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Doppler M, Reincke M, Bettinger D, Vogt K, Weiss J, Schultheiss M, Uller W, Verloh N, Goetz C. Predictive Value of [ 99mTc]-MAA-Based Dosimetry in Hepatocellular Carcinoma Patients Treated with [ 90Y]-TARE: A Single-Center Experience. Diagnostics (Basel) 2023; 13:2432. [PMID: 37510175 PMCID: PMC10378141 DOI: 10.3390/diagnostics13142432] [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: 06/06/2023] [Revised: 07/13/2023] [Accepted: 07/19/2023] [Indexed: 07/30/2023] Open
Abstract
Transarterial radioembolization is a well-established method for the treatment of hepatocellular carcinoma. The tolerability and incidence of hepatic decompensation are related to the doses delivered to the tumor and healthy liver. This retrospective study was performed at our center to evaluate whether tumor- and healthy-liver-absorbed dose levels in TARE are predictive of tumor response according to the mRECIST 1.1 criteria and overall survival. One hundred and six patients with hepatocellular carcinoma were treated with [90Y]-loaded resin microspheres and completed the follow-up. The dose delivered to each compartment was calculated using a compartmental model. The model was based on [99mTc]-labelled albumin aggregate images obtained before the start of therapy. Tumor response was assessed after three months of treatment. Kaplan-Meier analysis was used to assess survival. The mean age of our population was 66 ± 13 years with a majority being BCLC B tumors. Forty-two patients presented with portal vein thrombosis. The response rate was 57% in the overall population and 59% in patients with thrombosis. Target-to-background (TBR) values measured on initial [99mTc]MAA-SPECT-imaging and tumor model dosimetric values were associated with tumor response (p < 0.001 and p = 0.009, respectively). A dosimetric threshold of 136.5 Gy was predictive of tumor response with a sensitivity of 84.2% and specificity of 89.4%. Overall survival was 24.1 months [IQR 13.1-36.4] for patients who responded to treatment compared to 10.4 months [IQR 6.3-15.9] for the remaining patients (p = 0.022). In this cohort, the initial [99mTc]MAA imaging is predictive of response and survival. The dosimetry prior to the application of TARE can be used for treatment planning and our results also suggest that the therapy is well-tolerated. In particular, hepatic decompensation can be predicted even in the presence of PVT.
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Affiliation(s)
- Michael Doppler
- Department of Diagnostic and Interventional Radiology, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, 79085 Freiburg, Germany
| | - Marlene Reincke
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, 79085 Freiburg, Germany
| | - Dominik Bettinger
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, 79085 Freiburg, Germany
| | - Katharina Vogt
- Department of Diagnostic and Interventional Radiology, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, 79085 Freiburg, Germany
| | - Jakob Weiss
- Department of Diagnostic and Interventional Radiology, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, 79085 Freiburg, Germany
| | - Michael Schultheiss
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, 79085 Freiburg, Germany
- Berta-Ottenstein-Programme, Faculty of Medicine, University of Freiburg, 79085 Freiburg, Germany
| | - Wibke Uller
- Department of Diagnostic and Interventional Radiology, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, 79085 Freiburg, Germany
| | - Niklas Verloh
- Department of Diagnostic and Interventional Radiology, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, 79085 Freiburg, Germany
| | - Christian Goetz
- Department of Nuclear Medicine, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, 79085 Freiburg, Germany
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Goswami P, Adeniran OR, K. Frantz S, Matsuoka L, Du L, Gandhi RT, Collins ZS, Matrana MR, Petroziello M, Brower JS, Sze DY, Kennedy AS, Golzarian J, Wang EA, Brown DB. Overall survival and toxicity of Y90 radioembolization for hepatocellular carcinoma patients in Barcelona Clinic Liver Cancer stage C (BCLC-C). BMC Gastroenterol 2022; 22:467. [PMCID: PMC9670475 DOI: 10.1186/s12876-022-02528-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 10/04/2022] [Indexed: 11/19/2022] Open
Abstract
Introduction National Comprehensive Cancer Network HCC guidelines recommend Y90 to treat BCLC-C patients only in select cases given the development of systemic regimens. We sought to identify ideal candidates for Y90 by assessing survival and toxicities in this patient group.
Materials and methods The Radiation-Emitting Selective Internal radiation spheres in Non-resectable tumor registry is a prospective observational study (NCT: 02,685,631). Patients with advanced HCC were stratified into 3 groups based on tumor location, Eastern Cooperative Oncology Group (ECOG) performance status, and liver function. Group 1: liver isolated HCC, ECOG 0 and Child Pugh (CP) A (n = 12, 16%), Group 2: liver isolated HCC, ECOG ≥ 1 or CP B/C (n = 37, 49%), and Group 3: extrahepatic HCC with any ECOG or CP score (n = 26, 35%). Patients in any group could have macrovascular invasion. Overall survival (OS) and progression-free survival (PFS) with 95% confidence intervals (95% CI) were calculated. Grade 3 + toxicities were tracked using Common Terminology Criteria for Adverse Events v5. Cox proportional hazard model was performed to determine factors affecting OS.
