The SIRveNIB and SARAH trials, radioembolization vs. sorafenib in advanced HCC patients: reasons for a failure, and perspectives for the future

EASL Clinical Practice Guidelines on the management of hepatocellular carcinoma

Liver cancer is the third leading cause of cancer-related deaths worldwide, with hepatocellular carcinoma (HCC) accounting for approximately 90% of primary liver cancers. Advances in diagnostic and therapeutic tools, along with improved understanding of their application, are transforming patient treatment. Integrating these innovations into clinical practice presents challenges and necessitates guidance. These clinical practice guidelines offer updated advice for managing patients with HCC and provide a comprehensive review of pertinent data. Key updates from the 2018 EASL guidelines include personalised surveillance based on individual risk assessment and the use of new tools, standardisation of liver imaging procedures and diagnostic criteria, use of minimally invasive surgery in complex cases together with updates on the integrated role of liver transplantation, transitions between surgical, locoregional, and systemic therapies, the role of radiation therapies, and the use of combination immunotherapies at various stages of disease. Above all, there is an absolute need for a multiparametric assessment of individual risks and benefits, considering the patient's perspective, by a multidisciplinary team encompassing various specialties.

Measure of 90Y-glass microspheres residue post-TARE using PET/CT and potential impact on tumor absorbed dose in comparison 99mTc-MAA SPECT/CT dosimetry

BACKGROUND

Transarterial radio-embolization (TARE) became a routine procedure for non-resectable liver tumor mainly hepatocellular carcinoma (HCC). Personalized dosimetry to the index lesion increased tumor response rate. However, there is no requirement to measure the precise activity injected during TARE. We measured 90Y-glass microspheres residue (90Y-Res) in the application system after TARE and assessed its potential impact on the tumor absorbed dose (AD) previously planned with 99mTc MAA SPECT/CT.

METHODS

We measured 90Y-Res using PET/CT in all patients that underwent TARE using 90Y-glass-microspheres for non-resectable liver tumors over one year.

RESULTS

90Y-Res was measured in 34 patients (HCC n = 22) with 61 injections, 93.1 ± 94.6 MBq [2-437] that was 4.8 ± 3.5% [0.2-13.7] in comparison to the activity measured in the sealed TheraSphere™ vial (ρ = 0.697; p < 0.001).

CONCLUSION

We reported an average of 5% 90Y-Res using PET/CT after TARE with the strongest association to the activity in the TheraSphere™ vial. Therefore, when a high 90Y-Res is suspected on the survey meter, a 90Y-PET/CT scan of 90Y-Res might be useful as a first step to estimate if the target lesion received the recommended AD, especially in HCC patients with borderline tumor dosimetry on the pre-treatment 99mTc-MAA SPECT/CT.

British Society of Gastroenterology guidelines for the management of hepatocellular carcinoma in adults

Deaths from the majority of cancers are falling globally, but the incidence and mortality from hepatocellular carcinoma (HCC) is increasing in the United Kingdom and in other Western countries. HCC is a highly fatal cancer, often diagnosed late, with an incidence to mortality ratio that approaches 1. Despite there being a number of treatment options, including those associated with good medium to long-term survival, 5-year survival from HCC in the UK remains below 20%. Sex, ethnicity and deprivation are important demographics for the incidence of, and/or survival from, HCC. These clinical practice guidelines will provide evidence-based advice for the assessment and management of patients with HCC. The clinical and scientific data underpinning the recommendations we make are summarised in detail. Much of the content will have broad relevance, but the treatment algorithms are based on therapies that are available in the UK and have regulatory approval for use in the National Health Service.

Radiometals in Imaging and Therapy: Highlighting Two Decades of Research

The present article highlights the important progress made in the last two decades in the fields of molecular imaging and radionuclide therapy. Advancements in radiometal-based positron emission tomography, single photon emission computerized tomography, and radionuclide therapy are illustrated in terms of their production routes and ease of radiolabeling. Applications in clinical diagnostic and radionuclide therapy are considered, including human studies under clinical trials; their current stages of clinical translations and findings are summarized. Because the metalloid astatine is used for imaging and radionuclide therapy, it is included in this review. In regard to radionuclide therapy, both beta-minus (β-) and alpha (α)-emitting radionuclides are discussed by highlighting their production routes, targeted radiopharmaceuticals, and current clinical translation stage.

Contemporary applications of Y90 for the treatment of hepatocellular carcinoma

Transarterial radioembolization (TARE) with yttrium-90 (90Y) microspheres has been widely adopted for the treatment of HCC. Recent advances in yttrium-90 (90Y) dosimetry have led to durable local responses. Radiation segmentectomy has become a viable alternative to thermal ablation for early-stage HCC (Barcelona Clinic Liver Cancer 0 and A) and has been commonly used as a bridge to transplant. TARE is also commonly used for downstaging to transplant using traditional lobar dosimetry and radiation segmentectomy techniques. Radiation lobectomy has a dual role in local tumor control and induction of contralateral liver lobe hypertrophy as a bridge to resection for patients with an inadequate future liver remnant. TARE continues to provide disease control for patients with limited vascular invasion and may be an alternative to systemic therapy for patients with localized advanced disease. The potential synergy between TARE and immunotherapy has been recognized, and prospective studies evaluating this combination are needed for patients with Barcelona Clinic Liver Cancer B and C HCC.

A Sodium Alginate-Based Multifunctional Nanoplatform for Synergistic Chemo-Immunotherapy of Hepatocellular Carcinoma

Efficient hepatocellular carcinoma (HCC) treatment remains a significant challenge due to the inherent limitations of traditional strategies. The exploration of polysaccharides' natural immunity for HCC immunotherapy is rarely explored. For this purpose, facile construction of a multifunctional nanoplatform, biotinylated aldehyde alginate-doxorubicin nano micelle (BEACNDOXM) is reported in this study for synergistic chemo-immunotherapy by using constant β-D-mannuronic acid (M) units and modulated α-L-guluronic acid (G) units in the alginate (ALG) structure. The M units show natural immunity and specific binding ability with mannose receptors (MRs) via strong receptor-ligand interactions, and the G units serve as highly reactive conjugation sites for biotin (Bio) and DOX. Therefore, this formulation not only integrates the natural immunity of ALG and the immunogenic cell death (ICD) triggering function of DOX, but also shows dual targeting properties to HCC cells via MRs and Bio receptors (BRs)-mediated endocytosis. Notably, BEACNDOXM mediates a tumor inhibitory efficiency 12.10% and 4.70% higher than free DOX and single targeting aldehyde alginate-doxorubicin nano micelle controls, respectively, at an equivalent DOX dose of 3 mg kg-1 in Hepa1-6 tumor-bearing mice. This study reports the first example of integrating the natural immunity of ALG and the ICD effect of anticancer drugs for enhanced chemo-immunotherapy of HCC.

