Yttrium-90 Radioembolization For Hepatocellular Carcinoma Research Articles

Predictive Value of Day of Treatment SPECT/CT Radiomics in Lobar Y90 Radioembolization of Hepatocellular Carcinoma: A Pilot Study

Transarterial Radioembolization (TARE) with Yttrium-90 (Y90) microspheres is a well-tolerated liver-directed therapy for patients with inoperable hepatocellular carcinoma (HCC). Y90 TARE uses pretreatment and post-treatment single photon emission computed tomography (SPECT)/CT for assessment of microsphere biodistribution within tumor. Patients who develop disease progression (PD) after lobar TARE have poor overall survival (OS). Conventional radiography can require several months follow-up to assess tumor response per modified RECIST (mRECIST), resulting in treatment delays for patients with PD. Predictive models capable of identifying patients at high risk for PD could prompt close surveillance and rapid initiation of salvage therapies, enhancing disease control (DC). Predictive models in various cancers have incorporated radiomics, an analytic technique that extracts digital patterns from medical imaging. We hypothesized that radiomics of immediate post-treatment SPECT/CT can predict objective response (OR) to Y90 TARE. A total of 38 lobar TARE treatments were assessed retrospectively. For all treatments, the prescribed dose was 120 Gy. SPECT/CT obtained immediately after TARE underwent radiomics analysis. A total of 75 features related to gray-level (GL) co-occurrence matrices (COM), dependency matrices (DM), run length matrices (RLM), zone size matrices (ZSM), and neighborhood difference matrices (NDM) were examined and balanced between cohorts with and without OR by aid of Gaussian noise up-sampling. Top features were chosen for a weighted k-nearest neighbors (KNN) classifier based on rank as determined by the RELIEF-F algorithm. Performance of the developed classifier was evaluated by receiver operating characteristic (ROC) curve analysis. Most patients (76%) were Child-Pugh A cirrhotic, while Barcelona Clinic Liver Cancer (BCLC) stage was evenly distributed A to C. On radiographic review, 22 treatments (58%) achieved OR. The selected top features consisted of two from CT (GLNDM-based coarseness; GLDM-based small dependence low gray level emphasis) and two from SPECT (GLNDM-based coarseness; GLZSM-based zone entropy). The weighted KNN classifier built using the selected features demonstrated a relatively strong power for predicting OR, with a ROC area under curve (AUC) of 0.83. In lobar TARE Y90 of inoperable HCC, a predictive model using texture features extracted from day of treatment SPECT/CT distinguished responders from non-responders with high accuracy. Limitations of this study include its retrospective nature and the absence of toxicity analysis. These findings suggest that predictive modeling incorporating SPECT/CT radiomics could enhance the therapeutic ratio for vulnerable HCC patients and merits further investigation in prospective clinical trials of Y90 TARE.

Abstract No. 195 Tumor size is an independent risk factor for mortality after yttrium-90 radioembolization for HCC

Tumor size impacts patient eligibility for surgical interventions, staging, and locoregional approaches to treatment. The purpose of this study was to evaluate tumor size as a prognosticator for long-term overall survival (OS) in hepatocellular carcinoma (HCC) patients treated with yttrium-90 radioembolization (Y-90). The hypothesis was tumor size would stratify long-term OS after Y-90.

Biochemical Safety of Ablative Yttrium-90 Radioembolization for Hepatocellular Carcinoma as a Function of Percent Liver Treated.

