Faculty Bibliography

UNLABELLED: The aim of this study was to compare radiological and pathological changes and test the adjunct efficacy of Sorafenib to Y90 as a bridge to transplantation in hepatocellular carcinoma (HCC). 15 patients with 16 HCC lesions were randomized to Y90 without (Group A, n = 9) or with Sorafenib (Group B, n = 7). Size (WHO, RECIST), enhancement (EASL, mRECIST) and diffusion-weighted imaging criteria (apparent diffusion coefficient, ADC) measurements were obtained at baseline, then at 1 and every 3 months after treatment until transplantation. Percentage necrosis in explanted tumors was correlated with imaging findings. 100%, 50%-99% and <50% pathological necrosis was observed in 6 (67%), 1 (11%), and 2 (22%) tumors in Group A and 3 (42%), 2 (28%), and 2 (28%) in Group B, respectively (P = 0.81). While ADC (P = 0.46) did not change after treatment, WHO (P = 0.06) and RECIST (P = 0.08) response at 1 month failed to reach significance, but significant responses by EASL (P < 0.01/0.03) and mRECIST (P < 0.01/0.03) at 1 and 3 months were observed. Response was equivalent by EASL or mRECIST. No difference in response rates was observed between groups A and B at 1 and 3 months by WHO, RECIST, EASL, mRECIST or ADC measurements. Despite failing to reach significance, smaller baseline size was associated with complete pathological necrosis (CPN) (RECIST: P = 0.07; WHO: P = 0.05). However, a cut-off size of 35 mm was predictive of CPN (P = 0.005). CPN could not be predicted by WHO (P = 0.25 and 0.62), RECIST (P = 0.35 and 0.54), EASL (P = 0.49 and 0.46), mRECIST (P = 0.49 and 0.60) or ADC (P = 0.86 and 0.93). CONCLUSION: The adjunct of Sorafenib did not augment radiological or pathological response to Y90 therapy for HCC. Equivalent significant reduction in enhancement at 1 and 3 months by EASL/mRECIST was noted. Neither EASL nor mRECIST could reliably predict CPN.

This is the second of a two-part overview of the fundamentals of oncology for interventional radiologists. The first part focused on clinical trials, basic statistics, assessment of response, and overall concepts in oncology. This second part aims to review the methods of tumor characterization; principles of the oncology specialties, including medical, surgical, radiation, and interventional oncology; and current treatment paradigms for the most common cancers encountered in interventional oncology, along with the levels of evidence that guide these treatments.

BACKGROUND & AIMS: Portal vein embolization (PVE) is a standard technique for patients not amenable to liver resection due to small future liver remnant ratio (FLR). Radiation lobectomy (RL) with (90)Y-loaded microspheres (Y90) is hypothesized to induce comparable volumetric changes in liver lobes, while potentially controlling the liver tumor and limiting tumor progression in the untreated lobe. We aimed at testing this concept by performing a comprehensive time-dependent analysis of liver volumes following radioembolization. METHODS: 83 patients with right unilobar disease with hepatocellular carcinoma (HCC; N=67), cholangiocarcinoma (CC; N=8) or colorectal cancer (CRC; N=8) were treated by Y90 RL. The total liver volume, lobar (parenchymal) and tumor volumes, FLR and percentage of FLR hypertrophy from baseline (%FLR hypertrophy) were assessed on pre- and post-Y90 CT/MRI scans in a dynamic fashion. RESULTS: Right lobe atrophy (p=0.003), left lobe hypertrophy (p<0.001), and FLR hypertrophy (p<0.001) were observed 1 month after Y90 and this was consistent at all follow-up time points. Median %FLR hypertrophy reached 45% (5-186) after 9 months (p<0.001). The median maximal %FLR hypertrophy was 26% (-14 --> 86). Portal vein thrombosis was correlated to %FLR hypertrophy (p=0.02). Median Child-Pugh score worsening (6 --> 7) was seen at 1 to 3 months (p=0.03) and 3 to 6 months (p=0.05) after treatment. Five patients underwent successful right lobectomy (HCC N=3, CRC N=1, CC N=1) and 6 HCCs were transplanted. CONCLUSIONS: Radiation lobectomy by Y90 is a safe and effective technique to hypertrophy the FLR. Volumetric changes are comparable (albeit slightly slower) to PVE while the right lobe tumor is treated synchronously. This novel technique is of particular interest in the bridge-to-resection setting.