Results Seventy-five BCLC-C patients treated between 2015 and 2019 were reviewed. The groups were similar in age, sex, race, and ethnicity (all p > 0.05). Bilobar disease was least common in Group 1 (p < 0.001). Median OS of the entire cohort was 13.6 (95% CI 7.5–16.1) months. Median OS of Groups 1–3 were 21.8, 13.1 and 11.5 months respectively (p = 0.6). Median PFS for the cohort was 6.3 (4.8–14.7) months. Median PFS for group 1 was not reached. Mean PFS for Group 1 was 17.3 ± 4.8 months. Median PFS for Groups 2 and 3 was 6.8 and 5.9 months (X2 = 1.5, p = 0.5). Twenty-four Grade 3 or greater toxicities developed, most commonly hyperbilirubinemia (8/75, 11%) and thrombocytopenia (2/75, 3%). The incidence of toxicities between groups was similar (all p > 0.05). Cox Proportional Hazard analysis predicted shorter OS with CP class B/C (X2 = 6.7, p = 0.01), while macrovascular invasion (X2 = 0.5, p = 0.5) and ECOG score of ≥ 1 (X2 = 2.1, p = 0.3) was not associated with OS. Conclusions OS of CPA patients with advanced HCC and performance status of 0 was 21.8 months following Y90. CP A cirrhosis is the best predictor of prolonged OS in advanced (BCLC-C) HCC.
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Affiliation(s)
- Pulak Goswami
- grid.152326.10000 0001 2264 7217Vanderbilt University School of Medicine, Nashville, TN USA
| | - Oladapo R. Adeniran
- grid.412807.80000 0004 1936 9916Division of Interventional Radiology, Vanderbilt University Medical Center, CCC-1118 Medical Center North, 1161 21st Ave S, Nashville, TN 37232 USA
| | - Shelby K. Frantz
- grid.412807.80000 0004 1936 9916Division of Interventional Radiology, Vanderbilt University Medical Center, CCC-1118 Medical Center North, 1161 21st Ave S, Nashville, TN 37232 USA
| | - Lea Matsuoka
- grid.412807.80000 0004 1936 9916Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, TN USA
| | - Liping Du
- grid.412807.80000 0004 1936 9916Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN USA
| | - Ripal T. Gandhi
- grid.418212.c0000 0004 0465 0852Miami Cardiac and Vascular Institute/Miami Cancer Institute, Miami, FL USA
| | - Zachary S. Collins
- grid.266515.30000 0001 2106 0692Division of Interventional Radiology, University of Kansas, Kansas City, KS USA
| | - Marc R. Matrana
- grid.240416.50000 0004 0608 1972Division of Hematology/Oncology, Ochsner Medical Center, New Orleans, LA USA
| | - Michael Petroziello
- Division of Interventional Radiology, Roswell Park Medical Institute, Buffalo, NY USA
| | - Jayson S. Brower
- grid.416441.20000 0004 0457 8213Department of Radiology, Sacred Heart Medical Center, Spokane, WA USA
| | - Daniel Y. Sze
- grid.168010.e0000000419368956Division of Interventional Radiology, Stanford University, Palo Alto, CA USA
| | - Andrew S. Kennedy
- grid.419513.b0000 0004 0459 5478Department of Radiation Oncology, Sarah Cannon Research Institute, Nashville, TN USA
| | - Jafar Golzarian
- grid.17635.360000000419368657Division of Interventional Radiology, University of Minnesota, Minneapolis, MN USA
| | - Eric A. Wang
- grid.239494.10000 0000 9553 6721Department of Radiology, Carolinas Medical Center, Charlotte, NC USA
| | - Daniel B. Brown
- grid.412807.80000 0004 1936 9916Division of Interventional Radiology, Vanderbilt University Medical Center, CCC-1118 Medical Center North, 1161 21st Ave S, Nashville, TN 37232 USA
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Goyal P, Salem R, Mouli SK. Role of interventional oncology in hepatocellular carcinoma: Future best practice beyond current guidelines. Br J Radiol 2022; 95:20220379. [PMID: 35867889 PMCID: PMC9815732 DOI: 10.1259/bjr.20220379] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is a leading cause of cancer-related deaths globally. Liver transplant remains the goal of curative treatment, but limited supply of organs decreases accessibility and prolongs waiting time to transplantation. Therefore, interventional oncology therapies have been used to treat the majority of HCC patients, including those awaiting transplant. The Barcelona Clinic Liver Cancer (BCLC) classification is the most widely used staging system in management of HCC that helps allocate treatments. Since its inception in 1999, it was updated for the fifth time in November 2021 and for the first time shaped by expert opinions outside the core BCLC group. The most recent version includes additional options for early-stage disease, substratifies intermediate disease into three groups, and lists alternates to Sorafenib that can double the expected survival of advanced-stage disease. The group also proposed a new BCLC staging schema for disease progression, and endorsed treatment stage migration (TSM) directly into the main staging and treatment algorithm. This article reviews the recent developments underlying the current BCLC guidelines and highlights ongoing research, particularly involving radioembolization, that will shape future best practice.