PurposeTransarterial radioembolization can serve as an ablative therapy for early-stage hepatocellular carcinoma (HCC). Given the volumetric variability of liver segments, this study aimed to characterize the safety of ablative radioembolization by determining percent liver treated (%LT) thresholds associated with biochemical toxicity.Patients and MethodsPatients with HCC receiving a single ablative radioembolization treatment using glass microspheres from 2017 through 2020 were reviewed. %LT was calculated as treatment angiosome volume divided by whole liver volume. Biochemical toxicities were defined as increases in Albumin-Bilirubin (ALBI) grade or Child-Pugh (CP) class compared to baseline and albumin or bilirubin adverse events (AEs) per the Common Terminology Criteria for Adverse Events. Receiver operating characteristic curves and multivariate logistic regression analyses were performed to assess the impact of %LT on toxicities.ResultsOf 141 patients analyzed, 53% (n=75) were ALBI 1, 45% (n=64) ALBI 2, 79% (n=111) CP-A, and 21% (n=30) CP-B. A %LT ≥14.5% was associated with grade/class increases in ALBI 2 (p≤0.01) and CP-B patients (p=0.026). In multivariate analysis, a %LT ≥14.5% was an independent predictor of increases in the ALBI 2 and CP-B groups (p<0.01). No significant %LT threshold was found for ALBI 1 and CP-A patients. No grade 3/4 albumin or bilirubin AEs were reported, while grade 2 AEs were related to an initial whole liver volume <1.3 L (p≤0.01).ConclusionPatients with ALBI 2 and CP-B liver function are less likely to have an increase in their respective grade/class when treating <14.5% of the liver using glass microspheres. ALBI 1 and CP-A patients showed no definitive %LT threshold for biochemical toxicity within the range of this study.

MRI-Derived Sarcopenia Associated with Increased Mortality Following Yttrium-90 Radioembolization of Hepatocellular Carcinoma.

To evaluate the influence of sarcopenia on survival in patients with hepatocellular carcinoma (HCC) treated with 90Y radioembolization. This single-center retrospective cohort study analyzed 82 consecutive patients (65 men and 17 women, mean age 65years, range 31-83years) with HCC treated with 90Y radioembolization between December 2013 and December 2017. Sarcopenia was assessed on pre-procedure MRI performed within 100days prior to 90Y radioembolization by segmenting the paraspinal musculature at the level of the superior mesenteric artery origin and subtracting fat-intensity pixels to yield fat-free muscle area (FFMA). Sarcopenia was defined as FFMA ≤31.97 cm2 for men and ≤28.95 cm2 for women. Survival at 90days, 180days, 1year, and 3years following initial treatment was assessed using medical and public obituary records. Sarcopenia was identified in 30% (25/82) of patients. Death was reported for 49% (32/65) of males and 71% (8/17) of females (mean follow-up 19.6months, range 21days-58months). Patients with sarcopenia were found to have increased mortality at 180days (31.8% vs. 8.9%) and 1year (68.2% vs. 21.2%). Sarcopenia was an independent predictor of mortality adjusted for BCLC stage and sub-analysis demonstrated that sarcopenia independently predicted increased mortality for patients with BCLC stage B disease. Sarcopenia was associated with increased 180-day and 1-year mortality in HCC patients undergoing 90Y radioembolization. Sarcopenia was an independent predictor of survival adjusted for BCLC stage with significant deviation in the survival curves of BCLC stage B patients with and without sarcopenia.

Yttrium-90 Radioembolization for Hepatocellular Carcinoma: Virtual Tumor Absorbed Dose as a Predictor of Complete Response.

To evaluate the impact of virtual tumor absorbed dose (vTAD) on tumor response in patients with hepatocellular carcinoma (HCC) treated with yttrium-90 radioembolization. The institutional review board approved this retrospective single center study, which comprised 100 patients with nodular HCC who underwent yttrium-90 radioembolization between November 2015 and December 2019. The vTAD was calculated assuming that all infused microspheres were distributed only in the tumor. The ability of mean absorbed dose (mAD) and vTAD in predicting complete response were evaluated by receiver operating characteristic (ROC) curve analyses. The mAD was 263.9 Gy ± 125.8, and the mean vTAD was 2005.8 Gy ± 2348.9. In terms of tumor response, 63 patients had complete response, 25 partial response, and 12 stable disease. For predicting complete response, ROC curve analyses revealed that the area under the curve (AUC) value of the vTAD was significantly higher (p<0.001) than that of the mAD. Multivariate analysis revealed that Child-Pugh class A5, unilobar disease, and vTAD (>952 Gy) were significant factors in predicting complete response. High vTAD (>952 Gy) plays a significant role in complete response in patients with nodular HCC.