The Hong Kong consensus statements on unresectable hepatocellular carcinoma: narrative review and update for 2021

Background and Objective

Hong Kong, like many parts of Asia, faces a high burden of hepatocellular carcinoma (HCC) caused by high endemic rates of hepatitis B virus infection. Hong Kong clinicians have developed a high level of expertise in HCC treatment across surgical, transarterial, ablative, radiotherapeutic and systemic modalities. This publication summarizes the latest evidence-based recommendations on how these modalities should be used.

Methods

In two meetings held in 2020, a multidisciplinary panel of surgeons, oncologists and interventional radiologists performed a narrative review of evidence on the management of HCC, with an emphasis on treatment of HCC not amenable to surgical resection. Close attention was paid to new evidence published since the previous version of these statements in 2018.

Key Content and Findings

The expert panel has formulated 60 consensus statements to guide the staging and treatment of unresectable HCC. Since the previous version of these statements, considerable additions have been made to the recommendations on use of targeted therapies and immunotherapies because of the large volume of new evidence.

Conclusions

Our consensus statements offer guidance on how to select HCC patients for surgical or non-surgical treatment and for choosing among non-surgical modalities for patients who are not candidates for resection. In particular, there is a need for more evidence to aid physicians in the selection of second-line systemic therapies, as currently most data are limited to patients with disease progression on first-line sorafenib.

Treatment patterns, risk factors and outcomes for patients with newly diagnosed hepatocellular carcinoma in France: a retrospective database analysis

BACKGROUND & AIMS

The aim of this analysis was to describe the nationwide distribution of patients with newly diagnosed Hepatocellular carcinoma (HCC) according to treatment pattern, aetiologies, and outcomes in France.

METHOD

A retrospective cohort of patients with newly diagnosed HCC was selected over the period 2015-2017 in a French claims database covering 99% of the population. Treatment pattern was described using an algorithm based on a ranking of curative and palliative HCC treatments identified. Survival was analyzed using Kaplan-Meier curves according to major treatments and aetiologies.

RESULTS

A total of 20,083 incident patients were identified with a mean age of 69.2 years (SD: 11.0) and 82.4% of men. The mean duration of follow-up was 10.0 months (SD: 9.7). At least one HCC risk factor could be identified in 87.0% of patients. The most frequent aetiologies were alcohol-related liver disease present in 50.8% of patients, a metabolic disease (NAFLD, NASH or diabetes) without alcohol or viral hepatitis (44.5%) and viral hepatitis (20.0%). Only 32.7% of patients received a curative therapy, with a 1-year survival of 89.5%, while 38.0% of patients received only best supportive care, with a 1-year survival of 12.9%. The highest rates of curative treatments were found in patients with viral hepatitis, associated or not with another risk factor.

CONCLUSION

Hepatocellular carcinoma was still most often diagnosed at an advanced disease stage as shown by the low rate of curative treatment observed and the very poor prognosis. Viral hepatic aetiology was associated with the best survival.

Advances in Delivery of Selective Internal Radiation Therapy (SIRT): Economic and Logistical Effects of Same-Stay Work-Up and Procedure in the Treatment of Unresectable Liver Tumors in England

INTRODUCTION

Selective internal radiation therapy (SIRT) is a targeted method of treatment for unresectable liver tumors in which radiation therapy is directly delivered to the tumor(s) via the hepatic vasculature. Successful outcomes with SIRT are dependent on the specific vasculature of the liver and tumor, and the patient therefore needs to attend a "work-up" to map the hepatic vasculature prior to the SIRT procedure. Recent advances in SIRT delivery have enabled same-day or same-stay work-up and procedure, requiring only one hospital visit rather than two. We aimed to evaluate the economic, travel time, and transport-related environmental impact of a new brachytherapy device delivery program, the order-map-treat (OMT) program, in patients with unresectable hepatocellular carcinoma (HCC) in England.

METHODS

A healthcare resource group (HRG)-based analysis of costs from a national payer (Department of Health and Social Care, DHSC) perspective was conducted assuming that, with OMT, patients would have to attend hospital only once for both the SIRT work-up and procedure versus twice without OMT. Patient travel time and CO₂ emissions were then estimated by identifying the SIRT center closest to the centroid of each clinical commissioning group (CCG) and calculating straight-line distances with a "detour index" to capture the effect of indirect routes via road or rail.

RESULTS

It was estimated that 856 patients per annum would be eligible for SIRT treatment for unresectable HCC in England. OMT would be anticipated to save GBP 2842 per patient versus performing SIRT without OMT. Furthermore, across all patients with HCC eligible for SIRT in England, OMT would avoid 74,500 km of travel, 2299 h of travel time, and 13.9 metric tons of patient transport-related CO₂ emissions annually.

CONCLUSION

OMT reduces the number of hospital visits required for SIRT by 50%, resulting in financial savings from the DHSC perspective, time savings from the patient perspective, and reduced CO₂ emissions arising from patient transport.

Radioembolization in patients with hepatocellular carcinoma: a series of 53 cases

OBJECTIVE

To contribute our results to increase the scientific evidence about the use of radioembolization in the management of patients with hepatocellular carcinoma.

MATERIAL AND METHODS

This retrospective review included 53 patients with hepatocellular carcinoma treated with radioembolization at our center. Patients were classified according to the BCLC algorithm in detail according to their Child-Pugh functional status. We analyzed survival using the Kaplan-Meier method. We used Cox regression analysis to determine clinically significant parameters, including the doses administered in the parameters studied.

RESULTS

Patients ranged in age from 28 to 86 years (mean, 60 years). A total of 61 procedures were done. The mean activity administered was 2.8GBq (0.7-6.4GBq), with a mean dose of 229.9Gy (74-425.9Gy) administered in the tumor. Progression-free survival was 6.7 months and overall survival was 12.8 months. Differences in disease-free survival according to BCLC and Child-Pugh classification were not significant (p=0.848 and p=0.252, respectively). The clinical parameters that were significantly different with respect to overall survival were bilirubin levels (p<0.001), pretreatment transaminase levels (AST) (p=0.022), Child-Pugh subclassification (p=0.003), and dose administered in the tumor (p=0.001). Only one patient had a severe adverse reaction, developing posttreatment liver failure resulting in death.

