RADIATION SEGMENTECTOMY Robert J Lewandowski, MD
Robert Lewandowski, M.D. Consultant/Advisory Board: Cook Medical, LLC, Arsenal, BTG International, Boston Scientific Corp., ABK Reference Unlabeled/Unapproved uses of drugs or products: In the US Radioembolization and drug-eluting embolic platforms are often used off-label
RADIATION SEGMENTECTOMY Apply ablative doses to HCC-bearing parenchyma Whole Liver Infusion Segmental Infusion Lobar Infusion Direct Infusion into Tumor Tumor Tissue not Infused Infused Tissue
Baseline Demographics (n=102): 33 patients had surgery 1. CP A (49%), CP B (51%) 2. Tumors in the hepatic dome (58%) 17/33 3. Median (52%) tumor size Complete 2.5 cm (2.1 pathologic 3.6 cm) necrosis 4. Median tumor volume 165 cc (108 240 cc) 16/33 (48%) Pathologic necrosis > 90% 5. Median activity delivered 0.95 GBq (0.63 1.27 GBq) 6. Median dose administered 242 Gy (173 369 Gy) JHEP 2014
Pathologic Outcome by Radiation Dose More complete necrosis observed when irradiation dose > 190Gy, suggesting possibility of threshold dose needed to achieve CPN
57-YEAR-OLD FEMALE WITH HCV Arterial-Phase MRI Venous-Phase MRI
SEPARATE SEGMENT 4 ARTERY Celiac Angiogram Middle Hepatic Angiogram
SEGMENT 4 RADIOEMBOLIZATION MHA Cone-Beam CT
FOLLOW-UP Pre-Treatment 1-Month Post Y90 AFP 312-48
FOLLOW-UP Pre-Treatment 4-Months Post Y90
TRANSPLANT? TUMOR 5.4 CM; TBILI CHRONICALLY 3.5
DOWNSTAGING 1 month 36 9 months
Resection? 65 y/o Male with Hep C FLR 30%
Differential Dosing
1-month post Y90
Segmentectomy/Lobectomy FLR 30% FLR 61%
ABLATION? Arterial-Phase MRI Venous-Phase MRI
ANGIOGRAPHY Celiac Angiogram Selective Angiography
ANGIOGRAPHY Axial Cone Beam CT Coronal Cone Beam CT
FOLLOW-UP PRE-Y90 12-Month 1-Month 6-Month Follow-up
RADIATION SEGMENTECTOMY VS. RFA FOR SOLITARY HCC
NEEDLE TRACT SEEDING: 1. Llovet, J.M., Vilana, R., Brú, C. et al, Increased risk of tumor seeding after percutaneous radiofrequency ablation for single hepatocellular carcinoma. Hepatology. 2001;33:1124 29. 2. Imamura, J., Tateishi, R., Shiina, S. et al, Neoplastic seeding after radiofrequency ablation for hepatocellular carcinoma. Am J Gastroenterol. 2008;103:3057 3062. 3. Chang, S., Kim, S.H., Lim, H.K. et al, Needle tract implantation after percutaneous interventional procedures in hepatocellular carcinomas: lessons learned from a 10-year experience. Korean J Radiol. 2008;9:268 274. 4. Germani, G., Pleguezuelo, M., Stigliano, R., Burroughs, A.K. Risk of seeding is reduced by associating diagnostic biopsy with percutaneous ablation for hepatocellular carcinoma. Gut. 2009;58:734 735. 5. Snoeren, N., Jansen, M.C., Rijken, A.M. et al, Assessment of viable tumour tissue attached to needle applicators after local ablation of liver tumours. Dig Surg. 2009;26:56 62. 6. Yu JI, Liang P, Yu XL, Cheng ZG, Han ZY, Dong BW. Needle track seeding after percutaneous microwave ablation of malignant liver tumors under ultrasound guidance: analysis of 14-year experience with 1462 patients at a single center. Eur J Radiol. 2012 Oct;81(10):2495-9.
TACE? 57 y/o Woman with Hep C AFP 4,491.5
AFP 4,491.5 AFP 70.6
AFP 4,492 Pre-Y90 AFP 69 9 months post Y90
Prospective, randomized, phase 2 trial Clinical trial number: NCT00956930 179 met enrollment criteria 43 declined research despite tumor board recommendation 29 selected other clinical trials 49 requested Y90 13 requested ctace 45 treatment-naïve Barcelona Clinic Liver Cancer stage A/B patients randomly assigned to ctace or Y90 Imaging by 2 independent radiologists Primary outcome = time-to-progression (TTP) [intention-to-treat] Secondary outcomes = safety, RR, and OS Salem et al. Under Review
TIME TO PROGRESSION Significant difference in median TTP was observed ctace 6 4 months (CI: 3.2-9.1) Y90: not reached (CI: 14.5-NC) p=0.0020 [HR: 0.13 (CI: 0.03-0.60, p=0.009)]
TACE +/- ABLATION 4.4 cm HCC
TACE +/- ABLATION? 1-MONTH POST Y90
TACE +/- ABLATION? 4-MONTHS POST Y90
TACE +/- ABLATION? 11-MONTHS POST Y90
2 YEARS POST Y90
95 YEAR OLD WITH HCC Pre-Y90 16 months post y90 AFP 950 95-5
27 months post Y90 (now 98!)
SUMMARY SAFE Tumors in difficult locations Chronic hyperbilirubinemia EFFECTIVE Curative VERSATILE Downsizing to other therapies (surgery)
Question 1 The concept of Radiation Segmentectomy is to deliver the lowest radiation dose possible directly to the tumor: a) True b) False Answer B. Reference: Riaz A, Gates VL, Atassi B, Lewandowski RJ, Mulcahy MF, Ryu RK, Sato KT, Baker T, Kulik L, Gupta R, Abecassis M, Benson AB 3 rd, Omary R, Millender L, Kennedy A, Salem R. Radiation Segmentectomy: A novel approach to increase safety and efficacy of radioembolization. Int J Radiat Oncol Biol Phys. 2011;79(1):163-71.
Question 2 For Radiation Segmentectomy, more complete pathologic necrosis is observed when irradiation dose exceeds: a) 130 Gray b) 160 Gray c) 190 Gray d) 220 Gray Answer C. Reference: Vouche M, Habib A, Ward TJ, Kim E, Kulik L, Ganger D, Mulcahy M, Baker T, Abecassis M, Sato KT, Caicedo JC, Fryer J, Hickey R, Hohlastos E, Lewandowski RJ, Salem R. Unresectable solitary hepatocellular carcinoma not amendable to radiofrequency ablation: multicenter radiology-pathology correlation and survival of radiation segmentectomy. Hepatology. 2014 Jul;60(1):192-201.