Efficacy of the Combination of Systemic Sequential Therapy and Locoregional Therapy in the Long-Term Survival of Patients with BCLC Stage C Hepatocellular Carcinoma

BACKGROUND

The aim of this study was to evaluate the clinical impact of a combination of systemic sequential therapy and locoregional therapy on the long-term survival of patients with Barcelona Clinic Liver Cancer (BCLC) stage C hepatocellular carcinoma (HCC).

METHODS

Sixty-four consecutive patients with intrahepatic target nodules who had initially received systemic therapy (lenvatinib and atezolizumab plus bevacizumab) were reviewed. The clinical impact of the combined use of systemic sequential therapy and locoregional therapy was evaluated by determining overall survival (OS). The combined use of systemic sequential therapy with more than two agents and locoregional treatment was defined as multidisciplinary combination therapy (MCT), while only systemic sequential therapy and repeated locoregional-treatment was defined as a single treatment procedure (STP).

RESULTS

R0 resection, MCT, and STP resulted in significantly better OS compared with no additional treatment (median OS, not reached vs. 18.2 months and 12.6 vs. 8.1 months, respectively; p = 0.002). Multivariate analysis confirmed that the use of R0 resection and MCT were associated with better OS (hazard ratio [HR]; 0.053, p = 0.006 and 0.189, p < 0.001, respectively) compared with that for STP (HR; 0.279, p = 0.003).

CONCLUSIONS

MCT is may effective in patients with BCLC stage C HCC and intrahepatic target nodules who have previously received systemic therapy-based treatment.

Impact of Systemic Autoimmune Diseases on Treatment Outcomes and Radiation Toxicities in Patients with Stage I Non-Small Cell Lung Cancer Receiving Stereotactic Body Radiation Therapy: A Matched Case-Control Analysis

We aimed to evaluate the impact of systemic autoimmune diseases (SADs) on treatment outcomes and radiation toxicities following stereotactic body radiation therapy (SBRT) for stage I non-small cell lung cancer (NSCLC). We queried an institution-based database on patients with SADs treated with SBRT for lung cancer between 2001 and 2016 (SAD group). Each patient was matched to three controls without SADs. The primary outcomes of interest were the overall survival (OS) and local control rate (LCR). The secondary outcomes were radiation toxicities of grades ≥2 (≥G2). Twelve patients with SADs were matched to 36 controls. The median follow-up duration was 3.6 years. There was a significant intergroup difference in the OS (hazard ratio [HR]: 4.11, 95% confidence incidence [CI]: 1.82−9.27, p < 0.001) and LCR (HR: 15.97, 95% CI: 2.89−88.29, p < 0.001). However, there were no significant intergroup differences in the odds of acute (odds ratio [OR]: 0.38, 95% CI: 0.02−8.91, p = 0.550) and late (OR: 2.20, 95% CI: 0.32−15.10, p = 0.422) ≥G2 radiation pneumonitis. No other ≥G2 toxicities were identified. In conclusion, although radiation toxicities are not enhanced by SADs, SADs are risk factors of poor prognosis following SBRT for stage I NSCLC.

Modified Glasgow Prognostic Score is predictive of prognosis for non-small cell lung cancer patients treated with stereotactic body radiation therapy: a retrospective study

We aimed to assess the predictive value of the modified Glasgow prognostic score (mGPS) in patients with non-small cell lung cancer (NSCLC) who underwent stereotactic body radiation therapy (SBRT). We retrospectively reviewed the records of 207 patients, with a median age of 79 years. The pretreatment mGPS was calculated and categorized as high (mGPS = 1-2) or low (mGPS = 0). The median follow-up duration was 40.7 months. The five-year overall survival (OS), progression-free survival (PFS) and time to progression (TTP) rates were 44.3%, 36% and 54.4%, respectively. Multivariate analysis revealed that mGPS was independently predictive of OS (hazard ratio [HR] 1.67; 95% confidence interval 1.14-2.44: P = 0.009), PFS (HR 1.58; 1.10-2.28: P = 0.014) and TTP (HR 1.66; 1.03-2.68: P = 0.039). Patients who had high mGPS showed significantly worse OS (33.3 vs 64.5 months, P = 0.003) and worse PFS (23.8 vs 39 months, P = 0.008) than those who had low mGPS. The data showed a trend that patients with high mGPS suffered earlier progression compared to those with low mGPS (54.3 vs 88.1 months, P = 0.149). We confirmed that mGPS is independently predictive of prognosis in NSCLC patients treated with SBRT.