CONCLUSIONS

Radioembolization is safe and efficacious in the treatment of patients with hepatocellular carcinoma. Liver function and the doses received by the tumor are key parameters for the efficacy of treatment. The increase in the scientific evidence supports the inclusion of this technique in treatment guidelines.

Target Trial Emulation: A Design Tool for Cancer Clinical Trials

PURPOSE

To apply target trial emulation to explore the potential impact of eligibility criteria on the primary outcome of a randomized controlled trial.

METHODS

Simulations of a real-world explanatory trial of transarterial radioembolization for advanced unresectable hepatocellular carcinoma with portal vein invasion were performed to examine the effects of cohort specification on survival outcomes and patient sample size. Simulations comprised 24 different permutations of the trial varied on three disease nonspecific eligibility parameters. Treatment and control arms for these emulated trials were drawn from the National Cancer Database and matched by treatment propensity. Target trial emulation served as the causal framework for this analysis, allowing the architecture of a true controlled experiment to address forms of bias routinely encountered in comparative effectiveness studies involving real-world observational data.

RESULTS

Twenty-four propensity score-matched cohorts comprising a wider clinical spectrum of patients than specified by the original target trial were successfully generated using the National Cancer Database. The arms for each of the emulated trials demonstrated exchangeability across all eligibility criteria and other clinical covariates. Significant treatment benefits were associated with only a narrow range of eligibility criteria, indicating that the original target trial was well specified.

CONCLUSION

The impact of patient selection on treatment outcomes can be studied using target trial emulation. This analytical framework can furthermore serve to leverage existing real-world data to inform the task of cohort specification for a randomized controlled trial, facilitating a more data-driven approach for this important step in clinical trial design.

Improved Survival after Transarterial Radioembolisation for Hepatocellular Carcinoma Gives the Procedure Added Value

BACKGROUND

Transarterial Radioembolisation (TARE) requires multidisciplinary experience and skill to be effective. The aim of this study was to identify determinants of survival in patients with hepatocellular carcinoma (HCC), focusing on learning curves, technical advancements, patient selection and subsequent therapies.

METHODS

From 2005 to 2020, 253 patients were treated. TARE results achieved in an initial period (2005-2011) were compared to those obtained in a more recent period (2012-2020). To isolate the effect of the treatment period, differences between the two periods were balanced using "entropy balance".

RESULTS

Of the 253 patients, 68 were treated before 2012 and 185 after 2012. In the second period, patients had an Eastern Cooperative Oncology Group (ECOG) Performance Status (PS) score of 1 (p = 0.025) less frequently, less liver involvement (p = 0.006) and a lesser degree of vascular invasion (p = 0.019). The median overall survival (OS) of patients treated before 2012 was 11.2 months and that of patients treated beginning in 2012 was 25.7 months. After reweighting to isolate the effect of the treatment period, the median OS of patients before 2012 increased to 16 months.

CONCLUSIONS

Better patient selection, refinement of technique and adoption of personalised dosimetry improved survival after TARE. Conversely, sorafenib after TARE did not impact life expectancy.

Factors impacting survival after transarterial radioembolization in patients with hepatocellular carcinoma: Results from the prospective CIRT study

Background & Aims

Transarterial radioembolization (TARE) with Yttrium-90 resin microspheres is an established treatment option for patients with hepatocellular carcinoma (HCC). However, optimising treatment application and patient selection remains challenging. We report here on the effectiveness, safety and prognostic factors, including dosing methods, associated with TARE for HCC in the prospective observational CIRT study.

Methods

We analysed 422 patients with HCC enrolled between Jan 2015 and Dec 2017, with follow-up visits every 3 months for up to 24 months after first TARE. Patient characteristics and treatment-related data were collected at baseline; adverse events and time-to-event data (overall survival [OS], progression-free survival [PFS] and hepatic PFS) were collected at every 3-month follow-up visit. We used the multivariable Cox proportional hazard model and propensity score matching to identify independent prognostic factors for effectiveness outcomes.

Results

The median OS was 16.5 months, the median PFS was 6.1 months, and the median hepatic PFS was 6.7 months. Partition model dosimetry resulted in improved OS compared to body surface area calculations on multivariable analysis (hazard ratio 0.65; 95% CI 0.46-0.92; p = 0.0144), which was confirmed in the exact matching propensity score analysis (hazard ratio 0.56; 95% CI 0.35-0.89; p = 0.0136). Other independent prognostic factors for OS were ECOG-performance status >0 (p = 0.0018), presence of ascites (p = 0.0152), right-sided tumours (p = 0.0002), the presence of portal vein thrombosis (p = 0.0378) and main portal vein thrombosis (p = 0.0028), ALBI grade 2 (p = 0.0043) and 3 (p = 0.0014). Adverse events were recorded in 36.7% of patients, with 9.7% of patients experiencing grade 3 or higher adverse events.

Conclusions

This large prospective observational dataset shows that TARE is an effective and safe treatment in patients with HCC. Using partition model dosimetry was associated with a significant improvement in survival outcomes.

Impact and implications

Transarterial radioembolization (TARE) is a form of localised radiation therapy and is a potential treatment option for primary liver cancer. We observed how TARE was used in real-life clinical practice in various European countries and if any factors predict how well the treatment performs. We found that when a more complex but personalised method to calculate the applied radiation activity was used, the patient responded better than when a more generic method was used. Furthermore, we identified that general patient health, ascites and liver function can predict outcomes after TARE.

Clinical trial number

NCT02305459.

Radioembolization of Hepatocellular Carcinoma with 90Y Glass Microspheres: No Advantage of Voxel Dosimetry with Respect to Mean Dose in Dose-Response Analysis with Two Radiological Methods

Simple Summary

We confirmed that the non-uniformity of an intra-lesion dose distribution, which was introduced in calculations as voxel dosimetry, did not significantly improve the AUC values of the dose–response relationship with respect to the mean dose. This was probably derived from the strong correlations (all p < 0.0001) among all voxel-based dosimetric variables (minimum Spearman correlation coefficient: 0.67) caused by the limited spatial resolution of nuclear medicine images. Responses were assessed with mRECIST and with an experimental densitometric method with a response threshold optimized at 20% HU variation. Significant dose–response agreement was obtained only with the densitometric method and only with post-therapy 90Y-PET data. More unexpectedly, the injection of Theraspheres™ on day 8 from the reference date rather than on day 4 worsened the dose–response correlation and reduced the efficacy at high doses. This may be explained by the increased non-uniformity following the non-linear mega-clustering effect triggered by the higher number of microspheres/GBq injected on day 8.

