AIM: To analyze the epidemiology, clinical characteristics, treatment patterns and outcome in hepatocellular carcinoma (HCC) patients.
Purpose: To prospectively assess the performance of hydrogel-coated versus fibered microcoils in the prophylactic occlusion of the gastroduodenal artery (GDA) before yttrium-90 (90Y) radioembolization.
AIM: To evaluate the long-term natural history of the gastroduodenal lesions secondary to extrahepatic embolization with Ytrium 90 (90Y) spheres.
This document replaces previous guidance on selective internal radiation therapy for colorectal metastases in the liver (interventional procedure guidance 93)
Purpose: To evaluate the toxicity and response to radioembolization with yttrium-90 (90Y) glass microspheres in patients with hepatocellular carcinoma (HCC) and existing transjugular intrahepatic portosystemic shunts (TIPS).
Unresectable hepatocellular carcinoma has a high frequency of vascular invasion and arterial parasitization. Trans-arterial radioembolization using yttrium-90 (Y90) microspheres is a possible treatment option. Paramount to its success is the meticulous angiographic interrogation of tumor feeding arteries and extra-hepatic supply. We describe a patient with tumor invasion of the inferior vena cava with arterial supply from the right inferior phrenic artery, which was exquisitely visualized using intra-arterial computed tomographic angiography (IACTA) during the planning technetium-99m macro aggregated albumin phase. This technique was useful in planning which artery to administer Y90 microspheres into for maximal brachytherapy. Although patient outcome was poor due to significant arterio-portal shunting, we believe that IACTA is a useful adjunct to conventional digital subtraction angiography in planning radioembolization therapy.
AIM: To introduce the combination method of radiochemoembolization for the treatment of selected hepatic metastases.
The incidence of hepatocellular carcinoma is increasing. Most patients present beyond potentially curative options and are usually affected by underlying cirrhosis. In this scenario, trans-arterial therapies, such as radioembolization, are rapidly gaining acceptance as a potential therapy for hepatocellular carcinoma and liver metastases. Radioembolization is a catheter-based liver-directed therapy that involves injection of micron-sized embolic particles loaded with a radioisotope by use of percutaneous transarterial techniques. Cancer cells are preferentially supplied by arterial blood and normal hepatocytes by portal venous blood; radioembolization therefore specifically targets tumor cells with a high dose of lethal radiation and spares healthy hepatocytes.
Radioembolization offers a novel way to treat the nonresectable, liver predominant hepatic malignancies with better tumor response and overall progression-free survival rates. Transarterial catheter-based radioembolization procedure involves the hepatic arterial administration of glass- or resin-based beta emitting Yttirum-90 microspheres. Safe delivery of the tumoricidal radiation dose requires careful angiogram planning and coil embolization to quantify lung shunting and prevent systemic toxicity, respectively. Diagnostic pretreatment angiogram also serves to identify the hepatic arterial variant anatomy and other coexisting pathologies that might require a different or alternative approach. We describe a complex case of celiac artery stenosis with tortuous pancreaticoduodenal arterial arcade precluding access to the right hepatic artery for performing radioembolization. Celiac artery stenting of the stenosis was performed to facilitate subsequent safe and successful Yttrium-90 microsphere radioembolization.
Purpose: Before yttrium-90 (90Y) radioembolization administration, the authors consolidated arterial inflow by embolizing variant hepatic arteries (HAs) to make microsphere delivery simpler and safer. The present study reviews the technical and clinical success of these consolidation procedures. Journal of Vascular and Interventional Radiology Volume 22, Issue 10 , Pages 1364-1371.e1, October 2011. Copiright © 2011 SIR. Published by Elsevier Inc. All rights reserved.
Hepatocellular carcinoma is a primary malignant tumor of the liver that accounts for an important health problem worldwide. Only 10 to 15% of hepatocellular carcinoma patients are suitable candidates for treatment with curative intent, such as hepatic resection and liver transplantation. A majority of patients have locally advanced, liver restricted disease (Barcelona Clinic Liver Cancer (BCLC) staging system intermediate stage). Transarterial loco regional treatment modalities offer palliative treatment options for these patients; transarterial chemoembolization (TACE) is the current standard treatment. During TACE, a catheter is advanced into the branches of the hepatic artery supplying the tumor, and a combination of embolic material and chemotherapeutics is delivered through the catheter directly into the tumor. Yttrium-90 radioembolization (90Y-RE) involves the transarterial administration of minimally embolic microspheres loaded with Yttrium-90, a β-emitting isotope, delivering selective internal radiation to the tumor. 90Y-RE is increasingly used in clinical practice for treatment of intermediate stage hepatocellular carcinoma, but its efficacy has never been prospectively compared to that of the standard treatment (TACE). In this study, we describe the protocol of a multicenter randomized controlled trial aimed at comparing the effectiveness of TACE and 90Y-RE for treatment of patients with unresectable (BCLC intermediate stage) hepatocellular carcinoma.