Lenvatinib-Transarterial Chemoembolization Sequential Therapy as an Effective Treatment at Progression during Lenvatinib Therapy for Advanced Hepatocellular Carcinoma

BACKGROUND

The aims of this study were to evaluate the efficacy of additional treatment, especially lenvatinib-transarterial chemoembolization (TACE) sequential therapy, for unresectable hepatocellular carcinoma (HCC).

METHODS

Consecutive 56 patients who underwent lenvatinib treatment were reviewed. Oncological aggressiveness of tumor was estimated using a dynamic CT enhancement pattern classification, and clinical impact of subsequent treatment was investigated through analysis of progression-free survival (PFS), post-progression survival (PPS), and multivariate analysis of potential confounders for survival after progression during lenvatinib therapy.

RESULTS

Heterogeneous enhancement patterns (Type-3 and -4), which are reportedly associated with higher oncological aggressiveness of HCC, were associated with better objective response to lenvatinib compared to homogeneous enhancement pattern (Type-2) (86 and 85% vs. 53% in modified Response Evaluation Criteria in Solid Tumors), resulting in similar PFS (p = 0.313). Because of significantly worse PPS, overall survival of Type-4 tumor was poor compared to Type-2 or -3 tumors (p = 0.009). However, subgroup of patients who achieved subsequent treatment showed significantly better PPS, regardless of CT enhancement pattern. Multivariate analysis confirmed that use of lenvatinib-TACE sequential treatment after progression during lenvatinib therapy was associated with better PPS (hazard ratio [HR], 0.08; 95% CI, 0.01-0.71; p = 0.023), while Type-4 enhancement pattern was correlated with worse PPS (HR, 2.92; 95% CI, 1.06-8.05; p = 0.039).

CONCLUSION

Oncological aggressiveness of HCC estimated by CT enhancement pattern was predictive of PPS after progression during lenvatinib. Successful subsequent treatment with lenvatinib-TACE sequential therapy may offer survival benefit regardless of CT enhancement pattern of HCC.

Stereotactic body radiotherapy in patients with lung tumors composed of mainly ground-glass opacity

We retrospectively reviewed the effect of stereotactic body radiation therapy (SBRT) in patients with stage I lung cancer whose lung tumor showed a nodular appearance of ground glass opacity, so-called ground glass nodule (GGN). A total of 84 patients (42 men, 42 women; mean age, 75 years) with stage I lung cancer with GGN accompanying a solid component <50% in diameter of the tumor and no metastases were studied. Concerning histology, 32 tumors were adenocarcinoma, 1 was squamous cell carcinoma, 2 were unclassified carcinoma and 49 cases were histology-unproven but increased in size or had a positive finding in 18F-FDG positron emission tomography (PET) examination. The median tumor size was 20 mm (range, 10-41 mm). All of the patients were treated with SBRT, and the total prescribed dose at the isocenter ranged between 48 Gy in four fractions and 84 Gy in ten fractions. Median follow-up duration was 33 months. No patient had local failure nor regional lymph node failure. The 3-year rate of distant failure was 2.6%. Two patients who experienced distant metastases had a past surgical history of initial lung cancer before SBRT. The rates of cause-specific and overall survival at 3 years were 98.2 and 94.6%, respectively. Treatment-related adverse events of ≥grade 4 were not reported. Although more cases and longer follow-ups are mandatory, SBRT may be one of the radical treatment options for patients with GGN.

Renal Cancer is Not Radioresistant: Slowly but Continuing Shrinkage of the Tumor After Stereotactic Body Radiation Therapy

Purpose:

To evaluate the safety and efficacy of stereotactic body radiation therapy for primary lesion of renal cell carcinoma with long-term and regular follow-up of tumor size and renal function.

Methods:

This prospective study included 13 patients treated with stereotactic body radiation therapy for primary lesion of stage I renal cell carcinoma between August 2007 and June 2016 in our institution. Diagnosis of renal cell carcinoma was made by 2 radiologists using computed tomography or magnetic resonance imaging. A dosage of 60 Gy in 10 fractions or 70 Gy in 10 fractions was prescribed. The higher dose was selected if dose constraints were satisfied. Tumor response on imaging examination, local progression-free rate, overall survival, and toxicity were assessed.

