healy MA, Wong SL. Surgical Treatment Options for Stage IV Melanoma. Surg Clin North Am 2014; 94:1075-89, ix. [DOI: 10.1016/j.suc.2014.07.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Hickey RM, Lewandowski RJ, Salem R. Rationale of transcatheter intra-arterial therapies of hepatic cancers. Hepat Oncol 2014; 1:285-291. [PMID: 30190963 DOI: 10.2217/hep.14.11] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Transcatheter, intra-arterial therapies for primary and metastatic hepatic malignancies comprise angiographically guided procedures that provide for the administration of tumoricidal agents directly to liver tumors. These locoregional therapies have demonstrated encouraging clinical outcomes for liver tumors that are otherwise not amenable or not responsive to standard surgical or systemic treatments. This article provides a review of transcatheter therapies for hepatic cancers and reported clinical outcomes.
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Affiliation(s)
- Ryan M Hickey
- Northwestern University, Department of Radiology, Division of Vascular & Interventional Radiology, Chicago, IL 60611, USA
| | - Robert J Lewandowski
- Northwestern University, Department of Radiology, Division of Vascular & Interventional Radiology, Chicago, IL 60611, USA
| | - Riad Salem
- Northwestern University, Department of Radiology, Division of Vascular & Interventional Radiology, Chicago, IL 60611, USA
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Agarwala SS, Eggermont AMM, O'Day S, Zager JS. Metastatic melanoma to the liver: a contemporary and comprehensive review of surgical, systemic, and regional therapeutic options. Cancer 2014; 120:781-9. [PMID: 24301420 DOI: 10.1002/cncr.28480] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 10/15/2013] [Indexed: 12/17/2022]
Abstract
Effective management of hepatic metastases from ocular and cutaneous melanoma remains a major therapeutic challenge. Treatment options include hepatic resection, hepatic intra-arterial (HIA) chemotherapy, chemoembolization, and hepatic perfusions. Evaluating the efficacy of these interventions is limited by the retrospective nature of most of the data, although controlled phase 3 studies are starting to emerge. Studies of hepatic resection are strongly suggestive of a survival benefit following surgery in selected patients. Effective systemic agents for metastatic cutaneous melanoma are available and supported by randomized controlled phase 3 trials. In contrast, no active systemic treatment has yet been identified for metastatic ocular melanoma. HIA and intravenous delivery of fotemustine have been compared in a randomized phase 3 trial in patients with unresectable metastases from melanoma, but no differences between the 2 approaches were observed. Hepatic arterial chemoembolization appears only to be moderately effective according to uncontrolled studies; targeting patients with less liver involvement may improve outcomes. A recent phase 3 study showed a significant improvement in hepatic progression-free survival with percutaneous hepatic perfusion compared with best alternative care in patients with metastatic melanoma; however, the overall survival analysis was confounded by crossover of control patients to active treatment. In conclusion, hepatic resection offers the possibility of long-term survival in carefully selected patients with liver-limited metastases from melanoma. In patients with unresectable cutaneous melanoma, effective systemic therapy is the best treatment option. For patients with unresectable ocular melanoma, regional treatments are likely to assume a greater role until effective systemic treatments are identified.
