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Abstracts from the Symposium on Clinical Interventional Oncology (CIO) 2016
ABSTRACTS FROM CIO
The Symposium on Clinical Interventional Oncology (CIO) 2016 February 6–7, 2016, Hollywood, Florida
CIO Abstracts
Single vs Triple Drug Chemoembolization for Hepatocellular Carcinoma: Comparing Toxicity, Response & Survival S. Mouli, R. Hickey, B. Thornburg, K. Desai, K. Sato, R. Salem, R. Lewandowski Purpose: Conventional lipiodol chemoembolization (cTACE) remains a standard of care therapy for patients with unresectable hepatocellular carcinoma (HCC). Shortages of chemotherapeutic agents have initiated a transition to single-agent doxorubicin from historic triple-drug therapy. The purpose of this study was to determine the HI¿FDF\ RI VLQJOH YV WULSOHGUXJ F7$&( DV PHDVXUHG E\ WR[LFLW\ WXPRU UHVSRQVH time-to-progression (TTP), and overall survival. Material and Methods: With institutional review board approval, a single- center retrospective review was performed on patients who underwent chemoembolization. Imaging characteristics and clinical follow-up post-cTACE were evaluated to deterPLQH7732YHUDOOVXUYLYDO 26 IURPWKHWLPHRI¿UVWF7$&(ZDVFDOFXODWHG UHVXOWV ZHUHVXEVWUDWL¿HGDFFRUGLQJWR&KLOG3XJK &3 FODVVDQG%DUFHORQD&OLQLFIRU/LYHU Cancer (BCLC) staging system. Results: One hundred seventy-two patients underwent triple-drug cTACE; 165 consecutive patients underwent single-agent doxorubicin cTACE (total: 337 patients). Median TTP was similar between the two groups: 7.9 months (CI: 7.1-9.4) and 6.8 months (CI: 4.6-8.6), for triple and single drug, respectively (p < 0.05). For singleDJHQW F7$&( PHGLDQ 26 YDULHG VLJQL¿FDQWO\ E\ %&/& $ PRQWKV % months; C, 10.9 months; p < 0.01. Results from 172 patients treated with triple-drug WKHUDS\GHPRQVWUDWHGDPHGLDQVXUYLYDOWKDWDOVRYDULHGVLJQL¿FDQWO\E\%&/& $ 28.9 months; B, 18.1 months; C, 9.0 months (p < 0.01). For patients with preserved liver function and BCLC A/B, single-drug cTACE demonstrated longer median OS compared to triple drug (p < 0.05). Conclusions: Single-agent chemoembolization with doxorubicin and ethiodized oil GHPRQVWUDWHVDFFHSWDEOHHI¿FDF\DVPHDVXUHGE\773DQG265HVXOWVFRPSDUHIDYRUably with traditional triple-drug therapy. Mid-term Local Control and Survival Case Series of Lung Malignancy Ablations with a 2450-MHz Mic rowave Device C.J. Jones, C. Bailey, N, Corridoni, B. Steadman Purpose: Percutaneous radiofrequency ablation (RFA) is an option for local treatment of lung malignancies in nonsurgical patients. Despite promising early reports, RFA has not been as effective as stereotactic external beam radiation therapy (EBRT), which has reported local control rates as high as 90% at 2 years. Since 2011, several manufacturers have introduced 2450-MHz generator microwave ablation devices capable of increased power, resulting in ablations of much higher temperature and sizes than RFA. We hypothesize that lung ablation with a 2450-MHz microwave device will result in more effective local control of lung malignancies than RFA. Material and Methods: Midterm results from lung microwave ablation on 13 patients with 17 lung tumors (11 non-small-cell lung carcinoma, 6 colorectal) treated from September 20, 2011 to August 28, 2014 are reported. Preprocedure tumor size and intraprocedure measures including temperature, power, and time of ablation were UHFRUGHG /RFDO UHFXUUHQFH ZDV FRQ¿UPHG E\ SRVLWURQ HPLVVLRQ WRPRJUDSK\FRP-
$OO&,2DEVWUDFWVDQGSRVWHUVDUHJUDGHGYLDEOLQGHGSHHUUHYLHZEDVHGRQVFLHQWL¿F merit, originality, relevance, and clarity. SIR assumes no legal liability or responsibility for the completeness, accuracy, and correctness of the information presented in the abstracts. Abstracts will be published in the Journal of Vascular and Interventional Radiology as submitted by the authors, except for minor stylistic adjustments to ensure consistency of format and adherence to journal style. © SIR, 2016 J Vasc Interv Radiol 2016; 27:e22–e29 http://dx.doi.org/10.1016/j.jvir.2016.01.090
puted tomography. The Kaplan-Meier method was used to estimate survival and local control rates. Results: Mean maximal diameter of tumors was 2.2 cm. An average of 1.6 ablations ZHUHSHUIRUPHGRQHDFKPDVVZLWKWHPSHUDWXUHVRI Û& UDQJHÛWRÛ& IRU 5.2 minutes (range 3 to 10 minutes). Median power was 95 W (range 45 W to 140 W). Average follow-up is 21.3 months (range 6 to 36 months). The 1-, 2-, and 3-year local tumor progression-free rates were 94%, 84%, and 72%. For tumor size <4.0 cm, the 1-, 2-, 3-year local tumor progression-free rates were 100%, 100%, and 86%. The 1-, 2-, and 3-year overall survival rates were 92%, 67%, and 56%. Conclusions: Ablation of lung malignancies with a 2450-MHz generator microwave device appears to result in more effective local control than RFA with results comparable to stereotactic EBRT. DEBIRI Combined with Systemic Chemotherapy for Pretreated Liver mCRC: Procedure and Patients Outcomes O. Pellerin, G. Amouyal, C. del Giudice, M. Sapoval Purpose: The use of trans-arterial chemo-embolization with irinotecan drug-eluting beads (DEBIRI) for liver-dominant metastatic colorectal cancer (mCRC) is usually proposed for end-stage patients as a salvage treatment without any concomitant sysWHPLFWUHDWPHQW7KHJRDOVRIRXUVWXG\ZHUHWRHYDOXDWHWKHVDIHW\DQGHI¿FDF\RIWKH DEBIRI procedure in patients treated by concomitant systemic chemotherapy. Material and Methods: Between April 2011 and April 2014, all consecutive ECOG PS 0-2 patients with stable or progressive liver-dominant mCRC pretreated by at least 2 previous chemotherapy lines were referred for DEBIRI as salvage treatment. All patients received in addition systemic chemotherapy. Safety of the procedure, toxicities (NCI-CTC AE V4.02), tumor response rates (RECIST 1.1), progression-free survival (PFS), and overall survival (OS) were recorded. Results: Forty-nine consecutive patients (mean age 63 years) underwent 81 DEBIRI sessions administered in a lobar manner in the same session. Altogether, 45 grade 3 to 4 arterial hypertension crises occurred during the procedure, 11 grade 3 postembolization syndrome, and 5 grade 2 to 3 toxicities (cholecystitis, pancreatitis, or nonmalignant ascites) were observed. Median maximal procedural pain reported by the patient was 7. All toxicities were successfully managed. No toxic death occurred. The average hospital stay was 4.5 days. The 3-month response and disease control rates were 31% and 80%, respectively. Tumor response was correlated with the tumor involvement. Median PFS and OS were 8.1 and 21 months, respectively. Conclusions: DEBIRI plus intravenous chemotherapy for pretreated liver-domiQDQWP&5&SURYLGHSURPLVLQJHI¿FDF\UHVXOWVWRJHWKHUZLWKVSHFL¿FDQGVHYHUHVLGH effects that need to be adequately managed. Outcomes of Radiation Segmentectomy for Unresectable Solitary Hepatocellular Carcinoma 3 Cm D.M. Biederman, J. Titano, V. Bishay, P. O'Connor, G. Sivananthan, M. Schwartz, M. Facciuto, S. Florman, G. Gunasekaran, A. Fischman, R. Patel, F. Nowakowski, R. Lookstein, E. Kim Purpose: 7RHYDOXDWHVDIHW\DQGHI¿FDF\RIWDUJHWHGVHJPHQWDOUDGLRHPEROL]DWLRQ 5( LQSDWLHQWVZLWKXQUHVHFWDEOHVROLWDU\KHSDWRFHOOXODUFDUFLQRPD +&& FP Material and Methods: From January 2010 to June 2015 a total of 417 consecuWLYHSDWLHQWVZLWK+&&XQGHUZHQWJODVVEDVHG5(/RFRUHJLRQDOWKHUDS\QDÕYHSDWLHQWVZLWKXQUHVHFWDEOHVROLWDU\+&&FPZLWKRXWHYLGHQFHRISRUWDOYHLQLQYDVLRQ RUH[WUDKHSDWLFPHWDVWDVLVZHUHUHWURVSHFWLYHO\LGHQWL¿HGDQGLQFOXGHGLQWKHVWXG\ Forty-one patients with RE (age: 65.7 ± 8.5, male: 70.7%) met the above criteria with demographics as follows: HCV positive (n = 25, 61.0%), ECOG 0 (n = 29, 70.7%), Child-Pugh class A (n = 30, 73.2%), mean tumor size (2.0 ± 0.5 cm), AFP < 200 ng/ mL (n = 38, 92.7%). Outcome variables included CTCAE v4.03 graded 180-day laboratory toxicities, imaging response (mRECIST), time to progression (TTP), reason for progression, and survival. Results: Median (interquartile range) treatment dose was 1.38 (1.04-1.88) Gbq. Grade 3 to 4 bilirubin and AST toxicity were 7.3% and 4.9%, respectively. Complete response (CR) of the target lesion at 90 days was observed in 35 (85.3%) patients. The overall CR rate (target and nontarget) was 82.9% (34/41). The 7 patients without a CR
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(partial response: 5, stable disease: 1, disease progression: 1) underwent additional treatment (RE: 3, chemoembolization: 4) at a median of 79 days. The overall median (95% CI) TTP was 11.1 months (8.8 to 25.6). There were 13 cases of disease progression that occurred after an initial complete response, with one case occurring in the initial target segment and the remaining cases of progression occurring secondary to new HCC in nontargeted segments. Overall median (95% CI) follow-up time was 11.4 months (8.4 to 16.5) during which there were 2 deaths [mean (95% CI) overall survival: 30.8 (28.1 to 33.5) months]. Four patients were bridged to liver transplant at a median (range) of 437 (232-879) days post RE. Conclusions: 5DGLDWLRQ VHJPHQWHFWRP\ LV D KLJKO\ HI¿FDFLRXV WUHDWPHQW RSWLRQ IRUSDWLHQWVZLWKXQUHVHFWDEOHVROLWDU\+&&3 cm with a very low incidence with of target lesion recurrence. Analysis of Residual and Recurrent Hepatocellular Carcinoma post Microwave Ablation
CIO Abstracts
R.J. Durrani, D. Bierderman, E. Dayan, J. Titano, G. Sivananthan, M. Schwartz, M. Facciuto, G. Gunasekaran, S. Florman, A. Fischman, R. Patel, F.S. Nowakowski, R. Lookstein, E. Kim Purpose: To evaluate the incidence of and potential risk factors related to residual and recurrent tumor in patients undergoing microwave ablation (MWA) for unresectable solitary hepatocellular carcinoma (HCC). Material and Methods: From January 2011 to June 2015, a total of 281 consecutive patients underwent treatment with MWA (Certus, Neuwave, Madison, WI). A UHWURVSHFWLYHUHYLHZRIORFRUHJLRQDOWKHUDS\QDÕYHSDWLHQWVZLWKXQUHVHFWDEOHVROLWDU\+&&FPZDVFRQGXFWHG3DWLHQWVZLWKSRUWDOYHLQLQYDVLRQRUH[WUDKHSDWLF metastasis were excluded. A total of 81 patients treated with MWA met the above criteria (age: 65.6 ± 8.0, male: 65.4%) with baseline demographics as follows: ECOG 0 (n = 58, 81.7%), Child-Pugh class A (n = 51, 63.0%), mean tumor size (1.81 ± 0.6 cm), AFP < 200 ng/mL (n = 76, 93.8%). Imaging response was graded according to P5(&,67FULWHULD5HVLGXDOWXPRUZDVGH¿QHGDVDYLDEOHWDUJHWOHVLRQWXPRURQLQLWLDOIROORZXSLPDJLQJ5HFXUUHQWWXPRUZDVGH¿QHGDVDQLQLWLDOFRPSOHWHUHVSRQVH with subsequent tumor visualization within or adjacent to the ablation cavity. Time to progression (TTP), reason for progression, and overall survival were also evaluated. Results: A total of 81 treatments were successfully performed with an initial target and overall complete response rate of 88.9% (72 out of 81) and 67% (54 out of 81) respectively. The 9 patients with residual tumor underwent secondary therapy FKHPRHPEROL]DWLRQ UDGLRHPEROL]DWLRQ DEODWLRQ DW DPHGLDQ ,45 RI (45.3-141.3) days post initial ablation. The 67 patients with an initial overall complete response had a median (95% CI) follow-up time of 22.4 (19.8-26.5) months during which there were 30 patients with mRECIST progression on imaging follow-up. Local recurrence comprised 30% (9 out of 30) of instances of progression occurring at median (95% CI) of 11.7 (7.6-17.3) months. The 21 cases of nontarget progresVLRQZHUHREVHUYHGDWPHGLDQ &, RI DVLJQL¿FDQWO\VKRUWHUWLPH course than the cases of local recurrence (p = 0.036, HR: 0.46 [0.23-0.95]). The overall median (95% CI) TTP was 11.7 (7.5-19.1) months. Twelve patients were bridged WROLYHUWUDQVSODQWDWDPHGLDQ ,45 RI GD\V0HDQ &, RYHUDOO survival was 44.0 (39.9-48.1) months. Conclusions: MWA for patients with unresectable solitary HCC has a high rate of initial complete response. Early imaging progression after an initial complete response was more often due to non-target progression with local tumor recurrence developing over a later time course. Getting the Shaft: Preoperative Ablation of Long Bone Metastasis, a New Technique to Decrease Blood Loss from Arthroplasty Z. A. Miller, M. Schiffman Purpose: Up to 90% of patients undergoing total hip arthroplasty lose enough blood to require transfusion. Preoperative transcatheter embolization of bone metastasis has proven an effective method for decreasing blood loss. We present 2 cases of malignant bone metastasis where long bone ablation was performed via the medullary cavity in an orientation parallel to the cortex, providing an alternative method to decrease blood loss. Material and Methods: Case 1: An 85-year-old female with history of breast cancer presented with biopsy-proven right femoral head metastasis and associated hip IUDFWXUH8VLQJVHULDOFRPSXWHGWRPRJUDSK\VFRXW¿OPJXLGDQFHDFP$PLFDPLcrowave ablation needle (Healthtronics, Austin, TX) was advanced into the proximal femur, and 3 ablation cycles were performed. The patient underwent total hip arthroplasty the next day with estimated blood loss of 600 cc. Case 2: A 72-year-old male with biopsy-proven metastatic renal cell carcinoma to the left trochanter, deemed high risk for fracture. A 27-cm Amica needle was used to access the metastatic lesion via the greater trochanter. Ablation was performed at 20W for 2 minutes. The patient underwent total hip arthroplasty the next day with estimated blood loss of 300 cc. Results: In both of our patients who underwent prearthroplasty ablation via a parallel intramedullary approach, blood loss was less than the median estimated blood loss in hip replacements, which was 984 cc as reported in the Journal of Orthopaedic Surgery and Research in 2015.
