Real-life experience with selective internal radiation therapy (SIRT) in multimodality treatment of advanced hepatocellular carcinoma (HCC)

Introduction:

Radioembolization by Yttrium-90 Selective Internal Radiotherapy (⁹⁰Y SIRT) is associated with a similar survival as the multikinase inhibitor sorafenib in patients with intermediate- to advanced-stage hepatocellular carcinoma (HCC). However, the role of SIRT in the multimodal treatment for HCC is not well defined. We have retrospectively assessed the efficacy and safety of SIRT in patients with advanced HCC receiving different sequential treatments.

Methods:

109 patients (87 male, mean age 64 ± 0.9 (range, 36 – 85) years, 73 with liver cirrhosis Child-Pugh A (n = 60), B (n = 12) or C (n = 1)) with advanced HCC who had received SIRT (1, 2 and 3 applications in 89, 19 and 1 patient; mean dose, 3,365 ± 1,902 GBq, 90Y glass microspheres) in terms of a multimodal HCC treatment approach between 2012 and 2016 in one center were retrospectively analysed. Before SIRT, BCLC scores A1, A2, A4, B and C applied to 2, 6, 5, 67 and 25, ECOG scores 0 – 3 in 56, 27, 8 and 1, ALBI scores 1 – 3 in 55, 47 and 5 and CLIP scores 1 to 3 in 12, 74 and 11 patients, respectively. HCC was present in the left, right or in both liver lobes in 12, 40, and in 52 patients. Before or after SIRT, transarterial chemoembolization was performed in 44 and 19 patients, and sorafenib treatment in 25 and 24 patients, respectively. Three patients received liver transplantation after SIRT.

Result:

The mean overall survival (OS) after first diagnosis of HCC was 21 ± 1.5 (range, 2 – 78) months, as compared to 19 months estimated by CLIP score, and 12 patients survived longer than 36 months. After first SIRT the mean OS was 10 ± 0.96 (range, 0 – 54) months, and 45 patients (49%) showed radiological response. The mean time to progression after SIRT was 5.9 ± 0.7 (range, 0 – 54) months. Risk factors for shorter OS were liver adverse events (increase in ALT > 5 times over baseline or worsening in Child-Pugh score) (p = 0.002) and an ALBI score of 3 at baseline (p = 0.004). Liver toxicity was diagnosed in 6 patients (7%), and associated with elevated gGT (p = 0.027) or ALT (p = 0.023) before, and an ALBI score of 3 after SIRT (p = 0.032).

Conclusion:

SIRT as part of a multimodal treatment approach was safe and associated with a promising OS when compared to predicted survival by the CLIP score.