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Affiliation(s)
- Sanjiv S Agarwala
- Department of Hematology/Oncology, St. Luke's University Health Network, Bethlehem, Pennsylvania
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Pflugfelder A, Kochs C, Blum A, Capellaro M, Czeschik C, Dettenborn T, Dill D, Dippel E, Eigentler T, Feyer P, Follmann M, Frerich B, Ganten MK, Gärtner J, Gutzmer R, Hassel J, Hauschild A, Hohenberger P, Hübner J, Kaatz M, Kleeberg UR, Kölbl O, Kortmann RD, Krause-Bergmann A, Kurschat P, Leiter U, Link H, Loquai C, Löser C, Mackensen A, Meier F, Mohr P, Möhrle M, Nashan D, Reske S, Rose C, Sander C, Satzger I, Schiller M, Schlemmer HP, Strittmatter G, Sunderkötter C, Swoboda L, Trefzer U, Voltz R, Vordermark D, Weichenthal M, Werner A, Wesselmann S, Weyergraf AJ, Wick W, Garbe C, Schadendorf D. S3-guideline "diagnosis, therapy and follow-up of melanoma" -- short version. J Dtsch Dermatol Ges 2014; 11:563-602. [PMID: 23721604 DOI: 10.1111/ddg.12044] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Farshid P, Darvishi A, Naguib N, Bazrafshan B, Paul J, Mbalisike E, Vogl TJ. Repetitive chemoembolization of hypovascular liver metastases from the most common primary sites. Future Oncol 2013; 9:419-26. [PMID: 23469977 DOI: 10.2217/fon.12.191] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
AIM To evaluate tumor response in patients with hypovascular liver metastases from the most common primary sites treated with chemoembolization. MATERIALS & METHODS Chemoembolization was performed in 190 patients (five groups) who had hypovascular liver metastases from the colon (n = 66), breast (n = 40), uveal malignant melanoma (n = 20), pancreas (n = 48) and stomach (n = 16). Surgical resection of primary sites had been performed for all included patients. Tumor response, survival statistics from the first chemoembolization using Kaplan-Meier method and progression rate of embolized lesions were evaluated by analysis of variance with Tukey's post hoc test. RESULTS Multiple comparison between the groups showed no statistical significant difference in local tumor response (H: 9.23; p > 0.05). Survival indices of the patients, including survival rate, progression-free survival rate, median survival time and time to progression, demonstrated significant difference between the groups during the follow-up period (H: 9.7; p = 0.045). The progression rate of treated liver metastases from colon, breast, uvea, pancreas and stomach were 16.6, 17.5, 30.0, 25.0 and 32.0%, respectively (p = 0.002). CONCLUSION Hypovascular liver metastases treated with chemoembolization may demonstrate equal local response, but are significantly different in rate of progression and survival.
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Affiliation(s)
- Parviz Farshid
- Department of Radiology, Marienhospital Osnabrueck, Bischofsstrasse 1, 49074 Osnabrueck, Germany.
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Fotemustine chemoembolization of hepatic metastases from uveal melanoma: a retrospective single-center analysis. AJR Am J Roentgenol 2013; 199:1387-92. [PMID: 23169735 DOI: 10.2214/ajr.11.7748] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE The purpose of the current study was to retrospectively evaluate response and survival in patients with hepatic metastasis from uveal melanoma treated by palliative transarterial chemoembolization (TACE) with fotemustine. MATERIALS AND METHODS During the study period, 21 patients with hepatic metastases from uveal melanoma were treated by TACE. A series of TACE interventions (mean number per patient, 3.29 interventions; range, 1-6 interventions) was performed on each patient with an emulsion of fotemustine dissolved in 10 mL of saline mixed with 10 mL of an oily contrast agent. Tumor response based on the Response Evaluation Criteria in Solid Tumors was evaluated using contrast-enhanced CT scans obtained 6-10 weeks after embolization. RESULTS CT showed partial regression after TACE in three patients (14%). Six patients (29%) presented with stable disease but no significant change in tumor size after TACE, and 12 patients (57%) presented with progressive disease after TACE treatment. The overall response rate was 43%. The mean survival after diagnosis of hepatic metastasis was 28.7 months. CONCLUSION TACE of hepatic metastasis from uveal melanoma with fotemustine is well tolerated, and the survival rates in this study (mean, 28.7 months) are among the longest reported.
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Schicher N, Edelhauser G, Harmankaya K, Schindler K, Gleiss A, Pehamberger H, Hoeller C. Pretherapeutic laboratory findings, extent of metastasis and choice of treatment as prognostic markers in ocular melanoma- a single centre experience. J Eur Acad Dermatol Venereol 2012; 27:e394-9. [PMID: 23057648 DOI: 10.1111/jdv.12006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Uveal melanoma is the most common intraocular neoplasm with a high tendency to metastasize predominantly to the liver. Prognostic parameters for progression and overall survival are not well defined. The aim of this study was to assess the value of pretherapeutic serum levels of C-reactive protein (CRP), lactate dehydrogenase, albumin and fibrinogen in patients with uveal melanoma and to evaluate their significance as prognostic parameters for survival. METHODS Forty-nine patients with metastatic uveal melanoma treated between 2000 and 2010 were retrospectively analysed. The potential influence of levels of CRP, lactate dehydrogenase, fibrinogen and albumin as well as other commonly known prognostic variables on progression-free and overall survival were investigated. RESULTS Patients' age and treatment with systemic chemotherapy were the only variables to show significant influences on progression-free and overall survival in a univariate analysis. Multivariate analysis confirmed the influence of these variables on progression-free survival, presence of metastasis, pretherapeutic CRP levels and treatment with systemic chemotherapy were associated with overall survival. CONCLUSION In this patient cohort elevated pretherapeutic CRP and extent of metastasis are independent prognostic factors for decreased overall survival, whereas treatment with systemic chemotherapy showed a significant association with improved overall survival.
