⁹⁰Y Radioembolization for Locally Advanced Hepatocellular Carcinoma with Portal Vein Thrombosis: Long-Term Outcomes in a 185-Patient Cohort

Abstract

We report survival outcomes for patients with advanced-stage hepatocellular carcinoma (HCC) with portal vein thrombosis (PVT) treated with Y radioembolization. With institutional review board approval, we searched our prospectively acquired database for Y patients treated between 2003 and 2017. Inclusion criteria were patients who had HCC with tumor PVT. Patients with metastases were excluded. Laboratory data were collected at baseline and 1 mo afterY radioembolization. Toxicity grades were reported according to the Common Terminology Criteria for Adverse Events, version 4.0, and long-term survival outcomes were reported and stratified by Child-Pugh class (CP). Overall survival was calculated using the Kaplan-Meier method. Multivariate analysis was performed using Cox proportional hazards regression. A subanalysis for patients with a high level of α-fetoprotein (AFP) (>100 ng/dL) was conducted. In total, 185 patients with HCC PVT underwentY radioembolization. Seventy-four (40%) were CP-A, 51 (28%) were CP-B7, and 60 (32%) were ≥CP-B8. New albumin, bilirubin, and alkaline phosphatase grade 3/4 toxicities were, respectively, 3%, 10%, and 0% for CP-A; 14%, 12%, and 6% for CP-B7; and 23%, 32%, and 3% for ≥CP-B8. Median overall survival for CP-A patients was 13.3 mo (95% confidence interval [CI], 8.7-15.7 mo). CP-B7 and ≥CP-B8 patients exhibited median overall survival of 6.9 mo (95% CI, 5.3-10.1 mo) and 3.9 mo (95% CI, 2.9-5.0 mo), respectively. Significant overall survival prognosticators on univariate analysis were albumin, bilirubin, ascites, tumor size 5 cm or smaller, focality, distribution, infiltration, Eastern Cooperative Oncology Group status, AFP level, and PVT extent. Multivariate analysis showed the prognosticators of overall survival to be bilirubin, no ascites, tumor size 5 cm or smaller, solitary lesion, baseline AFP level lower than 100 ng/dL, and Eastern Cooperative Oncology Group status. Of 123 patients with a high AFP level (>100 ng/dL), 12 patients achieved restored normal AFP levels (<13 ng/dL) and exhibited median overall survival of 23.9 mo (95% CI, 20.1-124.1 mo). AFP responders at 1 mo had better overall survival than nonresponders, at 8.5 mo versus 4.8 mo ( = 0.018); AFP responders at 3 mo had overall survival of 13.3 mo, versus 6.9 mo for nonresponders ( = 0.021). Y radioembolization can serve as a safe and effective treatment for advanced-stage HCC patients with tumor PVT. Overall survival outcomes are affected by baseline liver function, tumor size, and AFP level.

Chemoembolization related to good survival for selected patients with hepatocellular carcinoma invading segmental portal vein

“…The median survival times after radioembolization in previous studies seemed to be better than that after TACE in our study in Child A (14.3‐15.7 vs 11.6 months) and similar to that in Child B (6.5 vs 6.4 months) patients. However, the sample size in previous studies was too small to compare the median survival with that in our study. Furthermore, previous studies excluded patients with extrahepatic metastasis, while these patients were included in our study.…”

“…However, the sample size in previous studies was too small to compare the median survival with that in our study. Furthermore, previous studies excluded patients with extrahepatic metastasis, while these patients were included in our study. Thus, future comparative (TACE vs radioembolization) and well‐designed studies with sufficient sample sizes are warranted for the treatment of HCC with segmental PVTT.…”

“…In a report by Memon et al, the median survival times were 15.7 and 6.5 months in Child‐Pugh Class A (n = 35) and B7 (n = 28) patients, respectively, after radioembolization in HCC patients with branch/lobar PVTT. Very recently, Abouchaleh et al reported median survival times of 14.3 and 6.5 months in Child A (n = 24) and B7 (n = 11) patients, respectively, after radioembolization in patients with HCC with segmental PVTT. In our study, the median survival times were 11.6 and 6.4 months for patients with Child A (n = 279) and B (n = 52) respectively, after TACE for HCC combined with segmental PVTT.…”

Intra-Arterial TheraSphere Yttrium-90 Glass Microspheres in the Treatment of Patients With Unresectable Hepatocellular Carcinoma: Protocol for the STOP-HCC Phase 3 Randomized Controlled Trial

“…Treatment of HCC associated with PVTT would be a good indication for TheraSphere microspheres because the small size and number of TheraSphere microspheres administered makes them less embolic than other devices, and the ensuing effect on vascular dynamics is smaller than with other devices [ 43 - 45 ]. TARE with TheraSphere microspheres was found to be tolerable and effective in HCC patients with branch or lobar PVTT [ 44 , 46 , 47 ].…”

Molecular Mechanisms of Hepatocarcinogenesis Following Sustained Virological Response in Patients with Chronic Hepatitis C Virus Infection

“…The immune checkpoint inhibitor nivolumab shows promise in prolonging survival in patients who fail to respond to sorafenib by modulating the immune response [ 13 ]. For advanced HCC patients with portal vein thrombosis, yttrium-90 radioembolization has been shown to be safe and effective with survival times of up to 13.3 months for patients with Child-Pugh class A and 3.9 months for Child-Pugh class B [ 14 , 15 ].…”