The Role of Transarterial Radioembolization (TARE) in the ... HCC... · Assistant Professor of...
Transcript of The Role of Transarterial Radioembolization (TARE) in the ... HCC... · Assistant Professor of...
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The Role of Transarterial Radioembolization (TARE) in the Management of Hepatocelllar Carcinoma
Raj Ayyagari M.D.Assistant Professor of RadiologySection of Interventional RadiologyYale University School of [email protected]
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Disclosures
• I do not have any financial interest or other relationship with the manufacturers of any products or providers of services I intend to discuss.
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Overview
• TARE Treatment Rationale
• Patient selection
• Technique
• Dosimetry
• Side Effects, Complications
• Clinical OutcomesWang EA, Broadwell SR, Bellavia RJ, Stein JP. J Gastrointest Oncol. 2017;8(2):266-278.
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TARE Treatment Rationale
• Transarterial radioembolization (TARE) is the hepatic intra-arterial injection of the radioisotope Yttrium-90to treat unresectable HCC.
• Yttrium-90 , a β-emitter with a ½-life of 64.2h and tissue penetration of 2.5-11 mm, is incorporated into glass (TheraSphere) or resin (SIR-Spheres) microspheres 20-60µm in diameter.
• By delivering an internal radiation source, TARE is a form of brachytherapy. Allows safe administration of therapeutically high radiation doses (up to 150 Gy) with lower risk of radiation-induced liver damage than external beam radiation (at 35-40 Gy).
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TARE Treatment Rationale
• High tumoricidal doses achieved by preferential deposit of particles in tumor due to differential perfusion.
• Treatments can be…– Whole liver (higher risk)– Lobar– Segmental (“Radiation
Segmentectomy”)– Sequential– Repeated?
SIRTex, Incorporated
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Patient Selection for TARE• Multifactoral assessment involving disease burden,
biochemical profile, and performance status.
• Unresectable, with large majority of tumor burden (if not all of it) in the liver, with <70% of the liver involved.
• Adequate functional liver reserve needed: total bilirubin <2 mg/dL, albumin >3 g/dL, and a normal INR.
• ECOG performance status score of 0-1, maybe 2.
• Extreme caution when treating patients with ampulla of Vater manipulations due to increased risk of liver abscess.
• Portal vein patency not required, and in fact tumoralportal thrombus cannot be treated any other way.
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TARE Technique
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TARE Technique
• Outpatient procedure involving an initial mapping mesenteric angiogram combined with a liver-lung shunt scan, followed by dose planning and a subsequent angiographic treatment procedure.
• If radioactive particles embolize anywhere but the targeted liver (via shunts, collaterals, reflux)…– Lungs: Radiation pneumonitis– Stomach/Bowel: Ulcers,
bleeding, perforation– Can be DEVASTATING.
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TARE Technique
• Mapping mesenteric angiogram goals:
– embolize collaterals (GDA, right gastric artery)…hepatic arterial variants are common!
– evaluate arterial anatomy to plan catheter placement
– obtain liver lobar/segmental/tumoral volumes…needed for dosimetry.
– inject ~4 mCi technetium-99m MAA test dose…arteriovenous shunting can be extensive!
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TARE Technique
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TARE Technique
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TARE Dosimetry
• Lobar or segmental liver volumes are calculated using diagnostic MRI/CT, axial SPECT-CT, or even better, cone-beam CTA images.
• Liver tumor volumes are calculated using a diagnostic MRI/CT.
• BSA is calculated using patient height and weight.• Lung shunt fraction is calculated by a nuclear medicine
scan that measures the amount of 99mTc-MAA that gets to the lungs.
• Treatment Dose calculation method differs based on whether glass TheraSpheres (2500 Bq/sphere) or resin SIR-Spheres (50 Bq/sphere) are being used.
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TARE Dosimetry
• TheraSpheres:
Activity = Absorbed Dose (Gy) x Mass of Liver50 x (1-%LSF/100) x (1-%R/100)
Target delivered activity is typically 80-150 Gy
• SIR-Spheres:
Activity = BSA – 0.2 + %Tumor Involvement100
LSF <10% = no dose reduction; LSF 10-15% = 20% reduction; LSF 15-20% = 40% reduction
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TARE Side Effects, Complications
SIDE EFFECTS:• Fatigue – 50-60% patients in first 1-2 weeks after.• Low grade abdominal pain, nausea/vomiting – 20%.
COMPLICATIONS:• Radiation-induced GI ulcers often refractory to
conservative management.• Biliary complications (10%): dyskinesia, cholecystitis
(2.7%), stricture (2.4%), necrosis (3.9%), biloma (1%).• Radiation-induced liver disease – sinusoidal congestion,
venous occlusion, hepatic fibrosis; 4-8 weeks after; 4-7%, but in a series including liver metastatic lesions previously treated with chemotherapy; no predictive model for RILD.
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TARE Clinical Outcomes
• 1-year survival rates of untreated HCC patients are ~50% among intermediate stage (BCLC-B) patients and ~25% among advanced stage (BCLC-C) patients.
• Salem et al reported TARE results in 291 intermediate and advanced stage patients. Response rates were 42% (WHO) and 57% (EASL). TTP was 7.9 mo. CP-A patients had median survival of 17.2 mo, CP-B 7.7 mo, and CP-B with PVT 5.6 mo.
• Hilgard et al validated these results in 108 patients, and showed outcomes equivalent to cTACE and DEB-TACE.
• A 325 patient study by Sangro et al showed TARE patients to have median survival of 24.4 mo (BCLC-A), 16.9 mo (BCLC-B), and 10.0 mo (BCLC-C).
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TARE Clinical Outcomes
• As yet, no RCT comparing TARE and TACE in HCC.
• Salem et al’s “comparative effectiveness report” of a 245 patient cohort (123 TARE, 122 cTACE) described adverse events, toxicities, repsonse rates, and TTP to be improved in TARE, with no difference in overall survival.
• TARE has also been shown to superior favorable rate of down-staging HCC patients to transplantation.
• TARE also seems to cause less hepatotoxicity than TACE in patients with a TIPS in place, likely due to the minimal embolic effect of TARE.
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