Conclusions: The parallel intramedullary ablative technique offers a way to decrease operative hemorrhage without violating the cortex, decreasing the risk for tumor seeding and/or skin burns. This technique also obviates the need for contrast, making it a good alternative for patients with renal dysfunction. Not only useful in decreasing blood loss in our 2 example cases, this technique may also prove useful in treatment of other malignant and nonmalignant bone tumors in a medullary location. Thermoprotective Techniques of the Gallbladder and Main Bile Ducts During Thermal Hepatic Ablations P. Gilbert, M. Guimaraes, D. Arrington Purpose: To describe gallbladder and bile duct lavage as a protective technique during percutaneous thermal ablative therapy (PTAT) of hepatic lesions in close proximity to the gallbladder or major bile ducts. Material and Methods: PTAT of lesions within close proximity to the gallbladder RUPDLQELOHGXFWVLVIUDXJKWZLWKWHFKQLFDOGLI¿FXOWLHVGXHWRWKHULVNRIJDOOEODGGHU perforation and possible peritonitis or bile duct stricture. Results: For lesions in close approximation to the gallbladder for which lavage is GHHPHGWREHRISURWHFWLYHEHQH¿WDJDXJH&KLED &RRN0HGLFDO%ORRPLQJWRQ IN) needle is percutaneously guided through uninvolved hepatic parenchyma into the gallbladder lumen under computed tomography or ultrasound guidance. Any bile within the gallbladder is aspirated and the gallbladder decompressed. This is done to eliminate any overdistention, possible seepage, or bacteremia, as well as bile peritonitis if there is a gallbladder rupture. Following decompression, 30 cc to 50 cc, roughly the amount of bile aspirate, of chilled D5W is hand-injected into the gallbladder followed by continuous infusion of 50 cc per hour. D5W is preferred for its nonionic and iso-osmolar properties. For lesions in close approximation to main bile ducts, a nasobiliary tube is advanced into the duct of concern, and chilled D5W is instilled into the bile ducts.
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Conclusions: Protection strategies for PTAT are feasible and safe and should be considered for treatment of lesions that may have previously been considered not amenable to PTAT. These techniques may provide a more adequate ablation zone despite close proximity to adjacent structures such as the gallbladder or main bile ducts. It is our position that the usage of these thermal protective strategies can increase the number of patients that may be candidates for PTAT as well as decreasing major complications of damage to surrounding structures. More studLHVDUHQHHGHGWRUH¿QHWKHVHWHFKQLTXHVEXWRXUH[SHULHQFHKDVEHHQH[WUHPHO\ favorable.
DC-beads M1 Doxorubicin Drug-Loaded Chemoembolization (DEBDOX) for Liver-Limited Breast Cancer Metastases O. Pellerin, G. Amouyal, C. del Giudicce, M. Sapoval Purpose: To study the 3-month liver response rate and the progression-free survival after 2 sessions of DEBDOX chemoembolization for patients with liver-dominant breast cancer metastases. Material and Methods: From April 2011 to December 2013, all patients with progressive liver-dominant breast cancer metastases were screened to be enrolled in the
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DC-beads M1 Irinotecan Drug-Eluting Beads as a Closure Treatment: A Chemotherapy Holiday Option O. Pellerin, G. Amouyal, C. Del Giudice, M. Sapoval Purpose: Chemotherapy holidays for stable patients under treatment is a major quality-of-life issue. Our hypothesis was that 2 treatments with irinotecan-loaded drug-eluting beads (DEBIRI) could help to reach sustainable lesion stability. The goal of our study was to assess liver response rate and progression-free survival (PFS) at 3 months. Material and Methods: This monocentric study was performed from March 2012 to December 2014. All consecutive patients asking for a chemo holiday with controlled colorectal carcinoma liver metastases were referred to DEBIRI, and 2 sessions of DEBERI were scheduled at 30-day intervals. Whole-liver DEBIRI treatment was administrated in a regional manner. Results: A total of 18 patients (62.8 ± 11.1 years old, range 47-80) were referred to DEBIRI. Patients had previously received 2.7 ± 1.20 (range 2-6) chemotherapy lines per patient. All patients were SD; 29 DEBIRI sessions were performed (1.6 sessions per patient), and 11 (61%) patients received 2 DEBIRI sessions. The tumor diameter at baseline was 38 mm ± 26 mm (15-170). Liver invasion by tumors was <25% and 26% to 50% in 10 (62%) and 6 (30%) patients, respectively. At the 3-month follow-up, all patients were alive. The average tumor diameter was 29 mm ± 22 (12-169). Partial response and SD were observed in 4 (15%) and 12 (75%) patients, respectively. The progression-free survival was 253 ± 35.4 days (171-321). Conclusions: DEBIRI as closure therapy for patients requiring a chemo holiday based on a “2-stop-shop” approach provides sustainable local disease control with a low rate of complications. Same-Day Discharge After 30-60-Micron Quadrasphere Microsphere Drug-Eluting Bead Transarterial Chemoembolization
C). No patients in the same-day discharge or overnight hospitalization group had severe PES. Conclusions: Patients treated with DEB-TACE using 30-60-micron spheres have low rates of PES, and those with PES have typically milder symptoms than patients treated with conventional chemoembolization. In retrospect, most of the patients hospitalized after DEB-TACE could have been discharged the same day as the procedure. Same-day discharge should be considered for patients undergoing DEB-TACE with 30-60-micron spheres, particularly those with BCLC stage A and B disease. Magnetic Nanoparticles: Their Role in Future Interventional Oncology Practice J. Hoffman, A. Lee, A. Baadh, R. Farhat Purpose: To review the development of magnetic nanoparticles as a targeted oncologic therapy, detail their potential use in thermotherapy, and educate interventional radiologists and trainees about their potential for future use in interventional oncologic procedures. Material and Methods:7KLVHGXFDWLRQDOSRVWHUZLOOGH¿QHLPSRUWDQWWHUPVVXFKDV magnetic nanoparticles, magnetic drug targeting (MDT), and thermotherapy, and will also detail the role of such technology in the treatment of cancer patients. This project will include a detailed literature review on these topics, so that the reader can gain understanding on the current use of the therapies, as well as likely increased options for use in the future. Results: Magnetic nanoparticles and MDT can be used for more targeted cancer treatments, such as targeting tumors that are located near important nerves or blood vessels. The more targeted therapeutic approach can decrease the systemic side effects that are seen with standard chemotherapy and radiotherapy, similar to how commonly used interventional oncology procedures such as embolization and ablation can deliver therapy to a tumor while minimizing systemic effects. Magnetic nanoparticles are approximately 100 nanometers in size and consist of an iron core surrounded by a polysaccharide shell. Chemotherapy medications can be bound to the particles through a reversible chemical bond. With MDT, a physician injects the nanoparticle-medication combination through a catheter placed in the artery IHHGLQJWKHWXPRU$QH[WHUQDOPDJQHWLF¿HOGFDQEHDSSOLHGVRWKDWWKHQDQRSDUticles highly target the location of the tumor. Once the particles have imbedded in and around the tumor, they slowly dissolve and begin a slow release of the chePRWKHUDSHXWLF DJHQW :LWK WKHUPRWKHUDS\ DQ H[WHUQDO DOWHUQDWLYH PDJQHWLF ¿HOG can be used to heat the nanoparticles (utilize temperatures of 42ºC-45ºC to cause apoptosis of cancer cells but still protect healthy tissue). The cancer cells have a greater sensitivity to hyperthermia compared to normal cells, thus tumor cells can be killed while protecting nearby normal tissue. In addition, the hyperthermia can make tumor cells more sensitive to the effects of radiation and/or chemotherapeutic agents. This differs from thermoablation, where temperatures greater than 46ºC are used to cause necrosis of cancer cells, but these temperatures can also affect adjacent healthy tissues. Conclusions: Magnetic drug targeting and thermotherapy are exciting targeted therapies that may have increased role in future interventional oncology practice. It is important for interventional oncologists to be aware of such treatments, as they can be involved in particle delivery in the future.
J. Hoffmann, Y. Peterkin, S. Mittal, D. Phung, A. Rahman, A. Baadh Purpose: Historically, when undergoing transarterial chemoembolization patients are hospitalized for at least 1 night for management of postembolization syndrome (PES), which can include fever, abdominal pain, nausea, and vomiting. Drug-eluting bead transarterial chemoembolization (DEB-TACE) is associated with lower percentages and severity of PES. This study reports on the feasibility of using 30-60-micron spheres for DEB-TACE with same-day discharge. Material and Methods: A single institution retrospective analysis was performed RQFRQVHFXWLYH'(%7$&(SURFHGXUHVXWLOL]LQJPLFURQVSKHUHV 4XDGUDsphere Microspheres, Merit Medical Systems, South Jordan, UT) from March 2013 through January 2015. Each vial of spheres was loaded with 50 mg of doxorubicin. Some patients were planned for overnight admission before starting the procedure due to comorbidities and/or advanced disease. Other patients were treated with the primary intent of same-day discharge. Records were reviewed to determine degree of PES, pertinent lab values, Child-Pugh score, BCLC stage, ECOG status, admission status, and 30-day readmission rates. Results: A total of 27 DEB-TACE procedures with 30-60-micron spheres were performed during the study period. A total of 18 patients were hospitalized after DEB-TACE according to the attending physician’s plan before starting the procedure (deemed appropriate for admission due to comorbidities, labs, and/or performance status). Out of the 9 patients planned for same-day discharge, all were discharged the same day with mild or no PES. One patient in this group was hospitalized and died within 30 days due to pneumonia and rapidly developing metastatic disease (BCLC
Hepatitis C Virus: The Role of Newer Anti-Viral Therapies and the Impact on Future Interventional Oncology Practice J. Hoffman, A. Singh, A. Baadh, P. Malet Purpose: +HSDWLWLV&YLUXV +&9 LVDFDXVHRIVLJQL¿FDQWPRUELGLW\DQGPRUWDOLW\ in the United States, but treatment regimens have improved in recent years. As HCV is a major cause of cirrhosis and hepatocellular carcinoma (HCC) in the United States, it is prudent for interventional radiologists to be familiar with treatment options and how better control and treatment of HCV will likely impact IR/IO practice. A number of newer medications are now used in the United States to treat HCV, which can lead to lower rates of HCC and potentially fewer HCC-related procedures in interventional radiology. We review these newer medications, and suggest how their success will impact interventional oncology practice over the next 10 years. Material and Methods: New oral agents are now available in the United States to treat HCV. Increasing use of these medications will likely lead to lower rates of HCC in the United States; therefore, interventional radiologists must be aware that HCCrelated procedural volumes may decrease over the next 10 years or more. Results: Review important factors about HCV that are crucial for interventional radiologists, such as etiology, association with HCC, and current role of antiviral medications to treat HCV. Further, we describe trends in new HCV cases reported in the United States and review the relevant literature, while also comparing this to sales of newer antiviral medications used to treat HCV. The trends are then used to extrapolate
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study. Inclusion criteria: liver-limited progressive disease, <75% liver involvement by tumor, tumor invasion not suitable for surgery or ablation, OMS status 0-1. ExcluVLRQFULWHULD OLYHULQVXI¿FLHQF\SRUWDOYHLQWKURPERVLVELOLDU\LQMXULHVDQGSUHYLRXV administrated dose of doxorubicin > 450 mg/m². Two sessions of DEBDOX (drugeluting bead doxorubicin, 100 mg of doxorubicin) were scheduled at 30-day intervals. The DEBDOX was administrated in a regional manner for both lobes in the same session. In addition, patients received hormonotherapy if required. The primary endpoint was liver response rate at 3 months. The secondary endpoint was progression-free VXUYLYDOIURPWKH¿UVW'(%'2; Results: A total of 23 women (57.5 years old, range 40-78) were referred for DEBDOX. A total of 2 (range 2-6) chemotherapy lines per patient were previously given. A total of 40 DEBDOX sessions were performed. Seventeen (74%) patients received 2 sessions of DEBDOX. Baseline average tumor diameter was 165.3 mm ± 81.9 (range 82-380). At 3 months, all patients were alive, and the average tumor diameter FKDQJHZDVí í $SDUWLDOUHVSRQVHDQG6'ZHUHREVHUYHGLQ 6 (26%) and 13 (57%). The progression-free survival was 229 ± 28.8 days (range 188-269). Conclusions: DEBDOX chemoembolization for limited liver breast cancer metastases offer tumor control in 83% at 3 months with a PFS of 229 days.