BACKGROUND & AIMS: Quality of life (QoL) is an important aspect of any palliative treatment. However, few data are available from studies comparing how embolotherapy affects QoL for patients with hepatocellular carcinoma (HCC). We performed a health-related QoL study in patients with HCC treated by transarterial chemoembolization (TACE) or (90)Y radioembolization. METHODS: We performed a prospective study of patients undergoing (90)Y radioembolization (n = 29) or TACE (n = 27) for HCC. We assessed patients before treatment and 2 and 4 weeks after treatment using the Functional Assessment of Cancer Therapy-Hepatobiliary (FACT-Hep) survey. We compared differences in health-related QoL between the treatment groups using linear regression repeated-measures analysis. RESULTS: At baseline, the groups had comparable baseline Child-Pugh class and performance statuses, although patients undergoing TACE had lower tumor burdens (P = .018) and less-advanced disease, based on United Network for Organ Sharing and Barcelona stage (P = .03 and P = .02, respectively), permitting injections at segmental arteries (P < .0001). There were no significant differences between groups in overall FACT-Hep health-related QoL scores (P = .055, effect size [ES], .54), owing to a limited sample size. Despite the more advanced disease of patients who received (90)Y radioembolization, they had a significantly better QoL, based on social well being (P = .019; ES, .65), functional well-being (P = .031; ES, .60), and embolotherapy-specific scores (P = .018; ES, .67). They also had a trend toward better overall QoL (P = .055; ES, .54) and higher Trial Outcome Index (P = .05; ES, .56) and FACT-Hep scores (P = .071; ES, .52). CONCLUSIONS: In a prospective study, although (90)Y radioembolization was used to treat patients with more advanced disease, those who received this treatment had significant increases in several features of QoL, whereas patients who received TACE had decreases in QoL scores. However, because of the limited sample size, there was no significant difference in overall FACT-Hep health-related QoL scores. The increase was greatest in the embolotherapy-specific score. ClinicalTrials.gov, number NCT00739167.

Biliary complications following yttrium-90 ((90)Y) radioembolization are rare, and radiation-induced cholecystitis requiring intervention represents an even smaller proportion of these complications, reportedly occurring in fewer than 1% of patients treated with (90)Y [1]. However, its implications are serious, as the treatment of radiation cholecystitis may require cholecystectomy in patients otherwise considered poor surgical candidates. While biliary complications such as intrahepatic biliary strictures or bilomas may be unavoidable in the course of treating hepatic malignancies due to local field effects of radiation, radiation cholecystitis results from non-target embolization of radioactive microspheres. Meticulous attention to anatomic detail and catheter position may be adequate in preventing this avoidable complication. Herein we discuss the clinical, radiographic, and pathologic findings, as well as the outcome, of a patient who experienced radiation cholecystitis following (90)Y radioembolization.

PURPOSE: To evaluate the imaging of hemodialysis arteriovenous (AV) fistulas and grafts with use of magnetic resonance (MR) angiography with generalized autocalibrating partially parallel acquisition (GRAPPA) and time-resolved echo-sharing angiographic technique (TREAT) and compare the findings with those of digital subtraction angiography (DSA). MATERIALS AND METHODS: The vascular tree directly related to AV fistulas and grafts was divided into nine segments. Images of each segment obtained on GRAPPA MR angiography were evaluated for the presence of stenosis, occlusion, and any other disease (eg, pseudoaneurysm) by two independent observers and compared with a consensus reading of the same segments on DSA imaging. Sensitivity and specificity were calculated with use of DSA as the gold standard modality, and each image on MR angiography and DSA was rated for quality. Linear-weighted kappa scores were calculated as a measure of interobserver variability in the detection of pathologic processes. RESULTS: A total of 80 segments were evaluated by each observer. For both observers, sensitivity rates for the detection of stenosis, occlusion, and any disease were 100% (95% CI, 52%-100%), 100% (95% CI, 20%-100%), and 100% (95% CI, 60%-100%), respectively. For observer 1, specificity rates for the detection of stenosis, occlusion, and any disease were 96% (95% CI, 88%-99%), 100% (95% CI, 94%-100%), and 96% (95% CI, 88%-99%), respectively. For observer 2, the specificity rates for the detection of stenosis, occlusion, and any disease were 93% (95% CI, 84%-98%), 100% (95% CI, 94%-100%), and 93% (95% CI, 84%-97%), respectively. Linear-weighted kappa values for MR angiography and DSA were 0.78+/-0.084 and 0.62+/-0.152, respectively. CONCLUSION: Time-resolved MR angiography with GRAPPA and TREAT offers excellent image quality and provides an accurate and reliable modality for the detection of pathologic processes in hemodialysis AV fistulas and grafts.