BACKGROUND Hepatocellular carcinoma(HCC)with advanced features such as Budd-Chiari syndrome,chronic liver failure and multiple intrahepatic metastases poses significant therapeutic challenges.Yttrium-90(90Y)radioembol...BACKGROUND Hepatocellular carcinoma(HCC)with advanced features such as Budd-Chiari syndrome,chronic liver failure and multiple intrahepatic metastases poses significant therapeutic challenges.Yttrium-90(90Y)radioembolization is a locoregional treatment option with potential benefits in such complex cases.This case report explores the application of 90Y radioembolization in combination with systemic therapies,highlighting its potential role in managing advanced HCC.CASE SUMMARY A 51-year-old male presented with HCC characterized by massive intrahepatic lesions,multiple metastases,and chronic liver failure secondary to Budd-Chiari syndrome.The patient underwent 90Y radioembolization following hepatic arterial infusion chemotherapy and was subsequently combined with lenvatinib.Posttreatment follow-up revealed a significant reduction in tumor size,with the maximum diameter decreasing from 142.45 mm to 73.16 mm over six months.Liver function improved from Child-Pugh class B to A.However,new intrahepatic lesions emerged at ten months,and liver function deteriorated to Child-Pugh class C.The patient survived for 18 months after initial diagnosis.CONCLUSION Yttrium-90 radioembolization combined with systemic therapies demonstrated significant tumor regression and temporary liver function improvement in a patient with advanced HCC,suggesting its potential as a treatment option in complex cases.展开更多
As the third leading cause of cancer-related deaths worldwide,hepatocellular carcinoma(HCC)represents a significant global health challenge.This paper provides an introduction and comprehensive review of transarterial...As the third leading cause of cancer-related deaths worldwide,hepatocellular carcinoma(HCC)represents a significant global health challenge.This paper provides an introduction and comprehensive review of transarterial radioembolization(TARE)with Yttrium-90(Y90),a widely performed transcatheter procedure for HCC patients who are not suitable candidates for surgery.TARE involves the targeted delivery of radioactive microspheres to liver tumors,offering a promising treatment option for managing HCC across various stages of the disease.By evaluating Y90 TARE outcomes across early,intermediate,and advanced stages of HCC,the review aims to present a thorough understanding of its efficacy and safety.Additionally,this paper highlights future research directions focusing on the potential of combination therapies with systemic and immunotherapies,as well as personalized treatments.The exploration of these innovative approaches aims to improve treatment outcomes,reduce adverse events,and provide new therapeutic opportunities for HCC patients.The review underscores the importance of ongoing research and clinical trials to optimize TARE further and integrate it into comprehensive HCC treatment paradigms.展开更多
BACKGROUND The coronavirus disease 2019(COVID-19)pandemic has made it more challenging for patients to undergo yttrium-90(Y-90)radioembolization(RE).Same day Y-90 RE provides an opportunity to minimize logistical chal...BACKGROUND The coronavirus disease 2019(COVID-19)pandemic has made it more challenging for patients to undergo yttrium-90(Y-90)radioembolization(RE).Same day Y-90 RE provides an opportunity to minimize logistical challenges and infection risk associated with COVID-19,thus improving patient access.AIM To describe the use of same day Y-90 RE with routine single photon emission computed tomography/computed tomography(SPECT/CT)in order to optimize therapy.METHODS All patients were selected for Y-90 RE through a multidisciplinary tumor board,and were screened and tested for COVID-19 infection per institutional protocol.A same day procedure was developed,consisting of angiography,imaging,and Y-90 resin particle delivery.Routine SPECT/CT after technetium-99m macroaggregated albumin(Tc-99m MAA)administration was performed for assessment of arterial supply,personalized dosimetry,and extrahepatic activity.Post-treatment Y-90 bremsstrahlung SPECT/CT was performed for confirmation of particle delivery,by utilization of energy windowing to limit signal from previously administered Tc-99m MAA particles.RESULTS A total of 14 patients underwent same day Y-90 RE between March and June 2020.Mean lung shunt fraction was 6.13%(range 3.5%-13.1%).Y-90 RE was performed for a single lesion in 7 patients,while the remaining 7 patients had treatment of multifocal lesions.The largest lesion measured 8.3 cm.All patients tolerated the procedure well and were discharged the same day.CONCLUSION Same day Y-90 RE with resin-based microspheres is feasible,and provides an opportunity to mitigate infection risk and logistical challenges associated with the COVID-19 pandemic and beyond.We recommend consideration of SPECT/CT,especially among patients with complex malignancies,for the potential to improve outcomes and eligibility of patients to undergo same day Y-90 RE.展开更多
Hepatocellular carcinoma(HCC)is the sixth most common cancer in the world.The majority of patients with HCC present with unresectable disease.These patients have historically had limited treatment options secondary to...Hepatocellular carcinoma(HCC)is the sixth most common cancer in the world.The majority of patients with HCC present with unresectable disease.These patients have historically had limited treatment options secondary to HCC demonstrating chemoresistance to the currently available systemic therapies.Additionally, normal liver parenchyma has shown intolerance to tumoricidal radiation doses,limiting the use of external beam radiation.Because of these limitations,novel percutaneous liver-directed therapies have emerged. The targeted infusion of radioactive microspheres (radioembolization)represents one such therapy. Radioembolization is a minimally invasive transcatheter therapy through which radioactive microspheres are infused into the hepatic arteries that supply tumor. Once infused,these microspheres traverse the hepatic vascular plexus and selectively implant within the tumor arterioles.Embedded within the arterioles, the 90Y impregnated microspheres emit high energy and low penetrating radiation doses selectively to the tumor.Radioembolization has recently shown promise for the treatment of patients with unresectable HCC. The objective of this review article is to highlight twocurrently available radioembolic devices(90Y,188Rh)and provide the reader with a recent review of the literature.展开更多
In the last decade trans-arterial radioembolization has given promising results in the treatment of patients with intermediate or advanced stage hepatocellular carcinoma(HCC),both in terms of disease control and toler...In the last decade trans-arterial radioembolization has given promising results in the treatment of patients with intermediate or advanced stage hepatocellular carcinoma(HCC),both in terms of disease control and tolerability profile.This technique consists of the selective intra-arterial administration of microspheres loaded with a radioactive compound(usually Yttrium90),and exerts its therapeutic effect through the radiation carried by these microspheres.A careful and meticulous selection of patients is crucial before performing the radioembolization to correctly perform the procedure and reduce the incidence of complications.Radioembolization is a technically complex and expensive technique,which has only recently entered clinical practice and is supported by scant results from phase Ⅲ clinical trials.Nevertheless,it may represent a valid alternative to transarterial chemoembolization(TACE) in the treatment of intermediate-stage HCC patients,as shown by a comparative retrospective assessment that reported a longer time to progression,but not of overall survival,and a more favorable safety profile for radioembolization.In addition,this treatment has reported a higher percentage of tumor shrinkage,if compared to TACE,for pre-transplant downsizing and it represents a promising therapeutic option in patients with large extent of disease and insufficient residual liver volume who are not immediately eligible for surgery.Radioembolization might also be a suitable companion to sorafenib in advanced HCC or it can be used as a potential alternative to this treatment in patients who are not responding or do not tolerate sorafenib.展开更多