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HCV-related cirrhosis and new HCC cases in the United States over the coming 5 to 10 years. This will provide interventional radiologists with projections as to how these medications will alter interventional radiology and interventional oncology practice over the next decade, including the impact of potential decrease in number of HCC cases diagnosed in the United States leading to changes in ablation and embolization volumes. Conclusions: Newer oral medications now used in the United States to treat HCV will likely result in a substantial decrease of rates of HCC and a corresponding drop in the number of interventional oncology procedures needed to treat these patients. What Every Radiology Resident Needs to Know About the Treatment of Primary and Metastatic Liver Tumors N. P. Shah, B. Patel, S. Shah Purpose: Interventional oncology has seen tremendous growth with the development of a multitude of treatments including targeted chemotherapy, internal radiation, focal ablations, and adjunctive transplantation procedures. Many radiology residencies do not provide adequate formal training for practice-based oncological protocols. We set out to provide residents with a comprehensive review of the available treatments for hepatic tumors. Material and Methods: The overview describes the veritable arsenal available for targeting and treating liver tumors. Treatment modalities include bland embolization, radioembolization, and traditional ablation, as well as combination therapy. Explanation regarding indications, contraindications, and complications are included in the poster. Images were meticulously harvested from multiple patients within our institution. Figures contain pre- and post-therapy images across a variety of imaging modalities. Results: N/A Conclusions: In the vast and sometimes complicated world of interventional oncology, our poster attempts to deconstruct and demystify different oncologic protocols for resident and fellow education. As interventional radiology shifts to a direct-path-
way model, the need to introduce complex protocols at an introductory level will only increase the demand for such initiatives. AZD9291 in Pretreated Patients with T790M-Positive Advanced Non-Small Cell Lung Cancer (NSCLC): Phase II Pooled Analysis G. D. Goss, J. C.-H. Yang, M.-J. Ahn, C.-M. Tsai, L. Bahzenova, L. Sequist, S. Ramalingam, F. Shepherd, M. Cantarini, H. Mann, T. Mitsudomi, P. Jänne Purpose: AZD9291 is a potent oral irreversible epidermal growth factor receptor tyrosine kinase inhibitor (EGFR-TKI), selective for both EGFR-TKI–sensitizing (EGFRm) and T790M resistance mutations. We report pooled results from 2 global phase II studies in pretreated patients with EGFRm advanced non-small cell lung FDQFHUZLWKFHQWUDOO\FRQ¿UPHG7 0SRVLWLYHVWDWXV WKH$85$VWXG\SKDVH,,H[tension (NCT01802632) and the AURA2 phase II study (NCT02094261). Material and Methods: Eligible patients had measurable disease, World Health Organization performance status (WHO PS) 0/1, and acceptable organ function; stable brain metastases were allowed. A tumor sample was taken after most recent GLVHDVH SURJUHVVLRQ IRU SURVSHFWLYH FRQ¿UPDWLRQ RI 7 0 SRVLWLYH VWDWXV &REDV EGFR Mutation Test, Roche, Basel, Switzerland). Patients received AZD9291 at 80 mg once daily. Data cut-off (DCO) was May 1, 2015. Results: In total, 411 patients were dosed (full analysis set [FAS]), and 398 were evaluable for response, as 13 dosed patients had no measurable disease at baseline by independent central review (ICR). EGFRm subtypes were: Ex19del, 68%; L858R, 29%; and other, 3%. Median age was 63 years; female sex, 68%; Asian, 60%; WHO 36 VHFRQGOLQHWKLUGOLQH $W'&2PHGLDQWUHDWment exposure was 7.7 months, and 296 (72%) patients remain on treatment. ObjecWLYHUHVSRQVHUDWH 255 E\,&5ZDV FRQ¿GHQFHLQWHUYDO>&,@ 61-71); disease control rate was 91% (362/398; 95% CI, 88-94). Consistent ORRs ocFXUUHGDFURVVOLQHVRIWKHUDS\ VHFRQGOLQH> &,@ WKLUGOLQH 66% [180/274; 95% CI, 60-71]), ethnicity (Asian, 70% [166/237; 95% CI, 64-76]; nonAsian, 60% [97/161; 95% CI, 52-68]), and EGFR mutation (Ex19del, 70% [188/270;
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95% CI, 64-75]; L858R, 59% [66/112; 95% CI, 49-68]). Median progression-free survival in the FAS (N = 411) was 9.7 months (95% CI, 8.3-NC) as evaluated by ICR. 7KHPRVWFRPPRQDOOFDXVDOLW\DGYHUVHHYHQWV $(V ZHUHGLDUUKHD *U DQGUDVK *U SDWLHQWVH[SHULHQFHG*U$(V,QWHUVWLWLDO lung disease was reported in 11 (3%) patients, 4 of which were fatal (1%) and were considered possibly causally related to AZD9291 by the investigator. Twenty-three patients (6%) discontinued treatment due to an AE. Conclusions: In the evaluable-for-response population (n = 398), AZD9291 demonstrated a 66% ORR by ICR that was generally consistent across all subgroups. 7KH WROHUDELOLW\ SUR¿OH REVHUYHG LQ ERWK SKDVH ,, VWXGLHV ZDV FRQ¿UPHG E\ WKH pooled data. Design, Execution, and Preliminary Biomarker Results: From Paired Tumor Biopsy Cohorts of the AZD9291 AURA Trial K. S. Thress, J. Leeson, J. Geradts, M. Schuler, M.-J. Ahn, J. Wolf, K. Gold, J. C.-H. Yang, F. Blackhall, W.-C. Su, V. Jacobs, N. Smith, H. Angell, K. Brown, K. Vishwanathan, J. C. Barrett, M. Cantarini, P. Jänne Purpose: AZD9291, an oral, irreversible epidermal growth factor receptor tyrosine kinase inhibitor (EGFR-TKI), has potency against EGFR-sensitizing and T790Mresistance mutations. In the ongoing phase I AURA study (NCT01802632), AZD9291 induced durable responses in patients with acquired resistance to EGFR-TKIs. We report results of paired biopsy cohorts in the AURA trial, reviewing modulation of key molecular biomarkers of AZD9291 activity in patient tumor samples. Material and Methods: Patients consented to paired tumor biopsy collection; all KDG7 0SRVLWLYHSUHVWXG\WXPRUELRSVLHVFRQ¿UPHGE\FHQWUDOODERUDWRU\(*)5 testing (Cobas EGFR Mutation Test, Roche, Basel, Switzerland). After 8 to 15 days of once-daily AZD9291 (80 mg or 160 mg), a new tumor biopsy was performed. Baseline and on-study biopsies of tumor tissue were processed for routine histology and pathology. Biomarker scoring required >100 viable tumor cells per sample. )RUPDOLQ¿[HG SDUDI¿QHPEHGGHG ELRSV\ VDPSOHV ZHUH SUR¿OHG E\ LPPXQRKLVWRchemistry (phospho[p]-EGFR, pERK, pAKT, pS6, PD-L1, CD8). Plasma pharmacokinetic samples were also collected on the on-study biopsy day.
Results: As of February 2015, 58 patients with an evaluable baseline biopsy were dosed in the paired biopsy cohorts. Of these, 16 did not proceed to an on-study biopsy DVWKHLGHQWL¿HGOHVLRQVUHJUHVVHGWRRVXEVWDQWLDOO\RUZHUHQRWFRQVLGHUHGVXLWDEOHIRU rebiopsy, 1 patient was medically excluded from rebiopsy, and 1 patient’s sample was not available. In total, 40 patients supplied matched pre- and on-study biopsies. As of 0DUFKSDLUHGWXPRUVDPSOHVZHUHDYDLODEOHIRUTXDOLW\FRQWURO 4& IURP of 40 patients. Inadequate tumor content in 10 of 26 biopsy specimens subsequently IDLOHG4&OHDYLQJSDLUHGWXPRUVDPSOHVDYDLODEOHIRUELRPDUNHUDQDO\VLVRIZKLFK 5 have thus far been evaluated. AZD9291 treatment inhibited EGFR pathway components in most on-study tumor biopsies. Updated data will be provided. Conclusions: Analysis of a paired biopsy cohort within the AURA trial was challenging due to the rapid onset of antitumor effects of AZD9291. The on-study biopsy procedure was not performed for approximately 29% (17/58) of patients due to tumor regression; 38% (10/26) of performed on-study biopsies contained too little tumor for analysis. In the evaluable tumor pairs, pharmacodynamic modulation of the EGFR pathway was evident. Further biomarker analyses, including evidence of modulation of immune system markers, may help inform future combination strategies. Maximizing Reimbursement for Radioembolization: The Keys to Appropriate Documentation -+RIIPDQQ$%DDGK$*ULI¿WK60LWWDO Purpose: Over the past 10 years, interventional radiologists have been performing increasing numbers of radioembolization procedures in treatment of liver-only or liver-dominant hepatic malignancy. The purpose of this exhibit is to review radioemEROL]DWLRQVSHFL¿FFRGLQJJXLGHOLQHVVRWKDWLQWHUYHQWLRQDOUDGLRORJLVWVFDQGHYHORS a better understanding of what documentation is key in their reports, leading to appropriate reimbursement. Material and Methods: This exhibit will review coding for radioembolization procedures, from initial patient interventional radiology clinic visit to postprocedure follow-up imaging. The exhibit will highlight the importance of adequate documentation during clinic visits, image-guided interventions, and postprocedure cross-sectional imaging to ensure maximal reimbursement.
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Results: The treatment of liver tumors using 90Y microspheres placed by intraarterial embolization/delivery merges key concepts well known to radiation oncology and interventional radiology practices. A typical radioembolization case includes the initial patient consultation; a diagnostic angiogram to allow for treatment planning and possible pretreatment embolization of arteries such as the gastroduodenal artery, right gastric artery, and/or supraduodenal artery; and the actual 90Y radioembolization treatment. SPECT nuclear medicine scans for tumor localization and contrastenhanced multi-phasic cross-sectional imaging for therapy planning and longer-term follow-up are also obtained. Thus, thorough documentation of patient history, indications for treatment, appropriateness of therapy, and dosimetry calculations by interYHQWLRQDOUDGLRORJLVWVDUHFULWLFDOWRREWDLQHI¿FLHQWSURFHGXUDODSSURYDOE\LQVXUDQFH companies and appropriate reimbursement. This exhibit will detail the CPT codes relevant to radioembolization and will highlight the importance of adequate documentation throughout the treatment process. Conclusions: The emergence of radioembolization with 90Y in the treatment of liver tumors brings with it additional challenges for the interventional radiologist that make clear, precise documentation critical. An understanding of radioembolization coding will allow interventional radiologists to provide improved documentation, leading to PRUHHI¿FLHQWWUHDWPHQWDXWKRUL]DWLRQDQGUHLPEXUVHPHQWE\LQVXUDQFHFRPSDQLHV Hepatocellular Carcinoma with Portal Vein Thrombosis: A Time-Dependent Toxicity Analysis E. Kim, D. Biederman, P. O’Connor, L. Mao, J. Titano, N. Tabori, R. Patel, M. Schwartz, M. Facciuto, G. Gunasekaran, S. Florman, A. Fischman, F. Nowakowski, R. Lookstein Purpose: Portal vein thrombosis (PVT) is a negative prognostic factor in the survival of patients with hepatocellular carcinoma (HCC) as it increases the probability of extrahepatic spread and decreases the tolerability of trans-arterial therapy. In this study we analyze patients with HCC and PVT treated with yttrium-90 (90Y) radioembolization (RE) to better elucidate the relative contributions of treatment related toxicity and toxicity secondary to disease progression. Material and Methods: Patients included in the study had unresectable HCC with PVT and were treated with glass-based RE (Therasphere, BTG, United Kingdom). PVT was documented on the most recent pre-treatment imaging study (<90) by an independent radiologist. Patients with contralateral PVT were excluded from analyVLV3DWLHQWVZHUHVWUDWL¿HGDFFRUGLQJWRSULRUWKHUDS\&KLOG3XJK &3 FODVV(&2* performance status, tumor characteristics, extent of PVT (lobar vs main), and alphafetoprotein (AFP) levels. The primary outcome variable was the development of CTCAE v 4.03 grade 3/4 total bilirubin (T-Bili) toxicity. Time to toxicity (TTT) T-Bili was calculated for T-Bili using all available laboratory values at any point in time post initial treatment and analyzed using Kaplan-Meier methods. Patients were censored for curative therapy. Secondary outcome variables included, imaging response (mRECIST), time-to-progression (TTP), and overall survival. Results: From January 2005 to September 2014, a total of 709 patients who underwent RE treatment were retrospectively reviewed, of which 69 patients (age: 65.6 ± 11.3, male: 78%) undergoing 77 treatments (median dose: 120 gy) met inclusion criteria in the study. Four patients were lost to toxicity follow-up. No patients had baseline grade 3/4 T-Bili toxicity. Grade 3/4 T-Bili toxicity occurred in 20 patients (30.7%). The median (95% CI) TTT of patients who developed grade 3/4 toxicity was 114 (50-183) days. A trend towards lower toxicity in CP-A (78.3%) relative to CP-B (21.7%) was seen for T-Bili (p = 0.07). ECOG performance status of >1 (14.4%) was associated with a greater incidence of T-Bili toxicity (p = 0.005, HR: 4.9, 95% CI: 1.6 WR 7DUJHWGRVHZDVQRWDVLJQL¿FDQWSUHGLFWRURI7%LOLWR[LFLW\ !J\ 120 gy: 20%, <120 gy: 30%; p = 0.62). The 90-day objective response rate (OR) and disease control (DC) rates were 41% and 55%, respectively. Both OR (p = 0.018, HR: 3.2, 95% CI: 1.2-8.4) and DC (p = 0.009, HR: 3.2, 95% CI: 1.1-8.9) were predictive of T-Bili toxicity. Median (95% CI) TTP and overall survival were 5.9 (4.2-9.1) months and 9.5 (7.6-15.0) months respectively. Both TTP (p < 0.0001, HR: 6.9, 95% CI: 3.215.0 and T-Bili TTT (p < 0.0001, HR: 7.6, 95% CI: 3.8-14.9) were strongly predictive of overall survival when analyzed using a Cox time-dependent covariate model. Conclusions: The strong temporal relationship of both TTP and T-Bili TTT as predictors of overall survival coupled with the association of imaging response as a predictor of toxicity development implicates disease progression as a substantial contributor to post-treatment toxicities in patients with HCC treated with RE. United States RESIN Registry for the Study and Evaluation of Patients Treated with SIR-Spheres D. Brown, A. Lipnik, F. Banovac Purpose: Yttrium-90 (90Y) resin microspheres are approved for use in the United States for treatment of colorectal cancer. They are frequently used off-label for other OLYHUGRPLQDQWWXPRUV+RZHYHUUREXVWGDWDVHWVUHJDUGLQJEHQH¿WVDQGULVNVRIWKLV therapeutic modality across tumor types are lacking.
