Radioemboliza+on  results  in  longer  +me-­‐to-­‐progression  and  reduced  toxicity  compared  with  chemoemboliza+on  in  pa+ents  with  hepatocellular  carcinoma    

RFS  Journal  Primer  

BOTTOM  LINE  •  Patients   with   hepatocellular   carcinoma   were   treated   by   either   chemoembolization   or   90Y  

radioembolization   over   a   9   year   period.   Though   there   was   no   difference   in   overall   survival,   90Y  radioembolization  resulted  in  longer  time-­‐to-­‐progression  and  less  toxicity.  

 MAJOR  POINTS    •  There  was  no  signiEicant  difference   in  median  survival   times  between  chemoembolization  and   90Y  

radioembolization  groups  (17.4  vs.  20.5  months,  p=0.232)  •  Time-­‐to-­‐progression  was  longer  for  90Y  radioembolization  compared  to  chemoembolization  (17.4  vs  

20.5  months,  p=0.046)  •  Patients   treated   with   90Y   radioembolization   seemed   to   have   a   higher   response   rates   than   those  

treated  with  chemoembolization  (49%  vs  36%,  p=0.104)    CRITICISM  •  Sample  size  is  insufEicient  to  demonstrate  signiEicant  differences  in  median  survival  times  between  

chemoembolization  and  90Y  radioembolization  groups  

•  Lack  of  direct  or  randomized  comparative  data  •  Bias   of   using   chemoemboliztion   for   younger   patients   to   bridge   to   transplant   and   90Y  

radioembolization  for  older  patients  as  it  is  better  tolerated  (66  vs  61,  p<.001)  

Quick  Summary  

RETROSPECTIVE  COMPARATIVE  EFFECTIVENESS  ANALYSIS    •  463  patients  with  chemoembolization  

or  90Y  radioembolization    •  Time  range:  9  years  

INCLUSION  CRITERIA  •  Patients  with  unresectable  HCC  as  

determined  by  transplant  surgery  and  bilirubin  <  3.0  mg/dL  

 

EXCLUSION  CRITERIA  •  Patients  previously  treated  with  both  

chemoembolization  and  90Y  at  any  time  •  Patients  who  exhibit  portal  vein  

thrombosis  •  Patients  with  extrahepatic  metastases  •  Patients  lacking  imaging  follow-­‐up  

from  expedited  transplantation    

Study  design  

Figure  1.  Study  Elow  chart  

•  This  study  is  seeks  to  compare  90Y  radioembolization  with  chemembolization,  the  standard  treatment  for  unresectable,  non-­‐advanced  hepatocellular  carcinoma  in  terms  of  adverse  effects,  response  time,  time-­‐to-­‐progression,  and  overall  survival.  

Purpose  

Retrieved  from  http://ami-­‐ir.com/pages/what-­‐interventional-­‐oncology  

•  Patients  were  treated  with  either  chemoembolization  or  90Y  radioembolization  •  Chemoembolization:  30mg  mitomycin,  30mg  adriamycin,  and  100mg  cisplatin  mixed  

with  lipiodol  followed  by  arterial  embolization  using  occlusive  300-­‐500  micron  particles.  Median  number  of  treatments  was  2  [inter-­‐quartile  range:  1-­‐3].  

•  90Y  Radioembolization:  glass-­‐based  microspheres  (ThereSphere®)  were  comprised  of  20-­‐30  micron  beta-­‐emitting  particles  given  after  pre-­‐treatment  with  mesenteric  angiography  and  technetium-­‐99m  macroaggregated  albumin  scans  to  asses  for  GI  Elow  and  lung  shunting.  Median  number  of  treatments  was  1  [inter-­‐quartile  range:  1-­‐2].  

•  Patients  were  followed  for  adverse  events  every  2-­‐3  months  until  death  for  clinical  and  laboratory  events  using  the  National  Cancer  Institute  Common  Terminology  Criteria  v3.0.  

•  Patient  AFP  levels  were  followed,  along  with  imaging  analysis  to  determine  response  rate  as  per  the  WHO  size  and  European  Association  for  Study  of  the  Liver  necrosis  criteria.  

Interven7on  

Outcome    

•  AFP  levels  were  signiEicantly  reduced  by  >50%  post  treatment  for  both  chemoembolization  and  90Y  radioembolization    (59%  and  80%,  respectively).  

•  Imaging  Outcomes  •  Response  rate  as  determined  by  WHO  size  criteria  trended  towards  90Y  radioembolization  

vs  chemoembolization  (49%  vs  36%,  p=0.104).  Median  time  to  WHO  partial  response  also  trended  towards  90Y  radioembolization    (6.6  vs  10.3  months,  p=0.05)  

•  Time-­‐to-­‐Progression  (as  determined  by  progression  by  WHO,  EASL,  UNOS  stage,  development  of  PVT,  or  appearance  of  new  or  extrahepatic  lesions)  was  signiEicantly  increased  in  90Y  radioembolization  vs  chemoemboliazation  (13.3  months  vs  8.4  months,  p=0.046).  

 •  Clinical/Laboratory  Toxicities  showed  that  

fatigue  and  fever  were  increased  with  90Y  radioembolization  but  diarrhea,  abdominal  pain  (p<.001)  and  transaminitis  (p=.004)  were  decreased.  

•  Survival  rates  were  not  signiEicantly  different  between  patients  treated  with  chemoembolization  or  90Y  radioembolization  (17.4  vs  20.5  months,  p=0.232)  and  were  even  more  similar  in  patients  with  intermediate-­‐stage  disease  (17.5  vs  17.2  months,  p=0.42)  

Figure  2.  Survival  distribution  function  by  treatment  Group  adjusted  for  covarities  (p=0.780)  

Credits  

SUMMARY  BY:    Dean  Thongkham,  MS4  St.  George’s  University      Salen  R,  Lewandowski  RJ,  Kulik  L  et  al.  Radioemboliza7on  results  in  longer  7me-­‐to-­‐progression  and  reduced  toxicity  compared  with  chemoemboliza7on  in  pa7ents  with  hepatocellular  carcinoma.  Gastroenterology.  2011  Feb;  140(2):497-­‐507.        

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