Y-90 Treatment of Pancreatic Cancer Patients with Liver-Dominant Metastatic Disease

Transarterial Radioembolization Treatment of Pancreatic Cancer Patients with Liver-Dominant Metastatic Disease using Yttrium-90 Glass Microspheres: A Single-Institution Retrospective Study

Clinical question
How safe and efficacious is transarterial radioembolization (TARE) with yttrium-90 (90Y)-labeled glass microspheres in pancreatic adenocarcinoma patients with liver-dominant metastatic disease?

Take-away point
TARE with 90Y-labeled glass microspheres is safe with promising overall survival (OS) in liver-dominant metastatic pancreatic cancer.

Reference
Transarterial Radioembolization Treatment of Pancreatic Cancer Patients with Liver-Dominant Metastatic Disease using Yttrium-90 Glass Microspheres: A Single-Institution Retrospective Study. Kayaleh, R et al. Journal of Vascular and Interventional Radiology, Volume 31, Issue 7, 1060-1068.

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Study design

Retrospective review

Funding source

Self-funded or unfunded

Setting

Single institution

Summary

There have been a limited number of studies evaluating the feasibility of Y90 treatment for liver-dominant metastatic pancreatic adenocarcinoma, with much of the work to date focusing on use of resin microspheres. The authors of this study investigated the role of glass microspheres for treatment of liver-dominant metastatic pancreatic adenocarcinoma.

This was a retrospective review of 26 patients with liver-dominant metastatic pancreatic adenocarcinoma treated over a 7 year period at the authors’ institution. Of these 26 patients, eight patients underwent surgical resection of the primary pancreatic cancer; 7 patients had pancreaticoduodenectomy; and 1 patient had distal pancreatectomy. There was a median interval of 17.7 months between diagnosis and TARE treatment. At the time of TARE treatment, 14 patients had multiple liver metastases (≥2); of these, 11 had bilobar disease. Nineteen patients had extrahepatic disease. All patients received systemic chemotherapy before TARE, and 19 received systemic therapy after TARE. Median time between TARE treatment and adjuvant chemotherapy was 22 days (chemotherapy consisted of 5-flurouracil/leucovorin ± irinotecan ± oxaliplatin and gemcitabine-based chemotherapy). TARE was performed using 90Y-labeled glass microspheres. In patients with bilobar disease, the left and right lobes were treated separately, approximately 4–6 weeks apart, except for 2 patients who had the left and right lobe treated at the same time.

Nineteen patients received 1 TARE treatment; 5 patients received 2 treatments (3 of these patients had bilobar disease and 2 had unilobar disease); 1 patient received 3 treatments; and 1 patient received 4 treatments. The average delivered dose was 137.6 ± 27.6 Gy (range, 105–380 Gy). The median OS from pancreatic adenocarcinoma diagnosis was 33.0 months, the median OS from diagnosis of liver metastasis was 21.8 months, and the median OS from TARE treatment was 7.0 months. The median hepatic PFS was 2.7 months. Interestingly, a statistically significant association was found showing that patients with solitary liver metastasis had a lower median OS than patients with multiple liver metastases. There were 42 episodes of grade 1–2 clinical adverse events and 3 episodes of grade 3 clinical adverse events. The MELD score was not significantly different at the 3-month follow-up than the baseline score before TARE. Baseline and follow-up imaging at 3 months were available for 22 of 26 patients, which showed partial response in 1 patient (4.5%), stable disease in 9 patients (40.9%), and progressive disease in 12 patients (54.5%), with a disease control rate (partial response + stable disease) of 45%.

Commentary

Pancreatic cancer remains a leading cause of cancer-related death. The only curative therapy is surgical resection, however, a minority of patients are viable surgical candidates and, even after surgery, there is a high rate of recurrence. In addition, a majority of patients initially present with metastatic disease. TARE is effective in achieving local control in a variety of different tumor types and there has been some work to date, albeit limited, evaluating its role in treatment of liver-dominant metastatic pancreatic adenocarcinoma. This study is the first to demonstrate the role of 90Y-labeled glass microspheres in the treatment of metastatic pancreatic cancer patients. The authors showed that treatment was well-tolerated with low toxicity with OS similar to that of surgical resection of hepatic metastases. Therefore, TARE may be an attractive option when compared to surgery for patients with advanced disease. Larger, prospective studies are anticipated with interest for validation of these findings.

Post Author:
Zagum Bhatti, MD
Assistant Professor
Department of Radiology, Interventional Radiology Division
University of Texas Health Science Center at Houston, Houston, TX
@ZagumBhatti