Abstract No. 170 Magnetic resonance imaging–derived sarcopenia associated with mortality following Yttrium-90 radioembolization for hepatocellular carcinoma

Abstract No. 170 Magnetic resonance imaging–derived sarcopenia associated with mortality following Yttrium-90 radioembolization for hepatocellular carcinoma

Abstract No. 4 Accuracy of scout dose Y90 liver biodistribution for personalized treatment planning of Y90 radioembolization of hepatocellular carcinoma: interim analysis of a prospective clinical trial

To evaluate the accuracy of scout dose Yttrium-90 (Y90) resin microspheres versus technetium-99m MAA (Tc99m-MAA) in predicting the therapeutic dose Y90 liver biodistribution for radioembolization (RE) planning in hepatocellular carcinoma (HCC) patients In a prospective single-arm clinical trial patients with HCC undergoing Y90 RE were recruited. Inclusion criteria included unilobar disease with ≤3 lesions with the largest lesion ≤ 7cm. Each patient underwent mapping angiography study with Tc99m-MAA and MAA SPECT/CT followed by second mapping study using 15 mCi Y90 resin microspheres and Y90 SPECT/CT and PET/CT. Prospective treatment planning with MAA data was performed using partition model with the goal of >200 Gy to the targeted tumor. Prescribed Y90 activity minus previously administered scout activity was administered 3 days after the mapping studies. Same microcatheter type and position were used for all stages of the study in each patient. Sureplan (MIM Software, Cleveland, OH) was used for all dosimetry analyses. Using paired t-test, the tumor:normal (TNR) calculated by MAA SPECT and scout dose Y90 SPECT and PET were compared to that of therapeutic dose Y90 SPECT and PET. First N = 15 patients treated in the clinical trial are included in this interim analysis. Mean TNR by MAA SPECT was 2.33. Mean TNR by scout dose Y90 SPECT and PET were 1.79 and 2.59, respectively. Mean TNR by therapeutic dose Y90 SPECT and PET were 1.75 and 2.65, respectively. MAA TNR was greater than both Y90 scout and therapeutic dose TNRs calculated by SPECT (Ps< 0.001). MAA TNR was statistically similar to both scout dose and therapeutic dose Y90 TNRs calculated by PET (P = 0.33 and P = 0.55, respectively). Y90 Scout and therapeutic dose TNRs calculated by SPECT were similar (P = 0.59) and the same finding was observed for Y90 TNRs calculated by Y90 scout and therapeutic dose PET (P = 0.74). Y90 scout dose is an accurate predictor of therapeutic Y90 dose biodistribution in the liver on both SPECT and PET, respectively. On the other hand, Tc99-MAA TNR was significantly greater than both Y90 scout and therapeutic dose TNRs on SPECT, whereas it was statistically similar to that of PET.

Abstract No. 525 Yttrium-90 radioembolization of segment IV hepatocellular carcinoma: assessment of biliary complications in a region dense with biliary structures

Biliary complications are a known risk from Yttrium-90 radioembolization of hepatocellular carcinoma (HCC). The proposed mechanism of injury is due to microembolic effect and/or radiation-induced injury to the biliary system1. We investigate whether lesions treated in segment IV demonstrated a higher incidence of biliary complications compared to the literature due to the higher density of biliary structures within this segment. A single-institution retrospective analysis of patients with segment IV HCC treated with Yttrium-90 microspheres from 2013 to 2019. Inclusion criteria included: diagnosis of HCC to segment IV, at least one follow-up computed tomography or magnetic resonance examination within 90 days of treatment, and serum total bilirubin before and within 90 days post treatment. Exclusion criteria included liver transplantation. Thirty patients met criteria with an average length of follow-up imaging at 46 days. Biliary complications included, but were not limited to: biloma, cholecystitis, biliary strictures, and grade 3 or 4 biliary toxicity by National Cancer Institute criteria. Of 30 patients, one patient was found to have multifocal biliary strictures requiring two biliary stents on endoscopic retrograde cholangiopancreatography five months post procedure (n = 1, 3.3%). Two patients demonstrated grade 3/4 bilirubin toxicity (n = 2, 6.7%). The average treatment dosage was 135 Gray (range, 95–341 Gy). Compared to the biliary complication rate described in the literature for HCC with 2.1% for biliary findings on imaging and 6.8% for grade 3/4 bilirubin toxicity2, our study showed comparable rates of 3.3% and 6.7%, respectively. Yttrium-90 radioembolization of segment IV HCC demonstrated no significant difference in biliary complication rates compared to nonsegment specific biliary complication rates reported in the literature.