Results:

The mean follow-up period was 48.3 months (range: 11-108 months). The tumors showed very slow but continuous response during long-term follow-up. Three cases (23.1%) showed transient progression during the short follow-up. The mean duration until the day on which partial response was confirmed among the partial or complete response cases was 22.6 months (95% confidence interval, 15.3-30.0 months). Local progression-free rate was 92.3% for 3 years and overall survival rate 91.7% for 2 years and 71.3% for 3 years. Twelve cases (92.3%) had impaired renal function at baseline. Renal function decreased slowly and mildly in most of the cases, but 2 cases of solitary kidney showed grade 4 or 5 renal dysfunction.

Conclusion:

All renal tumors decreased in size slowly but continuously for years after stereotactic body radiation therapy. Renal cancer can be treated radically with stereotactic body radiation therapy as a radiosensitive tumor, but careful attention should be given in cases with solitary kidney.

Renal cell carcinoma treated with stereotactic radiotherapy with histological change confirmed on autopsy: a case report

Background

Treatment of primary renal cell carcinoma using radiotherapy with curative intent is rare, because renal cell carcinoma is generally regarded as a radiation-resistant tumor. Recently, stereotactic body radiation therapy has been radically applied for cancers in various organs including renal cell carcinoma. However, there were few reports describing pathological changes of renal cell carcinoma post stereotactic body radiation therapy. This is the first report we are aware of documenting late histological effects of stereotactic body radiation therapy on renal cell carcinoma and surrounding normal tissue.

Case presentation

A right renal tumor was identified in a Japanese 70-year-old man on follow-up computed tomography for his chronic hepatitis. T1N0M0 renal cell carcinoma was clinically diagnosed as the tumor was 3 cm in diameter and well-enhanced with intravenously infused contrast material in the arterial phase on computed tomography. No metastases in regional lymph nodes or distant sites were evident. Stereotactic body radiation therapy was selected as an alternative therapy to surgery because of his poor liver function. A total dose of 60 Gy in 10 fractions over 12 days was delivered using a 10-megavolt X-ray. The renal tumor gradually decreased in size and partial response had been achieved at 2 years after completing stereotactic body radiation therapy. Hepatocellular carcinoma was identified during follow-up in the patient and he died of progression of hepatocellular carcinoma with hepatic failure 2.5 years after completing stereotactic body radiation therapy. Autopsy was done and it showed almost complete necrosis of tumor tissues with a small amount of viable renal carcinoma cells. These pathological findings suggested marked effects of stereotactic body radiation therapy on clear cell renal cell carcinoma.

Conclusion

Our case demonstrates a good pathological response with small foci of remnant viable cancer cells after stereotactic body radiation therapy of 60Gy in 10 fractions for small renal cell carcinoma. Although further experiences and longer follow-up are mandatory to conclude the optimal treatment schedule and efficacy of stereotactic body radiation therapy for renal cell carcinoma, stereotactic body radiation therapy may represent a novel less-invasive option for the treatment of primary renal cell carcinoma.

Rib fracture after stereotactic radiotherapy for primary lung cancer: prevalence, degree of clinical symptoms, and risk factors

Background

As stereotactic body radiotherapy (SBRT) is a highly dose-dense radiotherapy, adverse events of neighboring normal tissues are a major concern. This study thus aimed to clarify the frequency and degree of clinical symptoms in patients with rib fractures after SBRT for primary lung cancer and to reveal risk factors for rib fracture. Appropriate α/β ratios for discriminating between fracture and non-fracture groups were also investigated.

Methods

Between November 2001 and April 2009, 177 patients who had undergone SBRT were evaluated for clinical symptoms and underwent follow-up thin-section computed tomography (CT). The time of rib fracture appearance was also assessed. Cox proportional hazard modeling was performed to identify risk factors for rib fracture, using independent variables of age, sex, maximum tumor diameter, radiotherapeutic method and tumor-chest wall distance. Dosimetric details were analyzed for 26 patients with and 22 randomly-sampled patients without rib fracture. Biologically effective dose (BED) was calculated with a range of α/β ratios (1–10 Gy). Receiver operating characteristics analysis was used to define the most appropriate α/β ratio.

