Liver mets and Y90 radioembolisationTips and Tricks
1
Jens Ricke
Radiology and Nuclear medicine, University of Magdeburg
Potential Serious Adverse Events
CTCAE v3: Common Terminology Criteria for Adverse Events version 3.0
ENRY, Hepatology 2011
Pathophysiology of RILD
• Weight gain in 90 – 95 % • Ascites in 50 – 85%• Bilirubin in 98 % with
– Moderate increase: AST & ALT, intense: AP– Right upper quadrant pain in 50-75%
• Biopsy, hepatic porto-venous pressure
• Incidence 20% in total liver RE*
Clinical criteria of REILD
*Sangro 2008
Risk factors for REILD
Sangro 2008
Recommended Medication
Premedication:20 mg dexamethasone iv (e.g., Fortecortin®)*8 mg ondansetrone iv (e.g., Zofran®)
*Gil-Alzugaray, Sangro et al. Hepatology 2013
Sequential lobar vs. bilobar radioembolisation
Primary endpoint•Hepatotoxicity
Secondary endpoint•Overall survival
REILD: prevention by split dose?
Seidensticker CVIR 2011
12,0%
0,0%
35,0%
18,0%
0%
5%
10%
15%
20%
25%
30%
35%
40%
Ant
eil P
atie
nten
mit
Gra
d 3/
4 To
xizi
tät
6 Wochen3 Monate
bilobar sequential(n=17) (n=17)
Liver toxicity: grade 3 or 4
p=0.4
Seidensticker CVIR 2011
13,210,2
19,1
10,4
52,3
18,7
0
10
20
30
40
50
60
Bili
rubi
n [µ
mol
/l]
vor RE6 Wochen3 Monate
bilobar sequential(n=17) (n=17)
Results: bilirubin
Bilirubin elev. 3months post RE: p=0.02
Seidensticker CVIR 2011
Next step: liver protection
•Current protocol: ELDORADO, NCI 2078864
•Preventive effect of low dose heparine, ursodesoxicolic acid and pentoxyfiline after HDR single fraction irradiation of liver metastases
•Sponsor: University of Magdeburg
•Endpoint: Uptake of Gd-EOB-DTPA at 6 and 12 weeks in relation to dose exposure
Seidensticker, Ricke EASL 2014
Ursodeoxycholic acid3 x 250 mg daily,oral administration
Pentoxiphylline3 x 400 mg dailyoral administration
Enoxaparin1 x 40 mg dailysubcutaneous injection
Study medicationRationale:Improvement of biliary excretion
Improvement of blood flow in sinusoids and ventral veins
Improvement of blood flow in sinusoids and ventral veins
6 weeks 3 monthsafter HDR brachytherapy
beforeHDR brachytherapy
Control Group
No protective medication administered!
Images: Ricke
Medication Group
6 weeks 3 monthsafter HDR brachytherapy
Baseline
Medication given for 8 weeks after therapy!
Images: Ricke
• 56y old male, mCRC, total liver Tx– Salvage post 3rd line, Tu-load 50%
• Weight gain of 6kg • Massive Ascites • Bilirubin 6md/dl
– AST, ALT ↑
– AP ↑ ↑ ↑
Y90-Radioembolisation hazards
Gianturco venous stent
Take home RILD
•Ascites 6 weeks post Y90 RE is not tumor progression!•Recommended treatment:
– Symptomatic relief (e.g. paracenthesis, diuresis)– Treat RILD directly:
• Ursodeoxycholic acid 3 x 250 mg daily• Pentoxiphylline 3 x 400 mg daily• Enoxaparin 40mg s.c.
– Cortisone maybe considered for long term outcome
www.dafmt.com