Abstract

In this confirmatory study, we tested if a calculation that included the non-uniformity of dose deposition through a voxel-based dosimetric variable Ψ was able to improve the dose–response agreement with respect to the mean absorbed dose D. We performed dosimetry with ^99mTc-MAA SPECT/CT and ⁹⁰Y-PET/CT in 86 patients treated 8 instead of 4 days after the reference date with 2.8 times more ⁹⁰Y glass microspheres/GBq than in our previous study. The lesion-by-lesion response was assessed with the mRECIST method and with an experimental densitometric criterion. A total of 106 lesions were studied. Considering Ψ as a prognostic response marker, having no Ψ provided a significantly higher AUC than D. The correlation, t-test, and AUC values were statistically significant only with the densitometric method and only with post-therapy dosimetry. In comparison with our previous study, the dose–response correlation and AUC values were poorer (maximum r = 0.43, R² = 0.14, maximal AUC = 0.71), and the efficacy at a high dose did not reach 100%. The expected advantages of voxel dosimetry were nullified by the correlation between any Ψ and D due to the limited image spatial resolution. The lower AUC and efficacy may be explained by the mega-clustering effect triggered by the higher number of microspheres/GBq injected on day 8.

New Radionuclides and Technological Advances in SPECT and PET Scanners

Simple Summary

Advances in nuclear medicine are made by technological and radionuclide improvements. Throughout nuclear medicine’s history, these advances were often intertwined and complementary based on different clinical questions, availability and need. This paper covers some of these developments in radionuclides and instrumentation.

Abstract

Developments throughout the history of nuclear medicine have involved improvements in both instrumentation and radionuclides, which have been intertwined. Instrumentation developments always occurred during the search to improving devices’ sensitivity and included advances in detector technology (with the introduction of cadmium zinc telluride and digital Positron Emission Tomography—PET-devices with silicon photomultipliers), design (total body PET) and configuration (ring-shaped, Single-Photon Emission Computed Tomography (SPECT), Compton camera). In the field of radionuclide development, we observed the continual changing of clinically used radionuclides, which is sometimes influenced by instrumentation technology but also driven by availability, patient safety and clinical questions. Some areas, such as tumour imaging, have faced challenges when changing radionuclides based on availability, when this produced undesirable clinical findings with the introduction of unclear focal uptakes and unspecific uptakes. On the other end of spectrum, further developments of PET technology have seen a resurgence in its use in nuclear cardiology, with rubidium-82 from strontium-82/rubidium-82 generators being the radionuclide of choice, moving away from SPECT nuclides thallium-201 and technetium-99m. These continuing improvements in both instrumentation and radionuclide development have helped the growth of nuclear medicine and its importance in the ever-evolving range of patient care options.

Beyond the MAA-Y90 Paradigm: The Evolution of Radioembolization Dosimetry Approaches and Scout Particles

Radioembolization is a well-established treatment for primary and metastatic liver cancer. There is increasing interest in personalized treatment planning supported by dosimetry, as it provides an opportunity to optimize dose delivery to tumor and minimize nontarget deposition, which demonstrably increases the efficacy and safety of this therapy. However, the optimal dosimetry procedure in the radioembolization setting is still evolving; existing data are limited as few trials have prospectively tailored dose based on personalized planning and predominantly semi-empirical methods are used for dose calculation. Since the pretreatment or "scout" procedure forms the basis of dosimetry calculations, an accurate and reliable technique is essential. ^99m Tc-MAA SPECT constitutes the current accepted standard for pretreatment imaging; however, inconsistent patterns in published data raise the question whether this is the optimal agent. Alternative particles are now being introduced to the market, and early indications suggest use of an identical scout and treatment particle may be superior to the current standard. This review will undertake an evaluation of the increasingly refined dosimetric methods driving radioembolization practices, and a horizon scanning exercise identifying alternative scout particle solutions. Together these constitute a compelling vision for future treatment planning methods that prioritize individualized care.

Expression and Prognostic Role of E2F2 in Hepatocellular Carcinoma

Introduction

Hepatocellular carcinoma (HCC) is a common clinical malignancy. Recent studies reported that E2F transcription factor 2 (E2F2) plays a significant role in tumor progression. However, its expression and biological function in HCC are still unclear. Therefore, we explored the relationship between E2F2 expression and tumor progression in HCC.

Methods

In this study, we utilized some online tools to explore the E2F2 expression in pan-carcinoma and HCC. The association of E2F2 expression with the clinical characteristics and prognosis of HCC was further studied. In addition, we explored the co-expressed genes of E2F2 and mined the positively/negatively corrected significant genes and excavated the possible functions. Meanwhile, the hub gene set was constructed based on protein-protein interaction (PPI) network, and the relationship between E2F2 and immunity was discovered.

Results

We observed that the expression level of E2F2 was generally upregulated in HCC. However, E2F2 expression was not significantly different between HCC and normal tissues in regard to the disease stage 4. Furthermore, we also observed the poor prognosis in patients with high E2F2 expression. The co-expressed genes of E2F2 were identified and further detected. Thereafter, we identified the positively/negatively corrected significant genes and constructed the hub gene network of E2F2 based on PPI network. We also found that E2F2 expression was positively correlated with the infiltration levels of CD4+ T, CD8+ T cells, macrophages, neutrophils, and dendritic cells.

Conclusion

Our findings suggested that E2F2 could be a potential prognostic factor for HCC, which could provide a therapeutic target for the molecular treatment of HCC.

Hepatocellular carcinoma locoregional therapies: Outcomes and future horizons

Hepatocellular carcinoma (HCC) is the most common primary cancer of the liver and has an overall five-year survival rate of less than twenty percent. For patients with unresectable disease, evolving liver-directed locoregional therapies provide efficacious treatment across the spectrum of disease stages and via a variety of catheter-directed and percutaneous techniques. Goals of locoregional therapies in HCC may include curative intent in early-stage disease, bridging or downstaging to surgical resection or transplantation for early or intermediate-stage disease, and local disease control and palliation in advanced-stage disease. This review explores the outcomes of chemoembolization, bland embolization, radioembolization, and percutaneous ablative therapies. Attention is also given to prognostic factors related to each of the respective techniques, as well as future directions of locoregional therapies for HCC.

