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New consensus guidelines provide recommendations on how to uniformly collect, analyze, and report oncologic outcomes for patients treated with image-guided tumor ablation and definitions of patient-, session-, and tumor-related parameters. The project is a collaboration between the Society of Interventional Oncology and the Definition for the Assessment of Time-to-Event End Points in Cancer Trials Initiative (DATECAN) group. The international panel of 62 experts convened to develop recommendations using the validated three-step modified Delphi consensus method. Among the panel's key recommendations are when to assess oncologic outcomes per patient, per session, and per tumor; definitions of starting and ending times; definitions of survival time; and time-to-event endpoints. "Clear definitions will provide the necessary foundation for scientific reproducibility between studies as they will ensure an objective and reliable interpretation of results, allow for accurate comparison of outcomes, and avoid misinterpretations," the panel wrote. There was no consensus on the preferred classification system for reporting complications, quality of life, and health economic issues; however, the experts agreed on using the latest version of a validated patient-reported outcome questionnaire. Implementation of the recommendations, the authors noted, will improve communication of scientific advances in interventional oncology across the globe.
INDUSTRY NEWS
New consensus guidelines provide recommendations on how to uniformly collect, analyze, and report oncologic outcomes for patients treated with image-guided tumor ablation and definitions of patient-, session-, and tumor-related parameters. The project is a collaboration between the Society of Interventional Oncology and the Definition for the Assessment of Time-to-Event End Points in Cancer Trials Initiative (DATECAN) group. The international panel of 62 experts convened to develop recommendations using the validated three-step modified Delphi consensus method. Among the panel's key recommendations are when to assess oncologic outcomes per patient, per session, and per tumor; definitions of starting and ending times; definitions of survival time; and time-to-event endpoints. "Clear definitions will provide the necessary foundation for scientific reproducibility between studies as they will ensure an objective and reliable interpretation of results, allow for accurate comparison of outcomes, and avoid misinterpretations," the panel wrote. There was no consensus on the preferred classification system for reporting complications, quality of life, and health economic issues; however, the experts agreed on using the latest version of a validated patient-reported outcome questionnaire. Implementation of the recommendations, the authors noted, will improve communication of scientific advances in interventional oncology across the globe.
Radiology (09/28/21) RS Puijk; M Ahmed; A Adam; et al.
Researchers conducted a systematic review of Phase III randomized controlled trials (RCTs) about hepatocellular carcinoma (HCC) to examine the current evidence and identify possible factors that affect response to treatments. They identified 49 high-quality RCTs conducted in HCC between 2002 and 2020. In all, 22,113 patients underwent adjuvant (7 trials), and primary treatment for early (2), intermediate (7), and advanced (first-line, 21; second-line, 12) stages of disease. Nine of the studies had positive results, including seven whose treatments have been adopted in treatment guidelines for advanced HCC. A meta-analysis of pooled data involving 3,739 patients found that immune checkpoint inhibitor (ICI) therapy was more effective in patients with viral hepatitis compared with nonviral-related HCC. However, there were no etiology-related differences seen in patients treated with tyrosine-kinase inhibitor/anti–vascular endothelial growth factor, which suggests this feature may be unique to ICI, the researchers note.
Gastroenterology (09/21) Vol. 161, No. 3, P. 879 PK Haber; M Puigvehí; F Castet; et al.
A retrospective study compared portal vein embolization (PVE) with radiation
lobectomy with Yttrium-90 micropheres before resection of hepatocellular carcinoma (HCC) in patients with chronic liver disease (CLD). The study included 73 patients who underwent PVE and 22 who underwent Yttrium-90 for tumor control and/or to induce hypertrophy of future liver remnants before a major liver resection. Nearly half (47%) of the patients in the PVE group first required additional locoregional procedures for tumor control, compared with none in the Yttrium-90 group. Post-Yttrium-90, more than a quarter (27%) of patients required additional therapy, mostly to induce further hypertrophy. While both treatments reached the goal of >40% FLR, the degree of hypertrophy was 63% for patients in the Yttrium-90 group compared with 36% for PVE. Tumor response was higher in the Yttrium-90 group, with 50% of patients achieving a complete response. Meanwhile, the resectability rate was 85% for PVE and 64% for Yttrium-90. The most common reason precluding surgery was tumor progression to the contralateral liver lobe or extrahepatic disease. The median time from therapy to surgery was 8 months for Yttrium-90 vs. 1 month for PVE. For 18% of patients (4) after Yttrium-90, surgery was not pursued due to complete tumor control. The findings demonstrate that both procedures raise liver resectability rates in patients with HCC and CLD; however, Yttrium-90 lobectomy resulted in improved tumor control and allowed for greater time to evaluate treatment response.