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Affiliation(s)
- N Schicher
- Department of Dermatology, Division of General Dermatology Department of Radiology, Division of Cardiovascular and Interventional Radiology Center for Medical Statistics, Informatics and Intelligent Systems Medical University of Vienna, Waehringer Guertel, Vienna, Austria
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Radioembolization as locoregional therapy of hepatic metastases in uveal melanoma patients. Cardiovasc Intervent Radiol 2012; 36:158-65. [PMID: 22526099 DOI: 10.1007/s00270-012-0373-5] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Accepted: 03/07/2012] [Indexed: 10/28/2022]
Abstract
PURPOSE To retrospectively evaluate the overall survival, safety, and efficacy of metastatic uveal melanoma patients after radioembolization as salvage therapy. MATERIALS AND METHODS Thirteen patients were treated with radioembolization of branches of the hepatic artery with resin-based yttrium-90 ((90)Y)-labelled microspheres. Twelve patients underwent a single application, and 1 patient underwent 4 interventions. Dosages from 644 to 2,450 MBq (mean activity 1,780) were applied. Treatment response was evaluated by way of liver magnetic resonance imaging and computed tomography (CT) as well as whole-body fluorodeoxyglucose positron emission tomography (PET)/CT with evaluation of percentage changes in SUV(max) before and at 2-3 months after therapy. Kaplan-Meier analysis was calculated to determine overall survival. RESULTS Partial remission (PR) was observed in 8 (62 %), stable disease (SD) in 2 (15 %), and progressive disease (PD) in 3 (23 %) patients under terms of standard criteria and PR in 3 (23 %), SD in 3 (23 %), and PD in 7 (54 %) patients according to PET criteria. Neither RECIST nor PET criteria showed a significant difference in predicting overall survival (P = 0.12 and 0.11, respectively). Median survival time after radioembolization was 7 months. No acute toxicity with in-hospital morbidity was observed. One patient developed hepatomegaly, and 1 patient developed gastric ulceration. Throughout follow-up, progression of extrahepatic metastases was observed. CONCLUSION Radioembolization may be a promising therapy in uveal melanoma patients with predominant hepatic metastases. At first follow-up, we observed PR or SD in 77 % patients under terms of standard criteria with an acceptable toxicity profile.
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Boone BA, Bartlett DL, Zureikat AH. Isolated Hepatic Perfusion for the Treatment of Liver Metastases. Curr Probl Cancer 2012; 36:27-76. [DOI: 10.1016/j.currproblcancer.2011.12.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Receiver operating characteristic analysis: calculation for the marker 'melanoma inhibitory activity' in metastatic uveal melanoma patients. Melanoma Res 2011; 21:352-6. [PMID: 21540751 DOI: 10.1097/cmr.0b013e328347105e] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The serological marker melanoma inhibitory activity (MIA) has been shown to be significantly higher in the serum of patients suffering from metastatic uveal melanoma than in progression-free patients. The objective of this study was to calculate a meaningful receiver operating characteristic (ROC) curve for MIA based on a large patient collective and to find an appropriate threshold value. MIA tumor marker levels of 503 outpatients suffering from uveal melanoma were evaluated using enzyme-linked immunosorbent assay. Fifty-four patients had confirmed metastases and 449 patients showed no overt metastatic disease at the time the blood sample was taken. ROC analysis was performed and the area under the curve (AUC) was calculated. Metastatic patients showed significantly higher MIA levels (median 11.69 ng/ml) than patients in the group without overt metastatic disease (median 6.97 ng/ml) (the Mann-Whitney test, P<0.001). The AUC was 0.84 (95% confidence interval: 0.76-0.91). The ROC resulting from our study can be applied for test comparison by means of AUC. The AUC value of 0.84 for MIA demonstrates the accurate performance of the test. On the basis of this ROC curve, we propose a MIA threshold value for uveal melanoma patients of 8.3 ng/ml (with a corresponding sensitivity of 82% and specificity of 77%, positive predictive value of 0.30 and negative predictive value of 0.97). In patients with higher MIA serum levels, further diagnostics should be initiated.
