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Internal view of patient's torso demonstrating targeted accuracy of TheraSphere Y-90 Glass Microspheres in liver.

TheraSphere™ Y-90 Glass Microspheres

Radiation segmentectomy

Radiation segmentectomy overview

Potential curative therapy for early hepatocellular carcinoma

Radiology, 2018 Jun; 287(3); https://pubs.rsna.org/doi/10.1148/radiol.2018171768

Lewandowski RJ, Gabr A, Abouchaleh N, Ali R, Al Asadi A, Mora RA, Kulik L, Ganger D, Desai K, Thornburg B, Mouli S, Hickey R, Caicedo JC, Abecassis M, Riaz A and Salem R

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Curative treatment options for early-stage HCC (BCLC 0 or A) include transplantation, surgical resection and RF ablation with good survival outcomes ranging between 60-80%*1, however many patients are not candidates for these therapies.

  • Radiation segmentectomy is the application of selective ablative radiation doses of Yttrium-90 (Y-90) to tumors, usually delivered to no more than two hepatic segments2
  • The threshold dose of ≥ 190 Gy has been confirmed3 to maximize cytotoxicity and selective delivery minimizes risk of damage to surrounding parenchyma4

Objectives

  • To report one center’s long-term outcomes of patients with HCC ≤ 5 cm, not amenable to transplantation, resection or RF ablation, who underwent radiation segmentectomy
  • The authors hypothesized radiation segmentectomy could be considered potentially curative based on the same rationale as transplantation, resection and RF ablation

Methods

  • Retrospective, single center study looked at 70 patients with solitary HCC ≤ 5 cm, preserved liver function (Child Pugh A) and no vascular invasion or extrahepatic metastases who underwent radiation segmentectomy with Y-90 glass microspheres (target dose ≥ 190 Gy)
  • Patients who had surgical resection or transplant after a radioembolization procedure were excluded
  • A sub-analysis of patients with HCC ≤ 3 cm was also performed (cohort comparable to RF ablation)
  • All patients underwent long-term imaging (contrast material-enhanced magnetic resonance [MR] imaging or computed tomography [CT]) and clinical follow-up (toxicity assessment at 1- and 3-months and response assessment in clinic 1-month post and subsequently at 3-month intervals)

Results

Table describing radiographic response, time to progression (TTP), local tumor control, overall survival (OS).

Results: overall survival for all patients

Graph showing survival probability (%) over time (days) and number at risk.
Table on overall survival rate of one year, three year and five year, with tumor sizes of <=3cm (n=45), >3cm (N=25) and all <=5cm (n=70).
Contrast material–enhanced CT scan before Y-90 of an 87-year-old man with 4 cm hepatocellular carcinoma in right lobe.

Contrast material–enhanced CT scan before Y-90 of an 87-year-old man with 4 cm hepatocellular carcinoma in right lobe.

Contrast-enhanced MR image at subsequent 9-year follow-up (now aged 96 years) shows complete necrosis.

Contrast-enhanced MR image at subsequent 9-year follow-up (now aged 96 years) shows complete necrosis.

Conclusions

  • Liver transplantation, surgical resection and RF ablation are considered curative treatment options based on phase II randomized studies with limited data demonstrating improved survival
  • Data from the present publication suggests a radiation segmentectomy procedure should be considered curative in patients with unablatable BCLC stage 0 or A lesions ≤ 5 cm with preserved liver function (Child Pugh A) as radiation segmentectomy:
    • Provides local tumor control
    • Prolonged time to progression
    • Overall survival outcomes comparable to RF ablation, resection, and transplantation for patients with BCLC stage 0 or A HCC
  • Additionally, radiation segmentectomy is an outpatient, minimally invasive intra-arterial therapy with a low toxicity profile that may be a convenient treatment option for patients
  • Study strengths: homogeneity of patient cohort, >10 years of follow-up, strict patient selection
  • Study limitations: retrospective and nonrandomized analysis, selection bias, comparisons to published literature versus an internal control group

*RF ablation shows similar reported survival outcomes to resection and transplantation for HCC ≤ to 3 cm
BCLC = Barcelona Clinic Liver Cancer; HCC= hepatocellular carcinoma; RF= radiofrequency; EASL= European Association for the Study of the Liver
1. Bruix J, Reig M, Sherman M. Evidence-based diagnosis, staging, and treatment of patients with hepatocellular carcinoma. Gastroenterology 2016;150(4):835–853
2. Riaz A, Gates VL, Atassi B et al. Radiation segmentectomy: a novel approach to increase safety and efficacy of radioembolization. Int J Radiat Oncol Biol Phys 2011;79(1):163–171
3. Vouche M, Habib A, Ward TJ et al. Unresectable solitary hepatocellular carcinoma not amenable to radiofrequency ablation: multicenter radiology-pathology correlation and survival of radiation segmentectomy. Hepatology 2014;60(1):192–201
4. Vouche M, Lewandowski RJ, Atassi R et al. Radiation lobectomy: time-dependent analysis of future liver remnant volume in unresectable liver cancer as a bridge to resection. J Hepatol 2013;59(5):1029–1036

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