Effects of Trial Population Selection on Quality of Life and Healthcare Decision-Making: A Systematic Review and Example in the Treatment of Hepatocellular Carcinoma with Radioembolization

Background and Aims

Quality of life is among the most important considerations in the treatment of hepatocellular carcinoma (HCC), arguably second only to overall survival. Measuring and modeling patient quality of life is also crucial in the evaluation of the cost-effectiveness of health interventions. In the present study, we aimed to identify cost-utility analyses comparing selective internal radiation therapy (SIRT) with systemic therapy in patients with unresectable HCC and to compare the modeled incremental quality of life differences between the two therapies.

Methods

A systematic literature review was conducted. PubMed, EMBASE, the Cochrane Library, and health technology assessment agency websites were searched to identify cost–utility studies of SIRT versus systemic therapies in the treatment of HCC. Key characteristics of the studies, modeled populations and incremental quality of life outcomes were extracted from the included studies.

Results

The systematic literature review retrieved 1140 studies, of which four were ultimately included. Hand searches then identified two distinct analyses, and an updated version of one of the four studies identified initially. From these seven studies, 18 analyses were included. Analyses using data from the overall trial populations reported incremental quality-of-life estimates spanning −0.09 to +0.28 quality-adjusted life years (QALYs), with that range expanding to −0.09 to +0.60 QALYs when also considering post hoc sub-group analyses.

Conclusion

The wide range of incremental QALYs, with substantial differences between overall trial populations and subgroups, illustrates the impact that the choice of target population may have on the relative quality of life outcomes of the compared interventions, which may in turn affect clinical decision-making. The small differences also highlight both the importance of reporting measures of dispersion around the findings, and the limitations of the incremental cost-effectiveness ratio (ICER) for assessing the relative cost-effectiveness of interventions that are predicted to result in similar quality-of-life outcomes.

Management of Liver Tumors during the COVID-19 Pandemic: The Added Value of Selective Internal Radiation Therapy (SIRT)

Background: In the context of the coronavirus disease 2019 (COVID-19) pandemic, liver-directed therapies (LDTs) may offer minimally invasive integrative tools for tumor control. Among them, selective internal radiation therapy (SIRT) represents a safe, flexible and effective treatment. Purpose of this study is to present our experience with SIRT during the first wave of COVID-19 pandemic and provide an overview of the indications and challenges of SIRT in this scenario. Methods: We retrospectively analyzed the number of patients evaluated by Multidisciplinary Liver Tumor Board (MLTB) and who were undergoing LDTs between March and July 2020 and compared it with 2019. For patients treated with SIRT, clinical data, treatment details and the best radiological response were collected. Results: Compared to 2019, we observed a 27.5% reduction in the number of patients referred to MLTB and a 28.3% decrease in percutaneous ablations; transarterial chemoembolizations were stable, while SIRT increased by 64%. The majority of SIRT patients (75%) had primary tumors, mostly HCC. The best objective response and disease control rates were 56.7% and 72.2%, respectively. Conclusion: The first wave of the COVID-19 pandemic was characterized by an increased demand for SIRT, which represents a safe, flexible and effective treatment, whose manageability will further improve by simplifying the treatment workflow, developing user-friendly and reliable tools for personalized dosimetry and improving interdisciplinary communication.

Therapies for hepatocellular carcinoma: overview, clinical indications, and comparative outcome evaluation. Part two: noncurative intention

Locoregional therapies can be offered to hepatocellular carcinoma patients as a bridge to transplant, to downstage disease burden for transplant eligibility, or for disease control to prolong survival. Systemic therapies also play a large role in HCC treatment, occasionally in conjunction with other methods. This manuscript reviews the various treatment options for HCC with a historically noncurative intent.

Transarterial Radioembolization for Hepatocellular Carcinoma with Major Vascular Invasion: A Nationwide Propensity Score-Matched Analysis with Target Trial Emulation

PURPOSE

To examine National Cancer Database (NCDB) data to comparatively evaluate overall survival (OS) between patients undergoing transarterial radioembolization (TARE) and those undergoing systemic therapy for hepatocellular carcinoma with major vascular invasion (HCC-MVI).

METHODS

One thousand five hundred fourteen patients with HCC-MVI undergoing first-line TARE or systemic therapy were identified from the NCDB. OS was compared using propensity score-matched Cox regression and landmark analysis. Efficacy was also compared within a target trial framework.

RESULTS

TARE usage doubled between 2010 and 2015. Intervals before treatment were longer for TARE than for systemic therapy (mean [median], 66.5 [60] days vs 46.8 (35) days, respectively, P < .0001). In propensity-score-matched and landmark-time-adjusted analyses, TARE was found to be associated with a hazard ratio of 0.74 (95 % CI, 0.60-0.91; P = .005) and median OS of 7.1 months (95 % CI, 5.0-10.5) versus 4.9 months (95 % CI, 3.9-6.5) for systemically treated patients. In an emulated target trial involving 236 patients with unilobular HCC-MVI, a low number of comorbidities, creatinine levels <2.0 mg/dL, bilirubin levels <2.0 mg/dL, and international normalized ratio <1.7, TARE was found to be associated with a hazard ratio of 0.57 (95 % CI, 0.39-0.83; P = .004) and a median OS of 12.9 months (95 % CI, 7.6-19.2) versus 6.5 months (95 % CI, 3.6-11.1) for the systemic therapy arm.

CONCLUSIONS

In propensity-score-matched analyses involving pragmatic and target trial HCC-MVI cohorts, TARE was found to be associated with significant survival benefits compared with systemic therapy. Although not a substitute for prospective trials, these findings suggest that the increasing use of TARE for HCC-MVI is accompanied by improved OS. Further trials of TARE in patients with HCC-MVI are needed, especially to compare with newer systemic therapies.

Prediction of tumor response and patient outcome after radioembolization of hepatocellular carcinoma using 90Y-PET-computed tomography dosimetry

AIM

90Y-radioembolization using glass or resin microspheres is increasingly used for the treatment of hepatocellular carcinoma (HCC). The aim of this retrospective study is to determine the prognostic relevance of dosimetric parameters defined with 90Y-PET-CT obtained immediately after radioembolization.