Safety and Efficacy of Segmental Yttrium-90 Radioembolization for Hepatocellular Carcinoma after Transjugular Intrahepatic Portosystemic Shunt Creation

PurposeTo evaluate safety and efficacy of segmental yttrium-90 (Y90) radioembolization for hepatocellular carcinoma (HCC) after transjugular intrahepatic portosystemic shunt (TIPS) placement. The hypothesis was liver sparing segmental Y90 for HCC after TIPS would provide high antitumor response with a tolerable safety profile. Materials and MethodsThis single-arm retrospective study included 39 patients (16 women, 23 men) with ages 49–81 years old who were treated with Y90. Child-Pugh A/B liver dysfunction was present in 72% (28/39) with a median Model for End-stage Liver Disease score of 18 (95% confidence interval, 16.4–19.4). Primary outcomes were clinical and biochemical toxicities and antitumor imaging response by World Health Organization (WHO) and European Association for the Study of the Liver (EASL) criteria. Secondary outcomes were orthotopic liver transplantation (OLT), time to progression (TTP), and overall survival (OS) estimates by the Kaplan-Meier method. ResultsThe 30-day mortality was 0%. Grade 3+ clinical adverse events and grade 3+ hyperbilirubinemia occurred in 5% (2/39) and 0% (0/39), respectively. Imaging response was achieved in 58% (22/38, WHO criteria) and 74% (28/38, EASL criteria), respectively. Median TTP was 16.1 months for any cause and 27.5 months for primary index lesions. OLT was completed in 88% (21/24) of listed patients at a median time of 6.1 months (range, 0.9–11.7 months). Median OS was 31.6 months and 62.9 months censored and uncensored to OLT, respectively. ConclusionsSegmental Y90 for HCC appears safe and efficacious in patients after TIPS. Preserved transplant eligibility suggests that Y90 is a useful tool for bridging these patients to liver transplantation.

3D image-based dosimetry for Yttrium-90 radioembolization of hepatocellular carcinoma: Impact of imaging method on absorbed dose estimates.

To improve therapy outcome of Yttrium-90 selective internal radiation therapy (90Y SIRT), patient-specific post-therapeutic dosimetry is required. For this purpose, various dosimetric approaches based on different available imaging data have been reported. The aim of this work was to compare post-therapeutic 3D absorbed dose images using Technetium-99m (99mTc) MAA SPECT/CT, Yttrium-90 (90Y) bremsstrahlung (BRS) SPECT/CT, and 90Y PET/CT. Ten SIRTs of nine patients with unresectable hepatocellular carcinoma (HCC) were investigated. The 99mTc SPECT/CT data, obtained from 99mTc-MAA-based treatment simulation prior to 90Y SIRT, were scaled with the administered 90Y therapy activity. 3D absorbed dose images were generated by dose kernel convolution with scaled 99mTc/90Y SPECT/CT, 90Y BRS SPECT/CT, and 90Y PET/CT data of each patient. Absorbed dose estimates in tumor and healthy liver tissue obtained using the two SPECT/CT methods were compared against 90Y PET/CT. The percentage deviation of tumor absorbed dose estimates from 90Y PET/CT values was on average -2±18% for scaled 99mTc/90Y SPECT/CT, whereas estimates from 90Y BRS SPECT/CT differed on average by -50±13%. For healthy liver absorbed dose estimates, all three imaging methods revealed comparable values. The quantification capabilities of the imaging data influence 90Y SIRT tumor dosimetry, while healthy liver absorbed dose values were comparable for all investigated imaging data. When no 90Y PET/CT image data are available, the proposed scaled 99mTc/90Y SPECT/CT dosimetry method was found to be more appropriate for HCC tumor dosimetry than 90Y BRS SPECT/CT based dosimetry.