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Affiliation(s)
- Piyush Goyal
- Department of Radiology, Section of Interventional Radiology, Northwestern Feinberg School of Medicine, Chicago, Illinois, United States
| | - Riad Salem
- Department of Radiology, Section of Interventional Radiology, Northwestern Feinberg School of Medicine, Chicago, Illinois, United States
| | - Samdeep K. Mouli
- Department of Radiology, Section of Interventional Radiology, Northwestern Feinberg School of Medicine, Chicago, Illinois, United States
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Reincke M, Schultheiss M, Doppler M, Verloh N, Uller W, Sturm L, Thimme R, Goetz C, Bettinger D. Hepatic decompensation after transarterial radioembolization: A retrospective analysis of risk factors and outcome in patients with hepatocellular carcinoma. Hepatol Commun 2022; 6:3223-3233. [PMID: 36064940 PMCID: PMC9592795 DOI: 10.1002/hep4.2072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/24/2022] [Accepted: 08/01/2022] [Indexed: 12/14/2022] Open
Abstract
Transarterial radioembolization (TARE) is a well-established therapy for intermediate and advanced tumor stages of hepatocellular carcinoma (HCC). Treatment-associated toxicities are rare. Previous studies have outlined that the prognosis after TARE is determined primarily by tumor stage and liver function. The subset of patients benefiting from TARE remains to be defined. Sixty-one patients with HCC treated with TARE between 2015 and 2020 were retrospectively included in the study. Hepatic decompensation was defined as an increase of bilirubin or newly developed ascites that was not explained by tumor progression within 3 months after TARE. Predictive factors of hepatic decompensation and prognostic factors were assessed. Hepatic decompensation was observed in 27.9% (n = 17) of TARE-treated patients during follow-up. Albumin-bilirubin (ALBI) score at baseline and radiation dose on nontumor liver proved to be independent risk factors for the development of hepatic decompensation in multivariable regression models (ALBI score: odds ratio [OR] 6.425 [1.735;23.797], p < 0.005; radiation dose: OR 1.072 [1.016;1.131], p < 0.011). The occurrence of hepatic decompensation markedly impaired the prognosis of the patients. Survival was significantly worsened. Hepatic decompensation has shown to be an independent negative prognostic factor for death, adjusted for Barcelona Clinic Liver Cancer stage, age and ALBI grade (hazard ratio 5.694 [2.713;11.952], p < 0.001). Conclusion: Hepatic decompensation after TARE for HCC treatment is a highly relevant complication with major effects on the prognosis of patients. Main risk factors are the pretreatment ALBI score and radiation dose. There is an urgent need to define safe cutoff values and exclusion criteria for TARE to limit complications and improve patient outcomes.
