IAEA RTC on Hybrid Imaging – Baltic Congress of Radiology S elective I nternal R adio-T herapy (SIRT) or T rans-A rterial R adio-E mbolization (TARE) Giuliano Mariani Regional Center of Nuclear Medicine University of Pisa, Pisa, Italy Parnu (Estonia), October 6 – 11, 2014
49
Embed
Selective Internal Radio-Therapy (SIRT) or Trans-Arterial Radio ... · IAEA RTC on Hybrid Imaging –Baltic Congress of Radiology Selective Internal Radio-Therapy (SIRT) or Trans-Arterial
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
IAEA RTC on Hybrid Imaging – Baltic Congress of Radiology
Abnormal ~20–40% particularly in combination none normallyLFTs1–6% grade 3–4 with chemo or HCC/cirrhosis; required
transient; resolves indays (ALT, AST), weeks
(bilirubin) or months (alb.)
SIRT: side effects - risks
Irene Burger
SAE Incidence Characteristics Prevention/action
Radiation ~5–10% non-target administration; meticulous technique &gastritis or 1–2% grade 3–4 immediate, severe occlusion of GI arteries;duodenitis unremitting pain prophylactic PPI for 1 mo
Radiation <1% non-target administration; meticulous technique &pancreatitis immediate, severe occlusion of GI arteries
unremitting pain
Radiation <1% non-target administration; various technicalcholecystitis right upper quadrant pain approaches; may require
cholecystectomy
Radiation- <1% excess radiation to normal liver; appropriate dose;Induced Liver onset typically 30–90 d post-SIRT; dose reduction inDisease (RILD) permanently elevated LFTs, portal patients with reduced
hypertension, eventual fibrosis hepatic reserve
SIRT: side effects - risks
Irene Burger
99mTc-MAA
90Y-Bremsstrahlung SPECT/CT
90Y-PET/CT
24-04-2013
31-05-2013 03-07-2013
02-10-2013
24-04-2013
Pre-treatment
4 months post-treatment
Clarck ME, Smith RR. Liver-directed therapies in
metastatic colorectal cancer. J Gastrointest Oncol. Oct
2014; 5: 374-387
•The response rates are 12.9-35.5%, with 24-65%
achieving stable disease.
•The median OS following 90Y is 10.2-12.6 months.
•This is achieved in patients who have failed all lines
of chemotherapy.
(Kennedy AS et al. Int J Radiat Oncol Biol Phys 2006;
Jakobs TF et al. J Vasc Interv Radiol 2008 Cianni R et
al. Cardiovasc Intervent Radiol 2009; Cosimelli M et al.
Br J Cancer 2010; Steel JL, et al. Int J Surg Oncol
2011; Bester L et al. J Vasc Interv Radiol 2012).
Braat AJ, et al. Hepatic radioembolization as a bridge to
liver surgery. Front Oncol. 2014 Jul 30;4:199.
Trans-arterial treatment of liver malignancies with RE is an
emerging treatment modality. RE is predominantly performed in
patients with no curative options, mostly in a salvage setting.
Potentially curative settings in which RE may be applied include
downstaging patients to resec disease, a bridge to transplantation
and induction of remnant liver hypertrophy. RE involves a
combination of tumor reduction and disease control, minimizing
the chance of tumor progression during the time interval prior to
liver surgery with curative intent. This may eventually lead to
prolonged survival, although prospective controlled trials are
needed to test this hypothesis. Imaging is indispensable for patient
selection and dosimetry-based treatment planning to use the full
potential that RE has to offer in patients with liver malignancy,
especially when liver surgery with curative intent might still be an
option.
Control group: 43 ± 8 months
SIR-Spheres microspheres 35 ± 16 months
n Median Survival
P < 0.001
supportive care only
active treatment
0
1.0
0.75
0.5
0.25
Act
uar
ial S
urv
ival
0 126 18 24 30 36
Months after Diagnosis
42
First-Line for HCC: SIRT versusSupportive Care
D'Avola et al . Hepato-gastroenterology 2009; 56: 1683–1688.
SIRT – clinical outcome: NET
LIVER METASTASES FROM NEUROENDOCRINE TUMORS: • Commonly high arterial perfusion• Overall better response rate compared to TACE or
chemotherapy.
Kennedy et al, Am J Clin Oncol 2008;31:271-9
Investigator n ORR SD Median Survival
>1st-line to treatment-refractory disease
Kennedy 148‡ 63.2% 22.7% 70 mo median
King 34 50% 14.7% 59% at 35.2 mo
Saxena 48 54% 23% 35 mo
Cao 58‡ 39.2% 27.4% 36 mo
Meranze 10 40% 60% 70% at 28 mo
Jakobs 25‡ 20.8% 75% 96% at 12 mo
Irene Burger
Only one retrospective trial with 46 patients with NET (G1/G2) – 19 SIRT patients versus 27 TACE patients
Gray et al. Ann Oncol 2001;12:1711–20. van Hazel et al. J Surg Oncol 2004;88:78–85Sharma et al. J Clin Oncol 2007;25:1099–106. Kosmider et al. J Vasc Interv Radiol 2011;
22:780-786. Tie et al. ESMO, Ann Oncol 2010;21(Suppl 8): Abs. 698.
Irene Burger
0
0.2
0.4
0.6
0.8
1
0 6 12 18 24 30 36Months from randomisation
Pro
port
ion s
urv
ivin
g
van Hazel et al. Journal of Surgical Oncology 2004; 88: 78–85.
Hazard Ratio 0.33 (95% CI 0.12–0.91)P =0.025
12.8 months5FU/LV
29.4 months5FU/LV + SIR-Spheres
Median Survivaln = 21
First line mCRC: SIRT/5FU vs 5/FU
Irene Burger
Eligible Patients:
•Unresectable liver-only or liver-predominant metastatic CRC
•No prior chemotherapy for mCRC
•Fit for combination therapy and SIRT
SIR-Spheres †
Secondary endpoints: ٠ PFS in liver٠ Overall survival٠ Response rate٠ Quality of life٠ Recurrence rate٠ Toxicity and safety