Drug-Eluting Beads on Thyroid Cancer Metastasis: Early Experience of an Oncological Center

Drug-Eluting Beads on Thyroid Cancer Metastasis:Early Experience of an Oncological Center

Dr ANTONIO MANCA MD, PhD

Istituto per la Ricerca e la Cura del Cancro Candiolo (Torino)Interventional Radiology UnitChief: Dr G.C.AnselmettiRadiology Dept - Chief Dr D.Regge

Drug-Eluting Beads on Thyroid Cancer Metastasis:VERY Early Experience of an Oncological Center

Dr ANTONIO MANCA MD, PhD

Istituto per la Ricerca e la Cura del Cancro Candiolo (Torino)Interventional Radiology UnitChief: Dr G.C.AnselmettiRadiology Dept - Chief Dr D.Regge

Drug-Eluting Beads on Thyroid Cancer Metastases

Thyroid Cancer is found in one third of autoptic specimen*is found in one third of autoptic specimen*

- < 5% of thyroid nodules undergone FNA are T. cancer- < 5% of Thyroid cancer gives distant metastases< 5% of Thyroid cancer gives distant metastases

-75%-85% papillary cancer with no mets or just N+- most of distant mets to lungs and bone

0,5 % of patients with Thyroid Cancer have liver metastases0,5 % of patients with Thyroid Cancer have liver metastases(up to 50% of pts w/ medullary thyroid cancer: 5-8% of ThyCa)

* Harach et al. "Occult papillary carcinoma of the thyroid. A "normal" finding in Finland. A systematic autopsy study.” Cancer 1985 56 (3): 531–8


Male Patient, 70 y.o.

1998 - Radical Prostatectomy for AdenoCarcinoma

2000 - Local recurrence: RT 70Gy and Casodex (ongoing, PSA t: 0,1-0,3)

2009 - Neck palpable nodule

US: Thyroid node (25 mm) on right lobe Biopsy: HURTHLE CELL CARCINOMA

March 2009: Total Thyroidectomy (pT2pN0) and I 131

July 2009:

- CT and PET-CT: multiple liver mets (biopsy: Hurthle cell Ca)

- Initial local recurrence and single cervical lymph node met

- No indication to I131 therapy unresponsive: - brief disease free survival

- no I131 uptake of mets(like most of Hurhle cell Ca)


Nov 2009:Nov 2009: liver PR (31mm vs 40 mm)liver PR (31mm vs 40 mm) Feb 2010: liver PD (50 mm vs 31 mm)Feb 2010: liver PD (50 mm vs 31 mm)

Sept 2009: Sept 2009: SORAFENIB (400 mg/day)SORAFENIB (400 mg/day)

Phase II Trial of Sorafenib in Advanced Thyroid CancerGupta-Abramson et al. JCO 2008 Vol 26, No 29: 4714-4719

30 pts - 77% overall clinical benefit (23% PR and 54% SD)



Chemotherapy with Doxorubicin in Progressive Medullary and Thyroid Carcinoma of the Follicular EpiteliumMatuszczyk et al. Horm Metab Res 2008; 40: 210-213

SIE-AIMN-AIFM (Italian) Guidelines for Thyroid Cancer Treatment: SIE-AIMN-AIFM (Italian) Guidelines for Thyroid Cancer Treatment: TACETACE (and/or RFA) for (and/or RFA) for unresectable liver metastasesunresectable liver metastases (treatment of liver mets not mentioned in American guidelines)(treatment of liver mets not mentioned in American guidelines)

DoxorubicinDoxorubicin in metastatic thyroid cancer in metastatic thyroid cancer::Bonadonna et al. Cancer Res 1970 Bonadonna et al. Cancer Res 1970 Gottlieb Cancer 1972 Gottlieb Cancer 1972 Haugen et al. Semin Surg Oncolm 1999Haugen et al. Semin Surg Oncolm 1999Sherman et al. (M.D.Anderson Cancer Center) Clinical Oncology 2010Sherman et al. (M.D.Anderson Cancer Center) Clinical Oncology 2010

22 pts. 27 % Hurthle-cell tumors 5% PR, 42% SD, 53% PDSide effects: Hair loss (42%), Nausea (23%), Resp. Infection (13%), Neutropenia (10%) Pneumonia (7%)


Lorenz et al. Surgery 2005 vol. 138 (6) pp. 986-93

Fromigue‘ et al. J Clin Endocrinol Metab 2006 vol. 91 (7) pp. 2496-9

11 Patients:TACE with Lipiodoland Doxorubicin

12 Patients:TACE with Lipiodoland DoxorubicinPR 42%, SD 42%


DEB-TACE


Varela et al. J Hepatol, 2007

C-TACE

Lesson learned from HCC…

Chemoembolization (TACE) with 100-300 micron DC Beads loaded with 37,5 mg/mL of DOXORUBICIN

First selective TACE with 100mg of Doxorubicinon the main lesion in segment VIII (5 cm)

CEUS pre-TACE CEUS post-TACE

During-TACEFentanilMidazolam

Post-TACETramadolOndasetron

Pre-TACEOndasetronRanidil

Prednisone


March-June 2010: 4 selective TACE sessions (40 -100mg di Doxorubicin per session, 3-4 weeks intervals)

No major complicationsGood compliance for the first three sessions G2 Pain, nausea and vomiting in the last session


Pre-TACE: CT and PET-CT

3 monts Post-TACE: CT and PET-CT


PRE-TACE PET-CT

3 Months POST-TACE PET-CT: Local relapse and bone mets


July 2010 - CT and PET-CT:July 2010 - CT and PET-CT:

Size decrease and good necrosis of bigger lesions Size decrease and good necrosis of bigger lesions (34 mm vs (34 mm vs 50 mm) with 50 mm) with minor viable tissue percentage minor viable tissue percentage (10% in S8)(10% in S8)

Complete necrosis of smaller lesions treatedComplete necrosis of smaller lesions treatedbut…but…

Neck local relapse and cervical node metastasisNeck local relapse and cervical node metastasis Bone metastases (detectable only with PET-CT)Bone metastases (detectable only with PET-CT)


The metastatic disease is no longer“Liver dominant”The metastatic disease is no longer“Liver dominant”

No more DEB-TACE sessionsNo more DEB-TACE sessions

“TAKE HOME MESSAGE”

DEB-TACE with DC Bead in this preliminary experience of metastatic Hurthle cell Carcinoma showed:

- Safety- Good patient compliance - Local control of liver metastases

despite extrahepatic progression



Mild neck discomfortModerate sciatic pain

Pain and discomfort relief afterRadiotherapy on Neck and L4-L5

ECOG 0, PS 90%Liver function not impaired


6Months

12Months

New lesions Treated lesions

Synergic effect of DEB-TACE + Sorafenib (ongoing) ?

“LESSON LEARNED”

DEB-TACE with DC Bead in this preliminary experience of metastatic Hurthle cell Carcinoma:

- Safe and effective in liver disease control

- Should be repeated until disappearance of viable tissue

- Uncertain benefit of adjuvant anti-neoangiogenic therapy


… waiting for SPACE trial

Aknowledgements

Dr. Camillo Aliberti

Dr. Gianluca Stoppa (TERUMO Italy)

www.chemioembolizzazione.it (site under construction)

[email protected]

Bigger Bead available on the market: 120mm size

First Man-Eluting Bead loadable with a medium size IR

- Safe- Comfortable

Documents

Drug-Eluting Beads on Thyroid Cancer Metastasis: Early Experience of an Oncological Center