Transarterial Yttrium-90 Radioembolization of Hepatocellular Carcinoma Perfused by the Cystic Artery: Multi-institutional Feasibility Study

PurposeTo assess the safety and efficacy of transarterial yttrium-90 radioembolization via the cystic artery for patients with hepatocellular carcinoma (HCC) adjacent to the gallbladder with cystic artery supply. Materials and MethodsThis retrospective study included 17 patients treated at 4 institutions. Patients with HCC perfused by the cystic artery who received ablative-dose radioembolization were included. Median tumor size was 3.8 cm (range, 2.0–8.8 cm). Fourteen patients (82%) had Child–Pugh class A cirrhosis and 3 (18%) had class B cirrhosis. Adverse events, tumor response, and time to progression were analyzed. ResultsMedian dose to the tissue perfused by the cystic artery was 340 Gy (range, 200–720 Gy). There were no occurrences of acute cholecystitis warranting invasive intervention. Four patients (24%) experienced transient right upper quadrant pain, with symptom resolution within 3 mo. Six patients (35%) exhibited gallbladder wall edema on follow-up imaging. Two (12%) and 0 grade 3/4 increases in alkaline phosphatase and bilirubin were observed, respectively. Follow-up imaging demonstrated complete response in 13 target tumors (76%) and partial response in 4 (24%). There were no cases of target tumor progression during a median follow-up of 9 mo (range, 3–72 mo). ConclusionsDirect infusion of 90Y microspheres via the cystic artery appears to have an acceptable safety profile, without resulting in acute cholecystitis warranting invasive intervention. In selected patients with HCC in whom other treatments may be contraindicated and the tumor is supplied via the cystic artery, treatment with selective ablative radioembolization can be considered.

Benign Biliary Stricture after Yttrium-90 Radioembolization for Hepatocellular Carcinoma

PurposeTo determine the frequency and possible causative factors of benign biliary stricture after radioembolization in patients with hepatocellular carcinoma (HCC). Materials and MethodsThis retrospective study comprised 232 patients with HCC who underwent yttrium-90 radioembolization between October 2015 and September 2019. Benign biliary stricture was defined as biliary ductal dilatation of segmental or lobar biliary ducts on follow-up images. Clinical and radiologic characteristics were compared using χ2 test or independent t test. ResultsMean target perfused tissue dose was 224.6 Gy ± 106.8 (median, 205.7 Gy; range, 47.0–694.7 Gy). Of 232 patients, 15 (6.5%) had benign biliary stricture, which was detected from 3 weeks to 10.3 months (mean, 3.9 months; median, 3.2 months). Whereas 5 patients did not have any symptoms or signs associated with benign biliary stricture, 10 patients had cholangitis and/or laboratory abnormality requiring biliary drainage procedures and intravenous antibiotic therapy. Selective radioembolization through a caudate artery was performed in 55 (23.7%) patients. The incidence of benign biliary stricture was 16.4% (9/55) and 3.4% (6/177) in patients with and without selective radioembolization through a caudate artery, respectively (P = .002). ConclusionsBenign biliary stricture following yttrium-90 radioembolization may be common among patients receiving selective treatment via a caudate artery.

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

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

Abstract No. 716 Long-term outcomes of Yttrium-90 radioembolization for hepatocellular carcinoma due to underlying non-alcoholic steatohepatitis

Abstract No. 716 Long-term outcomes of Yttrium-90 radioembolization for hepatocellular carcinoma due to underlying non-alcoholic steatohepatitis

Yttrium-90 radioembolization for hepatocellular carcinoma: Outcome prediction with MRI derived fat-free muscle area

PurposeSarcopenia is associated with adverse outcomes in several gastrointestinal malignancies and liver cirrhosis. We aimed to study the utility of magnetic resonance imaging (MRI) derived fat-free muscle area (FFMA) to predict clinical outcome in patients receiving yttrium-90 radioembolization (RE) for treatment of hepatocellular carcinoma (HCC). MethodsFifty-eight patients with unresectable HCC and pre-interventional liver MRI undergoing salvage RE were retrospectively evaluated. Using axial T2-weighted turbo spin echo sequences, FFMA was calculated by subtraction of the intramuscular adipose tissue area from the total cross-sectional area of paraspinal skeletal muscles at the superior mesenteric artery level. FFMA values lower than 3582 mm2 in male and 2301 mm2 in female patients were defined as low FFMA. Main outcomes were progression-free survival (PFS) and overall survival (OS). For outcome analysis, the Kaplan-Meier method with log rank test and multivariate cox regression analysis were used. ResultsMean time from pre-interventional MRI to RE was 27 ± 20 days. Median OS and PFS after RE were 250 (range: 21–1230 days) and 156 days (range: 21–674 days), respectively. Patients with low FFMA showed significantly reduced OS (197 vs. 294 days, P = 0.024) and tended to have shortened PFS (109 vs. 185 days, P = 0.068). Low FFMA (HR 2.675; P = 0.011), estimated liver tumor burden (HR 4.058; P = 0.001), and Eastern Cooperative Oncology Group (ECOG) performance status (1.763; P = 0.009) were independent predictors of OS on multivariate analysis. ConclusionsFFMA as a measure of sarcopenia predicts OS and might represent a promising new biomarker for survival prognosis in patients undergoing RE for treatment of unresectable HCC.