Transarterial radioembolization(TARE) is a form of brachytherapy in which intra-arterially injected yttrium-90-loaded microspheres serve as a source for internal radiation purposes.On the average,it produces disease c...Transarterial radioembolization(TARE) is a form of brachytherapy in which intra-arterially injected yttrium-90-loaded microspheres serve as a source for internal radiation purposes.On the average,it produces disease control rates exceeding 80% and it is a consolidated therapy for hepatocellular carcinoma(HCC);however,current data are all based on retrospective series or non-controlled prospective studies since randomized controlled trials comparing it with the other liver-directed therapies for intermediate and locally advanced stage HCC are still underway.The data available show that TARE provides similar or even better survival rates when compared to transarterial chemoembolization(TACE).First-line TARE is best indicated for both intermediatestage patients(staged according to the barcelona clinic liver cancer staging classification) who have lesions which respond poorly to TACE due to multiple tumors or a large tumor burden,and for locally advanced-stage patients with solitary tumors,and segmental or lobar portal vein tumor thrombosis.In addition,emerging data have suggested the use of TARE in patients who are classified slightly beyond the Milan criteria regarding radical treatment for downstaging purposes.As a secondline treatment,TARE can also be applied in patients progressing to TACE or sorafenib;a large number of phase Ⅱ/Ⅲ trials are ongoing with the purpose of evaluating the best association with systemic therapies.Transarterial radioembolization is very well tolerated and has a low rate of complications which are mainly related to unintended non-target tissue irradiation,including the surrounding liver parenchyma.The complications can be additionally reduced by accurate patient selection and a strict pre-treatment evaluation including dosimetry and assessment of the vascular anatomy.Since a correct treatment algorithm for potential TARE candidates is not clear and standardized,this comprehensive review analyzes the best selection criteria for patients who really benefit from TARE and also the new advances of this therapy,which can be a very important weapon against HCC.展开更多
AIM: To compare the efficacy and safety of yttrium-90 radioembolization(Y90RE) and transarterial chemoembolization(TACE) in hepatocellular carcinoma patients. METHODS: Bibliographic research was conducted on main scie...AIM: To compare the efficacy and safety of yttrium-90 radioembolization(Y90RE) and transarterial chemoembolization(TACE) in hepatocellular carcinoma patients. METHODS: Bibliographic research was conducted on main scientific databases. When there was no statistically significant heterogeneity, pooled effects were calculated using a fixed-effects model by means of Mantel-Haenszel test, otherwise, a random-effects model was used with Der Simonian and Laird test. Summary estimates were expressed in terms of odds ratios(ORs) and 95%CI. The probability of publication bias was assessed using funnel plots and with Begg and Mazumdar's test. Sensitivity analysis was finally conducted using the method of excluding extreme data.RESULTS: A total of 10 studies were analyzed, of which 2 randomized controlled trials. Survival rate(SR) assessed at 1 year showed an absolute similarity between the two treatment groups(OR = 1.01, 95%CI: 0.78-1.31, P = 0.93). As long as time elapsed since the treatment, ORs for survival rate tended to significantly increase, thus meaning better long-term outcomes in patients who underwent Y90RE(2-year SR: OR = 1.43, 1.08-1.89, P = 0.01; 3-year SR: OR = 1.48, 1.03-2.13, P = 0.04). Meta-analysis of plotted hazard ratios(HRs) determined a non-significant overall estimate in favor of Y90RE(HR = 0.91, 0.80-1.04, P = 0.16). Y90 RE showed a statistically significant benefit as compared to TACE in terms of higher progression-free survival rateassessed at 1 year(OR = 1.67; 95%CI: 1.10-2.55; P = 0.02). Pooled analyses do not revealed a statistically significant increase in OR for tumor objective responses after Y90 RE with respect to TACE(OR = 1.22, 95%CI: 0.69-2.16, P = 0.50). A non-significant trend in favor of Y90 RE was observed according to adverse event rate(OR = 0.70, 0.38-1.30, P = 0.26).CONCLUSION: Our meta-analysis reveals that Y90 RE and TACE show similar effects in terms of survival, response rate and safety profile, although tumor progression is delayed after radioembolization.展开更多
AIM To evaluate the value of pre-treatment 18F-FDG PET/CT in patients with HCC following liver radioembolization.METHODS We identified 34 patients with HCC who underwent an FDG PET/CT scan prior to hepatic radioemboli...AIM To evaluate the value of pre-treatment 18F-FDG PET/CT in patients with HCC following liver radioembolization.METHODS We identified 34 patients with HCC who underwent an FDG PET/CT scan prior to hepatic radioembolization at our institution between 2009 and 2013. Patients wereseen in clinic one month after radioembolization and then at 2-3 mo intervals. We assessed the influence of FDG tumor uptake on outcomes including local liver control(LLC), distant liver control(DLC), time to distant metastases(DM), progression free survival(PFS) and overall survival(OS).RESULTS The majority of patients were males(n = 25, 74%), and had Child Pugh Class A(n = 31, 91%), with a median age of 68 years(46-84 years). FDG-avid disease was found in 19(56%) patients with SUVmax ranging from 3 to 20. Female patients were more likely to have an FDG-avid HCC(P = 0.02). Median follow up of patients following radioembolization was 12 months(1.2-62.8 mo). FDG-avid disease was associated with a decreased 1 year LLC, DLC, DM and PFS(P < 0.05). Using multivariate analysis, FDG avidity predicted for LLC, DLC, and PFS(all P < 0.05).CONCLUSION In this retrospective study, pre-treatment HCC FDGavidity was found to be associated with worse LLC, DLC, and PFS following radioembolization. Larger studies are needed to validate our initial findings to assess the role of F-18-FDG PET/CT scans as biomarker for patients with HCC following radioembolization.展开更多
Purpose:The IMbrave150 PhaseⅢtrial demonstrated superiority of atezolizumab and bevacizumab(Atezo/Bev)over sorafenib for unresectable hepatocellular carcinoma(HCC).The present study aims to evaluate the feasibility o...Purpose:The IMbrave150 PhaseⅢtrial demonstrated superiority of atezolizumab and bevacizumab(Atezo/Bev)over sorafenib for unresectable hepatocellular carcinoma(HCC).The present study aims to evaluate the feasibility of TARE in combination with Atezo/Bev for treatment of intermediate and advanced staged HCC.Methods:Retrospective review at a single institution was performed between May 2021 and December 2022.Patients who received TARE using yttrium-90(Y90)with concomitant or sequential Atezo/Bev systemic treatment were included.The following outcomes were retrieved:overall survival(OS),radiologic tumor response,progression-free survival,technical adverse events related to TARE,and toxicity based on the National Cancer Institute–Common Terminology Criteria for Adverse Events version 5.0.Results:Ten consecutive patients with intermediate(n=4)and advanced stage HCC(n=6)were treated with TARE and sequential/concomitant Atezo/Bev.Tumor control was achieved in all TARE-treated target lesions(100%).Overall disease progression occurred in 4 patients with PFS of 78.8%and 66.7%at 6-and 12-months,respectively.Two patients died at follow-up,with 6-month and 12-month OS rates of 90.0%and 77.1%,respectively.Three(75%)patients with intermediate stage disease were downstaged into Milan criteria.One patient developed grade 3 transaminitis and hypoglobulinemia,while Atezo/Bev was switched to Lenvatinib in another patient due to immunotherapy related myositis.Conclusion:This study demonstrates initial safety and feasibility of combined TARE with Atezo/Bev for intermediate/advanced stage HCC.Further prospective studies with larger sample size are warranted.展开更多
Objective: To compare the effects and safety of conventional transarterial chemoembolization(c TACE) and yttrium-90 transarterial radioembolization [TARE(90 Y)] for hepatocellular carcinoma(HCC)Methods: Nine high-qual...Objective: To compare the effects and safety of conventional transarterial chemoembolization(c TACE) and yttrium-90 transarterial radioembolization [TARE(90 Y)] for hepatocellular carcinoma(HCC)Methods: Nine high-quality observational studies, one low bias-risk randomized controlled trial(RCT), and one moderate biasrisk RCT included 1,652 patients [c TACE, 1,124; TARE(90 Y), 528], from whom data were extracted for this systematic review and meta-analysis.Results: The extracted study outcomes included 1-year and 2-year overall survival(OS) rates, objective responses(ORs), and serious adverse events(AEs). 1-year OS rates: OR = 0.939, 95 % CI: 0.705-1.251, P = 0.66. 2-year OS rates: overall pooled OR =0.641, 95% CI: 0.382-1.075, P = 0.092; observational study subgroup OR = 0.575, 95% CI: 0.336-0.984, P = 0.043; RCT subgroup OR* = 0.641, 95% CI: 0.382-1.075, P = 0.346. OR: overall pooled OR = 0.781, 95% CI: 0.454-1.343, P = 0.371; m RECIST subgroup OR = 0.584, 95 % CI: 0.349-0.976, P = 0.040; WHO subgroup OR = 1.065; 95% CI: 0.500-2.268, P = 0.870. Serious AEs: overall pooled RR = 1.477, 95% CI: 0.864-2.526, P = 0.154; RCT subgroup RR = 0.680, 95% CI: 0.325-1.423, P = 0.306; observational study subgroup RR = 1.925; 95 % CI: 0.978-3.788, P = 0.058.Conclusions: TARE(90 Y) increased 2-year OS rates in the observational subgroup and resulted in better OR rates, according to m RECIST criteria, in comparison with c TACE. Furthermore, a lower risk of AEs was observed for TARE(90 Y) than for c TACE.展开更多