Results

Rib fracture was found on follow-up thin-section CT in 41 patients. The frequency of chest wall pain in patients with rib fracture was 34.1% (14/41), and was classified as Grade 1 or 2. Significant risk factors for rib fracture were smaller tumor-chest wall distance and female sex. Area under the curve was maximal for BED at an α/β ratio of 8 Gy.

Conclusions

Rib fracture is frequently seen on CT after SBRT for lung cancer. Small tumor-chest wall distance and female sex are risk factors for rib fracture. However, clinical symptoms are infrequent and generally mild. When using BED analysis, an α/β ratio of 8 Gy appears most effective for discriminating between fracture and non-fracture patients.

Value of dual time point F-18 FDG-PET/CT imaging for the evaluation of prognosis and risk factors for recurrence in patients with stage I non-small cell lung cancer treated with stereotactic body radiation therapy

PURPOSE

To investigate prognostic and risk factors for recurrence after stereotactic body radiation therapy (SBRT) in patients with stage I non-small cell lung carcinoma (NSCLC), focusing on dual time point [18]F-fluorodeoxyglucose positron emission tomography (FDG PET).

MATERIALS AND METHODS

We prospectively evaluated 57 patients with stage I NSCLC (45 T1N0M0 and 12 T2N0M0) who had undergone pretreatment FDG-PET/CT and were subsequently treated with SBRT. All patients received a whole-body PET/CT scan at 60 min and a whole-lung at 120 min after the injection. The maximum standardized uptake value (SUV) and retention index (RI) of the lesions were calculated. Local recurrence, regional lymph node metastasis, distant metastasis, and the recurrence pattern were evaluated. Cox proportional hazard regression analyses were performed to evaluate prognostic factors or risk factors of recurrence.

RESULTS

During the median follow-up period of 27 months, local recurrence, regional lymph node metastasis, and distant metastasis were seen in 17 (30%), 12 (21%), and 17 (30%) of the 57 patients, respectively. The 3-year overall survival rate was 63.4%. SUVmax did not affect any recurrence, DFS, OS, or CSS. RI significantly predicted higher distant metastasis (HR 47.546, p=0.026). In contrast, RI tended to predict lower local recurrence (HR 0.175, p=0.246) and regional lymph node metastasis (HR 0.109, p=0.115).

CONCLUSIONS

SUVmax at staging FDG-PET does not predict any recurrence, DFS, OS or CSS. In contrast, higher RI predicts higher distant metastasis and tended to predict lower local or regional lymph node metastasis.

Distinguishing hypervascular pseudolesions of the liver from hypervascular hepatocellular carcinomas with gadoxetic acid-enhanced MR imaging

PURPOSE

To retrospectively determine findings at gadoxetic acid-enhanced magnetic resonance (MR) imaging in hypervascular pseudolesions that were observed at computed tomography (CT) during hepatic arteriography, with special focus on distinguishing these pseudolesions from hypervascular hepatocellular carcinomas (HCCs).

MATERIALS AND METHODS

The institute ethics committee deemed study approval unnecessary. The study population comprised 80 patients (55 men, 25 women) with chronic liver disease who underwent CT during hepatic arteriography and arterial portography, gadoxetic acid-enhanced MR imaging, and follow-up dynamic contrast material-enhanced CT. The diagnosis of 104 pseudolesions and 123 HCCs was confirmed by means of histopathologic or multimodality evaluation. Two radiologists assessed the MR imaging findings of HCCs and pseudolesions in consensus, including the signal intensities (SIs) of the lesions on T2-weighted, diffusion-weighted (DW), and contrast-enhanced hepatocyte-phase images. The findings of nodular pseudolesions and HCCs were compared with the Fisher exact test. Additionally, the hepatocyte-phase SI ratio (ratio of lesion SI to liver SI) for HCCs and pseudolesions was compared by means of the Mann-Whitney U test.

RESULTS

There were 62 wedge-shaped, 32 nodular, and 10 linear pseudolesions. On gadoxetic acid-enhanced hepatocyte-phase MR images, 15% of pseudolesions (16 of 104) were hypointense compared with surrounding liver tissue. The mean hepatocyte-phase SI ratio of HCCs (0.65 +/- 0.14 [standard deviation]) was significantly lower (P < .01) than that of the nodular pseudolesions (0.95 +/- 0.11). The optimal cutoff value of hepatocyte-phase SI ratio for distinguishing between HCC and nodular pseudolesion was 0.84. No nodular pseudolesions were visible on DW images.

