Amit Singal, MD: Use of Selective Internal Radiation Therapy in a uHCC Patient

Would you consider using Selective Internal Radiation Therapy (SIRT) in this patient (i.e., Yttrium-90 spheres)?

This is actually a big debate in the field in terms of when you should use chemoembolization and when you should use radioembolization. Unfortunately, there are very few studies that can really guide the choice between chemoembolization and radioembolization. The only studies that we have comparing the two are non-randomized, so there is inherent selection bias in terms of who receives chemoembolization versus who receives radioembolization. Overall, when you look at the data, I think the data suggests they're both pretty equivalent in terms of effectiveness, but chemoembolization has a much stronger evidence base behind it.

The other thing that we notice is that patients may tolerate radioembolization better than chemoembolization with lower rates of post-embolization syndrome. Without high-quality data to guide us in terms of the choice between chemoembolization and radioembolization, you see a large variation in terms of practices across the country. It's very interesting, because some people who have localized disease that is small in nature will be treated routinely with chemoembolization, whereas if that patient was seen down the street, they would be routinely treated with radioembolization for that very same cancer in that very same patient. Really, it's just a matter of which center you're seen in and the local expertise.

At our center, we tend to use radioembolization for patients who have a larger tumor burden where you're afraid that either they're going to have significant post-embolization syndrome, or that you're not going to get a very good effect from chemoembolization. Radioembolization can definitely be considered in this person, it's just that we don't have great data comparing it to the effect of chemoembolization.

CASE 1: Unresectable Hepatocellular Carcinoma (uHCC)

Mario C is a 74-year-old retired steel worker from Allentown, Pennsylvania. His past medical history is notable for hepatitis B virus (HBV) infection (diagnosed in early 1990s).

In July 2013, patient was referred to a hepatologist with an elevated ALT (70 IU/mL) and AST (53 IU/mL).

Medical history is also notable for mild hypertension (currently controlled on antihypertensives) and hypercholesterolemia (currently controlled with diet); patient denies any alcohol use

Family history was relevant for an older brother who died of HCC and chronic HBV infection at age 70

On physical exam, no evidence of liver disease was noted and patient did not report any recent weight loss; patient reported some intermittent abdominal pain and there was mild tenderness in the lower right quadrant on palpation

Ultrasound revealed a poorly defined mass in the right lobe; contrast enhanced MRI showed a 12-cm mass in the lower right segment consistent with HCC and several smaller nodules. Bone scan and chest CT showed no evidence of metastatic disease

Patient presented to the Multidisciplinary Team (MDT) with Child Pugh Class A, with a MELD score of 7; patient’s performance status was 1

On surgical consult, the patient was deemed unresectable and the MDT recommended a TACE procedure for the larger lesion

In December of 2014, evidence of residual disease was detected on a follow up CT scan at the site of the first TACE procedure; smaller nodules also showed evidence of radiologic progression.