AIM:To evaluate the long-term natural history of the gastroduodenal lesions secondary to extrahepatic embolization with Ytrium 90(90 Y) spheres.METHODS:From September 2003 to January 2012,379 procedures of liver radio...AIM:To evaluate the long-term natural history of the gastroduodenal lesions secondary to extrahepatic embolization with Ytrium 90(90 Y) spheres.METHODS:From September 2003 to January 2012,379 procedures of liver radioembolization(RE) using resin microspheres loaded with 90 Y were performed in our center.We have retrospectively compiled the data from 379 RE procedures performed in our center.We report a comprehensive clinical,analytical,endoscopic and histologic long-term follow-up of a series of patients who developed gastroduodenal lesions after the treatment.RESULTS:Six patients(1.5%) developed gastrointestinal symptoms and had gastrointestinal lesions as shown by upper endoscopy in the next 12 wk after RE.The mean time between RE and the appearance of symptoms was 5 wk.Only one patient required endoscopic and surgical treatment.The incidence of gastrointestinal ulcerations was 3.75%(3/80) when only planar images were used for the pre-treatment evaluation.It was reduced to 1%(3/299) when singlephoton emission computed tomography(SPECT) images were also performed.The symptoms that lasted for a longer time were nausea and vomiting,until 25 mo after the treatment.CONCLUSION:All patients were free from severe symptoms at the end of follow-up.The routine use of SPECT has decreased the incidence of gastrointestinal lesions due to unintended deployment of 90 Y particles.展开更多
Liver resection(LR) with negative margins confers survival advantage in many patients with hepatic malignancies.However,an adequate future liver remnant(FLR) is imperative for safe LR.Presently,in patients with an ina...Liver resection(LR) with negative margins confers survival advantage in many patients with hepatic malignancies.However,an adequate future liver remnant(FLR) is imperative for safe LR.Presently,in patients with an inadequate FLR; the 2 most established clinical techniques performed to induce liver hypertrophy are portal vein embolization(PVE) and portal vein ligation.More recently,it has been observed that patients who undergo treatment via Y90 radioembolization experience hypertrophy of the contra-lateral untreated liver lobe.Based on these observations,several investigators have proposed the potential use of this modality as an alternative technique for increasing the FLR prior to liver resection.Y90 radioembolization induces hypertrophy at a slower rate than PVE but has the added advantage of concomitant local disease control and tumour downstaging.展开更多
Unresectable primary and secondary liver malignancies present a major problem in the treatment of solid tumors. Transarterial radioembolization(TARE) is an increasingly used technique for treating various types of mal...Unresectable primary and secondary liver malignancies present a major problem in the treatment of solid tumors. Transarterial radioembolization(TARE) is an increasingly used technique for treating various types of malignant liver tumors. This approach is appealing, as the mechanism of action is independent from other loco-regional treatments and potentially complementary to systemic therapies. There are two commercially available products in use for TARE: 90Y-resin and 90Y-glass microspheres. Currently available data indicates TARE so be safe and effective in hepatocellular carcinoma(HCC) and metastatic liver disease. In HCC the results compare well with chemoembolization, while the role of TARE in combination with kinase inhibitors has yet to be established. Current data on TARE in metastatic liver disease is promising, but there is a strong need for prospective randomized trials comparing TARE and modern chemotherapeutic regimen to support the growing role of TARE in metastatic liver disease.展开更多
BACKGROUND Impressive survival outcome of our previous study in unresectable hepatocellular carcinoma(HCC)patients undergoing yttrium-90 glass microspheres transarterial radioembolization(TARE)with/without sorafenib a...BACKGROUND Impressive survival outcome of our previous study in unresectable hepatocellular carcinoma(HCC)patients undergoing yttrium-90 glass microspheres transarterial radioembolization(TARE)with/without sorafenib according to individuals’disease burden,i.e.,intrahepatic tumor load(IHT)and adverse disease features(ADFs)might partly be confounded by other treatments and underlying hepatic function.Therefore,a dedicated study focusing on treatment response and assessment of failure patterns might be a way to improve treatment outcome in addition to patient selection based on the disease burden.AIM To assess the tumor response,disease control and patterns of disease progression following TARE with/without sorafenib in unresectable HCC patients.METHODS This retrospective study was conducted in successful TARE procedures with available pre-and post-treatment imaging studies(n=169).Three treatment subgroups were(1)TARE only(TARE_alone)for IHT≤50%without ADFs,i.e.,macrovascular invasion,extrahepatic disease(EHD)and infiltrative/ill-defined HCC(n=63);(2)TARE with sorafenib(TARE_sorafenib)for IHT>50%and/or presence of ADFs(n=81);and(3)TARE only for patients who could not receive sorafenib due to contraindication or intolerance(TARE_no_sorafenib)(n=25).Objective response rate(ORR;consisted of complete response(CR)and partial response(PR)),disease control rate(DCR;consisted of CR,PR and stable disease)and failure patterns of treated,intrahepatic and extrahepatic sites were assessed using the modified response evaluation criteria in solid tumors.Time to progression(TTP)was calculated from TARE to the first radiologic progression at any site using Kaplan-Meier method.Identification of prognostic factors for TTP using the univariate Kaplan-Meier method and multivariate Cox proportional hazard model were performed in major population subgroups,TARE_alone and TARE_sorafenib.RESULTS The median radiologic follow-up time was 4.4 mo(range 0.5-48.8).In treated area,ORR was highest in TARE_sorafenib(53.1%),followed by TARE_alone(41.3%)and TARE_no_sorafenib(16%).In intrahepatic area,DCR remained highest in TARE_sorafenib(84%),followed by TARE_alone(79.4%)and TARE_no_sorafenib(44%).The overall DCR was highest in TARE_alone(79.4%),followed by TARE_sorafenib(71.6%)and TARE_no_sorafenib(40%).Dominant failure patterns were intrahepatic for both TARE_alone(44.5%)and TARE_sorafenib(38.4%).Extrahepatic progression was more common in TARE_sorafenib(32%)and TARE_no_sorafenib(40%)than in TARE_alone(12.7%).TTP was longest in TARE_alone(8.6 mo;95%CI:3.4-13.8),followed by TARE_sorafenib(5.1 mo;95%CI:4.0-6.2)and TARE_no_sorafenib(2.7 mo;95%CI:2.2-3.1).Pre-existing EHD(HR:0.37,95%CI:0.24-0.56,P<0.001)was a sole prognostic factor for TTP in TARE_sorafenib with no prognostic factor for TTP in TARE_alone.CONCLUSION TARE with/without sorafenib according to individuals’disease burden provided DCR approximately 70%with intrahepatic progression as dominant failure pattern.Extrahepatic progression was more common in procedures with initially high disease burden.展开更多
BACKGROUND Liver metastases secondary to breast cancer are associated with unfavourable prognosis.Radioembolization with ytrrium-90 is an emerging option for management of liver metastases of breast cancer when other ...BACKGROUND Liver metastases secondary to breast cancer are associated with unfavourable prognosis.Radioembolization with ytrrium-90 is an emerging option for management of liver metastases of breast cancer when other systemic therapies have failed to achieve disease control.However,unlike the case of other liver tumours(colorectal/melanoma metastases/cholangiocarcinoma),its role in the management of breast liver metastases is yet to be elucidated.AIM The aims of this systematic review were to(1)assess the effect of radioembolization with yttrium-90 on tumour response;and(2)to estimate patient survival post radioembolization.METHODS The review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.A systematic literature search was performed using the PubMed and EMBASE databases from January 2007 to December 2018.The initial search yielded 265 reports which were potentially suitable for inclusion in this review.Studies published in English reporting at least one outcome of interest were considered to be suitable for inclusion.Conference abstracts;case reports,animal studies and reports not published in English were excluded from this review.Data was retrieved from each individual report on the name of primary author,year of publication,patient demographics,type of microspheres used,radiation dose delivered to tumour,duration of follow-up,disease control rate(%),tumour response,and overall patient survival.RESULTS The final number of studies which met the inclusion criteria was 12 involving 452 patients.There were no randomized controlled trials identified after the literature search.The age of the patients included in this review ranged from 52 to 61 years.The duration of the follow up period post-radioembolization ranged from 6 to 15.7 mo.The total number of patients with breast metastases not confined to the liver was 236(52.2%).Cumulative analysis revealed that radioembolization with yttrium-90 conferred tumour control rate in 81%of patients.Overall survival post-radioembolization ranged from 3.6 to 20.9 mo with an estimated mean survival of 11.3 mo.CONCLUSION Radioembolization with ytrrium-90 appears to confer control of tumour growth rate in most patients,however its effect on patient survival need to be elucidated further.Furthermore,quality evidence in the form of randomized trials is needed in order to assess the effect of radioembolization in more depth.展开更多
