How to identify better candidate to radioembolization in case of hepatocellular carcinoma and portal vein tumoral thrombosis
Editorial

How to identify better candidate to radioembolization in case of hepatocellular carcinoma and portal vein tumoral thrombosis

Giovanni Battista Levi Sandri1, Michel Rayar2

1Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy; 2Service de Chirurgie Hépatobiliaire et Digestive, CHU Rennes, Rennes, France

Correspondence to: Giovanni Battista. Department of Surgical Sciences, Sapienza University of Rome, Rome 00161, Italy. Email: gblevisandri@gmail.com.

Comment on: Spreafico C, Sposito C, Vaiani M, et al. Development of a prognostic score to predict response to Yttrium-90 radioembolization for hepatocellular carcinoma with portal vein invasion. J Hepatol 2018. [Epub ahead of print].


Submitted Oct 05, 2018. Accepted for publication Nov 08, 2018.

doi: 10.21037/hbsn.2018.11.03


Hepatocellular carcinoma (HCC) is the most common primary liver cancer and the fifth most common malignant tumor worldwide. Liver resection is a curative treatment for HCC and can be safety performed by a minimally invasive procedure in all liver segments without size limitations (1,2).

Nevertheless, some patients are diagnosed with HCC and portal vein tumor thrombosis (PVTT). According to the staging system of the Barcelona Clinic Liver Cancer (BCLC), patients with macrovascular invasion are staged as BCLC-C. For those patients, the prognosis is generally poor. However, the management of HCC with macrovascular invasion is still controversial. Indeed, recent studies proposed different surgical procedure such as one-stage resection or associating liver partition and portal vein ligation, with promising results (3-5).

Trans-arterial radioembolization (TARE) is a type of brachytherapy performed by selective intraarterial injection of yttrium-90 microspheres. This innovative technique has been described as a potential curative or downstaging therapy in the setting of liver transplantation even in patients with PVTT (6,7).

We read with great interest the manuscript entitled “Development of a prognostic score to predict response to yttrium-90 radioembolization for hepatocellular carcinoma with portal vein invasion” written by Dr. Spreafico et al. (8).

Authors present a retrospective single center study on 120 patients with HCC and PVTT, receiving TARE as elective treatment. Median age at TARE treatment was 64 years with a MELD score of 8. All patients were classified as BCLC-C, and the PVTT was graded as segmentary (PV1), secondary order branch (PV2) and first-order branch (PV3) in 53 (44.2%), 37 (30.8%) and 30 (25%) patients respectively. The median tumor diameter was 7.3 cm.

The authors reported a median overall survival of 14.1 months, without any death at 30 days after first dose treatment. The 1- and 3-year survival rates were 53.2% and 18.5% respectively. Only one patient was treated with a curative intent after TARE undergoing liver transplant. The majority of progression were observed into the liver (76.6%).

The authors developed a prognostic classification allowing to identify which patients would benefit from TARE. Bilirubin (cutoff 1.2 mg/dL =0 or 2 points), PVTT grade (PV1-2-3=0, 2 or 3 points) and tumor burden (cutoff 50% liver volume =0 or 3 points) at the time of TARE were the three variables independently correlated with survival. Thus, 3 prognostic categories were proposed: favorable prognosis (0 points), intermediate prognosis (2–3 points) and dismal prognosis (>3 points). The three categories had a median overall survival of 32.2, 14.9 and 7.8 months respectively.

According to the presented prognostic classification physicians may propose TARE in those patients with low bilirubin, PVTT grade PV1 and tumor burden inferior of 50% of liver volume. Those patients may be in a second-period candidate for liver resection or liver transplantation. In this way TARE would become an alternative bridge or downstaging therapy to transplantation (9,10). Furthermore, other studies have shown that TARE has a better response rate compared to TACE in patients with an advanced BCLC stage (11,12).

Nonetheless, no prospective comparison of liver resection versus systemic treatments or TARE has ever been reported (13).

Authors describe for patients with 0 points (absence of adverse prognostic factors) a median overall survival of 32.2 months and a median progression-free survival of 14.1 months. As suggested by authors and previously described in others series, the downstaging observed after TARE, could lead to a curative treatment in a patient with PVTT with subsequent liver transplant (6,10-14).