History and Evolution of Yttrium-90 Radioembolization for Hepatocellular Carcinoma.

Hepatocellular carcinoma (HCC) is the most common form of primary liver cancer and affects millions worldwide. Due to the lack of effective systemic therapies for HCC, researchers have been investigating the use of locoregional tumor control with Yttrium-90 (Y90) radioembolization since the 1960s. Following the development of glass and resin Y90 microspheres in the early 1990s, Y90 radioembolization has been shown to be a safe and efficacious treatment for patients with HCC across Barcelona Clinic Liver Cancer (BCLC) stages. By demonstrating durable local control, good long term outcomes, and equivalent if not superior tumor responses and tolerability when compared to alternative therapies including transarterial chemoembolization (TACE) and sorafenib, Y90 radioembolization is being increasingly used in HCC treatment. More recently, investigations into variations in Y90 radioembolization technique including radiation segmentectomy and radiation lobectomy have further expanded its clinical utility. Here, we discuss the history and evolution of Y90 use in HCC. We outline key clinical trials that have established the safety and efficacy of Y90 radioembolization, and also summarize trials comparing its efficacy to existing HCC treatments. We conclude by reviewing the techniques of radiation segmentectomy and lobectomy, and by discussing dosimetry.

Selective Internal Radiation Therapy Using Yttrium-90 Radioembolization for Hepatocellular Carcinoma

Background: Hepatocellular carcinoma (HCC) is a primary malignant tumor of the liver that accounts for an important health problem worldwide. It is the sixth most common cancer worldwide with an incidence of 626,000 new patients a year, and the third most common cause of cancer related death. Secondary or metastatic liver are more common than primary tumor. The most common sites of primary tumor are breast, lung, and colorectal cancer with the majority of secondary liver cancers are metastases from colorectal cancer. Several locoregional catheter-based therapies options are available such as transarterial chemoembolism (TACE), drug eluting bead chemo-embolism and 90Y radioembolization for treatment of choice for unresectable HCC. Aim: To assess the effectiveness, safety and cost-effectiveness of selective internal radiation therapy (SIRT) using 90Y microspheres for the treatment of hepatocellular carcinoma. Methods: Electronic databases searched through the Ovid interface using MEDLINE (R) In-Process and Other Non-Indexed Citations and Ovid MEDLINE (R) 1946 to present. Additional articles were identified from reviewing the references of retrieved articles. Last search was conducted on 25th February 2016. Results: Seventeen articles related to SIRT using 90Y microspheres for HCC were included in this report in term of safety and effectiveness. For primary HCC, limited fair level of retrievable evidence to demonstrate that yttrium-90 radioembolization increased clinical response rates, improve survival and downstaging tumor for resection or transplant in unresectable primary HCC. For liver metastatic disease in colorectal cancer, limited fair level of retrievable evidence to demonstrate improvement in clinical response rates, longer median time to liver progression and overall survival when used in combination with first, second or third line chemotherapy as well as salvage treatment of chemotherapy refractory disease. For liver metastasis in neuroendocrine tumor, limited low level of retrievable evidence to suggest the use of 90Y radioembolization improved clinical response rates and median overall survival. Sufficient fair level of retrievable to suggest that 90Y radioembolization is a safe and well-tolerated procedure with some radioembolization specific complications. No retrievable evidence on cost-effectiveness. Conclusion: SIRT using 90Y microspheres may be used for unresectable primary hepatocellular carcinoma (HCC) and liver metastasis from colorectal cancer (mCRC). Strict criteria should be applied for patient selection and treatment shall be delivered through multidisciplinary team approach. However, SIRT is not recommended for unresectable metastatic liver disease of neuroendocrine tumor (mNET).

