Trans-arterial radioembolisation (TARE) of unresectable HCC using Y-90 microspheres: is it dangerous in case of portal vein thrombosis?

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1 Trans-arterial radioembolisation (TARE) of unresectable HCC using Y-90 microspheres: is it dangerous in case of portal vein thrombosis? Poster No.: C-1634 Congress: ECR 2014 Type: Authors: Keywords: DOI: Scientific Exhibit F. Fiore, F. Somma, R. D'angelo; Naples/IT Gastrointestinal tract, Interventional vascular, Liver, Catheter arteriography, Ablation procedures, Arterial access, Radioembolisation, Cancer, Neoplasia /ecr2014/C-1634 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 10

2 Aims and objectives To assess the safety of the interventional procedure of Trans-Arterial Radio-Embolisation (TARE) using Yttrium-90 (Y90) microspheres, in case of locally advanced, liver restricted, HCC (stage C according to BCLC). Secondly, to investigate whether TARE is effective in HCC patients with portal vein thrombosis (PVT) or not. In particular, to show how tumoral vascular invasion behaves after the injection of radiating agents in the tumor-feeding arteries. Background: HCC is a major health problem worldwide, affecting more than 600,000 new patients per year. Curative treatments are hepatic resection, liver transplantation and percutaneous ablation (RFA). Although surveillance programs have led in Western countries to an increase in the applicability of radical therapies that nowadays are indicated in 30%-40% of patients, the majority of them are not treatable with surgical resection due to their advanced stage at presentation. In these cases, it is compulsory to find alternative treatment or palliative therapies. As HCC staging system, many have adopted the Barcelona Clinic Liver Cancer (BCLC) staging classification, which links the stage of the disease to a specific treatment strategy, such as curative treatments or palliative therapies. Indeed, many patients not eligible to the curative surgery have a locally advanced, liver restricted disease, known as BCLC advanced stage with no extra-hepatic spread, in which trans-arterial loco-regional modalities offer palliative treatment options. These therapies exploit the dual blood supply to liver, because it is well known that HCC derives its blood supply almost entirely from hepatic artery, whereas liver parenchyma derives more than 75% of its blood supply from the portal vein (fig 1). This anatomical fact is the basis for the development of the intra-arterial treatment of HCC, inducing a selective tumor necrosis while sparing surrounding parenchyma. So far, according to the BCLC staging system, trans-arterial chemo-embolisation (TACE) has been recommended as the standard of care only for intermediate stage HCC, while it may increase the risk of post-procedures complication in case of advanced stage HCC. Moreover, vascular invasion is still considered as a contraindication for TACE. In such cases, TARE may be performed as a loco-regional intra-arterial treatment in order to understage the neoplasm. Images for this section: Page 2 of 10

3 Fig. 1: Vascular anatomy of the liver. HCC derives its blood supply almost entirely from hepatic artery, whereas liver parenchyma derives more than 75% of its blood supply from the portal vein. Page 3 of 10

4 Fig. 2: TARE: therapeutic mechanism of action. Page 4 of 10

5 Methods and materials Between November 2005 and April 2013, seventy-nine TARE were performed in seventytwo patients with unresectable HCC and bilirubine values up to 2.6 mg/dl. Twentyone of them were diagnosed a single-branch portal vein tumoral invasion, at baseline. Every patient was studied with Multislice Computed Tomography (MSCT) scan and angiography before the procedure, while just some of them underwent the embolization of the Gastro-duodenal artery, using micro-coils. In these cases, a previous study was performed with the injection of TC-99MAA through a 3F microcatheter. Proton-Pump Inhibitors (PPI) were administered to reduce the risk of gastritis and gastro-intestinal ulcers. After a superselective catheterization of tumor-feeding arteries, the microspheres containing Y90 were released straight into the neoplasm, granting radiation to HCC cells and surrounding normal parenchyma for at most 11mm from the sphere. Images for this section: Page 5 of 10

6 Fig. 1: Vascular anatomy of the liver. HCC derives its blood supply almost entirely from hepatic artery, whereas liver parenchyma derives more than 75% of its blood supply from the portal vein. Fig. 2: TARE: therapeutic mechanism of action. Page 6 of 10

7 Results The average dose administered was 1.7 GBq. After the treatment, fever and abdominal pain were found in twenty-eight and nineteen patients, respectively. No other side-effect was observed. According to the RECIST criteria at least a partial response was found in 71% of cases three months after the procedure and in 88% at nine months (fig. 3, 4). The mean survival of patients with PVT was similar to those without thrombosis, as it is shown by our Kaplan-Meyer survival curves realized both for patients with and without portal vein tumoral invasion (fig 5). Moreover, a regression of PVT was registered in more than 50% of patients. Images for this section: Fig. 3: TARE in 44-year-old man with PVT: a) Evidence of large HCC in the left lobe of the liver on the preoperative angiography; b) PET-CT scan performed immediately after the injection of beta-emitting Y90 microspheres; c) CT scan at baseline; d) CT scan after three months. Page 7 of 10

8 Fig. 4: TARE in 36-year-old man with PVT: a) CT scan at baseline gives evidence of the unresectable HCC in the right lobe of the liver; b) CT scan one month after TARE shows the reduction in size of the lesion and its residual vascularization; d) CT scan three months after the procedure shows the downstaging of the neoplasm, which was subsequently resected. Fig. 5: Kaplan-Meyer survival curves comparing survival in patients with vascular invasion (PVT, Blue) and in patients without (non-pvt, Green). The difference was not statistically significant. Page 8 of 10

9 Conclusion Among the loco-regional treatments of HCC, TARE using Y-90 microspheres showed to be extremely useful in selected patients, such as in case of relapse after trans-arterial embolization (TAE) or TACE and in the downstaging of liver malignancies. Moreover, TARE showed low rates of post-procedure complications and resulted to be highly effective in patients with PVT, causing a regression of vascular invasion in most cases. Personal information References Salem R, Lewandowski R. Chemoembolisation and Radioembolisation of hepatocellular carcinoma. Clin Gastro Hepatol 2013;11: Eisenhauer EA et al. New response evaluation criteria in solid tumours: Revised RECIST guideline (version 1.1). Eur J of Cancer 2009;45: Liapi E, Geschwind JF. Transcatheter and ablative therapeutic approaches for solid malignancies. J Clin Oncol 2007;25: Llovet JM et al. Hepatocellular Carcinoma. Lancet 2003;362: Breedis C, Young G. The blood suppley of neoplasms in the liver. Am J Pathol 1954;30: Wigmore SJ et al. Postchemoembolisation syndrome - tumor necrosis or hepatocyte injury? British J of Cancer 2003;89: Forner A, Reig ME, de Lope CR, Bruix J (2010) Current strategy for staging and treatment: the BCLC update and future prospects. Semin Liver Dis 30:61-74 Lencioni R, Chen XP, Dagher L, Venook AP (2010) Treatment of intermediate/advanced hepatocellular carcinoma in the clinic: how can outcomes be improved? Oncologist 15(Suppl 4):42-52 Page 9 of 10

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