Page 191 - ebook HCC

188 PROGRAMME AND ABSTRACTS GENEVA, SWITZERLAND EASL HCC SUMMIT 189
FEBRUARY 13 - 16, 2014

RADIOEMBOLIZATION SORAFENIB AND NEW DRUGS IN FIRST
LINE IN HCC
Bruno Sangro 1
1 Liver Unit, Clinica Universidad de Navarra, and Centro de Investigacion Biomedica en
Red de Enfermedades Hepaticas y Digestivas (CIBEREHD), Pamplona, Spain Andrew X. Zhu 1
1 Massachusetts General Hospital Cancer Center,
Corresponding author’s e-mail: bsangro@unav.es Harvard Medical School, Boston, United States

Corresponding author’s e-mail: azhu@partners.org
Radioembolization (RE) (also called Selective Internal Radiation Therapy or SIRT) is a form
of intravascular brachytherapy that consists in the injection of radioactive microspheres into
the hepatic arteries with the aim of delivering tumoricidal doses of radiation to liver tumors Advanced HCC carries a poor prognosis and systemic therapy with cytotoxic agents provides
irrespective of their number, size, and location. The lack of a significant ischemic effect allows marginal benefit. Improved understanding of the mechanism of hepatocarcinogenesis
the consideration of RE for patients with macrovascular invasion and thrombosis. Although coupled with the arrival of many newly developed molecularly targeted agents has
well-tolerated by far, some 5-10% of patients may develop radioembolization-induced liver provided the unique opportunity to study some of these novel agents in advanced HCC.
disease (REILD) consisting in liver decompensation with jaundice and ascites.RE has a Despite the successful approval and extensive application of sorafenib, the prognosis for
clear palliative role in the management of hepatocellular carcinoma (HCC) by inducing patients with advanced HCC remains poor and the benefits with sorafenib are modest.
tumor necrosis and delaying progression. Tumor shrinkage occurs almost invariably after In the past few years, there have been renewed and continued interests and active
RE although it may take 3-6 months for the optimal response to manifest and median research in developing other molecularly targeted agents in HCC. While the initial efforts
time to response can consequently be as long as 6 months. Available data suggest the are focusing on anti-angiogenic therapy, other agents targeting the epidermal growth
ability of RE to achieve complete pathological necrosis in similar if not better rates than factor-receptor, mammalian target of rapamycin (mTOR), hepatocyte growth factor/c-Met
conventional TACE.For patients in the intermediate stage, cohort series and comparative among others have entered HCC clinical trials. Combining different molecularly targeted
effectiveness studies (including a small pilot randomized controlled trial) suggest that there agents or combining targeted agents with chemotherapy represent other strategies under
is no survival difference between RE and TACE. Hence, many centers have recognized RE
CLINICAL SPEAKERS ABSTRACTS burden or in those that progress or do not respond well to TACE. Among patients in the advanced HCC and discuss the future perspectives. CLINICAL SPEAKERS ABSTRACTS
investigation. The author will attempt to summarize the current status of other molecularly
as a treatment option in intermediate-stage patients, particularly in those with a high tumor
targeted agents or regimens beyond sorafenib under development in first line therapy for
advanced stage, outcomes are particularly encouraging in those with branch portal vein
thrombosis with overall survival exceeding that reported with the use of sorafenib and a
few patients responding to the point of being downstaged to resection. Importantly, besides
resulting in similar (if not better) survival in this population, RE is devoid of the significant
side effects of Sorafenib.While the European Society of Medical Oncology and the
National Comprehensive Cancer Networks have listed RE as a treatment option for HCC,
the American and European Associations for the Study of the Liver have not. Randomized
studies would probably be required to get RE universally accepted as first-line option in a
defined subgroup of patients with HCC. Several international, randomized controlled trials
are now in progress that investigate the role of RE when added to Sorafenib or examine in
a head-to-head comparison, Sorafenib vs. Y90 in prolonging the survival of intermediate
to advanced HCC patients. And a randomized phase 2 is comparing TACE and Y90 in
intermediate disease with time to progression as primary endpoint.Novel applications of
RE that deserve further research include i) the ability of apply high radiation doses to small
sectors of liver tissue in “radiation segmentectomy”; ii) the ability of right lobe RE to induce
significant contralateral hypertrophy that may enable anatomic liver resections otherwise
contraindicated because of a small future liver remnant; and iii) the ability of RE to allow
downsizing to liver transplantation or percutaneous ablation.