O19 A selective internal radiation therapy (SIRT) for hepatocellular carcinoma audit – informing UK MDT practice

Abstract

<h3>Introduction</h3> Hepatocellular Carcinoma (HCC) deaths are rising alarmingly. Many patients are unsuitable for available therapies. Poor response rates further hamper outcomes for those that are. Selective internal radiotherapy (SIRT) is an alternative arterial therapy for patients with HCC. Although randomised control trial (RCT) evidence showing superiority over standard therapies is lacking, it is a well-tolerated treatment with excellent outcomes for some patients. The National Institute for Clinical Excellence (NICE) has approved its use in NHS Trusts in England within a specialist multidisciplinary team (MDT) setting. Which patients benefit over standard treatment approaches remains unclear. Decision making aids for UK MDTs are needed. <h3>Methods</h3> As part of quality/service improvement, we audited consecutive patients treated with SIRT Theraspheres (Boston Scientific UK)(January 2015-June 2020) by the Newcastle-upon-Tyne Hospitals NHS Foundation Trust HCC MDT. Indications, Barcelona Clinic Liver Cancer (BCLC) stage, treatment response, subsequent therapies and survival at 30/09/2021 were assessed. <h3>Results</h3> Fifty-one patients received SIRT. Thirty-day mortality was zero. Three months partial response, stable disease and progressive disease on imaging were 50%, 22% and 28%. Overall median survival was 21 months. The MDT recognised 4 sub-groups: (1)BCLC-B: HCC &gt;7cm too large for TACE alone(n=21); (2) BCLC-B: HCC progressed post TACE(n=7); (3)BCLC-C: HCC with any combination of large tumour burden, branch portal vein thrombosis, non HCV etiology(n=16); (4)BCLC-C: sorafenib inappropriate(n=7). In Group 1, 5/21(23.8%) of patients were downstaged to resection, 33% were fit/suitable for subsequent medical therapies and median survival was &gt;40 months. In BCLC-B patients treated with SIRT 2^nd line(Group 2), median survival was 14.2 months. In BCLC-C, median survival was 20.2 months for Group 3 and 4.2 months for Group 4. BCLC stage is determined by the MDT. Preferred 1^st line therapies are shown. TACE is typically used for BCLC-B patients. If an MDT considers SIRT a more suitable option (green box), SIRT may be discussed with patients. For BCLC-B patients responding to SIRT, treatments for earlier stage disease may be considered (dotted line to left). For BCLC-B patients who progress, medical therapies would be considered (dotted line to right). For patients with BCLC 0-A, or BCLC-C stage HCC (**orange), SIRT can be considered as an alternative to preferred 1^st line therapies, subject to funding approval by individual NHS Trusts. <h3>Conclusions</h3> SIRT outcomes for advanced HCC, often bridging patients with adverse predictive factors to subsequent surgery or medical therapies, were encouraging. A role 2^nd line, or in presence of contraindications/intolerance to sorafenib, requires further assessment. Pending further RCT data or wider UK collaborative audit, the algorithm in Figure 1 is proposed.