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Affiliation(s)
- Marlene Reincke
- Department of Medicine II, Medical Center University of Freiburg, Faculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Michael Schultheiss
- Department of Medicine II, Medical Center University of Freiburg, Faculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Michael Doppler
- Department of Diagnostic and Interventional Radiology, Medical Center University of Freiburg, Faculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Niklas Verloh
- Department of Diagnostic and Interventional Radiology, Medical Center University of Freiburg, Faculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Wibke Uller
- Department of Diagnostic and Interventional Radiology, Medical Center University of Freiburg, Faculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Lukas Sturm
- Department of Medicine II, Medical Center University of Freiburg, Faculty of MedicineUniversity of FreiburgFreiburgGermany,Berta‐Ottenstein‐Programme, Faculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Robert Thimme
- Department of Medicine II, Medical Center University of Freiburg, Faculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Christian Goetz
- Department of Nuclear Medicine, Medical Center University of Freiburg, Faculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Dominik Bettinger
- Department of Medicine II, Medical Center University of Freiburg, Faculty of MedicineUniversity of FreiburgFreiburgGermany
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Embolization therapy with microspheres for the treatment of liver cancer: State-of-the-art of clinical translation. Acta Biomater 2022; 149:1-15. [PMID: 35842035 DOI: 10.1016/j.actbio.2022.07.019] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 06/17/2022] [Accepted: 07/07/2022] [Indexed: 02/07/2023]
Abstract
Embolization with microspheres is a therapeutic strategy based on the selective occlusion of the blood vessels feeding a tumor. This procedure is intraarterially performed in the clinical setting for the treatment of liver cancer. The practice has evolved over the last decade through the incorporation of drug loading ability, biodegradability and imageability with the subsequent added functionality for the physicians and improved clinical outcomes for the patients. This review highlights the evolution of the embolization systems developed through the analysis of the marketed embolic microspheres for the treatment of malignant hepatocellular carcinoma, namely the most predominant form of liver cancer. Embolic microspheres for the distinct modalities of embolization (i.e., bland embolization, chemoembolization and radioembolization) are here comprehensively compiled with emphasis on material characteristics and their impact on microsphere performance. Moreover, the future application of the embolics under clinical investigation is discussed along with the scientific and regulatory challenges ahead in the field. STATEMENT OF SIGNIFICANCE: Embolization therapy with microspheres is currently used in the clinical setting for the treatment of most liver cancer conditions. The progressive development of added functionalities on embolic microspheres (such as biodegradability, imageability or drug and radiopharmaceutical loading capability) provides further benefit to patients and widens the therapeutic armamentarium for physicians towards truly personalized therapies. Therefore, it is important to analyze the possibilities that advanced biomaterials offer in the field from a clinical translational perspective to outline the future trends in therapeutic embolization.
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Kappadath SC, Lopez BP. Organ-level internal dosimetry for intra-hepatic-arterial administration of 99m Tc-macroaggregated albumin. Med Phys 2022; 49:5504-5512. [PMID: 35612924 DOI: 10.1002/mp.15726] [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: 11/16/2021] [Revised: 05/06/2022] [Accepted: 05/06/2022] [Indexed: 11/08/2022] Open
Abstract
PURPOSE There are no published data on organ doses following intra-hepatic-arterial administration of 99m Tc-macroaggregated-albumin (IHA 99m Tc-MAA) routinely used in 90 Y-radioembolization-treatment planning to assess intra- and extra-hepatic depositions and calculate lung-shunt-fraction (LSF). We propose a method to model the organ doses following IHA 99m Tc-MAA that incorporates three in vivo constituent biodistributions, the 99m Tc-MAA that escape the liver due to LSF, and the 99m Tc-MAA disassociation fraction (DF). METHODS The potential in vivo biodistributions for IHA 99m Tc-MAA are: Liver-Only MAA with all activity sequestered in the liver (LSF = 0&DF = 0), Intravenous MAA with all activity transferred intravenously as 99m Tc-MAA (LSF = 1&DF = 0), and Intravenous Pertechnetate with all activity is transferred intravenously as 99m Tc-pertechnetate (LSF = 0&DF = 1). Organ doses for Liver-Only MAA were determined using OLINDA/EXM 2.2, where liver was modeled as the source organ containing 99m Tc-MAA, while those for Intravenous MAA and Intravenous Pertechnetate were from ICRP 128. Organ doses for the general case can be determined as a weighted-linear-combination of the three constituent biodistributions depending on the LSF and DF. The maximum-dose scenario was modeled by selecting the highest dose rate for each organ amongst the three constituent cases. RESULTS For Liver-Only MAA, the liver as source organ received the highest dose at 98.6 and 126 mGy/GBq for the Adult Male and Adult Female phantoms, respectively; all remaining organs received <27 and <32 mGy/GBq. For Intravenous MAA, the lung as source organ received the highest dose at 66 and 97 mGy/GBq; all remaining organs received <16 and <21 mGy/GBq. The organ with the highest dose for Intravenous Pertechnetate was the upper-large-intestinal wall at 56 and 73 mGy/GBq; all remaining organs received <26 and <34 mGy/GBq. The liver and lung doses for the maximum-dose scenario with 5 mCi (185 MBq) 99m Tc-MAA were estimated at 18.2 and 12.2 mGy, and 23.3 and 17.9 mGy, for the Adult Male and Adult Female phantoms, respectively. CONCLUSION Organ dose estimates following IHA 99m Tc-MAA based on constituent biodistribution models and patient-specific LSF and DF values have been derived. Liver and lung were the organs with highest dose, receiving at most 15 - 25 mGy in the maximum-dose scenario, following 5 mCi IHA 99m Tc-MAA. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- S Cheenu Kappadath
- Department of Imaging Physics UT MD Anderson Cancer Center, Houston, Texas, 77030, USA
| | - Benjamin P Lopez
- Department of Imaging Physics UT MD Anderson Cancer Center, Houston, Texas, 77030, USA
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