Development of a prognostic score to predict response to Yttrium-90 radioembolization for hepatocellular carcinoma with portal vein invasion

Yttrium-90 transarterial radioembolization (TARE) has shown promising efficacy in the treatment of patients with hepatocellular carcinoma (HCC), associated with portal vein tumor thrombus (PVTT). The aim of this study is to identify prognostic factors for survival in patients with HCC and PVTT undergoing TARE, and build a prognostic classification for these patients. This is a single center retrospective study conducted over six years (2010-2015), on consecutive patients undergoing TARE. Patients were included if they met the following criteria: presence of at least one measurable HCC, presence of PVTT not occluding the main portal trunk, absence of extrahepatic metastases, Child-Pugh score within B7, Eastern Cooperative Oncology Group performance status 0-1. Uni- and multivariable analysis was used to explore the variables that showed an independent relationship with survival. A prognostic score was then derived, and three prognostic categories were identified. A total of 120 patients were included in the study. Median overall survival (OS) was 14.1 months (95% CI 10.7-17.5) and median progression-free survival (PFS) was 6.5 months (95% CI 3.8-9.2). The only variables independently correlated with OS were bilirubin, extension of PVTT and tumor burden. Three prognostic categories were identified: favourable prognosis (0 points), intermediate prognosis (2-3 points) and dismal prognosis (>3 points). Median OS in the three categories was 32.2 months, 14.9 months and 7.8 months respectively (p <0.0001). PFS (p = 0.045) and the risk of liver decompensation (p <0.0001) also significantly differed along the same prognostic categories. Radioembolization with Yttrium-90 is an effective therapy for patients with HCC and PVTT. The proposed prognostic stratification may help to better identify good candidates for the treatment, and those for whom TARE may be futile. Yttrium-90 transarterial radioembolization (TARE) is a microembolic procedure that minimizes alterations to hepatic arterial flow, and thus can be safely performed in patients with hepatocellular carcinoma (HCC) and portal vein tumor thrombus (PVTT). In this study, we retrospectively evaluated the independent predictors of long-term outcomes in patients with HCC and PVTT treated with TARE. Bilirubin level, extension of PVTT and tumor burden were independently related to post-treatment survival: the combination of these factors allowed us to build a prognostic stratification that may help to better identify good candidates for the treatment, and those for whom TARE may be futile.

A systematic review on the safety and effectiveness of yttrium-90 radioembolization for hepatocellular carcinoma with portal vein tumor thrombosis

Background/Aim:Over the past two decades, several advances have been made in the management of patients with hepatocellular carcinoma (HCC) and portal vein tumor thrombosis (PVTT). Yttrium-90 (90Y) radioembolization has recently been made a treatment option for patients with HCC and PVTT. However, there is still a need to systematicly evaluate the outcomes of 90Y radioembolization for HCC and PVTT. We aimed to assess the safety and effectiveness of 90Y radioembolization for HCC and PVTT. We performed a systematic review of clinical trials, clinical studies, and abstracts from conferences that qualified for analysis.Materials and Methods:PubMed, EMBASE, Cochrane Database of Systematic Review, CINAHL, and the “gray” literature (Google Scholar) were searched for all reports (1991-2016) related to 90Y radioembolization for HCC and PVTT.Results:A total of 14 clinical studies and three abstracts from conferences including 722 patients qualified for the analysis. The median length of follow-up was 7.2 months; the median time to progression was 5.6 months, and median disease control rate was 74.3%. Radiological response data were reported in five studies, and the median reported value of patients with complete response, partial response, stable disease, and progressive disease were 3.2%, 16.5%, 31.3%, and 28%, respectively. The median survival was 9.7 months for all patients, including the median overall survival (OS) were 12.1, 6.1 months of Child-Pugh class A and B patients, and the median OS were 6.1, 13.4 months of main and branch PVTT patients, respectively. The common toxicities were fatigue, nausea/vomiting, abdominal pain, mostly not requiring medical intervention needed no medication intervention.Conclusions:90Y radioembolization is a safe and effective treatment for HCC and PVTT.

Erratum to: Yttrium-90 radioembolization for hepatocellular carcinoma in hepatitis B: commentary on a 103-patient Asian cohort.

Erratum to: Yttrium-90 radioembolization for hepatocellular carcinoma in hepatitis B: commentary on a 103-patient Asian cohort.