Hepatocellular carcinoma (HCC) is the fifth most common cancer in the world. Surgery offers the only hope for cure. However, the potentially curable method is only possible for a small proportion of those afflicted, for the rest, palliative treatment is indicated. Despite all the treatment options when used as monotherapy, patients with HCC have a poor long term prognosis. In this setting, multimodal and combination therapy has emerged as an alternative treatment modality for HCC. Studies have looked at various forms of combination therapy, including neoadjuvant/adjuvant/downstaging therapy for surgery and the combined modality of non-operative therapies. The novel molecular targeted therapies are also being used as combination regimens for surgery or other non-operative therapies. Some forms of combination therapies, including downstaging therapy for surgery, salvage transplantation, and molecular targeted therapy have been shown to provide survival benefits for well selected patients, and need to be encouraged in the future. And others such as pre-operative bridging therapy for liver transplantation, adjuvant therapy for hepatic resection and combination of local and regional therapies have also shown some benefits in preliminary results, which need confirmation in further studies. In conclusion, multimodal and combination therapy is an encouraging treatment modality for HCC. Future research should continue to unravel the role of combination therapy with properly selected patients and appropriate end points.
Transarterial therapies play an important role in the treatment of hepatocellular carcinoma, both in a palliative setting and as an adjunct to surgery. These therapies exploit the dual blood supply of the liver to selectively target tumors via the hepatic artery, while sparing nontumorous liver. Currently available therapies include transarterial embolization; chemoembolization, with or without drug-eluting beads; and radioembolization. Transarterial techniques are also being used in the development of novel therapies. This article provides an outline of the technical and clinical applications of intraarterial therapies in the treatment of HCC and highlights pertinent future directions.
Purpose: Identifying gastroduodenal uptake of 99mTc-macroaggregated albumin (MAA), which is associated with an increased risk of ulcer disease, is a crucial part of the therapeutic management of patients undergoing radioembolization for liver tumours. Given this context, the use of MAA single photon emission computed tomography (SPECT)/CT may be essential, but the procedure has still not been thoroughly evaluated. The aim of this retrospective study was to determine the effectiveness of MAA SPECT/CT in identifying digestive extrahepatic uptake, while determining potential diagnostic pitfalls.
In the last years, new locoregional and systemic therapies have been developed for the management of hepatocellular carcinoma (HCC). Among the novel therapeutic procedures, yttrium-90 radioembolization (90Y-RE) has produced encouraging results across the whole spectrum of HCC, from early to advanced stages. In 90Y-RE intraarterially injected radioactive microspheres are used for internal radiation treatment. Microspheres reach the tumoral microvasculature, and there, high doses of radiation are delivered preferentially to tumor tissues. The toxicity profile of 90Y-RE is favorable. Adverse events, rather uncommon, result from irradiation of non-tumoral tissues as the gastrointestinal tract and the non-tumoral liver. The latter can lead to liver toxicity and is the most challenging adverse event in HCC patients arising in a cirrhotic liver. All the evidence that support the use of 90Y-RE in HCC is based on retrospective series or non-controlled prospective studies. 90Y-RE achieve intense tumor response in targeted lesions, supporting its use for the treatment of early tumors with a curative intent, as a bridge to liver transplantation, and for unresectable HCC who exceed the transplant criteria or are not suitable for liver resection, with a downstaging intention. In the intermediate stage, data from retrospective series shows similar survival rates between patients treated with transarterial chemoembolization and 90Y-RE, and it can be considered a treatment option for those patients who are not considered good candidates for TACE, as those with bulky disease, or affecting both lobes, or for patients who fail to respond to transarterial chemoembolization. Finally, 90Y-RE can be used safely and can be a true alternative to sorafenib for the treatment of advanced tumors without extrahepatic metastases. As progression after 90Y-RE is mainly due to the development of new lesions, combination therapy with systemic treatment and 90Y-RE seems reasonable.
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