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Material and Methods: The Radiation-Emitting SIR-Spheres in Non-Resectable (RESIN) liver tumor patient registry is a national, multicenter registry that will enroll patients with primary or secondary liver cancer scheduled for treatment with 90Y resin microspheres (SIR-Spheres, Sirtex, Woburn, MA) as part of their treatment. Patients may or may not receive concomitant systemic therapy as part of their overall oncologic management. This patient data will be collected as a registry study and not as research on the experimental use of microspheres. Results: Baseline data such as previous chemotherapy, performance status, tumor markers, and receptor targets for biologic therapy will be tracked. Tumor response and concomitant therapy will be tracked, as will toxicities using the common terminology criteria for adverse events v4. An initial 8 centers are involved with a baseline goal to enroll over 350 patients per year. There are separate goals for patients with tumors that are more vs less commonly treated with 90Y. For patients with colorectal or neuroendocrine tumors, we hope to perform subgroup analysis to identify utilization strategies for personalized 90Y applications including trials focused on combinations with targeted therapies. For less commonly described treatment applications, we hope the registry data can plan future trials for less-evaluated tumor types including breast, cholangiocarcinoma, and others. Conclusions: Information generated from this national multicenter registry study will contribute to the oncology community’s understanding of United States treatment patterns with 90Y therapy, gain additional insights into long-term outcomes, and guide future research with 90Y therapy, especially for conditions with limited data. Ytrrium-90 Resin in Castrate-Resistant Prostate Cancer with Liver Metastasis M. Scholz, R. Lam, J. Turner, C. Felarca Purpose: Prostate cancer (PC) is the second-leading cause of cancer-related death in men in the United States. The prognosis is especially poor in PC patients with liver metastases (PCLM), with a median overall survival of 10 to 12 months in castrateresistant patients receiving docetaxel regimens. Radioembolization with yttrium-90 (90Y) resin microspheres via the hepatic artery has been shown to improve survival in patients with colorectal liver metastases. We report our experience with 90Y resin treatment of 6 castrate-resistant patients with PCLM. Material and Methods: Retrospective review of patient records of 6 castrate-resistant patients who received 90Y resin for the treatment of liver metastases from PC. Results: Six males, ages 54 to 80 (median 67.5), who were diagnosed with stage D2 PC between the years 1996 to 2011 developed PCLM a median of 140.5 (21-202) months post diagnosis. Patients received a median of 6 (1-7) therapies, including leuprolide acetate and XBT, from their time of diagnosis with PC to the time that they developed PCLM. After developing PCLM, 3 patients received 1 therapy (Pt 1: nilutamide, Pt 2: cisplatin/etoposide, Pt 3: cabazitaxel/carboplatin) and 3 patients received no other therapy before treatment with 90Y resin. Patients were given 90Y resin 1 to 8 months (median 4) after their diagnosis of PCLM and received up to 3 treatments of 90 Y resin (median 1.5). Patients received 0 to 4 (median 1.5) non-90Y resin therapies subsequent to their initial treatment with 90Y resin. Median survival post 90Y resin was 13 (3-36) months. Median survival from initial diagnosis of PCLM was 16.5 (6-41) months. Patients experienced no notable toxicities. Conclusions: Historical median survival of castrate-resistant patients with PCLM is 10 to 12 months. In this review of 6 castrate-resistant PLCM patients in which 90Y resin was added to their multimodality therapeutic regimen, median survival was 16.5 months. No notable toxicities were experienced. Further investigation of the use of 90Y resin in patients with PCLM is warranted. Treatment Response In Glass vs Resin Radioembolization of Nonresectable Hepatic Metastasis J. Vavricek, S. Iqbal, A. Rohr, L. Rock, B. Jang, S. Hunt, J. Wick, A. Robinson, S. DeBacker, T. James, J. Hill, Z. Collins Purpose: To compare treatment response between glass and resin yttrium-90 (90Y) microsphere radioembolization of hepatic metastasis from colorectal and other systemic malignancies. Material and Methods: A retrospective analysis was performed on 70 patients with hepatic metastasis treated with glass or resin 90Y radioembolization from 2008 to 2014 at an academic medical center. Up to 2 treated lesions per lobe were measured using cross-sectional imaging in the X, Y, and Z planes at baseline and at 1-, 3-, 6-, and 12-month intervals. Response was evaluated using the World Health Organization (WHO) and Response Evaluation Criteria in Solid Tumors (RECIST) 1.1 criteria. Results: A total of 70 patients were evaluated with 39 (56%) receiving resin and 31 (44%) receiving glass particles. Of those, 34 (49%) patients had metastatic colorectal cancer (mCRC) with a mean MELD score of 8.5 (SD 2.1), and 36 (51%) had other primary malignancies with a mean MELD score of 7.7 (SD 1.7). Thirty-seven (53%) patients were female with a mean age of 59.7 years (SD 12.3) at treatment 1. Patients received an average radiation dose of 1.12 gigabecquerel (GBq) (SD 0.33) with resin treatments, compared to 3.08 GBq (SD 1.09) with glass treatments. Evaluation of
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Yttrium-90 Glass Microspheres in the Treatment of Hepatocellular Carcinoma with Concomitant HIV Infection J. Titano, D. Biederman, A. Fischman, R. Patel, N. Tabori, F. Nowakowski, R. Lookstein, E. Kim Purpose: Selective internal radiation therapy with yttrium-90 (90Y) glass microspheres (SIRT-glass) is a well-described, transarterial, locoregional therapy used in the WUHDWPHQWRIKHSDWRFHOOXODUFDUFLQRPD +&& +XPDQLPPXQRGH¿FLHQF\YLUXV +,9 coinfection has been shown to negatively impact outcomes in HCC secondary to viral hepatitis. We performed a retrospective analysis of the use of SIRT-glass in patients with unresectable HCC secondary to HBV or HCV and concomitant HIV infection. Material and Methods: We retrospectively reviewed 417 patients treated with SIRT-glass from January 1, 2010 to July 1, 2015. Of these, 30 patients (59.4 ± 6.4 years, male: 90%) with HCC and HIV infection underwent SIRT-glass. All patients ZHUH VWUDWL¿HG DFFRUGLQJ WR +&& HWLRORJ\ +&9 +%9 SULRU +&& WKHUDS\ (naïve: 12, ablation: 5, chemoembolization: 15, resection: 4), Child-Pugh class (A: 26, B: 4), performance status (ECOG 0: 15, ECOG 1: 10, ECOG 2: 5), tumor burden (solitary: 10, multifocal: 20; unilobar: 19, bilobar: 11), cirrhosis (present: 26, absent: 4), portal vein thrombosis (present: 9, absent: 21), ascites (present: 2, absent: 28), SUHUDGLRHPEROL]DWLRQ$)3OHYHO QJP/ !QJP/ DQG%&/&VWDJH (A: 4, B: 3, C: 23). Pretreatment laboratory values including alpha-fetoprotein, total bilirubin, INR, and albumin were recorded. Post-SIRT-glass transplantation was also
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recorded. Outcome variables included imaging response (mRECIST), time to progression, and overall survival. Results: A total of 39 treatments were administered (mean dose: 2.5 ± 1.7 GBq). Pretreatment laboratory values were recorded as follows: alpha-fetoprotein (median >,45@ >±@QJP/ WRWDOELOLUXELQ PJG/ ,15 and albumin (3.7 ± 0.55 g/dL). Overall objective response was 39.1% (mRECIST). The disease control rate was 69.7% (mRECIST). Mean and median (95% CI) time to progression were 6.4 (4.5-8.4) months and 4.6 (3.7-5.5) months, respectively. Median (95% CI) survival was 11.3 (8.9-13.6) months. There were no 30-day mortalities. Two patients went on to receive liver transplantation following SIRT-glass. Univariate analysis (log-rank test) showed decreased time to progression in the following patient group: absence of metastasis (p = 0.006). Univariate analysis (log-rank test) showed LPSURYHGVXUYLYDOLQWKHIROORZLQJSDWLHQWJURXSV (&2* S PDOHV S 0.025), and preprocedure clinical ascites (p = 0.001). Conclusions: In our experience, the absence of metastasis is a predictor of imSURYHGWLPHWRSURJUHVVLRQDQG(&2*SHUIRUPDQFHVWDWXVPDOHVH[DQGSUHprocedure clinical ascites are predictors of improved survival in patients undergoing SIRT-glass with HCC secondary to HCV or HBV and concomitant HIV infection. Complications of Transcatheter Arterial Chemoembolization with Focus on Embolization of the Hepatic Falciform Artery A. Rajput, T. Ahluwalia, A. Rajput, J. H. Hwoon, D. Nguyen, R. Gupta, A. Maleson Purpose: The purpose of this educational exhibit is to review the incidence, prevalence, and clinical presentation of common and uncommon complications in patients after transcatheter arterial chemoembolization (TACE) with our main focus on nontarget embolization of the hepatic falciform artery. Nontarget vessel involvement may lead to serious organ damage, and prophylactic measures should be considered. Knowing anatomical variants will allow the providing interventional radiologist to correctly approach each case and offer appropriate treatment. Material and Methods: TACE offers palliation for patients with unresectable liver tumors, predominantly hepatocellular carcinoma. The hepatic arteries are the primary blood supply of these tumors. Chemoembolization has proven to be very effective by working in 2 ways: limiting tumor blood supply and administering a focused, selective dose of chemotherapeutic agents. Serious complications may occur, and a comprehensive understanding of these entities and anatomical variants are vital for effective treatment. Results: The discussion will include a brief review of anatomy of the hepatic vasculature and common variants followed by the presentation of a case of nontarget involvement of the hepatic falciform artery resulting in skin ulceration and necrosis. Further discussion will include relevant complications including additional nontarget embolizations, postembolization syndrome, infection, liver failure, access-site injuries, hepatic artery injury, and renal failure. The review will also include gross and radiologic imaging that will help the radiologist to distinguish these variants and severe complications and will also provide appropriate recommendations regarding prevention and future management. Conclusions: 1RQWDUJHWHPEROL]DWLRQLVDVHULRXVFRPSOLFDWLRQRI7$&(&RQ¿GHQW SUHSURFHGXUDOLGHQWL¿FDWLRQDQGDGMXVWPHQWVPXVWEHFRQVLGHUHG$ZDUHQHVVRIVHYeral nontarget organ injuries from TACE is critical to prevent unnecessary complications and provide effective care.
CIO Abstracts
tumor response using WHO criteria found 1 (2.6%) patient had a complete response (CR), 13 (33.3%) had partial responses (PR), 19 (48.7%) had stable disease (SD), and 6 (15.4%) had progressive disease (PD) when treated with resin particles, and 0 (0.0%) had CR, 5 (16.1%) had PR, 21 (67.7%) had SD, and 5 (16.1%) had PD when treated with glass particles. RECIST 1.1 response criteria demonstrated 1 (2.6%) patient had CR, 13 (33.3%) had PR, 18 (46.2%) had SD, and 7 (17.9%) had PD when treated with resin, and 0 (0.0%) had CR, 7 (22.6%) had PR, 19 (61.3%) had SD, and 5 (16.1%) had PD when treated with glass (Table 1). Due to small sample sizes, we were unable to SHUIRUPIRUPDOVLJQL¿FDQFHWHVWLQJRQWKHGLVWULEXWLRQRIUHVSRQVHE\WUHDWPHQWW\SH Conclusions: Although both glass and resin 90<PLFURVSKHUHVDUHHI¿FDFLRXVWUHDWments for nonresectable metastatic hepatic disease, there is limited data on direct comparison of imaging response between the 2 treatment types. Our study demonstrates that resin-based 90Y therapy offers a comparable response when compared to glassbased 90Y therapy at nearly one-third the dose of radiation.