METHODS

Forty-five HCC patients, mostly with multiple lesions, were treated by radioembolization between 2011 and 2017. After treatment, all underwent a 90Y PET-CT with time of flight reconstruction (90Y-TOF-PET-CT). Tumor absorbed dose and cumulative tumor dose-volume histogram were calculated using a dose point Kernel convolution algorithm. The radiological tumor response was assessed using modified (m)-RECIST criteria. Progression-free-survival (PFS) and overall survival (OS) were analyzed using the Kaplan-Meier method and Cox regression analysis.

RESULTS

Twenty-six patients were treated with glass microspheres (73 lesions) and nineteen with resin microspheres (60 lesions). Thresholds of 118 and 61 Gy for glass and resin microspheres respectively correlate well with radiological response with a positive predictive value (PPV) of 98 and 80% and discriminate patient outcome with regard to PFS (P = 0.03 and 0.005) and OS (P = 0.003 and 0.007). Using dose volume histogram, a minimal absorbed dose of 40 Gy in 66% of the tumor volume (defined as D66) was highly predictive of radiological response (PPV = 94%), PFS (P < 0.001) and OS (P = 0. 008), for either device.

CONCLUSION

Dosimetric parameters obtained using 90Y-PET-CT are predictive of tumor response, PFS and OS. In clinical practice, a systematic dosimetric evaluation using 90Y PET should be implemented to help predicting patient outcomes.

Locoregional therapies in the era of molecular and immune treatments for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the fourth leading cause of cancer-related mortality and has an increasing incidence worldwide. Locoregional therapies, defined as imaging-guided liver tumour-directed procedures, play a leading part in the management of 50-60% of HCCs. Radiofrequency is the mainstay for local ablation at early stages and transarterial chemoembolization (TACE) remains the standard treatment for intermediate-stage HCC. Other local ablative techniques (microwave ablation, cryoablation and irreversible electroporation) or locoregional therapies (for example, radioembolization and sterotactic body radiation therapy) have been explored, but have not yet modified the standard therapies established decades ago. This understanding is currently changing, and several drugs have been approved for the management of advanced HCC. Molecular therapies dominate the adjuvant trials after curative therapies and combination strategies with TACE for intermediate stages. The rationale for these combinations is sound. Local therapies induce antigen and proinflammatory cytokine release, whereas VEGF inhibitors and tyrosine kinase inhibitors boost immunity and prime tumours for checkpoint inhibition. In this Review, we analyse data from randomized and uncontrolled studies reported with ablative and locoregional techniques and examine the expected effects of combinations with systemic treatments. We also discuss trial design and benchmarks to be used as a reference for future investigations in the dawn of a promising new era for HCC treatment.

A systematic literature review and network meta-analysis of first-line treatments for unresectable hepatocellular carcinoma based on data from randomized controlled trials

BACKGROUND

Hepatocellular carcinoma (HCC) is the most common form of primary liver cancer. First-line treatment options for unresectable HCC include sorafenib, lenvatinib, selective internal radiation therapy (SIRT), and transarterial chemoembolization (TACE). The present study reviewed randomized controlled trials (RCTs) of first-line therapies for unresectable HCC in TACE-ineligible patients.

RESEARCH DESIGN AND METHODS

A systematic literature review (SLR) was conducted to identify RCTs of first-line treatments for TACE-ineligible patients with unresectable HCC. Data on overall survival (OS) and progression-free survival were extracted and a contrast-based Bayesian network meta-analysis (NMA) was conducted using Markov Chain Monte Carlo techniques.

RESULTS

The SLR identified three RCTs: two comparing Y-90 resin microspheres with sorafenib, and one comparing sorafenib with lenvatinib. No RCTs were identified comparing other SIRT technologies with any other approved first-line HCC therapies. The NMA showed no significant OS differences between Y-90 resin microspheres and sorafenib (hazard ratio [HR] 0.92, 95% credible interval [CrI]: 0.79-1.08) or lenvatinib (HR: 0.88, 95% CrI: 0.63-1.22).

CONCLUSIONS

An SLR and NMA showed no significant differences between sorafenib, lenvatinib, and Y-90 resin microspheres in treating unresectable HCC. RCT evidence was not available for any other SIRT technologies and an evaluation of their relative efficacy was therefore not possible.

Benign and malignant mimickers of infiltrative hepatocellular carcinoma: tips and tricks for differential diagnosis on CT and MRI

Hepatocellular carcinoma (HCC) may have an infiltrative appearance in about 8-20% of cases. Infiltrative HCC can be a challenging diagnosis and it is associated with the worst overall survival among HCC patients. Infiltrative HCC is characterized by the spread of multiple minute nodules throughout the liver, without a dominant one, ultimately resulting into macrovascular invasion. On CT and MRI, infiltrative HCC appears as an ill-defined, large mass, with variable degree of enhancement, and satellite neoplastic nodules in up to 52% of patients. On MRI, it may show restriction on diffusion weighted imaging, hyperintensity on T2- and hypointensity on T1-weighted images, and, if hepatobiliary agent is used, hypointensity on hepatobiliary phase. Infiltrative HCC must be differentiated from other liver diseases, such as focal confluent fibrosis, steatosis, amyloidosis, vascular disorders of the liver, cholangiocarcinoma, and diffuse metastatic disease. In cirrhotic patients, the identification of vascular tumor invasion of the portal vein and its differentiation from bland thrombosis is of utmost importance for patient management. On contrast enhanced CT and MRI, portal vein tumor thrombosis appears as an enhancing thrombus within the portal vein, close to the main tumor and results into vein enlargement. The aim of this pictorial review is to show CT and MRI features that allow the diagnosis of infiltrative HCC and portal vein tumor thrombosis. A particular point of interest includes the tips and tricks for differential diagnosis with potential mimickers of infiltrative HCC.

Current Status and Future Direction of Hepatic Radioembolisation

Radioembolisation is a locoregional treatment modality for hepatic malignancies. It consists of several stages that are vital to its success, which include a pre-treatment angiographic simulation followed by nuclear medicine imaging, treatment activity choice, treatment procedure and post-treatment imaging. All these stages have seen much advancement over the past decade. Here we aim to provide an overview of the practice of radioembolisation, discuss the limitations of currently applied methods and explore promising developments.

Radioembolization in patients with hepatocellular carcinoma: a series of 53 cases

OBJECTIVE

To contribute our results to increase the scientific evidence about the use of radioembolization in the management of patients with hepatocellular carcinoma.