We report the case of a 57-year-old man who was diagnosed with a large unresectable cholangiocarcinoma associated with 2 satellite nodules and without clear margins with the right hepatic vein. Despite 4 cycles of GEM...We report the case of a 57-year-old man who was diagnosed with a large unresectable cholangiocarcinoma associated with 2 satellite nodules and without clear margins with the right hepatic vein. Despite 4 cycles of GEMOX (stopped due to a hypertransaminasemia believed to be due to gemcitabine) and 4 cycles of FOLFIRINOX, the tumor remained stable and continued to be considered unresectable. Radioembolization (resin microspheres, SIRS-spheres<sup>®</sup>) targeting the left liver (474 MBq) and segment IV (440 MBq) was performed. This injection was very well tolerated, and 4 more cycles of FOLFIRINOX were given while waiting for radioembolization efficacy. On computed tomography scan, a partial response was observed; the tumor was far less hypervascularized, and a margin was observed between the tumor and the right hepatic vein. A left hepatectomy enlarged to segment VIII was performed. On pathological exam, most of the tumor was acellular, with dense fibrosis around visible microspheres. Viable cells were observed only at a distance from beads. Radioembolization can be useful in the treatment of cholangiocarcinoma, allowing in some cases a secondary resection.展开更多
Intrahepatic cholangiocarcinoma(iCCA)is recognized as the second most frequently diagnosed liver malignancy,following closely after hepatocellular carcinoma.Its incidence has seen a global upsurge in the past several ...Intrahepatic cholangiocarcinoma(iCCA)is recognized as the second most frequently diagnosed liver malignancy,following closely after hepatocellular carcinoma.Its incidence has seen a global upsurge in the past several years.Unfortunately,due to the lack of well-defined risk factors and limited diagnostic tools,iCCA is often diagnosed at an advanced stage,resulting in a poor prognosis.While surgery is the only potentially curative option,it is rarely feasible.Currently,there are ongoing investigations into various treatment approaches for unresectable iCCA,including conventional chemotherapies,targeted therapies,immunotherapies,and locoregional treatments.This study aims to explore the role of transarterial radioembolization(TARE)in the treatment of unresectable iCCA and provide a comprehensive review.The findings suggest that TARE is a safe and effective treatment option for unresectable iCCA,with a median overall survival(OS)of 14.9 months in the study cohort.Studies on TARE for unresectable iCCA,both as a first-line treatment(as a neo-adjuvant down-staging strategy)and as adjuvant therapy,have reported varying median response rates(ranging from 34%to 86%)and median OS(12-16 mo).These differences can be attributed to the heterogeneity of the patient population and the limited number of participants in the studies.Most studies have identified tumor burden,portal vein involvement,and the patient’s performance status as key prognostic factors.Furthermore,a phase 2 trial evaluated the combination of TARE and chemotherapy(cisplatin-gemcitabine)as a first-line therapy for locally advanced unresectable iCCA.The results showed promising outcomes,including a median OS of 22 mo and a 22%achievement in down-staging the tumor.In conclusion,TARE represents a viable treatment option for unresectable iCCA,and its combination with systemic chemotherapy has shown promising results.However,it is important to consider treatment-independent factors that can influence prognosis.Further research is necessary to identify optimal treatment combinations and predictive factors for a favorable response in iCCA patients.展开更多
Preoperative radioembolization may improve the resectability of liver tumor by inducing tumor shrinkage,atrophy of the embolized liver and compensatory hypertrophy of non-embolized liver.We describe the case of a cirr...Preoperative radioembolization may improve the resectability of liver tumor by inducing tumor shrinkage,atrophy of the embolized liver and compensatory hypertrophy of non-embolized liver.We describe the case of a cirrhotic Child-Pugh A patient with a segmentⅣhepatocellular carcinoma requiring a left hepatectomy.Preoperative angiography demonstrated 2 separated left hepatic arteries,for segmentⅣand segmentsⅡ-Ⅲ.This anatomic variant allowed sequential radioembolizations,delivering high-dose^(90)Yttrium(160 Gy)to the tumor,followed 28 d later by lower dose(120 Gy)to segmentsⅡ-Ⅲ.After 3 mo,significant tumor response and atrophy of the future resected liver were obtained,allowing uneventful left hepatectomy.This case illustrates that,when anatomic disposition permits it,sequential radioembolizations,delivering different^(90)Yttrium doses to the tumor and the future resected liver,could represent a new strategy to prepare major hepatectomy in cirrhotic patients,allowing optimal tumoricidal effect while reducing the toxicity of the global procedure.展开更多
BACKGROUND Primary appendiceal cancers are rare,and they generally present with liver and/or peritoneal metastases.Currently there are no guidelines to treat metastatic appendiceal cancer,and hence they are treated as...BACKGROUND Primary appendiceal cancers are rare,and they generally present with liver and/or peritoneal metastases.Currently there are no guidelines to treat metastatic appendiceal cancer,and hence they are treated as metastatic colorectal cancer.Combining Yttrium 90(Y-90)radioembolization(RE)with systemic chemotherapy early in the treatment of right sided colon cancers has been shown to improve survival.Based on this data,a combination of systemic chemotherapy and Y-90 RE was used to treat a case of metastatic appendiceal cancer.CASE SUMMARY A 76-year-old male presented to the emergency room with progressive right lower quadrant pain.A Computed Tomography of the abdomen and pelvis was performed which showed acute appendicitis and contained perforation.Urgent laparoscopic appendectomy was then followed by histological analysis,which was significant for appendiceal adenocarcinoma.After complete workup he underwent right hemicolectomy and lymph node dissection.He received adjuvant chemotherapy as the local lymph nodes were positive.Follow-up imaging was significant for liver metastasis.Due to rapid growth of the liver lesions and new peritoneal nodules,the patient was treated with a combination of Y-90 RE and folinic acid,fluorouracil,and irinotecan with bevacizumab and not microwave ablation as previously planned.Follow up imaging demonstrated complete response of the liver lesions.At 12-mo follow-up,the patient continued to enjoy good quality of life with no recurrent disease.CONCLUSION Utilization of Y-90 RE concomitantly with systemic chemotherapy early in the treatment of appendiceal cancer may provide improved control of this otherwise aggressive cancer.展开更多
