This document discusses Y90 radioembolization for the treatment of hepatocellular carcinoma (HCC). It provides details on how Y90 microspheres are loaded with the beta emitter Yttrium-90 which targets tumors up to 11mm in range. Guidelines from EASL-EORTC recommend Y90 for strictly BCLC B stage HCC without portal vein thrombosis. A study found Y90 had superior time to progression over transarterial chemoembolization (TACE) especially for elderly patients, large tumors, or diffuse disease. For HCC with portal vein thrombosis, Y90 provided good local control. Ongoing trials are investigating combining Y90 with sorafenib to see if

1. Y90 radioembolisation
1
Jens Ricke
Radiology and Nuclear medicine, University of Magdeburg

2. SIRT: Y90 Radioembolisation
Mikrospheres (20-40 µm)
Loaded w/ Yttrium-90
Y-90: beta emitter
mean range: 3,9 mm
max. range: 11 mm
max. energy: 2,27 MeV
half life: 64 h

4. EASL-EORTC guidelines, J Hepatol 2012

5. TACE – lessons learned
Llovet, Bruix. Hepatology 2003
• Significant benefit TACE w/ cisplatin or doxorubicin (OR, 0.42; 95% CI, 0.20-0.88)
• No benefit with TAE alone (OR, 0.59; 95% CI, 0.29-1.20)

6. Selection of patients for TACE
Llovet Lancet 2002; Lo Hepatology 2002

7. Journal of Hepatology (2012) 56, 1330–1335
•Strictly BCLC B
•no PVT (even segmental!)
•Performance status 0
•Multinodular
•Selective treatment only
•But all nodules treated
•No of nodules must be small (?)

8. Prognostische Faktoren für TACE
Hu JVIR 2011
•n=362 Patienten, konventionelle TACE
•Multivariate Analyse, Overall survival

9. EASL-EORTC guidelines, J Hepatol 2012

11. Hepatology 2011

13. Baseline characteristics

14. Toxicity TACE vs. Y90

15. Gesamtüberleben

16. •TTP > in Y90 (p=0.046)
•Response > in Y90 (n.s.)
•Advantages for Y90 in subgroup analyses:
– TTP in BCLC B (only univariate)
– Survival in T3 and BCLC C (only univariate)
 Y90 in elderly, PVT, large or „diffuse“ tumors
Y90 RE vs. TACE*
*Salem et al. Gastroenterology 2011

17. Radioembolisation bei Pfortaderthrombose
Vor SIRT 10w post SIRT

18. Y90 in the perspective of the SHARP trial
Sangro Hepatology 2011

19. SIRVENIB and SARAH
•Y90 radioembolization vs. Sorafenib
– Asia-Pacific and France
•Endpoint: Survival, time-to-progression
•Will show that Y90 has superior responses in BCLC C
– Cross-over
– Imaging endpoint unfavourable for Sorafenib

21. Y90 in PVT

22. Systemic therapy after Y90 radioembolization
•Very good survival with PVT and Child Pugh A
– Not with Child Pugh B of 7 points
•With tumor progression also worsening of CP-status
•Very limited therapeutic window for Sorafenib
Memon et al J Hepatol 2013

23. SORAMIC - structure
Diagnosis
HCC Staging
Ablation therapy
Therapy w/ palliative intentionPrimovist MR vs. CT
Therapeutic decision
Primovist MR vs. CT
Therapeutic decision
RFA & Sorafenib vs. RFA & Placebo:
time-to-recurrence
RFA & Sorafenib vs. RFA & Placebo:
time-to-recurrence
SIRT & Sorafenib vs. Sorafenib
Overall survival
SIRT & Sorafenib vs. Sorafenib
Overall survival

24. Active sites & candidates in 2013/14
SORAMIC

25. SORAMIC: Interim on Safety*
•Y90 and Sorafenib vs. Sorafenib alone
•Sequential treatment right/left liver
– Interval 4-6 weeks
•Start Sorafenib 200 bid day 3
•Increase to 400 bid day 10
•Interim safety after 40 patients
* presented at the EASL 2013

26. Treatment characteristics
* presented at the EASL 2013

27. Results
* presented at the EASL 2013

28. Take home III: HCC
•Role of Y90 radioembolisation to be determined
– Large tumors, diffuse disease
– Portal vein infiltration
•Sorafenib and TACE simultaneously not recommended
•Combination of Y90 and Sorafenib is safe
– Data on efficacy 2015

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