Radioembolization is playing a role in the therapeutic algorithm of HCC for BCLC class A, B, and C. If we consider the possibility of downstaging HCC patient with PVTT, many patients could have a chance to be cured. Indeed, in front of these promising results, prospective comparative studies are needed to reinforce and confirm these preliminary results. In an alternative to accepted palliative treatment, the score from Spreafico et al. suggest in which patient to date a TARE treatment will be useful. For patients with a score over 3 points, authors suggest performing conventional palliative therapy. Multiple cases series have been reported worldwide even in patients with PVVT in a first-order branch (7). Maybe for those patients personalized dosimetry or sequential multiple TARE procedure will be helpful.


Acknowledgements

None.


Footnote

Conflicts of Interest: The authors have no conflicts of interest to declare.


References

  1. Levi Sandri GB, Ettorre GM, Aldrighetti L, et al. Laparoscopic liver resection of hepatocellular carcinoma located in unfavorable segments: a propensity score-matched analysis from the I Go MILS (Italian Group of Minimally Invasive Liver Surgery) Registry. Surg Endosc 2018. [Epub ahead of print].
  2. Levi Sandri GB, Spoletini G, Vennarecci G, et al. Laparoscopic liver resection for large HCC: short- and long-term outcomes in relation to tumor size. Surg Endosc 2018. [Epub ahead of print]. [Crossref] [PubMed]
  3. Kokudo T, Hasegawa K, Matsuyama Y, et al. Survival benefit of liver resection for hepatocellular carcinoma associated with portal vein invasion. J Hepatol 2016;65:938-43. [Crossref] [PubMed]
  4. Levi Sandri GB, Lai Q, Rayar M, et al. ALPPS procedure for hepatocellular carcinoma with macrovascular thrombosis: a new opportunity? J Hepatol 2015;62:241-2. [Crossref] [PubMed]
  5. Vennarecci G, Laurenzi A, Santoro R, et al. The ALPPS procedure: a surgical option for hepatocellular carcinoma with major vascular invasion. World J Surg 2014;38:1498-503. [Crossref] [PubMed]
  6. Levi Sandri GB, Ettorre GM, Colasanti M, et al. Hepatocellular carcinoma with macrovascular invasion treated with yttrium-90 radioembolization prior to transplantation. Hepatobiliary Surg Nutr 2017;6:44-8. [Crossref] [PubMed]
  7. Levi Sandri GB, Ettorre GM, Giannelli V, et al. Trans-arterial radio-embolization: a new chance for patients with hepatocellular cancer to access liver transplantation, a world review. Transl Gastroenterol Hepatol 2017;2:98. [Crossref] [PubMed]
  8. Spreafico C, Sposito C, Vaiani M, et al. Development of a prognostic score to predict response to Yttrium-90 radioembolization for hepatocellular carcinoma with portal vein invasion. J Hepatol 2018. [Epub ahead of print]. [Crossref] [PubMed]
  9. Mazzaferro V, Sposito C, Bhoori S, et al. Yttrium-90 radioembolization for intermediate-advanced hepatocellular carcinoma: a phase 2 study. Hepatology 2013;57:1826-37. [Crossref] [PubMed]
  10. Ettorre GM, Levi Sandri GB, Santoro R, et al. Bridging and downstaging to transplantation in hepatocellular carcinoma. Future Oncol 2014;10:61-3. [Crossref] [PubMed]
  11. Sangro B, Carpanese L, Cianni R, et al. Survival after yttrium-90 resin microsphere radioembolization of hepatocellular carcinoma across Barcelona clinic liver cancer stages: a European evaluation. Hepatology 2011;54:868-78. [Crossref] [PubMed]
  12. Salem R, Gordon AC, Mouli S, et al. Y90 Radioembolization Significantly Prolongs Time to Progression Compared With Chemoembolization in Patients With Hepatocellular Carcinoma. Gastroenterology 2016;151:1155-63.e2. [Crossref] [PubMed]
  13. Giovanardi F, Lai Q, Bertacco A, et al. Resection for hepatocellular cancer: overpassing old barriers. Transl Gastroenterol Hepatol 2018;3:64. [Crossref] [PubMed]
  14. Ettorre GM, Levi Sandri GB, Laurenzi A, et al. Yttrium-90 Radioembolization for Hepatocellular Carcinoma Prior to Liver Transplantation. World J Surg 2017;41:241-9. [Crossref] [PubMed]
Cite this article as: Levi Sandri GB, Rayar M. How to identify better candidate to radioembolization in case of hepatocellular carcinoma and portal vein tumoral thrombosis. Hepatobiliary Surg Nutr 2019;8(1):63-64. doi: 10.21037/hbsn.2018.11.03