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Radioembolisation in Hepatocellular Carcinoma: Principles of Management

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Liver Cancers

Abstract

Radioembolisation (RE) is a form of brachytherapy that aims to deliver a high dose of radiation to liver tumours irrespective of number and size. RE is based on the injection of microspheres loaded or labelled with yttrium-90 (Y90) into the hepatic arterial circulation. With varying levels of supporting evidence, RE is currently used for the treatment of single or multiple tumours with portal vein invasion, multiple tumours that cannot be treated by superselective TACE, tumours that show incomplete response after one or two sessions of TACE, single large tumours when resection is contraindicated due to a small future liver remnant or small tumours in patients waiting for liver transplantation. Contraindications include a significant risk of radioactive microsphere deposition in the gastrointestinal tract, an excessive lung shunting, a significant liver dysfunction, a high tumour burden, a lack of significant macroaggregated albumin uptake in the pretreatment workup or any contraindication to angiography. Complications may rarely appear during the first 3 months from the non-intended irradiation of non-target organs. Expected outcome varies depending on the tumour stage with median survival of 24.4 months for BCLC-A, 16.9 months for BCLC-B and 10.0 months for BCLC-C. Three small randomised trials comparing TACE to RE have reported similar survival. Also, two recent phase 3 multicentre trials comparing survival after sorafenib or RE have not shown a benefit in survival despite a delayed progression in the liver and better tolerability.

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References

  1. Sangro B, Iñarrairaegui M, Bilbao JI. Radioembolization for hepatocellular carcinoma. J Hepatol. 2012 Feb;56(2):464–73.

    Article  Google Scholar 

  2. Aramburu J, Antón R, Rivas A, Ramos JC, Sangro B, Bilbao JI, et al. Liver cancer arterial perfusion modelling and CFD boundary conditions methodology: a case study of the haemodynamics of a patient-specific hepatic artery in literature-based healthy and tumour-bearing liver scenarios. Int J Numer Method Biomed Eng. 2016;32(11) https://doi.org/10.1002/cnm.2764.

    Article  Google Scholar 

  3. Kennedy A, Coldwell D, Sangro B. Radioembolization for the treatment of liver tumours: general principles. Am J Clin Oncol. 2012;35(1):91–9.

    Article  Google Scholar 

  4. Sangro B, Carpanese L, Cianni R, Golfieri R, Gasparini D, Ezziddin S, et al. Survival after yttrium-90 resin microsphere radioembolization of hepatocellular carcinoma across Barcelona clinic liver cancer stages: a European evaluation. Hepatology. 2011;54(3):868–78.

    Article  Google Scholar 

  5. Rodríguez-Lago I, Carretero C, Herráiz M, Subtil JC, Betés M, Rodríguez-Fraile M, et al. Long-term follow-up study of gastroduodenal lesions after radioembolization of hepatic tumors. World J Gastroenterol. 2013;19(19):2935–40.

    Article  Google Scholar 

  6. Sangro B, Martínez-Urbistondo D, Bester L, Bilbao JI, Coldwell DM, Flamen P, et al. Prevention and treatment of complications of selective internal radiation therapy: expert guidance and systematic review. Hepatology. 2017 Sep;66(3):969–82.

    Article  Google Scholar 

  7. Gil-Alzugaray B, Chopitea A, Iñarrairaegui M, Bilbao JI, Rodriguez-Fraile M, Rodriguez J, et al. Prognostic factors and prevention of radioembolization-induced liver disease. Hepatology. 2013 Mar;57(3):1078–87.

    Article  CAS  Google Scholar 

  8. Johnson PJ, Berhane S, Kagebayashi C, Satomura S, Teng M, Reeve HL, et al. Assessment of liver function in patients with hepatocellular carcinoma: a new evidence-based approach—the ALBI grade. J Clin Oncol. 2015;33(6):550–8.

    Article  Google Scholar 

  9. Sangro B, Rodriguez M. Radioembolization for hepatocellular carcinoma: gaining insight on a personalized approach. Liver Int. 2017;37(1):32–4.

    Article  Google Scholar 

  10. Iñarrairaegui M, Thurston KG, Bilbao JI, D'Avola D, Rodriguez M, Arbizu J, et al. Radioembolization with use of Yttrium-90 resin microspheres in patients with hepatocellular carcinoma and portal vein thrombosis. J Vasc Interv Radiol. 2010;21(8):1205–12.

