Comparison of tumor response assessment methods in patients with metastatic colorectal cancer after locoregional therapy.

BACKGROUND: We evaluated the performance of the Response Evaluation Criteria in Solid Tumor (RECIST), modified RECIST, and the European Association for the Study of Liver (EASL) guidelines and correlated them with survival in patients with metastatic colorectal cancer (mCRC) treated with locoregional therapy (LRT). PATIENTS AND METHODS: Our LRT registry was evaluated from 2008 to 2013. 228 mCRC patients were treated with LRT (91% drug-eluting beads, 9% radioembolization) were evaluated. Cox regression and Kaplan-Meier (KM) statistics were utilized for survival analysis. RESULTS: Excellent inter-rater agreement between EASL/mRECIST (κ = 905) was seen. Correlations between RECIST/mRECIST (κ = 0.638) and EASL/RECIST were weaker (κ = 0.638 and 0.598, respectively). There were significant differences in KM and Cox regression survivals between responders and nonresponders with all three methods (all P < 0.0001). Multivariate analysis identified RECIST response, tumor extent, performance status, concomitant chemotherapy, and prior surgery/ablation as independent prognostic factors. EASL response and mRECIST response were not found to be independent prognostic factors. CONCLUSION: Imaging biomarkers are not efficient and do not represent ideal surrogates for survival; however, they all display prognostic significance. RECIST is superior to mRECIST/EASL given its ability to stratify survival benefit according to response category and demonstrate independent prognostic significance. J. Surg. Oncol. 2016;113:443-448. © 2016 Wiley Periodicals, Inc.

Transarterial chemoembolization and selective internal radiation for the treatment of patients with metastatic neuroendocrine tumors: a comparison of efficacy and cost.

BACKGROUND: Hepatic arterial therapy (HAT) has been proven to be effective at palliation of hormonal symptoms of metastatic neuroendocrine tumors (NETs), as well as a means of cytoreduction. Recently, the newer modalities of yttrium-90 and drug-eluting beads with doxorubicin (DEBDOX) have been reported to be effective in the treatment of metastatic NETs. The aim of this study was to compare the safety, efficacy, and cost of selective internal radiation with DEB therapy. METHODS: An institutional review board-approved, multicenter, multinational prospective treatment registry to investigate the safety and efficacy of yttrium-90 and doxorubicin microspheres was reviewed. RESULTS: In all, 43 patients underwent a combined 69 HAT treatments, with 15 patients receiving 23 yttrium-90 treatments and 28 patients receiving 46 DEBDOX treatments. The extent of disease-based on the number of lesions, bilobar distribution, patient performance status, and size of largest lesion-was similar in both the yttrium-90 and DEBDOX groups. After a median follow-up of 12 months, response rates were similar with the two treatments, but then there was a significantly lower response rate in the yttrium-90 group at 12 months than in the DEBDOX group. In an evaluation of cost for the two treatments, the median cost for yttrium-90 was $25,243 and the median cost for DEBDOX was $13,400. CONCLUSION: HAT is a safe and effective therapy in patients with unresectable NETs to the liver. The size of the lesions, total lesion volume, and expense of therapy need to be considered when choosing which HAT method is optimal.

Safety of hepatic resection in metastatic disease to the liver after yttrium-90 therapy.

BACKGROUND: Unresectable hepatic metastases from aerodigestive cancers are common and in most cases herald a poor prognosis. A small percentage of patients maybe amenable to surgical resection or ablation once the biology of the disease and the burden of hepatic disease are better understood. The use of hepatic arterial resin microspheres containing the ß emitter, yttrium-90, has been reported in the treatment of unresectable hepatic metastases. The goal of this review was to evaluate the use of yttrium-90 hepatic arterial therapy in the management of hepatic metastases and surgical downstaging. METHODS: We reviewed our prospective hepatic arterial therapy registry and found 44 patients who had received Sir Sphere treatment for unresectable hepatic malignancies from 11/06 to 7/08. Response was assessed by using CT-imaging and characterized using modified response evaluation criteria in solid tumors (RECIST). All patients were managed in a multidisciplinary tertiary referral center specializing in hepatic malignancies. RESULTS: A total of 44 patients, 34 men and 10 women, with a median age of 60 y (range 44-8), received 67 treatments. The disease types treated were one adenosquamous tongue, one adrenal, nine carcinoid, three cholangiocarcinoma, four esophageal, one gastric, one gastrinoma, one GIST, four HCC, 15 colorectal, one melanoma, one non-small-cell lung, one occular, and one sarcoma. Four patients treated proceeded to resection because of downstaging of disease or no evidence of extrahepatic progression. The median age in these patients was 61 y (range 49-62). All of the patients had less than 25% tumor burden in the liver. Surgical therapy consisted of two patients undergoing right hepatic lobectomy, one patient who also underwent two wedge resections of segment 3, and one patient who had a left lateral hepatectomy with right lobe microwave ablation. The median length of postoperative stay was 7 d. There was no evidence of liver dysfunction following resection in any of the patients. None of the patients show evidence of recurrence in the liver following resection. One patient has had progression of disease in the lungs following resection, histologically confirmed as metastatic rectal carcinoma. All of the patients are currently alive with a median survival of 2 y. CONCLUSION: Hepatic directed yttrium-90 is a minimally invasive, highly effective therapy that can be utilized to downstage the hepatic burden and/or assess the biology of the disease to allow for appropriate treatment. The use of yttrium-90 microspheres for radio-embolization of metastases in the liver can successfully downstage the lesions to allow for surgical resection in patients with amenable predictors, and can provide a significantly better prognosis in these patients. This form of therapy for the purposes of downstaging tumors for resection merits more extensive study in order to provide the best possible outcomes for patients with metastatic liver disease.