CONCLUSION

Gadoxetic acid-enhanced hepatocyte-phase MR imaging and DW imaging could be used to distinguish hypervascular pseudolesions from hypervascular HCCs; a hepatocyte-phase SI ratio below 0.84 and visibility on DW images were findings specific for HCCs rather than pseudolesions.

Liver parenchymal enhancement of hepatocyte-phase images in Gd-EOB-DTPA-enhanced MR imaging: which biological markers of the liver function affect the enhancement?

PURPOSE

To clarify the factors that predict enhancement of the liver parenchyma in hepatocyte-phase of gadolinium ethoxybenzyl diethylenetriaminepentaacetic acid (Gd-EOB-DTPA)-enhanced MR imaging.

MATERIALS AND METHODS

Gd-EOB-DTPA-enhanced hepatocyte-phase MR images of 198 patients with chronic liver diseases (Child-Pugh class A in 112 patients, class B in 74 patients, and class C in 12 patients) were retrospectively analyzed. The hepatocyte-phase images were obtained using fat-suppressed T1-weighted gradient-echo images with a 3D acquisition sequence 10 min and 20 min after IV administration of Gd-EOB-DTPA (0.025 mmol/kg body weight). The quantitative liver-spleen contrast ratio (Q-LSC) was calculated using the signal intensities of the liver and spleen. Serum albumin levels, total bilirubin levels, prothrombin activity, and the results of indocyanine green clearance tests (ICGs) were recorded and correlated with the Q-LSC. Logistic regression analysis was performed to analyze which factors predict sufficient liver enhancement using a Q-LSC of 1.5 as a cutoff value.

RESULTS

Only ICGs and Child-Pugh classifications showed a statistically significant correlation with the Q-LSC. Logistic regression analysis showed that ICGs were the only factors that accurately predicted liver enhancement on hepatocyte-phase images.

CONCLUSION

ICGs were found to be predictors of sufficient liver enhancement on hepatocyte-phase images.

Dilution method of gadolinium ethoxybenzyl diethylenetriaminepentaacetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance imaging (MRI)

PURPOSE

To elucidate whether a contrast agent dilution method (dilution method), in which gadoxetate disodium (Gd-EOB-DTPA) is diluted with saline, is useful for good-quality arterial-phase images.

MATERIALS AND METHODS

In this study we observed 494 hypervascular hepatocellular carcinomas (HCCs) in 327 patients with chronic liver disease. Three Gd-EOB-DTPA injection methods were adopted for comparison: 1) test injection method (undiluted Gd-EOB-DTPA and modified scan delay), in which a test dose of 0.5 mL of Gd-EOB-DTPA was injected to determine scan delay; 2) conventional method (undiluted Gd-EOB-DTPA and fixed scan delay); and (3) dilution method (diluted Gd-EOB-DTPA and fixed scan delay), in which Gd-EOB-DTPA was diluted to 20 mL with saline. Lesion-liver contrast was calculated. Image quality and lesion detectability were evaluated by two radiologists blinded to the injection methods.

RESULTS

The lesion-liver contrast of the dilution method was significantly higher than that of the other two methods. Lesion detectability of the conventional method (64%) was significantly lower than that of the other two methods (contrast agent dilution method, 95%; test injection method, 93%). The image quality of the contrast agent dilution method was significantly better than that of the other two methods.

CONCLUSION

The dilution method contributed to improved image quality, high lesion-liver contrast, and high lesion detectability in the arterial-phase images of GD-EOB-DTPA-enhanced MRI.

Galactonojirimycin derivatives restore mutant human beta-galactosidase activities expressed in fibroblasts from enzyme-deficient knockout mouse

Ten low molecular compounds analogous to galactose were screened for inhibition of human beta-galactosidase activity. Among them, 1-deoxy-galactonojirimycin and N-(n-butyl)-deoxy-galactonojirimycin showed an inhibitory effect at high concentrations. However, they restored mutant enzyme activities expressed in enzyme-deficient knockout mouse fibroblasts and human beta-galactosidosis fibroblasts at lower intracellular concentrations. This effect was more remarkable on G(M1)-gangliosidosis mutations (R201C, I51T, R201H, R457Q) than Morquio B disease mutations (W273L, Y83H). These low molecular compounds pass though the blood-brain barrier in mice. We hope that this new therapeutic approach will become clinically applicable in the near future.