Unresectable solitary hepatocellular carcinoma not amenable to radiofrequency ablation: Multicenter radiology-pathology correlation and survival of radiation segmentectomy

Abstract

Resection and radiofrequency ablation (RFA) are treatment options for hepatocellular carcinoma (HCC) <3 cm; there is interest in expanding the role of ablation to 3-5 cm. RFA is considered high-risk when the lesion is in close proximity to critical structures. Combining microcatheter technology and the localized emission properties of Y90, highly selective radioembolization is a possible alternative to RFA in such cases. We assessed the efficacy (response, radiology-pathology correlation, survival) of radiation segmentectomy in solitary HCC not amenable to RFA or resection. Patients with treatment-na€ ıve, unresectable, solitary HCC £ 5 cm not amenable to RFA were included in this multicenter study. Administered dose, response rate, time-to-progression (modified Response Evaluation Criteria in Solid Tumors [mRECIST]), radiology-pathology correlation and long-term survival were assessed. In all, 102 patients were included in this study. mRECIST complete response (CR), partial response (PR), and stable disease (SD) were 47/99 (47%), 39/99 (39%), and 12/99 (12%), respectively. Median time-to-disease-progression was 33.1 months. In all, 33/ 102 (32%) patients were transplanted with a median (interquartile range [IQR]) time-totransplantation of 6.3 months (3.6-9.7). Pathology revealed 100% and 50-99% necrosis in 17/33 (52%) and 16/33 (48%), respectively. Median overall survival was 53.4 months. Univariate analysis demonstrated a survival benefit for Eastern Cooperative Oncology Group (ECOG) 0 patients. In the multivariate model, age <65, ECOG 0, and Child-Pugh A were characteristics associated with longer survival. Conclusion: Radiation segmentectomy is an effective technique with a favorable risk profile and radiology-pathology outcomes for solitary HCC £ 5 cm. This approach may allow for treatment of HCC in difficult locations. Since RFA and resection are not options given tumor location, there appears to be a strong rationale for this technique as second choice. (HEPATOLOGY 2014;60:192-201) H epatocellular carcinoma (HCC) is a health problem of global proportions that has a wide variety of treatment options. Tumor location, size, number of lesions, liver function, and clinical symptoms all play a role in weighing various treatment modalities. Although liver transplantation and resection are considered curative, scarce transplant availability and patient/tumor characteristics limit Abbreviations: AASLD, American Association for the Study of the Liver; AFP, alpha

Personalized Dosimetry with Intensification Using 90Y-Loaded Glass Microsphere Radioembolization Induces Prolonged Overall Survival in Hepatocellular Carcinoma Patients with Portal Vein Thrombosis

“…Riaz et al have also previously described an intensification approach at a segmental level called radiation segmentectomy, producing good results (81% response rate; no clinical toxicity) and thus underlining the usefulness of the intensification concept (16,17). Recent results by means of radiation segmentectomy have demonstrated that the rate of complete histologic response was significantly higher for segments receiving a mean dose of 190 Gy or more (i.e., 66.6% for a segment dose $ 190 Gy, compared with only 25% for a segment dose , 190 Gy; P 5 0.03) (17). TDs were not provided in that study, thus rendering any direct comparison with our threshold TD of 205 Gy impossible.…”

Radiation Segmentectomy: Potential Curative Therapy for Early Hepatocellular Carcinoma

“…A subanalysis of patients with HCC less than or equal to 3 cm was also performed, creating a cohort potentially comparable to radiofrequency ablation. Twenty-four of the 70 patients have been previously reported (9). In that prior study, the concept of RS was introduced and validated by using results from pathologic explants.…”

90Y Hepatic Radioembolization: An Update on Current Practice and Recent Developments

“…In their cohort, 33% of patients were amenable to liver transplantation after radiation segmentectomy. At pathologic examination of the native liver specimens, 100% necrosis and more than 90% necrosis were found in, respectively, 52% and 48% of patients (64). In HCC, the downstaging success rate with radioembolization is around 50% (range, 29%-67%), with a median time to downstaging of 3.1-4 mo (65).…”