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The Symposium on Clinical Interventional Oncology (CIO) 2016 February 6–7, 2016, Hollywood, Florida
CIO Abstracts
Single vs Triple Drug Chemoembolization for Hepatocellular Carcinoma: Comparing Toxicity, Response & Survival S. Mouli, R. Hickey, B. Thornburg, K. Desai, K. Sato, R. Salem, R. Lewandowski Purpose: Conventional lipiodol chemoembolization (cTACE) remains a standard of care therapy for patients with unresectable hepatocellular carcinoma (HCC). Shortages of chemotherapeutic agents have initiated a transition to single-agent doxorubicin from historic triple-drug therapy. The purpose of this study was to determine the HI¿FDF\ RI VLQJOH YV WULSOHGUXJ F7$&( DV PHDVXUHG E\ WR[LFLW\ WXPRU UHVSRQVH time-to-progression (TTP), and overall survival. Material and Methods: With institutional review board approval, a single- center retrospective review was performed on patients who underwent chemoembolization. Imaging characteristics and clinical follow-up post-cTACE were evaluated to deterPLQH7732YHUDOOVXUYLYDO 26 IURPWKHWLPHRI¿UVWF7$&(ZDVFDOFXODWHG UHVXOWV ZHUHVXEVWUDWL¿HGDFFRUGLQJWR&KLOG3XJK &3 FODVVDQG%DUFHORQD&OLQLFIRU/LYHU Cancer (BCLC) staging system. Results: One hundred seventy-two patients underwent triple-drug cTACE; 165 consecutive patients underwent single-agent doxorubicin cTACE (total: 337 patients). Median TTP was similar between the two groups: 7.9 months (CI: 7.1-9.4) and 6.8 months (CI: 4.6-8.6), for triple and single drug, respectively (p < 0.05). For singleDJHQW F7$&( PHGLDQ 26 YDULHG VLJQL¿FDQWO\ E\ %&/& $ PRQWKV % months; C, 10.9 months; p < 0.01. Results from 172 patients treated with triple-drug WKHUDS\GHPRQVWUDWHGDPHGLDQVXUYLYDOWKDWDOVRYDULHGVLJQL¿FDQWO\E\%&/& $ 28.9 months; B, 18.1 months; C, 9.0 months (p < 0.01). For patients with preserved liver function and BCLC A/B, single-drug cTACE demonstrated longer median OS compared to triple drug (p < 0.05). Conclusions: Single-agent chemoembolization with doxorubicin and ethiodized oil GHPRQVWUDWHVDFFHSWDEOHHI¿FDF\DVPHDVXUHGE\773DQG265HVXOWVFRPSDUHIDYRUably with traditional triple-drug therapy. Mid-term Local Control and Survival Case Series of Lung Malignancy Ablations with a 2450-MHz Mic rowave Device C.J. Jones, C. Bailey, N, Corridoni, B. Steadman Purpose: Percutaneous radiofrequency ablation (RFA) is an option for local treatment of lung malignancies in nonsurgical patients. Despite promising early reports, RFA has not been as effective as stereotactic external beam radiation therapy (EBRT), which has reported local control rates as high as 90% at 2 years. Since 2011, several manufacturers have introduced 2450-MHz generator microwave ablation devices capable of increased power, resulting in ablations of much higher temperature and sizes than RFA. We hypothesize that lung ablation with a 2450-MHz microwave device will result in more effective local control of lung malignancies than RFA. Material and Methods: Midterm results from lung microwave ablation on 13 patients with 17 lung tumors (11 non-small-cell lung carcinoma, 6 colorectal) treated from September 20, 2011 to August 28, 2014 are reported. Preprocedure tumor size and intraprocedure measures including temperature, power, and time of ablation were UHFRUGHG /RFDO UHFXUUHQFH ZDV FRQ¿UPHG E\ SRVLWURQ HPLVVLRQ WRPRJUDSK\FRP-
$OO&,2DEVWUDFWVDQGSRVWHUVDUHJUDGHGYLDEOLQGHGSHHUUHYLHZEDVHGRQVFLHQWL¿F merit, originality, relevance, and clarity. SIR assumes no legal liability or responsibility for the completeness, accuracy, and correctness of the information presented in the abstracts. Abstracts will be published in the Journal of Vascular and Interventional Radiology as submitted by the authors, except for minor stylistic adjustments to ensure consistency of format and adherence to journal style. © SIR, 2016 J Vasc Interv Radiol 2016; 27:e22–e29 http://dx.doi.org/10.1016/j.jvir.2016.01.090
puted tomography. The Kaplan-Meier method was used to estimate survival and local control rates. Results: Mean maximal diameter of tumors was 2.2 cm. An average of 1.6 ablations ZHUHSHUIRUPHGRQHDFKPDVVZLWKWHPSHUDWXUHVRI Û& UDQJHÛWRÛ& IRU 5.2 minutes (range 3 to 10 minutes). Median power was 95 W (range 45 W to 140 W). Average follow-up is 21.3 months (range 6 to 36 months). The 1-, 2-, and 3-year local tumor progression-free rates were 94%, 84%, and 72%. For tumor size <4.0 cm, the 1-, 2-, 3-year local tumor progression-free rates were 100%, 100%, and 86%. The 1-, 2-, and 3-year overall survival rates were 92%, 67%, and 56%. Conclusions: Ablation of lung malignancies with a 2450-MHz generator microwave device appears to result in more effective local control than RFA with results comparable to stereotactic EBRT. DEBIRI Combined with Systemic Chemotherapy for Pretreated Liver mCRC: Procedure and Patients Outcomes O. Pellerin, G. Amouyal, C. del Giudice, M. Sapoval Purpose: The use of trans-arterial chemo-embolization with irinotecan drug-eluting beads (DEBIRI) for liver-dominant metastatic colorectal cancer (mCRC) is usually proposed for end-stage patients as a salvage treatment without any concomitant sysWHPLFWUHDWPHQW7KHJRDOVRIRXUVWXG\ZHUHWRHYDOXDWHWKHVDIHW\DQGHI¿FDF\RIWKH DEBIRI procedure in patients treated by concomitant systemic chemotherapy. Material and Methods: Between April 2011 and April 2014, all consecutive ECOG PS 0-2 patients with stable or progressive liver-dominant mCRC pretreated by at least 2 previous chemotherapy lines were referred for DEBIRI as salvage treatment. All patients received in addition systemic chemotherapy. Safety of the procedure, toxicities (NCI-CTC AE V4.02), tumor response rates (RECIST 1.1), progression-free survival (PFS), and overall survival (OS) were recorded. Results: Forty-nine consecutive patients (mean age 63 years) underwent 81 DEBIRI sessions administered in a lobar manner in the same session. Altogether, 45 grade 3 to 4 arterial hypertension crises occurred during the procedure, 11 grade 3 postembolization syndrome, and 5 grade 2 to 3 toxicities (cholecystitis, pancreatitis, or nonmalignant ascites) were observed. Median maximal procedural pain reported by the patient was 7. All toxicities were successfully managed. No toxic death occurred. The average hospital stay was 4.5 days. The 3-month response and disease control rates were 31% and 80%, respectively. Tumor response was correlated with the tumor involvement. Median PFS and OS were 8.1 and 21 months, respectively. Conclusions: DEBIRI plus intravenous chemotherapy for pretreated liver-domiQDQWP&5&SURYLGHSURPLVLQJHI¿FDF\UHVXOWVWRJHWKHUZLWKVSHFL¿FDQGVHYHUHVLGH effects that need to be adequately managed. Outcomes of Radiation Segmentectomy for Unresectable Solitary Hepatocellular Carcinoma 3 Cm D.M. Biederman, J. Titano, V. Bishay, P. O'Connor, G. Sivananthan, M. Schwartz, M. Facciuto, S. Florman, G. Gunasekaran, A. Fischman, R. Patel, F. Nowakowski, R. Lookstein, E. Kim Purpose: 7RHYDOXDWHVDIHW\DQGHI¿FDF\RIWDUJHWHGVHJPHQWDOUDGLRHPEROL]DWLRQ 5( LQSDWLHQWVZLWKXQUHVHFWDEOHVROLWDU\KHSDWRFHOOXODUFDUFLQRPD +&& FP Material and Methods: From January 2010 to June 2015 a total of 417 consecuWLYHSDWLHQWVZLWK+&&XQGHUZHQWJODVVEDVHG5(/RFRUHJLRQDOWKHUDS\QDÕYHSDWLHQWVZLWKXQUHVHFWDEOHVROLWDU\+&&FPZLWKRXWHYLGHQFHRISRUWDOYHLQLQYDVLRQ RUH[WUDKHSDWLFPHWDVWDVLVZHUHUHWURVSHFWLYHO\LGHQWL¿HGDQGLQFOXGHGLQWKHVWXG\ Forty-one patients with RE (age: 65.7 ± 8.5, male: 70.7%) met the above criteria with demographics as follows: HCV positive (n = 25, 61.0%), ECOG 0 (n = 29, 70.7%), Child-Pugh class A (n = 30, 73.2%), mean tumor size (2.0 ± 0.5 cm), AFP < 200 ng/ mL (n = 38, 92.7%). Outcome variables included CTCAE v4.03 graded 180-day laboratory toxicities, imaging response (mRECIST), time to progression (TTP), reason for progression, and survival. Results: Median (interquartile range) treatment dose was 1.38 (1.04-1.88) Gbq. Grade 3 to 4 bilirubin and AST toxicity were 7.3% and 4.9%, respectively. Complete response (CR) of the target lesion at 90 days was observed in 35 (85.3%) patients. The overall CR rate (target and nontarget) was 82.9% (34/41). The 7 patients without a CR
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(partial response: 5, stable disease: 1, disease progression: 1) underwent additional treatment (RE: 3, chemoembolization: 4) at a median of 79 days. The overall median (95% CI) TTP was 11.1 months (8.8 to 25.6). There were 13 cases of disease progression that occurred after an initial complete response, with one case occurring in the initial target segment and the remaining cases of progression occurring secondary to new HCC in nontargeted segments. Overall median (95% CI) follow-up time was 11.4 months (8.4 to 16.5) during which there were 2 deaths [mean (95% CI) overall survival: 30.8 (28.1 to 33.5) months]. Four patients were bridged to liver transplant at a median (range) of 437 (232-879) days post RE. Conclusions: 5DGLDWLRQ VHJPHQWHFWRP\ LV D KLJKO\ HI¿FDFLRXV WUHDWPHQW RSWLRQ IRUSDWLHQWVZLWKXQUHVHFWDEOHVROLWDU\+&&3 cm with a very low incidence with of target lesion recurrence. Analysis of Residual and Recurrent Hepatocellular Carcinoma post Microwave Ablation
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R.J. Durrani, D. Bierderman, E. Dayan, J. Titano, G. Sivananthan, M. Schwartz, M. Facciuto, G. Gunasekaran, S. Florman, A. Fischman, R. Patel, F.S. Nowakowski, R. Lookstein, E. Kim Purpose: To evaluate the incidence of and potential risk factors related to residual and recurrent tumor in patients undergoing microwave ablation (MWA) for unresectable solitary hepatocellular carcinoma (HCC). Material and Methods: From January 2011 to June 2015, a total of 281 consecutive patients underwent treatment with MWA (Certus, Neuwave, Madison, WI). A UHWURVSHFWLYHUHYLHZRIORFRUHJLRQDOWKHUDS\QDÕYHSDWLHQWVZLWKXQUHVHFWDEOHVROLWDU\+&&FPZDVFRQGXFWHG3DWLHQWVZLWKSRUWDOYHLQLQYDVLRQRUH[WUDKHSDWLF metastasis were excluded. A total of 81 patients treated with MWA met the above criteria (age: 65.6 ± 8.0, male: 65.4%) with baseline demographics as follows: ECOG 0 (n = 58, 81.7%), Child-Pugh class A (n = 51, 63.0%), mean tumor size (1.81 ± 0.6 cm), AFP < 200 ng/mL (n = 76, 93.8%). Imaging response was graded according to P5(&,67FULWHULD5HVLGXDOWXPRUZDVGH¿QHGDVDYLDEOHWDUJHWOHVLRQWXPRURQLQLWLDOIROORZXSLPDJLQJ5HFXUUHQWWXPRUZDVGH¿QHGDVDQLQLWLDOFRPSOHWHUHVSRQVH with subsequent tumor visualization within or adjacent to the ablation cavity. Time to progression (TTP), reason for progression, and overall survival were also evaluated. Results: A total of 81 treatments were successfully performed with an initial target and overall complete response rate of 88.9% (72 out of 81) and 67% (54 out of 81) respectively. The 9 patients with residual tumor underwent secondary therapy FKHPRHPEROL]DWLRQ UDGLRHPEROL]DWLRQ DEODWLRQ DW DPHGLDQ ,45 RI (45.3-141.3) days post initial ablation. The 67 patients with an initial overall complete response had a median (95% CI) follow-up time of 22.4 (19.8-26.5) months during which there were 30 patients with mRECIST progression on imaging follow-up. Local recurrence comprised 30% (9 out of 30) of instances of progression occurring at median (95% CI) of 11.7 (7.6-17.3) months. The 21 cases of nontarget progresVLRQZHUHREVHUYHGDWPHGLDQ &, RI DVLJQL¿FDQWO\VKRUWHUWLPH course than the cases of local recurrence (p = 0.036, HR: 0.46 [0.23-0.95]). The overall median (95% CI) TTP was 11.7 (7.5-19.1) months. Twelve patients were bridged WROLYHUWUDQVSODQWDWDPHGLDQ ,45 RI GD\V0HDQ &, RYHUDOO survival was 44.0 (39.9-48.1) months. Conclusions: MWA for patients with unresectable solitary HCC has a high rate of initial complete response. Early imaging progression after an initial complete response was more often due to non-target progression with local tumor recurrence developing over a later time course. Getting the Shaft: Preoperative Ablation of Long Bone Metastasis, a New Technique to Decrease Blood Loss from Arthroplasty Z. A. Miller, M. Schiffman Purpose: Up to 90% of patients undergoing total hip arthroplasty lose enough blood to require transfusion. Preoperative transcatheter embolization of bone metastasis has proven an effective method for decreasing blood loss. We present 2 cases of malignant bone metastasis where long bone ablation was performed via the medullary cavity in an orientation parallel to the cortex, providing an alternative method to decrease blood loss. Material and Methods: Case 1: An 85-year-old female with history of breast cancer presented with biopsy-proven right femoral head metastasis and associated hip IUDFWXUH8VLQJVHULDOFRPSXWHGWRPRJUDSK\VFRXW¿OPJXLGDQFHDFP$PLFDPLcrowave ablation needle (Healthtronics, Austin, TX) was advanced into the proximal femur, and 3 ablation cycles were performed. The patient underwent total hip arthroplasty the next day with estimated blood loss of 600 cc. Case 2: A 72-year-old male with biopsy-proven metastatic renal cell carcinoma to the left trochanter, deemed high risk for fracture. A 27-cm Amica needle was used to access the metastatic lesion via the greater trochanter. Ablation was performed at 20W for 2 minutes. The patient underwent total hip arthroplasty the next day with estimated blood loss of 300 cc. Results: In both of our patients who underwent prearthroplasty ablation via a parallel intramedullary approach, blood loss was less than the median estimated blood loss in hip replacements, which was 984 cc as reported in the Journal of Orthopaedic Surgery and Research in 2015.