MATERIAL AND METHODS

This retrospective review included 53 patients with hepatocellular carcinoma treated with radioembolization at our center. Patients were classified according to the BCLC algorithm in detail according to their Child-Pugh functional status. We analyzed survival using the Kaplan-Meier method. We used Cox regression analysis to determine clinically significant parameters, including the doses administered in the parameters studied.

RESULTS

Patients ranged in age from 28 to 86 years (mean, 60 years). A total of 61 procedures were done. The mean activity administered was 2.8 GBq (0.7-6.4 GBq), with a mean dose of 229.9Gy (74-425.9Gy) administered in the tumor. Progression-free survival was 6.7 months and overall survival was 12.8 months. Differences in disease-free survival according to BCLC and Child-Pugh classification were not significant (p=0.848 and p=0.252, respectively). The clinical parameters that were significantly different with respect to overall survival were bilirubin levels (p<0.001), pretreatment transaminase levels (AST) (p=0.022), Child-Pugh subclassification (p=0.003), and dose administered in the tumor (p=0.001). Only one patient had a severe adverse reaction, developing posttreatment liver failure resulting in death.

CONCLUSIONS

Radioembolization is safe and efficacious in the treatment of patients with hepatocellular carcinoma. Liver function and the doses received by the tumor are key parameters for the efficacy of treatment. The increase in the scientific evidence supports the inclusion of this technique in treatment guidelines.

Current locoregional therapies and treatment strategies in hepatocellular carcinoma

Locoregional therapies (lrts) play an important role in the treatment of hepatocellular carcinoma (hcc), with the aim of increasing overall survival while preserving liver function. Various forms of lrt are available, and choosing the best one depends on technical aspects, liver morphology, tumour biology, and the patient's symptoms. The purpose of the present review article is to provide an overview of the current evidence relating to the use of percutaneous ablation, transarterial chemoembolization, and transarterial radioembolization for the curative or palliative treatment of hcc. Special situations are also reviewed, including the combined use of systemic therapy and lrt, indications and techniques for bridging to transplant and downstaging, and the use of lrt to treat patients with hcc and macrovascular invasion.

Yttrium-90 Radioembolization for Hepatocellular Carcinoma with Portal Vein Invasion: Validation of the Milan Prognostic Score

The aim of the present study was to retrospectively analyze clinical outcomes of patients with hepatocellular carcinoma (HCC) and portal vein tumor thrombosis (PVTT) treated with yttrium-90 radioembolization stratified by Milan PVTT score according to PVTT extension, tumor burden, and bilirubin levels. Seventy patients were included and classified into good (n = 15; 21.4%), intermediate (n = 33; 47.1%), and dismal (n = 22; 31.4%) prognostic groups. Median overall survival durations were 24.6 mo, 13 mo (hazard ratio = 3.2; 95% confidence interval [CI], 1.2-9.7; P = .016), and 5.9 mo (hazard ratio = 4.1; 95% CI, 1.4-13.4; P = .0096), respectively. The Milan score represents an easy tool to select patients with HCC with PVTT who may benefit from radioembolization.

Clinical Application of Trans-Arterial Radioembolization in Hepatic Malignancies in Europe: First Results from the Prospective Multicentre Observational Study CIRSE Registry for SIR-Spheres Therapy (CIRT)

Purpose

To address the lack of prospective data on the real-life clinical application of trans-arterial radioembolization (TARE) in Europe, the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) initiated the prospective observational study CIRSE Registry for SIR-Spheres® Therapy (CIRT).

Materials and Methods

Patients were enrolled from 1 January 2015 till 31 December 2017. Eligible patients were adult patients treated with TARE with Y90 resin microspheres for primary or metastatic liver tumours. Patients were followed up for 24 months after treatment, whereas data on the clinical context of TARE, overall survival (OS) and safety were collected.

Results

Totally, 1027 patients were analysed. 68.2% of the intention of treatment was palliative. Up to half of the patients received systemic therapy and/or locoregional treatments prior to TARE (53.1%; 38.3%). Median overall survival (OS) was reported per cohort and was 16.5 months (95% confidence interval (CI) 14.2–19.3) for hepatocellular carcinoma, 14.6 months (95% CI 10.9–17.9) for intrahepatic cholangiocarcinoma. For liver metastases, median OS for colorectal cancer was 9.8 months (95% CI 8.3–12.9), 5.6 months for pancreatic cancer (95% CI 4.1–6.6), 10.6 months (95% CI 7.3–14.4) for breast cancer, 14.6 months (95% CI 7.3–21.4) for melanoma and 33.1 months (95% CI 22.1–nr) for neuroendocrine tumours. Statistically significant prognostic factors in terms of OS include the presence of ascites, cirrhosis, extra-hepatic disease, patient performance status (Eastern Cooperative Oncology Group), number of chemotherapy lines prior to TARE and tumour burden. Thirty-day mortality rate was 1.0%. 2.5% experienced adverse events grade 3 or 4 within 30 days after TARE.

Conclusion

In the real-life clinical setting, TARE is largely considered to be a part of a palliative treatment strategy across indications and provides an excellent safety profile.

Level of evidence

Level 3.

Trial registration

ClinicalTrials.gov NCT02305459.

Electronic supplementary material

The online version of this article (10.1007/s00270-020-02642-y) contains supplementary material, which is available to authorized users.

Molecular Imaging and Therapy of Liver Tumors

Liver cancer is one of the top leading causes of mortality worldwide. Conventional imaging using contrast enhanced CT and MRI are currently the mainstay of oncologic imaging of the liver for the diagnosis and management of cancer. In the past two decades, especially since the advent of hybrid imaging in the form of PET/CT and SPECT/CT, molecular imaging has been increasingly utilized for oncologic imaging and the variety of radionuclide probes for imaging liver cancers have been expanding. Beyond the usual workhorse of FDG as an oncologic tracer, there is a growing body of evidence showing that radiolabeled choline tracers, C-11 acetate and other new novel tracers may have increasing roles to play for the imaging of liver tumors. On the therapy front, there have also been advances in recent times in terms of targeted therapies for both primary and secondary liver malignancies, particularly with transarterial radioembolization. The concept of theranostics can be applied to transarterial radioembolization by utilizing a pretreatment planning scan, such as Tc-99m macroaggregated albumin scintigraphy, coupled with post treatment imaging. Radiation dose planning by personalized dosimetric calculations to the liver tumors is also being advocated. This article explores the general trends in the field of nuclear medicine for the imaging and treatment of liver cancer above and beyond routine diagnosis and management.

