+ Radioembolization for ColoRectal Cancer Metastatic to the Liver
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1 + Radioembolization for ColoRectal Cancer Metastatic to the Liver Oct 4 th 2017 Alain Hendlisz, Institut Jules Bordet 1 st International Course on THERANOSTICS & MOLECULAR RADIOTHERAPY
2 Indication and Rationale EMEA : Y 90 resin microspheres are indicated for the treatment of patients with non-operable liver cancer.
3 90 Y-Radioembolization 35μ diameter resin microspheres Yttrium 90 -loaded (beta-emitter 0.93 MeV) Half-life: 2.67 days Penetration 2cm max
4 Radioembolization : randomized data in CRC Trials Line Treatments N RR (%) TTP (mo) TTLP (mo) OS (mo) Gray et al Ann Oncol RE+ HAC HAC nr nr p=0.004 NS NS Van Hazel et al 1 RE+ 5FU/LV nr 29.4 J Surg Oncol FU/LV nr 12.8 Wasan et al 1 FOLFOX(+Beva) Lancet Oncol 2017 FOLFOX(+Beva)+SIRT p= NS p=0.002 NS
5 SIRFLOX, FOXFIRE & FOXFIRE global Wasan Lancet Oncol 2017
6 SIRFLOX, FOXFIRE & FOXFIRE global Wasan Lancet Oncol 2017
7 SIRFLOX, FOXFIRE & FOXFIRE global Wasan Lancet Oncol 2017
8 Wasan Lancet Oncol 2017 SIRFLOX, FOXFIRE & FOXFIRE global Radiological progression within the liver Non-liver progression
9 SIRFLOX, FOXFIRE & FOXFIRE global Wasan Lancet Oncol 2017
10 Tumour Response Rate Hepatic Resection Rate SIRFLOX Progression-Free Survival ORR at Any Site ORR in the Liver Hepatic Resection R + PR: 68.1% 76.4% p= % 78.7% p= % 80% 70% 70% 60% 50% 40% 30% 20% 10% 0% PR: PR: PR: PR: 66.5% 71.9% 66.9% 72.7% CR: CR: CR: CR: p= % 4.5% 1.9% 6.0% FOLFOX (n = 263) FOLFOX + SIRT (n = 267) CR: Complete Response; FOLFOX (n = 263) FOLFOX + SIRT (n = 267) PR: Partial Response. p= % 50% 40% 30% 20% 10% 0% 13.7% 14.2% FOLFOX (n = 263) FOLFOX + SIRT (n = 267) p=0.857 van Hazel J Clin Oncol 2016
11 Radioembolization : randomized data in CRC Trials Line Treatments N RR (%) TTP (mo) TTLP (mo) OS (mo) Gray et al Ann Oncol RE+ HAC HAC nr nr p=0.004 NS NS Van Hazel et al 1 RE+ 5FU/LV nr 29.4 J Surg Oncol FU/LV nr 12.8 Wasan et al 1 FOLFOX(+Beva) Lancet Oncol 2017 FOLFOX(+Beva)+SIRT p= NS p=0.002 NS
12 Radioembolization : randomized data in CRC Trials Line Treatments N RR (%) TTP (mo) TTLP (mo) OS (mo) Gray et al Ann Oncol RE+ HAC HAC nr nr p=0.004 NS NS Van Hazel et al 1 RE+ 5FU/LV nr 29.4 J Surg Oncol FU/LV nr 12.8 Wasan et al 1 FOLFOX(+Beva) Lancet Oncol 2017 FOLFOX(+Beva)+SIRT p= NS p=0.002 NS Hendlisz et al 3 RE+ protracted 5FU 21 0 * JCO 2010 protracted 5FU p=0.03 p=0.003 NS
13 Radioembolization improves PFS of CRC metastatic to the liver Chemorefractory liver only mcrc 44 patients R 5FU 300mg/m² D1-14 qw 3weeks 5FU 300mg/m² D1-14 qw 3weeks + Radioembolization at ( progression ) Radioembolization Hendlisz et al JCO 2010
14 To Radioembolize or not to Radioembolize? Wasan et al 1 FOLFOX(+Beva) Lancet Oncol 2017 FOLFOX(+Beva)+SIRT Hendlisz et al 3 RE+ protracted 5FU 21 0 * JCO 2010 protracted 5FU Main differences: Liver-limited versus Liver-only no difference in pts with LOmCRC
15 To Radioembolize or not to Radioembolize? Wasan et al 1 FOLFOX(+Beva) Lancet Oncol 2017 FOLFOX(+Beva)+SIRT Hendlisz et al 3 RE+ protracted 5FU 21 0 * JCO 2010 protracted 5FU Main differences: Liver-limited versus Liver-only Different Backbone Chemotherapy no difference in pts with LOmCRC FOLFOX+Beva > protracted 5FU Role of «adj» CT in LOmCRC unclear
16 Effect of CT + surgery in LOmCRC No effect of CT on PFS nor OS after locoregional treatment Nordlinger Lancet Oncol 2013
17 Effect of loco-regional Treatment in LOmCRC Survival after curative-intent surgery Radiological progression within the liver 25% 25% Tomlinson JCO
18 To Radioembolize or not to Radioembolize? Wasan et al 1 FOLFOX(+Beva) Lancet Oncol 2017 FOLFOX(+Beva)+SIRT Hendlisz et al 3 RE+ protracted 5FU 21 0 * JCO 2010 protracted 5FU Main differences: Liver-limited versus Liver-only Different Backbone Chemotherapy no difference in pts with LOmCRC FOLFOX+Beva > protracted 5FU Role of «adj» CT in LOmCRC unclear Different study design SIRT after 1st course CT Different diseases BETTER SELECTION OF PATIENTS
19 To Radioembolize or not to Radioembolize? Wasan et al 1 FOLFOX(+Beva) Lancet Oncol 2017 FOLFOX(+Beva)+SIRT Hendlisz et al 3 RE+ protracted 5FU 21 0 * JCO 2010 protracted 5FU Main differences: Liver-limited versus Liver-only Different Backbone Chemotherapy no difference in pts with LOmCRC FOLFOX+Beva > protracted 5FU Role of «adj» CT in LOmCRC unclear Different study design SIRT after 1st course CT Different diseases BETTER SELECTION OF PATIENTS
20 In Other Words Undoubtedly efficient but as for surgery, need for patients selection (biomarkers)
21 + Perspectives 1) Taking in account Tumoral Heterogeneity 2) Multimodal locoregional Approach
22 SIRT in Multimodality approach Intralesional Heterogeneity Pre SIRT PET-CT Pre SIRT MAA simulation SPECT-CT Post SIRT Y90- PET/CT Post SIRT PET-CT
23 SIRT in Multimodality approach Interlesional Heterogeneity NR NR R
24 Radiation Segmentectomy Baseline 4 weeks post first SIRT 3 months post second SIRT Gulec et al. WJSO 2009
25 Downstaging potential of SIRT Garlipp ASCO 2017 abs 3532
26 CONCLUSIONS Radioembolization effective & safe for liver mets Indicated as salvage for chemorefractory LOmCRC Alternative to Surgery (unresectable LOmCRC) Multimodal Therapy Liver hypertrophy presurgery! as Liver OligoResistant diseases Combined Ablative Modalities... Should improve patients selection (Tumor Biology) for any other locoregional approach
27 + Thank you Life is full of misery, loneliness, and suffering and it's all over much too soon. Woody Allen
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