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This single-center retrospective study evaluated patients who underwent treatment of a primary or secondary hepatic malignancy with injection of glass or resin yttrium-90 (90Y) microspheres with a corresponding hybrid angiography-computed tomography (angio-CT) and 90Y positron emission tomography (PET). Volumetric contours were defined by three independent observers and were used to calculate relative tumoral enhancement at angio-CT. This parameter was compared with the tumor-to-normal (T/N) activity ratio predicted by technetium-99m macro-aggregated albumin (99mTc-MAA) single photon emission computed tomography (SPECT) and microsphere activity distribution by 90Y PET. A similar correlation was observed for the enhancement ratio at angio-CT with observed microsphere distribution at 90Y PET (r=0.34) to that predicted by 99mTc-MAA SPECT (r=0.32). The enhancement ratio on angio-CT performed as well as 99mTc-MAA in the prediction of 90Y PET activity distribution. The technique could not be readily applied to tumors with large areas of hypoattenuation (necrosis) on angio-CT. With refinement and further study, this technique could be used as a quantitative adjunct to standard-of-care 99mTc-MAA SPECT for dosimetry calculations and prediction of microsphere distribution to maximize tumor response and minimize hepatotoxicity.
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Purpose The study aimed to evaluate the adverse event (AE) and hepatotoxicity profile, including radioembolization induced liver disease (REILD), following repeat radioembolization (RE) to the same or overlapping vascular territories in patients with hepatocellular carcinoma (HCC) and limited functional hepatic reserve/cirrhosis. Methods Nine patients (seven male and two female; median age, 66 years) with cirrhosis and HCC who underwent repeat RE (cycle 1 and cycle 2) between January 2012 and August 2019 were included. Patient demographics, clinical and treatment history, and pertinent laboratory values were recorded at baseline and post-treatment time points over a period of four months. Post-RE AE/hepatotoxicity was assessed, organized by type and frequency, and graded by severity according to the National Cancer Institute common terminology criteria for adverse events, version 5.0 (CTCAE v5.0). To assess rudimentary comparisons for post-RE hepatotoxicity vs. factors of interest, Spearman's rank correlation/rho was calculated, and all relevant plots were constructed. Kaplan-Meier analysis was performed along with associated median survival time. All statistical analyses were performed with Stata v16.1. Results Following cycle 1, 22 objective AE were identified according to CTCAE v.5 (17 grade I, four grade II, and one grade III), with grade I, II, and III AE experienced by 78%, 33%, and 11% of patients, respectively. Following cycle 2, 19 objective AE were identified according to CTCAE v.5 (11 grade I, seven grade II, and one grade III), with grade I, II, and III AE experienced by 89%, 56%, and 11% of patients, respectively. A single patient developed REILD after cycle 1, which progressed to fatal REILD following cycle 2. Following cycle 2, an additional patient advanced from less severe hepatotoxicity to REILD. Following cycle 2, positive correlations between the higher model for end-stage liver disease (MELD; rho=0.70) and Child-Pugh (rho=0.74) scores and degree of post-RE hepatotoxicity/REILD appear to emerge. Post-repeat RE median overall survival was 12.5 months. Conclusion Post-RE hepatotoxicity following repeat RE to the same or overlapping vascular territories in patients with limited functional hepatic reserve/cirrhosis is a common occurrence with variable severity ranging from transient laboratory derangement to fatal REILD. Lack of a consensus REILD definition and grading scale results in non-uniform reporting of incidence as well as clinical and laboratory features of the disease process. Strides aimed at improving clinical characterization, forming a more complete diagnostic definition, and establishing a uniform grading system with respect to REILD are of particular importance and would ultimately improve repeat RE patient selection and risk management.
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Trans-arterial radioembolization (TARE) with Y-90 microspheres is an endovascular, liver-directed therapy suitable for treatment of locally advanced hepatocellular carcinoma (HCC) often as a way to reduce tumor size and bridge patients to resection or liver transplant. Opdivo®, or nivolumab, a programmed cell death protein 1 (PD-1) inhibitor, is an immunotherapeutic drug approved in September 2017 for the treatment of HCC in patients who have received prior sorafenib. We report on a patient with hepatocellular carcinoma with right and left portal vein involvement, bony metastasis, and possible lung metastasis. The patient showed a significant response following consecutive treatment with TARE, sorafenib, and nivolumab. Our case suggests that TARE, sorafenib, and nivolumab may have a synergistic effect on the immune response to HCC.
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We describe a case of mixed liposarcoma of the axilla presenting as a high grade undifferentiated sarcoma with areas of well-differentiated and myxoid liposarcoma. MRI demonstrated a lobulated, septated intermuscular mass with marked heterogeneous gadolinium enhancement. A small focus of the tumor demonstrated fat suppressed signal more characteristic of well-differentiated liposarcoma. Pathologic analysis following wide local excision revealed a large, high grade sarcomatous component with highly pleomorphic cells with a thin rim of well-differentiated and myxoid liposarcoma on histologic examination. Dedifferentiated liposarcomas arising outside of the retroperitoneum are very rare, as are dedifferentiated liposarcomas arising from a histologically mixed liposarcoma. In this regard, this case illustrates an unusual combination of tumor location and histology which, to our knowledge, has not previously been reported.