BACKGROUND The hepatic arterial anatomy is highly variable, with the two most common variants being a replaced right hepatic artery(RHA) originating from the superior mesenteric artery(SMA) and a left hepatic artery(L...BACKGROUND The hepatic arterial anatomy is highly variable, with the two most common variants being a replaced right hepatic artery(RHA) originating from the superior mesenteric artery(SMA) and a left hepatic artery(LHA) originating from the left gastric artery(LGA). These anatomical variants could potentially increase the risk for non-target embolization during Y90-Radioembolization due to the close proximity between hepatic and enteric vessel branches.AIM To evaluate the safety of Yttrium-90radioembolization(90Y-RE) with resin microspheres in patients with a variant hepatic arterial anatomy.METHODS In this retrospective single-center observational study, 11 patients who underwent RE with 90Y-resin microspheres via a LHA originating from the LGA,and 13 patients via a RHA originating from the SMA were included. Patient and treatment data were reviewed regarding clinical and imaging evidence of nontarget embolization of 90Y-resin microspheres to the GI tract. Positioning of the tip of the microcatheter in relationship to the last hepatoenteric side branch was retrospectively analyzed using angiographic images, cone-beam CT and preinterventional CT-angiograms.RESULTS None of the 24 patients developed clinical symptoms indicating a potential nontarget embolization to the GI tract within the first month after 90Y-RE. On thepostinterventional 90Y-bremsstrahlung images and/or 90Y-positron emission tomographies, no evidence of extrahepatic 90Y-activity in the GI tract was noted in any of the patients. The mean distance between the tip of the microcatheter and the last enteric side branch during delivery of the 90Y microspheres was 3.2 cm(range: 1.9-5 cm) in patients with an aberrant LHA originating from a LGA. This was substantially shorter than the mean distance of 5.2 cm(range: 2.9-7.7 cm) in patients with an aberrant right hepatic originating from the SMA.CONCLUSION90Y-RE via aberrant hepatic arteries appears to be safe;at least with positioning of the microcatheter tip no less than 1.9 cm distal to the last hepatoenteric side branch vessel.展开更多
文摘BACKGROUND Hepatocellular carcinoma(HCC)with advanced features such as Budd-Chiari syndrome,chronic liver failure and multiple intrahepatic metastases poses significant therapeutic challenges.Yttrium-90(90Y)radioembolization is a locoregional treatment option with potential benefits in such complex cases.This case report explores the application of 90Y radioembolization in combination with systemic therapies,highlighting its potential role in managing advanced HCC.CASE SUMMARY A 51-year-old male presented with HCC characterized by massive intrahepatic lesions,multiple metastases,and chronic liver failure secondary to Budd-Chiari syndrome.The patient underwent 90Y radioembolization following hepatic arterial infusion chemotherapy and was subsequently combined with lenvatinib.Posttreatment follow-up revealed a significant reduction in tumor size,with the maximum diameter decreasing from 142.45 mm to 73.16 mm over six months.Liver function improved from Child-Pugh class B to A.However,new intrahepatic lesions emerged at ten months,and liver function deteriorated to Child-Pugh class C.The patient survived for 18 months after initial diagnosis.CONCLUSION Yttrium-90 radioembolization combined with systemic therapies demonstrated significant tumor regression and temporary liver function improvement in a patient with advanced HCC,suggesting its potential as a treatment option in complex cases.
文摘As the third leading cause of cancer-related deaths worldwide,hepatocellular carcinoma(HCC)represents a significant global health challenge.This paper provides an introduction and comprehensive review of transarterial radioembolization(TARE)with Yttrium-90(Y90),a widely performed transcatheter procedure for HCC patients who are not suitable candidates for surgery.TARE involves the targeted delivery of radioactive microspheres to liver tumors,offering a promising treatment option for managing HCC across various stages of the disease.By evaluating Y90 TARE outcomes across early,intermediate,and advanced stages of HCC,the review aims to present a thorough understanding of its efficacy and safety.Additionally,this paper highlights future research directions focusing on the potential of combination therapies with systemic and immunotherapies,as well as personalized treatments.The exploration of these innovative approaches aims to improve treatment outcomes,reduce adverse events,and provide new therapeutic opportunities for HCC patients.The review underscores the importance of ongoing research and clinical trials to optimize TARE further and integrate it into comprehensive HCC treatment paradigms.
文摘BACKGROUND The coronavirus disease 2019(COVID-19)pandemic has made it more challenging for patients to undergo yttrium-90(Y-90)radioembolization(RE).Same day Y-90 RE provides an opportunity to minimize logistical challenges and infection risk associated with COVID-19,thus improving patient access.AIM To describe the use of same day Y-90 RE with routine single photon emission computed tomography/computed tomography(SPECT/CT)in order to optimize therapy.METHODS All patients were selected for Y-90 RE through a multidisciplinary tumor board,and were screened and tested for COVID-19 infection per institutional protocol.A same day procedure was developed,consisting of angiography,imaging,and Y-90 resin particle delivery.Routine SPECT/CT after technetium-99m macroaggregated albumin(Tc-99m MAA)administration was performed for assessment of arterial supply,personalized dosimetry,and extrahepatic activity.Post-treatment Y-90 bremsstrahlung SPECT/CT was performed for confirmation of particle delivery,by utilization of energy windowing to limit signal from previously administered Tc-99m MAA particles.RESULTS A total of 14 patients underwent same day Y-90 RE between March and June 2020.Mean lung shunt fraction was 6.13%(range 3.5%-13.1%).Y-90 RE was performed for a single lesion in 7 patients,while the remaining 7 patients had treatment of multifocal lesions.The largest lesion measured 8.3 cm.All patients tolerated the procedure well and were discharged the same day.CONCLUSION Same day Y-90 RE with resin-based microspheres is feasible,and provides an opportunity to mitigate infection risk and logistical challenges associated with the COVID-19 pandemic and beyond.We recommend consideration of SPECT/CT,especially among patients with complex malignancies,for the potential to improve outcomes and eligibility of patients to undergo same day Y-90 RE.
文摘Hepatocellular carcinoma(HCC)is the sixth most common cancer in the world.The majority of patients with HCC present with unresectable disease.These patients have historically had limited treatment options secondary to HCC demonstrating chemoresistance to the currently available systemic therapies.Additionally, normal liver parenchyma has shown intolerance to tumoricidal radiation doses,limiting the use of external beam radiation.Because of these limitations,novel percutaneous liver-directed therapies have emerged. The targeted infusion of radioactive microspheres (radioembolization)represents one such therapy. Radioembolization is a minimally invasive transcatheter therapy through which radioactive microspheres are infused into the hepatic arteries that supply tumor. Once infused,these microspheres traverse the hepatic vascular plexus and selectively implant within the tumor arterioles.Embedded within the arterioles, the 90Y impregnated microspheres emit high energy and low penetrating radiation doses selectively to the tumor.Radioembolization has recently shown promise for the treatment of patients with unresectable HCC. The objective of this review article is to highlight twocurrently available radioembolic devices(90Y,188Rh)and provide the reader with a recent review of the literature.
文摘In the last decade trans-arterial radioembolization has given promising results in the treatment of patients with intermediate or advanced stage hepatocellular carcinoma(HCC),both in terms of disease control and tolerability profile.This technique consists of the selective intra-arterial administration of microspheres loaded with a radioactive compound(usually Yttrium90),and exerts its therapeutic effect through the radiation carried by these microspheres.A careful and meticulous selection of patients is crucial before performing the radioembolization to correctly perform the procedure and reduce the incidence of complications.Radioembolization is a technically complex and expensive technique,which has only recently entered clinical practice and is supported by scant results from phase Ⅲ clinical trials.Nevertheless,it may represent a valid alternative to transarterial chemoembolization(TACE) in the treatment of intermediate-stage HCC patients,as shown by a comparative retrospective assessment that reported a longer time to progression,but not of overall survival,and a more favorable safety profile for radioembolization.In addition,this treatment has reported a higher percentage of tumor shrinkage,if compared to TACE,for pre-transplant downsizing and it represents a promising therapeutic option in patients with large extent of disease and insufficient residual liver volume who are not immediately eligible for surgery.Radioembolization might also be a suitable companion to sorafenib in advanced HCC or it can be used as a potential alternative to this treatment in patients who are not responding or do not tolerate sorafenib.