    Article  Google Scholar 

  11. Riaz A, Gates VL, Atassi B, Lewandowski RJ, Mulcahy MF, Ryu RK, et al. Radiation segmentectomy: a novel approach to increase safety and efficacy of radioembolization. Int J Radiat Oncol Biol Phys. 2011;79(1):163–71.

    Article  Google Scholar 

  12. Fernández-Ros N, Silva N, Bilbao JI, Iñarrairaegui M, Benito A, Davola D, et al. Partial liver volume radioembolization induces hypertrophy in the spared hemiliver and no major signs of portal hypertension. HPB (Oxford). 2014;16(3):243–9.

    Article  Google Scholar 

  13. Seidensticker R, Seidensticker M, Damm R, Mohnike K, Schütte K, Malfertheiner P, et al. Hepatic toxicity after radioembolization of the liver using 90Y-microspheres: sequential lobar versus whole liver approach. Cardiovasc Intervent Radiol. 2012;35(5):1109–18.

    Article  Google Scholar 

  14. Sancho L, Rodriguez-Fraile M, Bilbao JI, Beorlegui Arteta C, Iñarrairaegui M, Moran V, et al. Is a technetium-99m macroaggregated albumin scan essential in the workup for selective internal radiation therapy with yttrium-90? An analysis of 532 patients. J Vasc Interv Radiol. 2017;28(11):1536–42.

    Article  Google Scholar 

  15. Lau WY, Kennedy AS, Kim YH, Lai HK, Lee RC, Leung TW, et al. Patient selection and activity planning guide for selective internal radiotherapy with yttrium-90 resin microspheres. Int J Radiat Oncol Biol Phys. 2012;82(1):401–7.

    Article  Google Scholar 

  16. Kennedy AS, Ball D, Cohen SJ, Cohn M, Coldwell DM, Drooz A, et al. Multicenter evaluation of the safety and efficacy of radioembolization in patients with unresectable colorectal liver metastases selected as candidates for (90)Y resin microspheres. J Gastrointest Oncol. 2015;6(2):134–42.

    PubMed  PubMed Central  Google Scholar 

  17. van Hazel GA, Heinemann V, Sharma NK, Findlay MP, Ricke J, Peeters M, et al. SIRFLOX: randomized phase III trial comparing first-line mfolfox6 (plus or minus Bevacizumab) versus mFOLFOX6 (plus or minus Bevacizumab) plus selective internal radiation therapy in patients with metastatic colorectal cancer. J Clin Oncol. 2016;34(15):1723–31.

    Article  Google Scholar 

  18. Salem R, Lewandowski RJ, Mulcahy MF, et al. Radioembolization for hepatocellular carcinoma using Yttrium-90 microspheres: a comprehensive report of long-term outcomes. Gastroenterology. 2010;138:52–64.

    Article  CAS  Google Scholar 

  19. Hilgard P, Hamami M, Fouly AE, et al. Radioembolization with yttrium- 90 glass microspheres in hepatocellular carcinoma: European experience on safety and long-term survival. Hepatology. 2010;52:1741–9.

    Article  CAS  Google Scholar 

  20. Mazzaferro V, Sposito C, Bhoori S, et al. Yttrium90 radioembolization for intermediate-advanced hepatocarcinoma: a phase II study. Hepatology.https://doi.org/10.1002/hep.26014.

    Article  CAS  Google Scholar 

  21. Sangro B, Carpanese L, Cianni R, European Network on Radioembolization with Yttrium-90 Resin Microspheres (ENRY). Survival after Yttrium-90 resin microsphere radioembolization of hepatocellular carcinoma across Barcelona clinic liver cancer stages: a European evaluation. Hepatology. 2011;54:868–78.

    Article  Google Scholar 

  22. Vilgrain V, Pereira H, Assenat E, et al. Efficacy and safety of selective internal radiotherapy with yttrium-90 resin microspheres compared with sorafenib in locally advanced and inoperable hepatocellular carcinoma (SARAH): an open-label randomised controlled phase 3 trial. Lancet Oncol. 2017;18(12):1624–36. https://doi.org/10.1016/S1470-2045(17)30683-6.

    Article  CAS  PubMed  Google Scholar 

  23. Chow PKH, Gandhi M, Tan SB, et al. SIRveNIB: Selective Internal Radiation Therapy Versus Sorafenib in Asia- Pacific Patients With Hepatocellular Carcinoma. J Clin Oncol. 2018;36(19):1913–21. https://doi.org/10.1200/JCO.2017.76.0892.

