Richard Finn, 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)?

The new local regional therapy on the block is radioembolization. Yttrium-90 is being used more and more. In reality, the data supporting the use of Y-90 is somewhat limited. There is a lot of single arm phase II type of data, and there are numerous phase III randomized studies that are ongoing. These will be very important studies to read out, and some of them are in combination with sorafenib as well which would probably include a patient like the one we’re talking about. Y-90 has not been shown to be superior to chemoembolization.

There is perhaps some toxicity benefit to Y-90, specifically in cases of portal vein thrombosis. But, at this time, I think most places would pursue with chemoembolization, given the large amount of data. Second to that would be consideration of systemic therapy, and Y-90 is, I think, an institutional preference if it is used.

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.