文摘Transarterial radioembolization(TARE) is a form of brachytherapy in which intra-arterially injected yttrium-90-loaded microspheres serve as a source for internal radiation purposes.On the average,it produces disease control rates exceeding 80% and it is a consolidated therapy for hepatocellular carcinoma(HCC);however,current data are all based on retrospective series or non-controlled prospective studies since randomized controlled trials comparing it with the other liver-directed therapies for intermediate and locally advanced stage HCC are still underway.The data available show that TARE provides similar or even better survival rates when compared to transarterial chemoembolization(TACE).First-line TARE is best indicated for both intermediatestage patients(staged according to the barcelona clinic liver cancer staging classification) who have lesions which respond poorly to TACE due to multiple tumors or a large tumor burden,and for locally advanced-stage patients with solitary tumors,and segmental or lobar portal vein tumor thrombosis.In addition,emerging data have suggested the use of TARE in patients who are classified slightly beyond the Milan criteria regarding radical treatment for downstaging purposes.As a secondline treatment,TARE can also be applied in patients progressing to TACE or sorafenib;a large number of phase Ⅱ/Ⅲ trials are ongoing with the purpose of evaluating the best association with systemic therapies.Transarterial radioembolization is very well tolerated and has a low rate of complications which are mainly related to unintended non-target tissue irradiation,including the surrounding liver parenchyma.The complications can be additionally reduced by accurate patient selection and a strict pre-treatment evaluation including dosimetry and assessment of the vascular anatomy.Since a correct treatment algorithm for potential TARE candidates is not clear and standardized,this comprehensive review analyzes the best selection criteria for patients who really benefit from TARE and also the new advances of this therapy,which can be a very important weapon against HCC.
文摘AIM: To compare the efficacy and safety of yttrium-90 radioembolization(Y90RE) and transarterial chemoembolization(TACE) in hepatocellular carcinoma patients. METHODS: Bibliographic research was conducted on main scientific databases. When there was no statistically significant heterogeneity, pooled effects were calculated using a fixed-effects model by means of Mantel-Haenszel test, otherwise, a random-effects model was used with Der Simonian and Laird test. Summary estimates were expressed in terms of odds ratios(ORs) and 95%CI. The probability of publication bias was assessed using funnel plots and with Begg and Mazumdar's test. Sensitivity analysis was finally conducted using the method of excluding extreme data.RESULTS: A total of 10 studies were analyzed, of which 2 randomized controlled trials. Survival rate(SR) assessed at 1 year showed an absolute similarity between the two treatment groups(OR = 1.01, 95%CI: 0.78-1.31, P = 0.93). As long as time elapsed since the treatment, ORs for survival rate tended to significantly increase, thus meaning better long-term outcomes in patients who underwent Y90RE(2-year SR: OR = 1.43, 1.08-1.89, P = 0.01; 3-year SR: OR = 1.48, 1.03-2.13, P = 0.04). Meta-analysis of plotted hazard ratios(HRs) determined a non-significant overall estimate in favor of Y90RE(HR = 0.91, 0.80-1.04, P = 0.16). Y90 RE showed a statistically significant benefit as compared to TACE in terms of higher progression-free survival rateassessed at 1 year(OR = 1.67; 95%CI: 1.10-2.55; P = 0.02). Pooled analyses do not revealed a statistically significant increase in OR for tumor objective responses after Y90 RE with respect to TACE(OR = 1.22, 95%CI: 0.69-2.16, P = 0.50). A non-significant trend in favor of Y90 RE was observed according to adverse event rate(OR = 0.70, 0.38-1.30, P = 0.26).CONCLUSION: Our meta-analysis reveals that Y90 RE and TACE show similar effects in terms of survival, response rate and safety profile, although tumor progression is delayed after radioembolization.
文摘AIM To evaluate the value of pre-treatment 18F-FDG PET/CT in patients with HCC following liver radioembolization.METHODS We identified 34 patients with HCC who underwent an FDG PET/CT scan prior to hepatic radioembolization at our institution between 2009 and 2013. Patients wereseen in clinic one month after radioembolization and then at 2-3 mo intervals. We assessed the influence of FDG tumor uptake on outcomes including local liver control(LLC), distant liver control(DLC), time to distant metastases(DM), progression free survival(PFS) and overall survival(OS).RESULTS The majority of patients were males(n = 25, 74%), and had Child Pugh Class A(n = 31, 91%), with a median age of 68 years(46-84 years). FDG-avid disease was found in 19(56%) patients with SUVmax ranging from 3 to 20. Female patients were more likely to have an FDG-avid HCC(P = 0.02). Median follow up of patients following radioembolization was 12 months(1.2-62.8 mo). FDG-avid disease was associated with a decreased 1 year LLC, DLC, DM and PFS(P < 0.05). Using multivariate analysis, FDG avidity predicted for LLC, DLC, and PFS(all P < 0.05).CONCLUSION In this retrospective study, pre-treatment HCC FDGavidity was found to be associated with worse LLC, DLC, and PFS following radioembolization. Larger studies are needed to validate our initial findings to assess the role of F-18-FDG PET/CT scans as biomarker for patients with HCC following radioembolization.
文摘Purpose:The IMbrave150 PhaseⅢtrial demonstrated superiority of atezolizumab and bevacizumab(Atezo/Bev)over sorafenib for unresectable hepatocellular carcinoma(HCC).The present study aims to evaluate the feasibility of TARE in combination with Atezo/Bev for treatment of intermediate and advanced staged HCC.Methods:Retrospective review at a single institution was performed between May 2021 and December 2022.Patients who received TARE using yttrium-90(Y90)with concomitant or sequential Atezo/Bev systemic treatment were included.The following outcomes were retrieved:overall survival(OS),radiologic tumor response,progression-free survival,technical adverse events related to TARE,and toxicity based on the National Cancer Institute–Common Terminology Criteria for Adverse Events version 5.0.Results:Ten consecutive patients with intermediate(n=4)and advanced stage HCC(n=6)were treated with TARE and sequential/concomitant Atezo/Bev.Tumor control was achieved in all TARE-treated target lesions(100%).Overall disease progression occurred in 4 patients with PFS of 78.8%and 66.7%at 6-and 12-months,respectively.Two patients died at follow-up,with 6-month and 12-month OS rates of 90.0%and 77.1%,respectively.Three(75%)patients with intermediate stage disease were downstaged into Milan criteria.One patient developed grade 3 transaminitis and hypoglobulinemia,while Atezo/Bev was switched to Lenvatinib in another patient due to immunotherapy related myositis.Conclusion:This study demonstrates initial safety and feasibility of combined TARE with Atezo/Bev for intermediate/advanced stage HCC.Further prospective studies with larger sample size are warranted.
文摘Objective: To compare the effects and safety of conventional transarterial chemoembolization(c TACE) and yttrium-90 transarterial radioembolization [TARE(90 Y)] for hepatocellular carcinoma(HCC)Methods: Nine high-quality observational studies, one low bias-risk randomized controlled trial(RCT), and one moderate biasrisk RCT included 1,652 patients [c TACE, 1,124; TARE(90 Y), 528], from whom data were extracted for this systematic review and meta-analysis.Results: The extracted study outcomes included 1-year and 2-year overall survival(OS) rates, objective responses(ORs), and serious adverse events(AEs). 1-year OS rates: OR = 0.939, 95 % CI: 0.705-1.251, P = 0.66. 2-year OS rates: overall pooled OR =0.641, 95% CI: 0.382-1.075, P = 0.092; observational study subgroup OR = 0.575, 95% CI: 0.336-0.984, P = 0.043; RCT subgroup OR* = 0.641, 95% CI: 0.382-1.075, P = 0.346. OR: overall pooled OR = 0.781, 95% CI: 0.454-1.343, P = 0.371; m RECIST subgroup OR = 0.584, 95 % CI: 0.349-0.976, P = 0.040; WHO subgroup OR = 1.065; 95% CI: 0.500-2.268, P = 0.870. Serious AEs: overall pooled RR = 1.477, 95% CI: 0.864-2.526, P = 0.154; RCT subgroup RR = 0.680, 95% CI: 0.325-1.423, P = 0.306; observational study subgroup RR = 1.925; 95 % CI: 0.978-3.788, P = 0.058.Conclusions: TARE(90 Y) increased 2-year OS rates in the observational subgroup and resulted in better OR rates, according to m RECIST criteria, in comparison with c TACE. Furthermore, a lower risk of AEs was observed for TARE(90 Y) than for c TACE.
