Cases of NET’s with liver metastases, technical illustration of radioembolization, chemoembolization Geert Maleux MD, PhDDepartment of RadiologyUniversity Hospitals LeuvenBelgium

Introduction

• Loco-regional therapies for NET liver metastases :

– Transarterial embolization• PVA-microparticles• Tris-acryl gelatin microspheres• Glue (mixture of enbucrylate and Lipiodol)

– Transarterial chemo-embolization• Conventional TACE (Lipiodol & drugs)• Drug-eluting beads• Starch microspheres & chemotherapeutic agents

– Yttrium-90 radioembolization (SIRT)

Introduction

• Loco-regional therapies for NET liver metastases :– Transarterial embolization

• PVA-microparticles• Tris-acryl gelatin microspheres• Glue (mixture of enbucrylate and Lipiodol)

– Transarterial chemo-embolization• Conventional TACE (Lipiodol & drugs)• Drug-eluting beads• Starch microspheres & chemotherapeutic agents

– Yttrium-90 radioembolization (SIRT)

Case 1

• 65-year-old female patient• 2006 : pNET

– Surgery (pancreatectomy, splenectomy, liver segmentectomies)

• 2009 – 2012 : everolimus• 2013 :

– Diffuse liver metastases– Hypoglycemias +++

Case 2

• 61-year-old woman• 2010 : pancreatic NET & liver metastases• R/ Sandostatin + everolimus• 2012 : progression of disease & hypoglycemia

Symptoms Complete relief

Partial relief No relief unknown

Carcinoidsyndrome:Diarrhea, flushing, headache

5 3 0 /

Islet cellsyndrome : hypoglycemia

3 1 0 /

pain 0 0 1 /

unknown / / / 3

Leuven experience with drug-eluting beads (SAP-microspheres)

Complication N° of patients (n=17) %

Ischemic cholecystitis 1 6%

Carcinoid storm 1 6%

Insulin storm 1 6%

Post-embolization syndrome 14 82%

None 3 18%

Leuven experience with drug-eluting beads (SAP-microspheres)

RECIST N° of patients (n=17) %

Partial response 2 13%

Stable disease 12 80%

Progression of disease 1 7%

unknown 2 /

EASL criteria N° of patients (n=17) %

Partial response 13 87%

Stable disease 1 7%

Progression of disease 1 7%

Unknown 2 /

DEB-TACE

• SAP-microspheres : safe & effective– 0% bilomas– Tumor burden :

• DC-beads (100 – 300 micron)– 54 % bilomas– < 30% tumor burden

Tumor burden N° of patients (n=17)0-10% 310-20% 320-50% 5>50% 4Unknown / not measurable 2

Bhagat et al. CVIR 2013

Case 3

• 43-year-old woman• 2008 : small bowel NET & liver metastases

– Enterectomy & RF-ablation– 90Y-DOTATOC

• 2011 progression of disease– SIRT (resin microspheres)

Yttrium-90 radioembolization

• Very effective : > 3 years no liver metastases

• Non-target embolization– Gastritis– Ulceration refractory to medical treatment– Surgery – Liver fibrosis -> cirrhosis ??

• Thank you for your attention

• geert.maleux@uzleuven.be