robert j. lewandowski, ahsun riaz, robert k. ryu, ramona gupta, vanessa l. gates, kent t. sato, reed...

Robert J. Lewandowski, Ahsun Riaz, Robert K. Ryu, Ramona Gupta, Vanessa L. Gates, Kent T. Sato, Reed Omary,

Riad Salem

Northwestern Memorial HospitalChicago, IL

Yttrium-90 Radioembolization for Hepatocellular Carcinoma: Yttrium-90 Radioembolization for Hepatocellular Carcinoma: Comprehensive Analysis of Long-term Outcomes in 291 PatientsComprehensive Analysis of Long-term Outcomes in 291 Patients

DisclosuresDisclosures

Consultant, Advisory Boards, Research Support

• MDS Nordion, Sirtex Medical

YY9090 Radioisotope Radioisotope

• 100% pure beta emitter, 0.9367 MeV100% pure beta emitter, 0.9367 MeV• Physical half-life of 64.2 hPhysical half-life of 64.2 h• Irradiates tissue with average range of 2.5 mmIrradiates tissue with average range of 2.5 mm• Maximum penetration of approx. 1.0 cmMaximum penetration of approx. 1.0 cm• A constituent of an insoluble glass matrixA constituent of an insoluble glass matrix• Microsphere diameter 25Microsphere diameter 25µ - 35µ µ - 35µ

Methodical Approach to Y90: Methodical Approach to Y90: 10 year experience10 year experience

• Investigated each conceptInvestigated each concept– SafetySafety– Angiographic TechniqueAngiographic Technique– Dosimetry Dosimetry – Niche ApplicationsNiche Applications

• Portal vein thrombosisPortal vein thrombosis• Radiation LobectomyRadiation Lobectomy• Radiation SegmentectomyRadiation Segmentectomy

– Lung dose, DistributionLung dose, Distribution– Liver MetastasesLiver Metastases

• CRCCRC• NETNET• Cholangiocarcinoma Cholangiocarcinoma

– Imaging criteriaImaging criteria– Pathologic analyses Pathologic analyses comparison with TACE comparison with TACE– BiomarkersBiomarkers– Long term SurvivalLong term Survival– Combination with Systemic AgentsCombination with Systemic Agents

• CapecitabineCapecitabine• SorafenibSorafenib

Northwestern 5-yr Experience Northwestern 5-yr Experience 291-Patient Cohort291-Patient Cohort

• December 2003 December 2008– Open label protocol: Y90 glass microspheres

• All baseline CT/MR– 1250 CT/MRI scans, total 4.3 scans per patient– Strict imaging definition of metastases at baseline– Comprehensive review at each stage in time for

development of metastases (CT chest, bone scans)– Prospectively followed all patients

RECIST (Uni-dimensional) GuidelineRECIST (Uni-dimensional) Guideline

System Classification Definition

Response Evaluation Criteria in

Solid Tumors (RECIST)

CR100% decrease in maximum diameter of target lesion

PR≥30% decrease in maximum diameter of target lesion

SD<30% decrease to ≤20% increase in maximum diameter of target lesion

PD>20% increase from maximum response of target lesion

Clinical OutcomesClinical Outcomes

• TTP: Progression defined as any of the following: progression by WHO, EASL, UNOS stage or appearance of new lesions

• Survival: from first treatment • Univariate (Kaplan-Meier with Logrank) and

Multivariate (Cox Regression Model) were used

N (%)

Age (years)

< 65 138 (47)

≥ 65 153 (53)

≥ 75 63 (22)

GenderMale 223 (77)

Female 68 (23)

Ethnicity

Caucasian 208 (71)

African American 37 (13)

Asian 29 (10)

Hispanic 17 (6)

Baseline DemographicsBaseline Demographics

N (%)

Etiology

HCV 100 (34)

Alcohol 56 (19)

Cryptogenic 54 (19)

HBV 26 (9)

HCV + Alcohol 23 (8)

NASH 6 (2)

Autoimmune 4 (1.3)

Hemochromatosis 4 (1.3)

HCV + HBV 3 (1)

PBC 1 (0.6)

Unknown 14 (5)

EtiologyEtiology

Imaging CharacteristicsImaging Characteristics

N (%)

DistributionSolitary 78 (27)

Multifocal 213 (73)

Tumor locationBilobar 139 (48)

Unilobar 152 (52)

Morphology

Uninodular & <50% 73 (25)

Multinodular & <50% 180 (62)

Massive or >50% 38 (13)

Tumor Burden

0-25% 223 (76.6)

26-50% 48 (16)

51-75% 19 (7)

76-100% 1 (0.4)

N (%)

PVT

None 166 (57)

Branch 58 (20)

Main 67 (23)

Metastases

None 245 (84)

LN 29 (10)

Other 17 (6)

Imaging CharacteristicsImaging Characteristics

N Mean (Range)

Size

Overall 2917

(1.2-22)

< 5 cm 116 (40)3.4

(1.2-4.9)

5-10 cm 123 (42)7.1

(5-10)