Conclusions: The parallel intramedullary ablative technique offers a way to decrease operative hemorrhage without violating the cortex, decreasing the risk for tumor seeding and/or skin burns. This technique also obviates the need for contrast, making it a good alternative for patients with renal dysfunction. Not only useful in decreasing blood loss in our 2 example cases, this technique may also prove useful in treatment of other malignant and nonmalignant bone tumors in a medullary location. Thermoprotective Techniques of the Gallbladder and Main Bile Ducts During Thermal Hepatic Ablations P. Gilbert, M. Guimaraes, D. Arrington Purpose: To describe gallbladder and bile duct lavage as a protective technique during percutaneous thermal ablative therapy (PTAT) of hepatic lesions in close proximity to the gallbladder or major bile ducts. Material and Methods: PTAT of lesions within close proximity to the gallbladder RUPDLQELOHGXFWVLVIUDXJKWZLWKWHFKQLFDOGLI¿FXOWLHVGXHWRWKHULVNRIJDOOEODGGHU perforation and possible peritonitis or bile duct stricture. Results: For lesions in close approximation to the gallbladder for which lavage is GHHPHGWREHRISURWHFWLYHEHQH¿WDJDXJH&KLED &RRN0HGLFDO%ORRPLQJWRQ IN) needle is percutaneously guided through uninvolved hepatic parenchyma into the gallbladder lumen under computed tomography or ultrasound guidance. Any bile within the gallbladder is aspirated and the gallbladder decompressed. This is done to eliminate any overdistention, possible seepage, or bacteremia, as well as bile peritonitis if there is a gallbladder rupture. Following decompression, 30 cc to 50 cc, roughly the amount of bile aspirate, of chilled D5W is hand-injected into the gallbladder followed by continuous infusion of 50 cc per hour. D5W is preferred for its nonionic and iso-osmolar properties. For lesions in close approximation to main bile ducts, a nasobiliary tube is advanced into the duct of concern, and chilled D5W is instilled into the bile ducts.
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Conclusions: Protection strategies for PTAT are feasible and safe and should be considered for treatment of lesions that may have previously been considered not amenable to PTAT. These techniques may provide a more adequate ablation zone despite close proximity to adjacent structures such as the gallbladder or main bile ducts. It is our position that the usage of these thermal protective strategies can increase the number of patients that may be candidates for PTAT as well as decreasing major complications of damage to surrounding structures. More studLHVDUHQHHGHGWRUH¿QHWKHVHWHFKQLTXHVEXWRXUH[SHULHQFHKDVEHHQH[WUHPHO\ favorable.
DC-beads M1 Doxorubicin Drug-Loaded Chemoembolization (DEBDOX) for Liver-Limited Breast Cancer Metastases O. Pellerin, G. Amouyal, C. del Giudicce, M. Sapoval Purpose: To study the 3-month liver response rate and the progression-free survival after 2 sessions of DEBDOX chemoembolization for patients with liver-dominant breast cancer metastases. Material and Methods: From April 2011 to December 2013, all patients with progressive liver-dominant breast cancer metastases were screened to be enrolled in the
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DC-beads M1 Irinotecan Drug-Eluting Beads as a Closure Treatment: A Chemotherapy Holiday Option O. Pellerin, G. Amouyal, C. Del Giudice, M. Sapoval Purpose: Chemotherapy holidays for stable patients under treatment is a major quality-of-life issue. Our hypothesis was that 2 treatments with irinotecan-loaded drug-eluting beads (DEBIRI) could help to reach sustainable lesion stability. The goal of our study was to assess liver response rate and progression-free survival (PFS) at 3 months. Material and Methods: This monocentric study was performed from March 2012 to December 2014. All consecutive patients asking for a chemo holiday with controlled colorectal carcinoma liver metastases were referred to DEBIRI, and 2 sessions of DEBERI were scheduled at 30-day intervals. Whole-liver DEBIRI treatment was administrated in a regional manner. Results: A total of 18 patients (62.8 ± 11.1 years old, range 47-80) were referred to DEBIRI. Patients had previously received 2.7 ± 1.20 (range 2-6) chemotherapy lines per patient. All patients were SD; 29 DEBIRI sessions were performed (1.6 sessions per patient), and 11 (61%) patients received 2 DEBIRI sessions. The tumor diameter at baseline was 38 mm ± 26 mm (15-170). Liver invasion by tumors was <25% and 26% to 50% in 10 (62%) and 6 (30%) patients, respectively. At the 3-month follow-up, all patients were alive. The average tumor diameter was 29 mm ± 22 (12-169). Partial response and SD were observed in 4 (15%) and 12 (75%) patients, respectively. The progression-free survival was 253 ± 35.4 days (171-321). Conclusions: DEBIRI as closure therapy for patients requiring a chemo holiday based on a “2-stop-shop” approach provides sustainable local disease control with a low rate of complications. Same-Day Discharge After 30-60-Micron Quadrasphere Microsphere Drug-Eluting Bead Transarterial Chemoembolization
C). No patients in the same-day discharge or overnight hospitalization group had severe PES. Conclusions: Patients treated with DEB-TACE using 30-60-micron spheres have low rates of PES, and those with PES have typically milder symptoms than patients treated with conventional chemoembolization. In retrospect, most of the patients hospitalized after DEB-TACE could have been discharged the same day as the procedure. Same-day discharge should be considered for patients undergoing DEB-TACE with 30-60-micron spheres, particularly those with BCLC stage A and B disease. Magnetic Nanoparticles: Their Role in Future Interventional Oncology Practice J. Hoffman, A. Lee, A. Baadh, R. Farhat Purpose: To review the development of magnetic nanoparticles as a targeted oncologic therapy, detail their potential use in thermotherapy, and educate interventional radiologists and trainees about their potential for future use in interventional oncologic procedures. Material and Methods:7KLVHGXFDWLRQDOSRVWHUZLOOGH¿QHLPSRUWDQWWHUPVVXFKDV magnetic nanoparticles, magnetic drug targeting (MDT), and thermotherapy, and will also detail the role of such technology in the treatment of cancer patients. This project will include a detailed literature review on these topics, so that the reader can gain understanding on the current use of the therapies, as well as likely increased options for use in the future. Results: Magnetic nanoparticles and MDT can be used for more targeted cancer treatments, such as targeting tumors that are located near important nerves or blood vessels. The more targeted therapeutic approach can decrease the systemic side effects that are seen with standard chemotherapy and radiotherapy, similar to how commonly used interventional oncology procedures such as embolization and ablation can deliver therapy to a tumor while minimizing systemic effects. Magnetic nanoparticles are approximately 100 nanometers in size and consist of an iron core surrounded by a polysaccharide shell. Chemotherapy medications can be bound to the particles through a reversible chemical bond. With MDT, a physician injects the nanoparticle-medication combination through a catheter placed in the artery IHHGLQJWKHWXPRU$QH[WHUQDOPDJQHWLF¿HOGFDQEHDSSOLHGVRWKDWWKHQDQRSDUticles highly target the location of the tumor. Once the particles have imbedded in and around the tumor, they slowly dissolve and begin a slow release of the chePRWKHUDSHXWLF DJHQW :LWK WKHUPRWKHUDS\ DQ H[WHUQDO DOWHUQDWLYH PDJQHWLF ¿HOG can be used to heat the nanoparticles (utilize temperatures of 42ºC-45ºC to cause apoptosis of cancer cells but still protect healthy tissue). The cancer cells have a greater sensitivity to hyperthermia compared to normal cells, thus tumor cells can be killed while protecting nearby normal tissue. In addition, the hyperthermia can make tumor cells more sensitive to the effects of radiation and/or chemotherapeutic agents. This differs from thermoablation, where temperatures greater than 46ºC are used to cause necrosis of cancer cells, but these temperatures can also affect adjacent healthy tissues. Conclusions: Magnetic drug targeting and thermotherapy are exciting targeted therapies that may have increased role in future interventional oncology practice. It is important for interventional oncologists to be aware of such treatments, as they can be involved in particle delivery in the future.
J. Hoffmann, Y. Peterkin, S. Mittal, D. Phung, A. Rahman, A. Baadh Purpose: Historically, when undergoing transarterial chemoembolization patients are hospitalized for at least 1 night for management of postembolization syndrome (PES), which can include fever, abdominal pain, nausea, and vomiting. Drug-eluting bead transarterial chemoembolization (DEB-TACE) is associated with lower percentages and severity of PES. This study reports on the feasibility of using 30-60-micron spheres for DEB-TACE with same-day discharge. Material and Methods: A single institution retrospective analysis was performed RQFRQVHFXWLYH'(%7$&(SURFHGXUHVXWLOL]LQJPLFURQVSKHUHV 4XDGUDsphere Microspheres, Merit Medical Systems, South Jordan, UT) from March 2013 through January 2015. Each vial of spheres was loaded with 50 mg of doxorubicin. Some patients were planned for overnight admission before starting the procedure due to comorbidities and/or advanced disease. Other patients were treated with the primary intent of same-day discharge. Records were reviewed to determine degree of PES, pertinent lab values, Child-Pugh score, BCLC stage, ECOG status, admission status, and 30-day readmission rates. Results: A total of 27 DEB-TACE procedures with 30-60-micron spheres were performed during the study period. A total of 18 patients were hospitalized after DEB-TACE according to the attending physician’s plan before starting the procedure (deemed appropriate for admission due to comorbidities, labs, and/or performance status). Out of the 9 patients planned for same-day discharge, all were discharged the same day with mild or no PES. One patient in this group was hospitalized and died within 30 days due to pneumonia and rapidly developing metastatic disease (BCLC
Hepatitis C Virus: The Role of Newer Anti-Viral Therapies and the Impact on Future Interventional Oncology Practice J. Hoffman, A. Singh, A. Baadh, P. Malet Purpose: +HSDWLWLV&YLUXV +&9 LVDFDXVHRIVLJQL¿FDQWPRUELGLW\DQGPRUWDOLW\ in the United States, but treatment regimens have improved in recent years. As HCV is a major cause of cirrhosis and hepatocellular carcinoma (HCC) in the United States, it is prudent for interventional radiologists to be familiar with treatment options and how better control and treatment of HCV will likely impact IR/IO practice. A number of newer medications are now used in the United States to treat HCV, which can lead to lower rates of HCC and potentially fewer HCC-related procedures in interventional radiology. We review these newer medications, and suggest how their success will impact interventional oncology practice over the next 10 years. Material and Methods: New oral agents are now available in the United States to treat HCV. Increasing use of these medications will likely lead to lower rates of HCC in the United States; therefore, interventional radiologists must be aware that HCCrelated procedural volumes may decrease over the next 10 years or more. Results: Review important factors about HCV that are crucial for interventional radiologists, such as etiology, association with HCC, and current role of antiviral medications to treat HCV. Further, we describe trends in new HCV cases reported in the United States and review the relevant literature, while also comparing this to sales of newer antiviral medications used to treat HCV. The trends are then used to extrapolate
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study. Inclusion criteria: liver-limited progressive disease, <75% liver involvement by tumor, tumor invasion not suitable for surgery or ablation, OMS status 0-1. ExcluVLRQFULWHULD OLYHULQVXI¿FLHQF\SRUWDOYHLQWKURPERVLVELOLDU\LQMXULHVDQGSUHYLRXV administrated dose of doxorubicin > 450 mg/m². Two sessions of DEBDOX (drugeluting bead doxorubicin, 100 mg of doxorubicin) were scheduled at 30-day intervals. The DEBDOX was administrated in a regional manner for both lobes in the same session. In addition, patients received hormonotherapy if required. The primary endpoint was liver response rate at 3 months. The secondary endpoint was progression-free VXUYLYDOIURPWKH¿UVW'(%'2; Results: A total of 23 women (57.5 years old, range 40-78) were referred for DEBDOX. A total of 2 (range 2-6) chemotherapy lines per patient were previously given. A total of 40 DEBDOX sessions were performed. Seventeen (74%) patients received 2 sessions of DEBDOX. Baseline average tumor diameter was 165.3 mm ± 81.9 (range 82-380). At 3 months, all patients were alive, and the average tumor diameter FKDQJHZDVí í $SDUWLDOUHVSRQVHDQG6'ZHUHREVHUYHGLQ 6 (26%) and 13 (57%). The progression-free survival was 229 ± 28.8 days (range 188-269). Conclusions: DEBDOX chemoembolization for limited liver breast cancer metastases offer tumor control in 83% at 3 months with a PFS of 229 days.