文摘AIM:To evaluate the long-term natural history of the gastroduodenal lesions secondary to extrahepatic embolization with Ytrium 90(90 Y) spheres.METHODS:From September 2003 to January 2012,379 procedures of liver radioembolization(RE) using resin microspheres loaded with 90 Y were performed in our center.We have retrospectively compiled the data from 379 RE procedures performed in our center.We report a comprehensive clinical,analytical,endoscopic and histologic long-term follow-up of a series of patients who developed gastroduodenal lesions after the treatment.RESULTS:Six patients(1.5%) developed gastrointestinal symptoms and had gastrointestinal lesions as shown by upper endoscopy in the next 12 wk after RE.The mean time between RE and the appearance of symptoms was 5 wk.Only one patient required endoscopic and surgical treatment.The incidence of gastrointestinal ulcerations was 3.75%(3/80) when only planar images were used for the pre-treatment evaluation.It was reduced to 1%(3/299) when singlephoton emission computed tomography(SPECT) images were also performed.The symptoms that lasted for a longer time were nausea and vomiting,until 25 mo after the treatment.CONCLUSION:All patients were free from severe symptoms at the end of follow-up.The routine use of SPECT has decreased the incidence of gastrointestinal lesions due to unintended deployment of 90 Y particles.
文摘Liver resection(LR) with negative margins confers survival advantage in many patients with hepatic malignancies.However,an adequate future liver remnant(FLR) is imperative for safe LR.Presently,in patients with an inadequate FLR; the 2 most established clinical techniques performed to induce liver hypertrophy are portal vein embolization(PVE) and portal vein ligation.More recently,it has been observed that patients who undergo treatment via Y90 radioembolization experience hypertrophy of the contra-lateral untreated liver lobe.Based on these observations,several investigators have proposed the potential use of this modality as an alternative technique for increasing the FLR prior to liver resection.Y90 radioembolization induces hypertrophy at a slower rate than PVE but has the added advantage of concomitant local disease control and tumour downstaging.
文摘Unresectable primary and secondary liver malignancies present a major problem in the treatment of solid tumors. Transarterial radioembolization(TARE) is an increasingly used technique for treating various types of malignant liver tumors. This approach is appealing, as the mechanism of action is independent from other loco-regional treatments and potentially complementary to systemic therapies. There are two commercially available products in use for TARE: 90Y-resin and 90Y-glass microspheres. Currently available data indicates TARE so be safe and effective in hepatocellular carcinoma(HCC) and metastatic liver disease. In HCC the results compare well with chemoembolization, while the role of TARE in combination with kinase inhibitors has yet to be established. Current data on TARE in metastatic liver disease is promising, but there is a strong need for prospective randomized trials comparing TARE and modern chemotherapeutic regimen to support the growing role of TARE in metastatic liver disease.
基金Institutional review board of The University of Texas MD Anderson Cancer Center,No.DR09-0025.
文摘BACKGROUND Impressive survival outcome of our previous study in unresectable hepatocellular carcinoma(HCC)patients undergoing yttrium-90 glass microspheres transarterial radioembolization(TARE)with/without sorafenib according to individuals’disease burden,i.e.,intrahepatic tumor load(IHT)and adverse disease features(ADFs)might partly be confounded by other treatments and underlying hepatic function.Therefore,a dedicated study focusing on treatment response and assessment of failure patterns might be a way to improve treatment outcome in addition to patient selection based on the disease burden.AIM To assess the tumor response,disease control and patterns of disease progression following TARE with/without sorafenib in unresectable HCC patients.METHODS This retrospective study was conducted in successful TARE procedures with available pre-and post-treatment imaging studies(n=169).Three treatment subgroups were(1)TARE only(TARE_alone)for IHT≤50%without ADFs,i.e.,macrovascular invasion,extrahepatic disease(EHD)and infiltrative/ill-defined HCC(n=63);(2)TARE with sorafenib(TARE_sorafenib)for IHT>50%and/or presence of ADFs(n=81);and(3)TARE only for patients who could not receive sorafenib due to contraindication or intolerance(TARE_no_sorafenib)(n=25).Objective response rate(ORR;consisted of complete response(CR)and partial response(PR)),disease control rate(DCR;consisted of CR,PR and stable disease)and failure patterns of treated,intrahepatic and extrahepatic sites were assessed using the modified response evaluation criteria in solid tumors.Time to progression(TTP)was calculated from TARE to the first radiologic progression at any site using Kaplan-Meier method.Identification of prognostic factors for TTP using the univariate Kaplan-Meier method and multivariate Cox proportional hazard model were performed in major population subgroups,TARE_alone and TARE_sorafenib.RESULTS The median radiologic follow-up time was 4.4 mo(range 0.5-48.8).In treated area,ORR was highest in TARE_sorafenib(53.1%),followed by TARE_alone(41.3%)and TARE_no_sorafenib(16%).In intrahepatic area,DCR remained highest in TARE_sorafenib(84%),followed by TARE_alone(79.4%)and TARE_no_sorafenib(44%).The overall DCR was highest in TARE_alone(79.4%),followed by TARE_sorafenib(71.6%)and TARE_no_sorafenib(40%).Dominant failure patterns were intrahepatic for both TARE_alone(44.5%)and TARE_sorafenib(38.4%).Extrahepatic progression was more common in TARE_sorafenib(32%)and TARE_no_sorafenib(40%)than in TARE_alone(12.7%).TTP was longest in TARE_alone(8.6 mo;95%CI:3.4-13.8),followed by TARE_sorafenib(5.1 mo;95%CI:4.0-6.2)and TARE_no_sorafenib(2.7 mo;95%CI:2.2-3.1).Pre-existing EHD(HR:0.37,95%CI:0.24-0.56,P<0.001)was a sole prognostic factor for TTP in TARE_sorafenib with no prognostic factor for TTP in TARE_alone.CONCLUSION TARE with/without sorafenib according to individuals’disease burden provided DCR approximately 70%with intrahepatic progression as dominant failure pattern.Extrahepatic progression was more common in procedures with initially high disease burden.
文摘BACKGROUND Liver metastases secondary to breast cancer are associated with unfavourable prognosis.Radioembolization with ytrrium-90 is an emerging option for management of liver metastases of breast cancer when other systemic therapies have failed to achieve disease control.However,unlike the case of other liver tumours(colorectal/melanoma metastases/cholangiocarcinoma),its role in the management of breast liver metastases is yet to be elucidated.AIM The aims of this systematic review were to(1)assess the effect of radioembolization with yttrium-90 on tumour response;and(2)to estimate patient survival post radioembolization.METHODS The review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.A systematic literature search was performed using the PubMed and EMBASE databases from January 2007 to December 2018.The initial search yielded 265 reports which were potentially suitable for inclusion in this review.Studies published in English reporting at least one outcome of interest were considered to be suitable for inclusion.Conference abstracts;case reports,animal studies and reports not published in English were excluded from this review.Data was retrieved from each individual report on the name of primary author,year of publication,patient demographics,type of microspheres used,radiation dose delivered to tumour,duration of follow-up,disease control rate(%),tumour response,and overall patient survival.RESULTS The final number of studies which met the inclusion criteria was 12 involving 452 patients.There were no randomized controlled trials identified after the literature search.The age of the patients included in this review ranged from 52 to 61 years.The duration of the follow up period post-radioembolization ranged from 6 to 15.7 mo.The total number of patients with breast metastases not confined to the liver was 236(52.2%).Cumulative analysis revealed that radioembolization with yttrium-90 conferred tumour control rate in 81%of patients.Overall survival post-radioembolization ranged from 3.6 to 20.9 mo with an estimated mean survival of 11.3 mo.CONCLUSION Radioembolization with ytrrium-90 appears to confer control of tumour growth rate in most patients,however its effect on patient survival need to be elucidated further.Furthermore,quality evidence in the form of randomized trials is needed in order to assess the effect of radioembolization in more depth.