> 10 cm 52 (18)14.9

(10.1-22)

Tumor SizeTumor Size

N (%)

Child Pugh

A 131 (45)

B 152 (52)

C 8 (3)

BCLC

A(n=39)

A1 3 (1)

A2 22 (8)

A3 8 (2)

A4 6 (2)

B 66 (23)

C 178 (61)

D 8 (3)

Baseline StageBaseline Stage

Treatment CharacteristicsTreatment Characteristics

Location Number of Treatments

(N)

Median dose (Gy)

Mean dose (Gy) [Range]

Liver 526 103112

(18-1693)

Lung (per treatment)

526 5.48.8

(0.09-89.9)

Lung (cumulative)

291 9.315.7

(0.09-110)

Adverse Event No. of Patients %

Fatigue 167 57

Abdominal Pain 67 23

Nausea/Vomiting 57 20

Anorexia 45 15

Fever/Chills 10 3

Diarrhea 7 2

Weight Loss 4 1

Clinical ToxicitiesClinical Toxicities

Child’s Class

PVT UNOS NEASL PR

N (%)

WHO PR N (%)

TTPMedian(95% CI)

Overall Survival Median (95% CI)

A

Overall CP A 116 (113) 78 (69) 59 (52) 10.8 (7.4-14) 17.2 (14.9-24)

PVT Absent

Overall 81 (79) 61 (77) 42 (53) 15.5 (10.7-25.9) 22.1 (17.2-32.5)

T1/T2 27 (25) 22 (88) 13 (52) 27.1 (8, -) 20.5 (14.9-27.4)

T3 27 (27) 24 (89) 17 (63) 21.9 (10.9-25.8) 35.7 (18.3-44.4)

T4a 27 (27) 15 (56) 12 (44) 8.6 (6, -) 14.9 (7.3-22.2)

PVT Present

T4b 35 (34) 17 (50) 17 (50) 5.6 (2.3-7.6) 10.4 (7.2-16.6)

B

Overall CP B 122 (114) 59 (52) 44 (39) 8.4 (5.9-12.3) 7.7 (6.5-11.2)

PVT Absent

Overall 65 (64) 43 (67) 30 (47) 13.0 (8.4-18.1) 14.8 (11.8-29.1)

T1/T2 22 (22) 15 (68) 8 (36) 13.0 (6.3-25) 29.1 (17.1, -)

T3 21 (21) 18 (86) 12 (57) 17.4 (8.4-33.9) 38.3 (6.9-41.7)

T4a 22 (21) 10 (48) 10 (48) 8.8 (3.6-18.1) 11.8 (6.2-19)

PVT Present

T4b 57 (50) 16 (32) 14 (28) 5.9 (4.2-7.9) 5.6 (4.5-6.7)

Liver-only diseaseLiver-only disease

Northwestern 5-yr Experience Northwestern 5-yr Experience 291-Patient Cohort291-Patient Cohort

• Significant findings:– 273/291 (94%) of patients had FU imaging– All as outpatients– 58% downstaged T3 T2– 32 transplanted– No GI ulcers

AFP 800AFP 800

AFP 8.0AFP 8.0

Pre treatment Pre treatment AFP AFP 2200 2200

6 months post 6 months post treatment treatment AFP AFP 4.5 4.5

After 2 treatmentsAfter 2 treatments

Pre treatmentPre treatment 22 months22 months

Pre Tx: AFP 1368Pre Tx: AFP 1368

36 months post 36 months post Tx: AFP 9.5Tx: AFP 9.5

Northwestern 5-yr Experience Northwestern 5-yr Experience 291-Patient Cohort291-Patient Cohort

• Continues to be evolving role of Y90 in HCC• Cohort data permits

– Exploratory subgroup analyses• Who benefits• Who doesn’t• Where should research be focused?• Downstaged to potential cures (transplant/resection)• Treatment in portal vein thrombosis patients

• Next considerations– Y90 vs chemoembolization– Y90 +/- Sorafenib (various combinations)

AcknowledgementsAcknowledgements

Radiology:Radiology:Robert LewandowskiRobert LewandowskiReed OmaryReed OmaryBob Ryu Bob Ryu Kent SatoKent SatoPaul NikolaidisPaul NikolaidisFrank MillerFrank Miller

MR Physicists: MR Physicists: Andrew LarsonAndrew Larson

Post-Doc Fellows:Post-Doc Fellows:Saad IbrahimSaad IbrahimAhsun RiazAhsun Riaz

Nurses:Nurses:Karen MarshallKaren MarshallSharon CoffeySharon CoffeyKrystina SalzigKrystina SalzigPeggy GilbertsenPeggy GilbertsenJennifer KarpJennifer KarpElizabeth GondaElizabeth Gonda

Hepatology/Oncology:Hepatology/Oncology:Laura KulikLaura KulikMary MulcahyMary MulcahyWilliam SmallWilliam SmallAl BensonAl BensonMichael AbecassisMichael AbecassisDaniel GangerDaniel GangerSteve FlammSteve Flamm