“Radioembolization is especially useful for patients with large or disseminated tumours”
Tuesday, 10 Jan 2012 10:46
The multidisciplinary University Hospital of Essen, Germany, liver cancer team which trains physicians across Europe in radioembolization comprises Andreas Bockisch, Department of Nuclear Medicine, Stefan P Mueller, Department of Nuclear Medicine, Thomas C Lauenstein, Department of Diagnostic and Interventional Radiology, Joerg F Schlaak, Department of Gastroenterology and Hepatology, Judith Ertle, Department of Gastroenterology and Hepatology. They answered some key questions on radioembolization for Interventional New.
Is there a sharp learning curve for clinicians training to use this therapy?
The training of emerging teams of physicians from centres about to start a radioembolization programme has two objectives: first, to provide an understanding of the different treatment alternatives for malignant liver tumours and their respective role in different stages of the disease and second, to learn the specific issues of patient selection, angiography with preparation for radioembolization, treatment planning and dosimetry, radiation protection, and follow-up of treated patients. Special emphasis is placed on the need for interdisciplinary cooperation, ideally in a radioembolization team, during all stages of the treatment process. After the training, the physicians should be able to set up a team at their home institution and perform this type of therapy. All participants are offered support if they have questions they want to discuss during the first steps of their treatment programme.
How does the procedure compare to other treatments available in terms of ease of application and obtaining results?
Selective internal radiation therapy requires significantly more interdisciplinary cooperation and pre-treatment work-up compared to transarterial chemoembolization, for example, while the number of treatment sessions is reduced to only one or two. Results can be easily seen on CT or MRI scan, because there is no embolic agent covering the treated lesion, and laboratory values, especially tumour markers respond very fast after therapy while conventional CT imaging may confirm a response only after months.
Andreas Bockisch
Judith Ertle
What is the patient experience compared to other treatments?
In general, this treatment affects the patient and his/her quality of life only minimally. Most patients only experience a fatigue-syndrome for 10–14 days after therapy. After that they have a good quality of life. There is also the advantage of a reduced number of treatment sessions, therefore short-term side effects occur only once or twice and not permanently as compared to systemic treatments like sorafenib (hepatocellular carcinoma) or conventional chemotherapy (other tumours).
From your perspective, how does radioembolization treatment fit within the hepatocellular carcinoma treatment algorithm?
Selective internal radiation therapy is especially useful for patients with large or disseminated tumours, who are not eligible for TACE or other local-ablative therapies, in other words patients with an advanced tumour disease.
After having treated 500 patients are you gathering any new insights that will affect future treatment?
From the beginning we have optimised the interventional technique, e.g. foregoing systematic coil occlusion of gastrointestinal collaterals in favour of using split injections in more distant hepatic arteries, resulting in one of the lowest rates for gastrointestinal complications worldwide without having to exclude a large number of patients from treatment. The emerging evidence of our and other’s data further narrows down the criteria for selecting the patients who will derive the greatest benefit from this treatment and lowest risk, furthering our main goal of helping patients without harm. In the beginning, we treated mainly patients with hepatocellular carcinoma but more recently we have treated a growing number of patients with liver metastasis of various tumours. Moreover, we are currently exploring options for an improved liver and tumour dosimetry.
Stefan P Mueller
Thomas C Lauenstein
Are you looking at comparing all the data? If so, what are your endpoints?
We are currently looking at the data in various entities and evaluating these. Our primary endpoints are: overall survival, time to progression/recurrence, adverse events and downstaging to liver transplantation.
Are you now seeing a trend towards better time to progression and survival rates (compared to 10 and 16.4 months)?
We are still evaluating the data.
What further randomised controlled trials do you feel would be valuable?
For regulatory purposes a head-to-head comparison of radioembolization with the standard of care, i.e. systemic therapy with sorafenib, appears to be necessary in patients who are no longer eligible for curative surgery or local ablative therapies such as radiofrequency ablation or transarterial chemoembolization but have disease limited to the liver and may not need systemic therapy. Furthermore, combination therapies as well as sequential approaches appear to be very attractive options for the management of liver tumours. This may include a combination of selective internal radiation therapy with all other therapeutic measures, i.e. resection and adjuvant chemotherapy, combined chemotherapy and local-ablative therapy, sequential therapy with different modalities as selective internal radiation therapy, transarterial chemoembolization, systemic therapy, and even resection/transplantation after successful downstaging.
