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Two articles in the latest issue of JVIR address downstaging HCC with drug-eluting bead chemoembolization and selective internal radiotherapy with Y-90. Downstaging is often used in regions where transplantation lists are extensive. The following are abstract summaries of the two articles. Questions for discussion: Do you perform downstaging at your institution? What technique do you tend to use and why?
Article 1:
Downstaging Disease in Patients with Hepatocellular Carcinoma Outside of Milan Criteria: Strategies Using Drug-eluting Bead Chemoembolization
Green TJ, Rochon PJ, Chang S, et al.
22 patients remained in a retrospective single-center analysis, 17 of whom experienced downstaging to Milan criteria (7 went to transplant, 1 remained on the transplant list, 6 had disease progression, 2 underwent conventional chemoembolization and 1 radiofrequency ablation. The patients who were downstaged and those who weren't had similar age, MELD. They did not find an association with ECOG, tumor burden, presence of multiple tumors, or hepatitis C infection (p > 0.05 for all of them). Baseline AFP did differ btw those who survived and those who didn't (p=0.02), however, this did not persist with progression free survival (p = 0.62).
Article 2:
Yttrium-90 Radioembolization as a Bridge to Liver Transplantation: A Single-Institution Experience
Tohme S, Sukato D, Chen HW, et al.
22 Y-90's performed in 20 patients before transplantation. 3.5 months median time from first therapy to transplant. 14 pts met Milan criteria at first treatment and 6 did not (number of patients for downstaging low, especially in comparison with the first article). All 14 under Milan criteria remained before transplant and 2 of the 6 were downstaged. 9 patients meeting mRECIST criteria who had complete or partial response. 5 of the 14 patients who met Milan criteria had no evidence of tumor on path.
At our institution, we use conventional TACE, DEB-TACE and Y-90, depending on specific features. Interestingly, we've had several cases of patients with portal vein tumor thrombus who were downstaged with Y-90. We've also had several Y-90 cases where the pathologists reported absence of viable tumor on path.
Article 1:
Downstaging Disease in Patients with Hepatocellular Carcinoma Outside of Milan Criteria: Strategies Using Drug-eluting Bead Chemoembolization
Green TJ, Rochon PJ, Chang S, et al.
22 patients remained in a retrospective single-center analysis, 17 of whom experienced downstaging to Milan criteria (7 went to transplant, 1 remained on the transplant list, 6 had disease progression, 2 underwent conventional chemoembolization and 1 radiofrequency ablation. The patients who were downstaged and those who weren't had similar age, MELD. They did not find an association with ECOG, tumor burden, presence of multiple tumors, or hepatitis C infection (p > 0.05 for all of them). Baseline AFP did differ btw those who survived and those who didn't (p=0.02), however, this did not persist with progression free survival (p = 0.62).
Article 2:
Yttrium-90 Radioembolization as a Bridge to Liver Transplantation: A Single-Institution Experience
Tohme S, Sukato D, Chen HW, et al.
22 Y-90's performed in 20 patients before transplantation. 3.5 months median time from first therapy to transplant. 14 pts met Milan criteria at first treatment and 6 did not (number of patients for downstaging low, especially in comparison with the first article). All 14 under Milan criteria remained before transplant and 2 of the 6 were downstaged. 9 patients meeting mRECIST criteria who had complete or partial response. 5 of the 14 patients who met Milan criteria had no evidence of tumor on path.
At our institution, we use conventional TACE, DEB-TACE and Y-90, depending on specific features. Interestingly, we've had several cases of patients with portal vein tumor thrombus who were downstaged with Y-90. We've also had several Y-90 cases where the pathologists reported absence of viable tumor on path.