    Article  PubMed  Google Scholar 

  24. Vilgrain V, Pereira H, Assenat E, Guiu B, Ilonca AD, Pageaux GP, et al. Efficacy and safety of selective internal radiotherapy with yttrium-90 resin microspheres compared with sorafenib in locally advanced and inoperable hepatocellular carcinoma (SARAH): an open-label randomised controlled phase 3 trial. Lancet Oncol. 2017;18(12):1624–36.

    Article  CAS  Google Scholar 

  25. Pierce H, Chow W, Gandhi M, Asia-Paciifc Hepatocellular Carcinoma Trials Group. Phase III multi-Centre open-label randomized controlled trial of selective internal radiation therapy (SIRT) versus sorafenib in locally advanced hepatocellular carcinoma: the SIRveNIB study. J Clin Oncol. 2017;35(15_suppl):4002.

    Article  Google Scholar 

  26. de la Torre MA, Buades-Mateu J, de la Rosa PA, Lué A, Bustamante FJ, Serrano MT, et al. A comparison of survival in patients with hepatocellular carcinoma and portal vein invasion treated by radioembolization or sorafenib. Liver Int. 2016;36(8):1206–12.

    Article  Google Scholar 

  27. European Association for the Study of the Liver. EASL–EORTC clinical practice guidelines: management of hepatocellular carcinoma. Eur J Cancer. 2012;48(5):599–641.

    Article  Google Scholar 

  28. Pitton MB, Kloeckner R, Ruckes C, Wirth GM, Eichhorn W, Wörns MA, et al. Randomized comparison of selective internal radiotherapy (SIRT) versus drug-eluting bead transarterial chemoembolization (DEB-TACE) for the treatment of hepatocellular carcinoma. Cardiovasc Intervent Radiol. 2015;38(2):352–60.

    Article  Google Scholar 

  29. Kolligs FT, Bilbao JI, Jakobs T, Iñarrairaegui M, Nagel JM, Rodriguez M, et al. Pilot randomized trial of selective internal radiation therapy vs. chemoembolization in unresectable hepatocellular carcinoma. Liver Int. 2015;35(6):1715–21.

    Article  Google Scholar 

  30. Salem R, Gordon AC, Mouli S, Hickey R, Kallini J, Gabr A, et al. Y90 Radioembolization significantly prolongs time to progression compared with chemoembolization in patients with hepatocellular carcinoma. Gastroenterology. 2016;151(6):1155–63.

    Article  Google Scholar 

  31. Pardo F, Sangro B, Lee RC, Manas D, Jeyarajah R, Donckier V, et al. The post-sir-spheres surgery study (p4s): retrospective analysis of safety following hepatic resection or transplantation in patients previously treated with selective internal radiation therapy with yttrium-90 resin microspheres. Ann Surg Oncol. 2017;24(9):2465–73.

    Article  Google Scholar 

  32. Salem R, Mazzaferro V, Sangro B. Yttrium 90 radioembolization for the treatment of hepatocellular carcinoma: biological lessons, current challenges, and clinical perspectives. Hepatology. 2013;58(6):2188–97.

    Article  CAS  Google Scholar 

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Author information

Authors and Affiliations

  1. Liver Unit and HPB Oncology Area, Clinica Universidad de Navarra, IDISNA and CIBEREHD, Pamplona, Spain

    Bruno Sangro

  2. Department of Medical Oncology, Istituto Scientifico Romagnolo per Lo Studio e Cura Dei Tumori (IRST) IRCCS, Meldola, Italy

    Andrea Casadei Gardini

Authors
  1. Bruno Sangro
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  2. Andrea Casadei Gardini
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Corresponding author

Correspondence to Bruno Sangro .

Editor information

Editors and Affiliations

  1. Royal Liverpool University Hospital, Liverpool, Merseyside, UK

    Tim Cross

  2. University of Liverpool, Liverpool Early Drug Development Unit, Liverpool, UK

    Daniel H. Palmer

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Sangro, B., Gardini, A.C. (2019). Radioembolisation in Hepatocellular Carcinoma: Principles of Management. In: Cross, T., Palmer, D. (eds) Liver Cancers. Springer, Cham. https://doi.org/10.1007/978-3-319-92216-4_11

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  • DOI: https://doi.org/10.1007/978-3-319-92216-4_11

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-92215-7

  • Online ISBN: 978-3-319-92216-4

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