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HCV-related cirrhosis and new HCC cases in the United States over the coming 5 to 10 years. This will provide interventional radiologists with projections as to how these medications will alter interventional radiology and interventional oncology practice over the next decade, including the impact of potential decrease in number of HCC cases diagnosed in the United States leading to changes in ablation and embolization volumes. Conclusions: Newer oral medications now used in the United States to treat HCV will likely result in a substantial decrease of rates of HCC and a corresponding drop in the number of interventional oncology procedures needed to treat these patients. What Every Radiology Resident Needs to Know About the Treatment of Primary and Metastatic Liver Tumors N. P. Shah, B. Patel, S. Shah Purpose: Interventional oncology has seen tremendous growth with the development of a multitude of treatments including targeted chemotherapy, internal radiation, focal ablations, and adjunctive transplantation procedures. Many radiology residencies do not provide adequate formal training for practice-based oncological protocols. We set out to provide residents with a comprehensive review of the available treatments for hepatic tumors. Material and Methods: The overview describes the veritable arsenal available for targeting and treating liver tumors. Treatment modalities include bland embolization, radioembolization, and traditional ablation, as well as combination therapy. Explanation regarding indications, contraindications, and complications are included in the poster. Images were meticulously harvested from multiple patients within our institution. Figures contain pre- and post-therapy images across a variety of imaging modalities. Results: N/A Conclusions: In the vast and sometimes complicated world of interventional oncology, our poster attempts to deconstruct and demystify different oncologic protocols for resident and fellow education. As interventional radiology shifts to a direct-path-
way model, the need to introduce complex protocols at an introductory level will only increase the demand for such initiatives. AZD9291 in Pretreated Patients with T790M-Positive Advanced Non-Small Cell Lung Cancer (NSCLC): Phase II Pooled Analysis G. D. Goss, J. C.-H. Yang, M.-J. Ahn, C.-M. Tsai, L. Bahzenova, L. Sequist, S. Ramalingam, F. Shepherd, M. Cantarini, H. Mann, T. Mitsudomi, P. Jänne Purpose: AZD9291 is a potent oral irreversible epidermal growth factor receptor tyrosine kinase inhibitor (EGFR-TKI), selective for both EGFR-TKI–sensitizing (EGFRm) and T790M resistance mutations. We report pooled results from 2 global phase II studies in pretreated patients with EGFRm advanced non-small cell lung FDQFHUZLWKFHQWUDOO\FRQ¿UPHG7 0SRVLWLYHVWDWXV WKH$85$VWXG\SKDVH,,H[tension (NCT01802632) and the AURA2 phase II study (NCT02094261). Material and Methods: Eligible patients had measurable disease, World Health Organization performance status (WHO PS) 0/1, and acceptable organ function; stable brain metastases were allowed. A tumor sample was taken after most recent GLVHDVH SURJUHVVLRQ IRU SURVSHFWLYH FRQ¿UPDWLRQ RI 7 0 SRVLWLYH VWDWXV &REDV EGFR Mutation Test, Roche, Basel, Switzerland). Patients received AZD9291 at 80 mg once daily. Data cut-off (DCO) was May 1, 2015. Results: In total, 411 patients were dosed (full analysis set [FAS]), and 398 were evaluable for response, as 13 dosed patients had no measurable disease at baseline by independent central review (ICR). EGFRm subtypes were: Ex19del, 68%; L858R, 29%; and other, 3%. Median age was 63 years; female sex, 68%; Asian, 60%; WHO 36 VHFRQGOLQHWKLUGOLQH $W'&2PHGLDQWUHDWment exposure was 7.7 months, and 296 (72%) patients remain on treatment. ObjecWLYHUHVSRQVHUDWH 255 E\,&5ZDV FRQ¿GHQFHLQWHUYDO>&,@ 61-71); disease control rate was 91% (362/398; 95% CI, 88-94). Consistent ORRs ocFXUUHGDFURVVOLQHVRIWKHUDS\ VHFRQGOLQH> &,@ WKLUGOLQH 66% [180/274; 95% CI, 60-71]), ethnicity (Asian, 70% [166/237; 95% CI, 64-76]; nonAsian, 60% [97/161; 95% CI, 52-68]), and EGFR mutation (Ex19del, 70% [188/270;
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95% CI, 64-75]; L858R, 59% [66/112; 95% CI, 49-68]). Median progression-free survival in the FAS (N = 411) was 9.7 months (95% CI, 8.3-NC) as evaluated by ICR. 7KHPRVWFRPPRQDOOFDXVDOLW\DGYHUVHHYHQWV $(V ZHUHGLDUUKHD *U DQGUDVK *U SDWLHQWVH[SHULHQFHG*U$(V,QWHUVWLWLDO lung disease was reported in 11 (3%) patients, 4 of which were fatal (1%) and were considered possibly causally related to AZD9291 by the investigator. Twenty-three patients (6%) discontinued treatment due to an AE. Conclusions: In the evaluable-for-response population (n = 398), AZD9291 demonstrated a 66% ORR by ICR that was generally consistent across all subgroups. 7KH WROHUDELOLW\ SUR¿OH REVHUYHG LQ ERWK SKDVH ,, VWXGLHV ZDV FRQ¿UPHG E\ WKH pooled data. Design, Execution, and Preliminary Biomarker Results: From Paired Tumor Biopsy Cohorts of the AZD9291 AURA Trial K. S. Thress, J. Leeson, J. Geradts, M. Schuler, M.-J. Ahn, J. Wolf, K. Gold, J. C.-H. Yang, F. Blackhall, W.-C. Su, V. Jacobs, N. Smith, H. Angell, K. Brown, K. Vishwanathan, J. C. Barrett, M. Cantarini, P. Jänne Purpose: AZD9291, an oral, irreversible epidermal growth factor receptor tyrosine kinase inhibitor (EGFR-TKI), has potency against EGFR-sensitizing and T790Mresistance mutations. In the ongoing phase I AURA study (NCT01802632), AZD9291 induced durable responses in patients with acquired resistance to EGFR-TKIs. We report results of paired biopsy cohorts in the AURA trial, reviewing modulation of key molecular biomarkers of AZD9291 activity in patient tumor samples. Material and Methods: Patients consented to paired tumor biopsy collection; all KDG7 0SRVLWLYHSUHVWXG\WXPRUELRSVLHVFRQ¿UPHGE\FHQWUDOODERUDWRU\(*)5 testing (Cobas EGFR Mutation Test, Roche, Basel, Switzerland). After 8 to 15 days of once-daily AZD9291 (80 mg or 160 mg), a new tumor biopsy was performed. Baseline and on-study biopsies of tumor tissue were processed for routine histology and pathology. Biomarker scoring required >100 viable tumor cells per sample. )RUPDOLQ¿[HG SDUDI¿QHPEHGGHG ELRSV\ VDPSOHV ZHUH SUR¿OHG E\ LPPXQRKLVWRchemistry (phospho[p]-EGFR, pERK, pAKT, pS6, PD-L1, CD8). Plasma pharmacokinetic samples were also collected on the on-study biopsy day.
Results: As of February 2015, 58 patients with an evaluable baseline biopsy were dosed in the paired biopsy cohorts. Of these, 16 did not proceed to an on-study biopsy DVWKHLGHQWL¿HGOHVLRQVUHJUHVVHGWRRVXEVWDQWLDOO\RUZHUHQRWFRQVLGHUHGVXLWDEOHIRU rebiopsy, 1 patient was medically excluded from rebiopsy, and 1 patient’s sample was not available. In total, 40 patients supplied matched pre- and on-study biopsies. As of 0DUFKSDLUHGWXPRUVDPSOHVZHUHDYDLODEOHIRUTXDOLW\FRQWURO 4& IURP of 40 patients. Inadequate tumor content in 10 of 26 biopsy specimens subsequently IDLOHG4&OHDYLQJSDLUHGWXPRUVDPSOHVDYDLODEOHIRUELRPDUNHUDQDO\VLVRIZKLFK 5 have thus far been evaluated. AZD9291 treatment inhibited EGFR pathway components in most on-study tumor biopsies. Updated data will be provided. Conclusions: Analysis of a paired biopsy cohort within the AURA trial was challenging due to the rapid onset of antitumor effects of AZD9291. The on-study biopsy procedure was not performed for approximately 29% (17/58) of patients due to tumor regression; 38% (10/26) of performed on-study biopsies contained too little tumor for analysis. In the evaluable tumor pairs, pharmacodynamic modulation of the EGFR pathway was evident. Further biomarker analyses, including evidence of modulation of immune system markers, may help inform future combination strategies. Maximizing Reimbursement for Radioembolization: The Keys to Appropriate Documentation -+RIIPDQQ$%DDGK$*ULI¿WK60LWWDO Purpose: Over the past 10 years, interventional radiologists have been performing increasing numbers of radioembolization procedures in treatment of liver-only or liver-dominant hepatic malignancy. The purpose of this exhibit is to review radioemEROL]DWLRQVSHFL¿FFRGLQJJXLGHOLQHVVRWKDWLQWHUYHQWLRQDOUDGLRORJLVWVFDQGHYHORS a better understanding of what documentation is key in their reports, leading to appropriate reimbursement. Material and Methods: This exhibit will review coding for radioembolization procedures, from initial patient interventional radiology clinic visit to postprocedure follow-up imaging. The exhibit will highlight the importance of adequate documentation during clinic visits, image-guided interventions, and postprocedure cross-sectional imaging to ensure maximal reimbursement.
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Results: The treatment of liver tumors using 90Y microspheres placed by intraarterial embolization/delivery merges key concepts well known to radiation oncology and interventional radiology practices. A typical radioembolization case includes the initial patient consultation; a diagnostic angiogram to allow for treatment planning and possible pretreatment embolization of arteries such as the gastroduodenal artery, right gastric artery, and/or supraduodenal artery; and the actual 90Y radioembolization treatment. SPECT nuclear medicine scans for tumor localization and contrastenhanced multi-phasic cross-sectional imaging for therapy planning and longer-term follow-up are also obtained. Thus, thorough documentation of patient history, indications for treatment, appropriateness of therapy, and dosimetry calculations by interYHQWLRQDOUDGLRORJLVWVDUHFULWLFDOWRREWDLQHI¿FLHQWSURFHGXUDODSSURYDOE\LQVXUDQFH companies and appropriate reimbursement. This exhibit will detail the CPT codes relevant to radioembolization and will highlight the importance of adequate documentation throughout the treatment process. Conclusions: The emergence of radioembolization with 90Y in the treatment of liver tumors brings with it additional challenges for the interventional radiologist that make clear, precise documentation critical. An understanding of radioembolization coding will allow interventional radiologists to provide improved documentation, leading to PRUHHI¿FLHQWWUHDWPHQWDXWKRUL]DWLRQDQGUHLPEXUVHPHQWE\LQVXUDQFHFRPSDQLHV Hepatocellular Carcinoma with Portal Vein Thrombosis: A Time-Dependent Toxicity Analysis E. Kim, D. Biederman, P. O’Connor, L. Mao, J. Titano, N. Tabori, R. Patel, M. Schwartz, M. Facciuto, G. Gunasekaran, S. Florman, A. Fischman, F. Nowakowski, R. Lookstein Purpose: Portal vein thrombosis (PVT) is a negative prognostic factor in the survival of patients with hepatocellular carcinoma (HCC) as it increases the probability of extrahepatic spread and decreases the tolerability of trans-arterial therapy. In this study we analyze patients with HCC and PVT treated with yttrium-90 (90Y) radioembolization (RE) to better elucidate the relative contributions of treatment related toxicity and toxicity secondary to disease progression. Material and Methods: Patients included in the study had unresectable HCC with PVT and were treated with glass-based RE (Therasphere, BTG, United Kingdom). PVT was documented on the most recent pre-treatment imaging study (<90) by an independent radiologist. Patients with contralateral PVT were excluded from analyVLV3DWLHQWVZHUHVWUDWL¿HGDFFRUGLQJWRSULRUWKHUDS\&KLOG3XJK &3 FODVV(&2* performance status, tumor characteristics, extent of PVT (lobar vs main), and alphafetoprotein (AFP) levels. The primary outcome variable was the development of CTCAE v 4.03 grade 3/4 total bilirubin (T-Bili) toxicity. Time to toxicity (TTT) T-Bili was calculated for T-Bili using all available laboratory values at any point in time post initial treatment and analyzed using Kaplan-Meier methods. Patients were censored for curative therapy. Secondary outcome variables included, imaging response (mRECIST), time-to-progression (TTP), and overall survival. Results: From January 2005 to September 2014, a total of 709 patients who underwent RE treatment were retrospectively reviewed, of which 69 patients (age: 65.6 ± 11.3, male: 78%) undergoing 77 treatments (median dose: 120 gy) met inclusion criteria in the study. Four patients were lost to toxicity follow-up. No patients had baseline grade 3/4 T-Bili toxicity. Grade 3/4 T-Bili toxicity occurred in 20 patients (30.7%). The median (95% CI) TTT of patients who developed grade 3/4 toxicity was 114 (50-183) days. A trend towards lower toxicity in CP-A (78.3%) relative to CP-B (21.7%) was seen for T-Bili (p = 0.07). ECOG performance status of >1 (14.4%) was associated with a greater incidence of T-Bili toxicity (p = 0.005, HR: 4.9, 95% CI: 1.6 WR 7DUJHWGRVHZDVQRWDVLJQL¿FDQWSUHGLFWRURI7%LOLWR[LFLW\ !J\ 120 gy: 20%, <120 gy: 30%; p = 0.62). The 90-day objective response rate (OR) and disease control (DC) rates were 41% and 55%, respectively. Both OR (p = 0.018, HR: 3.2, 95% CI: 1.2-8.4) and DC (p = 0.009, HR: 3.2, 95% CI: 1.1-8.9) were predictive of T-Bili toxicity. Median (95% CI) TTP and overall survival were 5.9 (4.2-9.1) months and 9.5 (7.6-15.0) months respectively. Both TTP (p < 0.0001, HR: 6.9, 95% CI: 3.215.0 and T-Bili TTT (p < 0.0001, HR: 7.6, 95% CI: 3.8-14.9) were strongly predictive of overall survival when analyzed using a Cox time-dependent covariate model. Conclusions: The strong temporal relationship of both TTP and T-Bili TTT as predictors of overall survival coupled with the association of imaging response as a predictor of toxicity development implicates disease progression as a substantial contributor to post-treatment toxicities in patients with HCC treated with RE. United States RESIN Registry for the Study and Evaluation of Patients Treated with SIR-Spheres D. Brown, A. Lipnik, F. Banovac Purpose: Yttrium-90 (90Y) resin microspheres are approved for use in the United States for treatment of colorectal cancer. They are frequently used off-label for other OLYHUGRPLQDQWWXPRUV+RZHYHUUREXVWGDWDVHWVUHJDUGLQJEHQH¿WVDQGULVNVRIWKLV therapeutic modality across tumor types are lacking.
