Predictors of Longer Survival after Radioembolization in Unilobar and Bilobar Advanced Hepatocellular Carcinoma with Yttrium-90

Background: Hepatocellular carcinoma (HCC) is a common cancer that typically occurs in liver cirrhosis. Incidence is expected to increase dramatically in the next few decades. Less than 10% of newly diagnosed tumors outside of screening programs can be curatively resected. Sorafenib is the standard treatment for advanced stage HCC, however, there is to date no consensus on second line therapy and alternative treatment options. Radioembolization (RE) with Yttrium-90 microspheres is a novel transarterial treatment option for patients with advanced HCC. Careful patient selection is a key factor for success with RE. Hepatic functional reserve seems to be one of the most important variables to consider predictors of longer survival before treatment with radioembolization in advanced HCCs.

Patients and Methods: During the time between November 2010 and March 2014, 202 consecutive patients with unresectable HCC were included either after TACE failure or with locally advanced HCC. Radioembolization with Yttrium-90 glass microspheres was performed in a lobar fashion through the right or left hepatic artery. In bilobar disease, right and left liver lobe were treated within 4 – 6 weeks intervals in between. The mean radiation dose was 127 (+/-29) Gy per treatment. Median survival time was considered as main endpoint with further subgroup clinical and biochemical analyses among unilobar and bilobar HCCs.

Results: Among 202 patients with advanced HCC treated by 334 sessions of radioembolization using Yttrium-90 glass microspheres (mean: 1.5 sessions/patient). Unilobar advanced HCC was presented in 85 (42%) patients and bilobar advanced HCC in 117 (58%). In unilobar HCC, serum AST level and CRP displayed together important predictors for survival during baseline before treatment with radioembolization. In low AST & CRP 36/85 (42%) median survival was 20.1 months (95CI:14.5 – 25.6); in high AST & low CRP 3/85 (4%) was 15.3 months (95CI:10.5 – 19.8); in low AST and high CRP 38/85 (45%) was 9.0 months (95CI:5.2 – 12.7); and in high both AST & CRP 8/85 (9%) was 1.9 months (95CI:0.0 – 5.2) which predicts the worst survival possibility with P value < 0.001. On the other hand in bilobar HCC, multivariant analysis showed that BCLC stage and abdominal ascites had significant impact on long term survival. Thus, the median survival time in bilobar HCC in Child A patients in the absence of ascites, was 18.4 months (95CI:13.4 – 23.3) in BCLC-B with normal CRP versus 11.1 months (95CI:4.7 – 13.7) in high CRP patients; and was 8.5 months (95CI:5.4 – 11.7) in BCLC-C with normal CRP versus 5.8 months (95CI:3.8 – 7.7) in high CRP patients, with P value 0.01. CRP and AST were valuable predictors for better survival in unilobar HCC, while BCLC tumor stage and the presence of ascites in addition to CRP had shown significant influence on the overall survival in bilobar HCC. The main obvious adverse events were transient fatigue-syndrome without any clinical impact. Grade 3 – 4 biochemical toxicities occurred more obvious after the second treatment session in bilobar HCC.

Conclusions: The number of HCC lesions, AST and CRP levels act as positive predictors for longer survival within unilobar HCC, while BCLC stage and ascites act as negative predictors in bilobar HCC.

 

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El Fouly, Amr

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