Radioembolization of hepatocarcinoma with 90Y glass microspheres: treatment optimization using the dose-toxicity relationship

AIM

Transarterial radioembolization (TARE) is, by all standards, a radiation therapy. As such, according to Euratom Directive 2013/59, it should be optimized by a thorough treatment plan based on the distinct evaluation of absorbed dose to the lesions and to the non-tumoural liver (two-compartment dosimetry). Since the dosimetric prediction with ^99mTc albumin macro-aggregates (MAA) of non-tumoural liver is much more accurate than the same prediction on lesions, treatment planning should focus on non-tumoural liver rather than on lesion dosimetry. The aim of this study was to determine a safety limit through the analysis of pre-treatment dosimetry with ^99mTc-MAA single photon emission computed tomography (SPECT/CT), in order to deliver the maximum tolerable absorbed dose to non-tumoural liver.

METHODS

Data from intermediate/advanced hepato-cellular carcinoma (HCC) patients treated with ⁹⁰Y glass microspheres were collected in this single-arm retrospective study. Injection was always lobar, even in case of bilobar disease, to avoid treating the whole liver in a single session. A three-level definition of liver decompensation (LD) was introduced, considering toxicity only in cases of liver decompensation requiring medical action (LD type C, LDC). We report LDC rates, receiver operating characteristic (ROC) analysis between LDC and NO LDC absorbed dose distributions, normal tissue complication probability (NTCP) curves and uni- and multivariate analysis of risk factors associated with toxicity.

RESULTS

A 6-month timeline was defined as necessary to capture all treatment-related toxicity events. Previous transarterial chemoembolization (TACE), presence or extension of portal vein tumoural thrombosis (PVTT) and tumour pattern (nodular versus infiltrative) were not associated with tolerance to TARE. On the contrary, at the multivariate analysis, the absorbed dose averaged over the whole non-tumoural liver (including the non-injected lobe) was a prognostic indicator correlated with liver decompensation (odds ratio = 4.24). Basal bilirubin > 1.1 mg/dL was a second even more significant risk factor (odds ratio = 6.35). NTCP analysis stratified with this bilirubin cut-off determined a 15% liver decompensation risk at 50 Gy/90 Gy for bilirubin >/< 1.1 mg/dL. These results are valid for a ⁹⁰Y glass microsphere administration 4 days after the reference time.

CONCLUSION

Given the low predictive accuracy of ^99mTc-MAA on lesion absorbed dose reported by several authors, an optimized TARE with ⁹⁰Y glass microspheres with lobar injection 4 days after reference time should aim at an absorbed dose averaged over the whole non-tumoural liver of 50 Gy/90 Gy for basal bilirubin higher/lower than 1.1 mg/dL, respectively.

Clinical Application of Radioembolization in Hepatic Malignancies: Protocol for a Prospective Multicenter Observational Study

Background

Radioembolization, also known as transarterial radioembolization or selective internal radiation therapy with yttrium-90 (90Y) resin microspheres, is an established treatment modality for patients with primary and secondary liver tumors. However, large-scale prospective observational data on the application of this treatment in a real-life clinical setting is lacking.

Objective

The main objective is to collect data on the clinical application of radioembolization with 90Y resin microspheres to improve the understanding of the impact of this treatment modality in its routine practice setting.

Methods

Eligible patients are 18 years or older and receiving radioembolization for primary and secondary liver tumors as part of routine practice, as well as have signed informed consent. Data is collected at baseline, directly after treatment, and at every 3-month follow-up until 24 months or study exit. The primary objective of the Cardiovascular and Interventional Radiological Society of Europe Registry for SIR-Spheres Therapy (CIRT) is to observe the clinical application of radioembolization. Secondary objectives include safety, effectiveness in terms of overall survival, progression-free survival (PFS), liver-specific PFS, imaging response, and change in quality of life.

Results

Between January 2015 and December 2017, 1047 patients were included in the study. The 24-month follow-up period ended in December 2019. The first results are expected in the third quarter of 2020.

Conclusions

The CIRT is the largest observational study on radioembolization to date and will provide valuable insights to the clinical application of this treatment modality and its real-life outcomes.

Trial Registration

ClinicalTrials.gov NCT02305459; https://clinicaltrials.gov/ct2/show/NCT02305459

International Registered Report Identifier (IRRID)

DERR1-10.2196/16296

Embolotherapeutic Strategies for Hepatocellular Carcinoma: 2020 Update

Hepatocellular carcinoma (HCC) represents a significant contributor to cancer-related morbidity and mortality with increasing incidence in both developing and developed countries. Embolotherapy as a locoregional therapeutic strategy consists of trans-arterial or "bland" embolization (TAE), trans-arterial chemoembolization (TACE), and selective internal radiotherapy (SIRT). Trans-catheter arterial therapies can be applied along all stages of HCC, either as an alternative or neoadjuvant to surgical resection/transplantation in very early and early stage HCC or as a palliative option for local disease control in unresectable and advanced stage HCC. In advanced stage HCC, SIRT did not demonstrate superiority in comparison to systemic treatment options in several recent large prospective trials, though for carefully selected patients, may confer improved tolerability with similar disease control rates. The latest embolotherapeutic techniques and literature as they pertain to the management of HCC, as well as future directions, are reviewed in this article.

Role of locoregional therapies in the wake of systemic therapy

Multiple systemic agents have recently been approved in the first- and second-line setting for hepatocellular carcinoma (HCC), increasing the therapeutic options for patients and treating physicians. The randomised controlled trials that led to these approvals were predominantly conducted in a population comprised of patients with advanced HCC. However, these trials also included a subset of patients who had progressed after locoregional therapies (LRTs), mostly transarterial chemoembolisation. With a greater number of systemic agents available, the role of LRTs has become a topic of debate, specifically regarding when to transition to systemic therapy in unresectable HCC and the potential opportunities for combining locoregional and systemic therapies. Trials of immuno-oncology agents (notably T cell checkpoint inhibitors) are ongoing in the advanced disease setting and these agents also present opportunities for combination therapies, both with other systemic agents and with LRTs in earlier stage disease. This article will review strategies to guide patient selection for LRT as well as the development of locoregional-systemic combinations based on scientific rationale and the challenges of clinical trial design in this setting.