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Material and Methods: The Radiation-Emitting SIR-Spheres in Non-Resectable (RESIN) liver tumor patient registry is a national, multicenter registry that will enroll patients with primary or secondary liver cancer scheduled for treatment with 90Y resin microspheres (SIR-Spheres, Sirtex, Woburn, MA) as part of their treatment. Patients may or may not receive concomitant systemic therapy as part of their overall oncologic management. This patient data will be collected as a registry study and not as research on the experimental use of microspheres. Results: Baseline data such as previous chemotherapy, performance status, tumor markers, and receptor targets for biologic therapy will be tracked. Tumor response and concomitant therapy will be tracked, as will toxicities using the common terminology criteria for adverse events v4. An initial 8 centers are involved with a baseline goal to enroll over 350 patients per year. There are separate goals for patients with tumors that are more vs less commonly treated with 90Y. For patients with colorectal or neuroendocrine tumors, we hope to perform subgroup analysis to identify utilization strategies for personalized 90Y applications including trials focused on combinations with targeted therapies. For less commonly described treatment applications, we hope the registry data can plan future trials for less-evaluated tumor types including breast, cholangiocarcinoma, and others. Conclusions: Information generated from this national multicenter registry study will contribute to the oncology community’s understanding of United States treatment patterns with 90Y therapy, gain additional insights into long-term outcomes, and guide future research with 90Y therapy, especially for conditions with limited data. Ytrrium-90 Resin in Castrate-Resistant Prostate Cancer with Liver Metastasis M. Scholz, R. Lam, J. Turner, C. Felarca Purpose: Prostate cancer (PC) is the second-leading cause of cancer-related death in men in the United States. The prognosis is especially poor in PC patients with liver metastases (PCLM), with a median overall survival of 10 to 12 months in castrateresistant patients receiving docetaxel regimens. Radioembolization with yttrium-90 (90Y) resin microspheres via the hepatic artery has been shown to improve survival in patients with colorectal liver metastases. We report our experience with 90Y resin treatment of 6 castrate-resistant patients with PCLM. Material and Methods: Retrospective review of patient records of 6 castrate-resistant patients who received 90Y resin for the treatment of liver metastases from PC. Results: Six males, ages 54 to 80 (median 67.5), who were diagnosed with stage D2 PC between the years 1996 to 2011 developed PCLM a median of 140.5 (21-202) months post diagnosis. Patients received a median of 6 (1-7) therapies, including leuprolide acetate and XBT, from their time of diagnosis with PC to the time that they developed PCLM. After developing PCLM, 3 patients received 1 therapy (Pt 1: nilutamide, Pt 2: cisplatin/etoposide, Pt 3: cabazitaxel/carboplatin) and 3 patients received no other therapy before treatment with 90Y resin. Patients were given 90Y resin 1 to 8 months (median 4) after their diagnosis of PCLM and received up to 3 treatments of 90 Y resin (median 1.5). Patients received 0 to 4 (median 1.5) non-90Y resin therapies subsequent to their initial treatment with 90Y resin. Median survival post 90Y resin was 13 (3-36) months. Median survival from initial diagnosis of PCLM was 16.5 (6-41) months. Patients experienced no notable toxicities. Conclusions: Historical median survival of castrate-resistant patients with PCLM is 10 to 12 months. In this review of 6 castrate-resistant PLCM patients in which 90Y resin was added to their multimodality therapeutic regimen, median survival was 16.5 months. No notable toxicities were experienced. Further investigation of the use of 90Y resin in patients with PCLM is warranted. Treatment Response In Glass vs Resin Radioembolization of Nonresectable Hepatic Metastasis J. Vavricek, S. Iqbal, A. Rohr, L. Rock, B. Jang, S. Hunt, J. Wick, A. Robinson, S. DeBacker, T. James, J. Hill, Z. Collins Purpose: To compare treatment response between glass and resin yttrium-90 (90Y) microsphere radioembolization of hepatic metastasis from colorectal and other systemic malignancies. Material and Methods: A retrospective analysis was performed on 70 patients with hepatic metastasis treated with glass or resin 90Y radioembolization from 2008 to 2014 at an academic medical center. Up to 2 treated lesions per lobe were measured using cross-sectional imaging in the X, Y, and Z planes at baseline and at 1-, 3-, 6-, and 12-month intervals. Response was evaluated using the World Health Organization (WHO) and Response Evaluation Criteria in Solid Tumors (RECIST) 1.1 criteria. Results: A total of 70 patients were evaluated with 39 (56%) receiving resin and 31 (44%) receiving glass particles. Of those, 34 (49%) patients had metastatic colorectal cancer (mCRC) with a mean MELD score of 8.5 (SD 2.1), and 36 (51%) had other primary malignancies with a mean MELD score of 7.7 (SD 1.7). Thirty-seven (53%) patients were female with a mean age of 59.7 years (SD 12.3) at treatment 1. Patients received an average radiation dose of 1.12 gigabecquerel (GBq) (SD 0.33) with resin treatments, compared to 3.08 GBq (SD 1.09) with glass treatments. Evaluation of
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Yttrium-90 Glass Microspheres in the Treatment of Hepatocellular Carcinoma with Concomitant HIV Infection J. Titano, D. Biederman, A. Fischman, R. Patel, N. Tabori, F. Nowakowski, R. Lookstein, E. Kim Purpose: Selective internal radiation therapy with yttrium-90 (90Y) glass microspheres (SIRT-glass) is a well-described, transarterial, locoregional therapy used in the WUHDWPHQWRIKHSDWRFHOOXODUFDUFLQRPD +&& +XPDQLPPXQRGH¿FLHQF\YLUXV +,9 coinfection has been shown to negatively impact outcomes in HCC secondary to viral hepatitis. We performed a retrospective analysis of the use of SIRT-glass in patients with unresectable HCC secondary to HBV or HCV and concomitant HIV infection. Material and Methods: We retrospectively reviewed 417 patients treated with SIRT-glass from January 1, 2010 to July 1, 2015. Of these, 30 patients (59.4 ± 6.4 years, male: 90%) with HCC and HIV infection underwent SIRT-glass. All patients ZHUH VWUDWL¿HG DFFRUGLQJ WR +&& HWLRORJ\ +&9 +%9 SULRU +&& WKHUDS\ (naïve: 12, ablation: 5, chemoembolization: 15, resection: 4), Child-Pugh class (A: 26, B: 4), performance status (ECOG 0: 15, ECOG 1: 10, ECOG 2: 5), tumor burden (solitary: 10, multifocal: 20; unilobar: 19, bilobar: 11), cirrhosis (present: 26, absent: 4), portal vein thrombosis (present: 9, absent: 21), ascites (present: 2, absent: 28), SUHUDGLRHPEROL]DWLRQ$)3OHYHO QJP/ !QJP/ DQG%&/&VWDJH (A: 4, B: 3, C: 23). Pretreatment laboratory values including alpha-fetoprotein, total bilirubin, INR, and albumin were recorded. Post-SIRT-glass transplantation was also
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recorded. Outcome variables included imaging response (mRECIST), time to progression, and overall survival. Results: A total of 39 treatments were administered (mean dose: 2.5 ± 1.7 GBq). Pretreatment laboratory values were recorded as follows: alpha-fetoprotein (median >,45@ >±@QJP/ WRWDOELOLUXELQ PJG/ ,15 and albumin (3.7 ± 0.55 g/dL). Overall objective response was 39.1% (mRECIST). The disease control rate was 69.7% (mRECIST). Mean and median (95% CI) time to progression were 6.4 (4.5-8.4) months and 4.6 (3.7-5.5) months, respectively. Median (95% CI) survival was 11.3 (8.9-13.6) months. There were no 30-day mortalities. Two patients went on to receive liver transplantation following SIRT-glass. Univariate analysis (log-rank test) showed decreased time to progression in the following patient group: absence of metastasis (p = 0.006). Univariate analysis (log-rank test) showed LPSURYHGVXUYLYDOLQWKHIROORZLQJSDWLHQWJURXSV (&2* S PDOHV S 0.025), and preprocedure clinical ascites (p = 0.001). Conclusions: In our experience, the absence of metastasis is a predictor of imSURYHGWLPHWRSURJUHVVLRQDQG(&2*SHUIRUPDQFHVWDWXVPDOHVH[DQGSUHprocedure clinical ascites are predictors of improved survival in patients undergoing SIRT-glass with HCC secondary to HCV or HBV and concomitant HIV infection. Complications of Transcatheter Arterial Chemoembolization with Focus on Embolization of the Hepatic Falciform Artery A. Rajput, T. Ahluwalia, A. Rajput, J. H. Hwoon, D. Nguyen, R. Gupta, A. Maleson Purpose: The purpose of this educational exhibit is to review the incidence, prevalence, and clinical presentation of common and uncommon complications in patients after transcatheter arterial chemoembolization (TACE) with our main focus on nontarget embolization of the hepatic falciform artery. Nontarget vessel involvement may lead to serious organ damage, and prophylactic measures should be considered. Knowing anatomical variants will allow the providing interventional radiologist to correctly approach each case and offer appropriate treatment. Material and Methods: TACE offers palliation for patients with unresectable liver tumors, predominantly hepatocellular carcinoma. The hepatic arteries are the primary blood supply of these tumors. Chemoembolization has proven to be very effective by working in 2 ways: limiting tumor blood supply and administering a focused, selective dose of chemotherapeutic agents. Serious complications may occur, and a comprehensive understanding of these entities and anatomical variants are vital for effective treatment. Results: The discussion will include a brief review of anatomy of the hepatic vasculature and common variants followed by the presentation of a case of nontarget involvement of the hepatic falciform artery resulting in skin ulceration and necrosis. Further discussion will include relevant complications including additional nontarget embolizations, postembolization syndrome, infection, liver failure, access-site injuries, hepatic artery injury, and renal failure. The review will also include gross and radiologic imaging that will help the radiologist to distinguish these variants and severe complications and will also provide appropriate recommendations regarding prevention and future management. Conclusions: 1RQWDUJHWHPEROL]DWLRQLVDVHULRXVFRPSOLFDWLRQRI7$&(&RQ¿GHQW SUHSURFHGXUDOLGHQWL¿FDWLRQDQGDGMXVWPHQWVPXVWEHFRQVLGHUHG$ZDUHQHVVRIVHYeral nontarget organ injuries from TACE is critical to prevent unnecessary complications and provide effective care.
CIO Abstracts
tumor response using WHO criteria found 1 (2.6%) patient had a complete response (CR), 13 (33.3%) had partial responses (PR), 19 (48.7%) had stable disease (SD), and 6 (15.4%) had progressive disease (PD) when treated with resin particles, and 0 (0.0%) had CR, 5 (16.1%) had PR, 21 (67.7%) had SD, and 5 (16.1%) had PD when treated with glass particles. RECIST 1.1 response criteria demonstrated 1 (2.6%) patient had CR, 13 (33.3%) had PR, 18 (46.2%) had SD, and 7 (17.9%) had PD when treated with resin, and 0 (0.0%) had CR, 7 (22.6%) had PR, 19 (61.3%) had SD, and 5 (16.1%) had PD when treated with glass (Table 1). Due to small sample sizes, we were unable to SHUIRUPIRUPDOVLJQL¿FDQFHWHVWLQJRQWKHGLVWULEXWLRQRIUHVSRQVHE\WUHDWPHQWW\SH Conclusions: Although both glass and resin 90<PLFURVSKHUHVDUHHI¿FDFLRXVWUHDWments for nonresectable metastatic hepatic disease, there is limited data on direct comparison of imaging response between the 2 treatment types. Our study demonstrates that resin-based 90Y therapy offers a comparable response when compared to glassbased 90Y therapy at nearly one-third the dose of radiation.
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