文摘We report the case of a 57-year-old man who was diagnosed with a large unresectable cholangiocarcinoma associated with 2 satellite nodules and without clear margins with the right hepatic vein. Despite 4 cycles of GEMOX (stopped due to a hypertransaminasemia believed to be due to gemcitabine) and 4 cycles of FOLFIRINOX, the tumor remained stable and continued to be considered unresectable. Radioembolization (resin microspheres, SIRS-spheres<sup>®</sup>) targeting the left liver (474 MBq) and segment IV (440 MBq) was performed. This injection was very well tolerated, and 4 more cycles of FOLFIRINOX were given while waiting for radioembolization efficacy. On computed tomography scan, a partial response was observed; the tumor was far less hypervascularized, and a margin was observed between the tumor and the right hepatic vein. A left hepatectomy enlarged to segment VIII was performed. On pathological exam, most of the tumor was acellular, with dense fibrosis around visible microspheres. Viable cells were observed only at a distance from beads. Radioembolization can be useful in the treatment of cholangiocarcinoma, allowing in some cases a secondary resection.
文摘Intrahepatic cholangiocarcinoma(iCCA)is recognized as the second most frequently diagnosed liver malignancy,following closely after hepatocellular carcinoma.Its incidence has seen a global upsurge in the past several years.Unfortunately,due to the lack of well-defined risk factors and limited diagnostic tools,iCCA is often diagnosed at an advanced stage,resulting in a poor prognosis.While surgery is the only potentially curative option,it is rarely feasible.Currently,there are ongoing investigations into various treatment approaches for unresectable iCCA,including conventional chemotherapies,targeted therapies,immunotherapies,and locoregional treatments.This study aims to explore the role of transarterial radioembolization(TARE)in the treatment of unresectable iCCA and provide a comprehensive review.The findings suggest that TARE is a safe and effective treatment option for unresectable iCCA,with a median overall survival(OS)of 14.9 months in the study cohort.Studies on TARE for unresectable iCCA,both as a first-line treatment(as a neo-adjuvant down-staging strategy)and as adjuvant therapy,have reported varying median response rates(ranging from 34%to 86%)and median OS(12-16 mo).These differences can be attributed to the heterogeneity of the patient population and the limited number of participants in the studies.Most studies have identified tumor burden,portal vein involvement,and the patient’s performance status as key prognostic factors.Furthermore,a phase 2 trial evaluated the combination of TARE and chemotherapy(cisplatin-gemcitabine)as a first-line therapy for locally advanced unresectable iCCA.The results showed promising outcomes,including a median OS of 22 mo and a 22%achievement in down-staging the tumor.In conclusion,TARE represents a viable treatment option for unresectable iCCA,and its combination with systemic chemotherapy has shown promising results.However,it is important to consider treatment-independent factors that can influence prognosis.Further research is necessary to identify optimal treatment combinations and predictive factors for a favorable response in iCCA patients.
文摘Preoperative radioembolization may improve the resectability of liver tumor by inducing tumor shrinkage,atrophy of the embolized liver and compensatory hypertrophy of non-embolized liver.We describe the case of a cirrhotic Child-Pugh A patient with a segmentⅣhepatocellular carcinoma requiring a left hepatectomy.Preoperative angiography demonstrated 2 separated left hepatic arteries,for segmentⅣand segmentsⅡ-Ⅲ.This anatomic variant allowed sequential radioembolizations,delivering high-dose^(90)Yttrium(160 Gy)to the tumor,followed 28 d later by lower dose(120 Gy)to segmentsⅡ-Ⅲ.After 3 mo,significant tumor response and atrophy of the future resected liver were obtained,allowing uneventful left hepatectomy.This case illustrates that,when anatomic disposition permits it,sequential radioembolizations,delivering different^(90)Yttrium doses to the tumor and the future resected liver,could represent a new strategy to prepare major hepatectomy in cirrhotic patients,allowing optimal tumoricidal effect while reducing the toxicity of the global procedure.
文摘BACKGROUND Primary appendiceal cancers are rare,and they generally present with liver and/or peritoneal metastases.Currently there are no guidelines to treat metastatic appendiceal cancer,and hence they are treated as metastatic colorectal cancer.Combining Yttrium 90(Y-90)radioembolization(RE)with systemic chemotherapy early in the treatment of right sided colon cancers has been shown to improve survival.Based on this data,a combination of systemic chemotherapy and Y-90 RE was used to treat a case of metastatic appendiceal cancer.CASE SUMMARY A 76-year-old male presented to the emergency room with progressive right lower quadrant pain.A Computed Tomography of the abdomen and pelvis was performed which showed acute appendicitis and contained perforation.Urgent laparoscopic appendectomy was then followed by histological analysis,which was significant for appendiceal adenocarcinoma.After complete workup he underwent right hemicolectomy and lymph node dissection.He received adjuvant chemotherapy as the local lymph nodes were positive.Follow-up imaging was significant for liver metastasis.Due to rapid growth of the liver lesions and new peritoneal nodules,the patient was treated with a combination of Y-90 RE and folinic acid,fluorouracil,and irinotecan with bevacizumab and not microwave ablation as previously planned.Follow up imaging demonstrated complete response of the liver lesions.At 12-mo follow-up,the patient continued to enjoy good quality of life with no recurrent disease.CONCLUSION Utilization of Y-90 RE concomitantly with systemic chemotherapy early in the treatment of appendiceal cancer may provide improved control of this otherwise aggressive cancer.
文摘BACKGROUND The hepatic arterial anatomy is highly variable, with the two most common variants being a replaced right hepatic artery(RHA) originating from the superior mesenteric artery(SMA) and a left hepatic artery(LHA) originating from the left gastric artery(LGA). These anatomical variants could potentially increase the risk for non-target embolization during Y90-Radioembolization due to the close proximity between hepatic and enteric vessel branches.AIM To evaluate the safety of Yttrium-90radioembolization(90Y-RE) with resin microspheres in patients with a variant hepatic arterial anatomy.METHODS In this retrospective single-center observational study, 11 patients who underwent RE with 90Y-resin microspheres via a LHA originating from the LGA,and 13 patients via a RHA originating from the SMA were included. Patient and treatment data were reviewed regarding clinical and imaging evidence of nontarget embolization of 90Y-resin microspheres to the GI tract. Positioning of the tip of the microcatheter in relationship to the last hepatoenteric side branch was retrospectively analyzed using angiographic images, cone-beam CT and preinterventional CT-angiograms.RESULTS None of the 24 patients developed clinical symptoms indicating a potential nontarget embolization to the GI tract within the first month after 90Y-RE. On thepostinterventional 90Y-bremsstrahlung images and/or 90Y-positron emission tomographies, no evidence of extrahepatic 90Y-activity in the GI tract was noted in any of the patients. The mean distance between the tip of the microcatheter and the last enteric side branch during delivery of the 90Y microspheres was 3.2 cm(range: 1.9-5 cm) in patients with an aberrant LHA originating from a LGA. This was substantially shorter than the mean distance of 5.2 cm(range: 2.9-7.7 cm) in patients with an aberrant right hepatic originating from the SMA.CONCLUSION90Y-RE via aberrant hepatic arteries appears to be safe;at least with positioning of the microcatheter tip no less than 1.9 cm distal to the last hepatoenteric side branch vessel.
