Outcomes of Yttrium-90 Radioembolization for Unresectable Combined Biphenotypic Hepatocellular-Cholangiocarcinoma

Clinical question
What is the hepatic response and overall survival following Y-90 radioembolizations in patients with hepatocellular-cholangiocarcinoma (cHCC-CC)?

Take-away point
Y90 radioembolization is a potential treatment option for cHCC-CC as a well tolerated procedure and reasonable response rates.

Reference
Christopher D. Malone et al. Outcomes of Yttrium-90 Radioembolization for Unresectable Combined Biphenotypic Hepatocellular-Cholangiocarcinoma. Journal of Vascular and Interventional Radiology. May, 2020: 31; 5.

Click here for abstract

Study design 

Retrospective Review

Funding source

Self-funded or unfunded

Setting

Single-Center

Figure 2. Kaplan-Meier survival curves and univariate Cox proportional hazard models of factors predicting survival after radioembolization. (a, b) Having > 1 tumor (a) and bilobar disease (b) both protended a >3 times increase in hazard of survival after radioembolization. (c) Although not statistically significant, there was a strong trend toward increased hazard of survival in nonresponders to radioembolization after treatment. (d) CA 19-9 level > 101.3 before treatment, which was derived from Youden statistic, portended a > 4 times increased hazard of survival after radioembolzation.

Summary

To date, there is little research concerning liver-directed therapy for combined biphenotypic hepatocellular-cholangiocarcinoma (cHCC-CC), with most being small series involving TACE. This is a rare primary malignancy with prognosis similar to cholangiocarcinoma. There are no consensus treatment guidelines to date.

This study evaluated 22 patients with biopsy confirmed cHCC-CC who underwent a total of 29 Y90 treatments utilizing resin microspheres. Overall survival and tumor response was analyzed. Median overall survival was 9.3 months following radioembolization. Complete response was seen in 15% with partial response in 40% of patients. The procedure was well tolerated with the majority of toxicities categorized as Grade 1 or 2. Poor prognostic indicators included bilobar disease, greater than one tumor, and elevated CA 19-9 levels.

Commentary

With surgical resection and transplantation often not an option for patients with cHCC-CC, liver directed therapies are likely to be a major treatment option for palliation. Interestingly, the overall survival rates reported in this study were significantly shorter than studies utilizing chemoembolization in Asia. However, given the incredible variability in tumor biology involving cHCC-CC, this could be explained by a population more resembling cholangiocarcinoma than hepatocellular carcinoma. However, the role of Y90 in treatment cHCC-CC remains unclear, especially as it should be positioned against TACE.

This study is limited by factors that limit many Y90 trials including small patient size and variable previous and future treatment regimens. Future studies are needed to compare Y90 to TACE in this population to help guide treatment guidelines.


Post Author:
David M Mauro, MD
Assistant Professor
Department of Radiology, Vascular and Interventional Radiology
University of North Carolina

@DavidMauroMD