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Kimple AJ, Bosch DE, Giguère PM, Siderovski DP. Regulators of G-protein signaling and their Gα substrates: promises and challenges in their use as drug discovery targets. Pharmacol Rev 2011; 63:728-49. [PMID: 21737532 DOI: 10.1124/pr.110.003038] [Citation(s) in RCA: 184] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Because G-protein coupled receptors (GPCRs) continue to represent excellent targets for the discovery and development of small-molecule therapeutics, it is posited that additional protein components of the signal transduction pathways emanating from activated GPCRs themselves are attractive as drug discovery targets. This review considers the drug discovery potential of two such components: members of the "regulators of G-protein signaling" (RGS protein) superfamily, as well as their substrates, the heterotrimeric G-protein α subunits. Highlighted are recent advances, stemming from mouse knockout studies and the use of "RGS-insensitivity" and fast-hydrolysis mutations to Gα, in our understanding of how RGS proteins selectively act in (patho)physiologic conditions controlled by GPCR signaling and how they act on the nucleotide cycling of heterotrimeric G-proteins in shaping the kinetics and sensitivity of GPCR signaling. Progress is documented regarding recent activities along the path to devising screening assays and chemical probes for the RGS protein target, not only in pursuits of inhibitors of RGS domain-mediated acceleration of Gα GTP hydrolysis but also to embrace the potential of finding allosteric activators of this RGS protein action. The review concludes in considering the Gα subunit itself as a drug target, as brought to focus by recent reports of activating mutations to GNAQ and GNA11 in ocular (uveal) melanoma. We consider the likelihood of several strategies for antagonizing the function of these oncogene alleles and their gene products, including the use of RGS proteins with Gα(q) selectivity.
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Affiliation(s)
- Adam J Kimple
- Department of Pharmacology, UNC Neuroscience Center, UNC School of Medicine, University of North Carolina at Chapel Hill, 120 Mason Farm Road, Suite 4010, Chapel Hill, NC 27599-7365, USA
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Arterial therapies of non-colorectal cancer metastases to the liver (from chemoembolization to radioembolization). ACTA ACUST UNITED AC 2011; 36:671-6. [DOI: 10.1007/s00261-011-9753-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Whole-body F-18-fluoro-2-deoxyglucose positron emission tomography/computed tomography imaging in the follow-up of metastatic uveal melanoma. Melanoma Res 2011; 20:511-6. [PMID: 20890225 DOI: 10.1097/cmr.0b013e3283403d6c] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Metastasis has been reported in the follow-up of up to 50% of uveal melanoma patients. Established oncological diagnostic modalities in tumor follow-up so far have limited sensitivity and specificity. The diagnostic value of combined positron emission tomography (PET)/computed tomography (CT) scans in the follow-up of patients with metastatic uveal melanoma was assessed. Eleven patients with successfully treated and one patient with suspected uveal melanoma underwent combined PET/CT scan. The indication for PET/CT scan was heterogenous and ranged from suspected metastatic choroidal melanoma in conventional imaging (n=3) to exclusion of further organ involvement before local therapy of liver metastases (n=5) and restaging after local or systemic therapy of metastases (n=4). PET/CT scan showed vital metastases from uveal melanoma in all patients (n=12). Ten patients showed vital hepatic metastases (83%), five osseous (42%), four lymphatic (33%), two pulmonary (17%), one adrenal (8%) and one had muscular metastases (8%). Six patients showed multiple organ involvement (50%). In addition, PET/CT scan correctly identified a primary intraocular tumor and ruled out pulmonary metastatic involvement with suspicious intrapulmonary findings in a CT scan and chest X-ray in two patients. It could also confirm an equivocal intrahepatic finding in an MRI scan as a vital metastasis. PET/CT scan is a very sensitive and specific tool for the detection and localization of metastatic disease in patients with uveal melanoma, assessing both anatomical morphology and cell metabolism in one single examination. With novel therapeutic approaches in evolution, PET/CT scanning can be of great importance for therapy planning and monitoring.
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