Surgery (05/01/21) Vol. 169, No. 5, P. 1044 Y Bekki; J Marti; T Toshima; et al.
The EPOCH (Evaluating TheraSphere in Patients with metastatic colorectal carcinoma Of the liver who have progressed on first-line Chemotherapy) study sought to investigate the role of transarterial radioembolization with Yttrium-90 (TARE) in combination with standard-of-care second-line chemotherapy for colorectal liver metastases (CLM). In the international, multicenter, Phase III trial, 428 patients with CLM who progressed on oxaliplatin- or irinotecan-based first-line therapy were randomized on a 1:1 basis to receive second-line chemotherapy with or without TARE. The hazard ratio (HR) for progression-free survival — one of the two primary endpoints — was 0.69, with a median PFS of 8.0 and 7.2 months in the TARE and chemotherapy groups, respectively. The hazard ratio for hepatic PFS — the second primary endpoint — was 0.59, with a median hPFS of 9.1 and 7.2 months, respectively. The objective response rate in the TARE group was 34.0%, compared with 21.1% in the chemotherapy group, while median overall survival was 14.0 and 14.4 months, respectively. There were more grade 3 adverse events (AEs) in the TARE group (68.4%) compared with the control group (49.3%), a finding which could be the result of the higher frequency of visits and AE reporting related to TARE procedures. Both groups received full-dose intensity second-line chemotherapy. Adding TARE to systemic therapy extended both PFS and hPFS, the researchers conclude, noting that additional study could help identify the patient population that would best benefit from TARE.
Journal of Clinical Oncology (09/21) MF Mulcahy; A Mahvash; M Pracht; et al.
This commentary discusses the use of portal vein embolization (PVE) to reduce adverse events related to perihilar cholangiocarcinoma surgery. While the procedure is commonly used for patients with the rare condition in Eastern centers, and mortality rates are lower, PVE is less frequent in Western centers, write Pim B. Olthof MD, PhD, and Thomas M. van Gulik MD, PhD, both of the Department of Surgery, Amsterdam UMC, University of Amsterdam. The authors note their research has demonstrated the benefits of PVE before major liver resection for perihilar cholangiocarcinoma. A propensity score matched comparison involved data from 1,667 patients found that rates of liver failure and mortality were 8% and 7%, respectively, with resection after PVE, compared with 36% and 18%, respectively, after resection without PVE. "The disease most often requires major liver resection as well as extrahepatic bile duct resection, which alone is high-risk surgery," the researchers write. "But these patients often suffer from obstructive jaundice requiring biliary drainage, which can induce cholangitis and further increase the risk of adverse outcomes." Future research, they suggest, should look for the optimal indications for PVE. "The goal is to provide a curative resection to as many patients as possible, while reducing the risks of adverse outcomes to a minimum," they conclude.
Annals of Surgical Oncology (07/21) Vol. 27, No. 7, P. 2319 PB Olthof; TM Van Gulik
The European Thyroid Association (ETA) and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) have issued guidelines for the appropriate use of minimally invasive treatments (MITs) in malignant thyroid lesions. The incidence of differentiated thyroid cancer (DTC) is increasing in Europe, with up to 9 cases per 100,000 person-years among women and 3 cases per 100,000 person-years among men. The new guidelines, developed by a task force from ETA and CIRSE, are based on the best available evidence and the expertise and experiences of the authors. Given that most DTCs do not involve aggressive tumors, as well as the costs and risks of surgery, active surveillance (AS) and ultrasound-guided MITs are suggested as alternatives to thyroidectomy in for suitable cases of incidental papillary thyroid microcarcinomas (PTMCs). In addition, AS and MIT are considered as alternatives for slow-growing DTC nodal metastases, in part due to the refractoriness of radioiodine, the risk of surgical complications, and declining repeat surgery. MIT is also proposed as a part of a multimodality therapeutic approach for distant radioiodine-refractory metastases not amenable to surgery. The authors write, "We recommend that when weighing between surgery, radioiodine, AS, or MIT for DTC, a multidisciplinary team including members with expertise in interventional radiology assess the demographic, clinical, histological, and imaging characteristics for appropriate selection of patients eligible for MIT. Consider [thermal ablation] in low-risk PTMC patients who are at surgical risk, have short life expectancy, relevant comorbidities, or are unwilling to undergo surgery or AS." They note the use of ethanol ablation and high-intensity focused ultrasound is not recommended for the treatment of PTMC. MIT should be considered as an alternative to surgical neck dissection in patients with radioiodine refractory cervical recurrences who are at surgical risk or refuse additional surgery. Factors in favor of MIT include previous neck dissection, presence of surgical complications, small size metastases, and <4 involved latero-cervical lymph nodes. The authors recommend thermal ablation (TA) as a treatment option for patients with unresectable oligometastatic or oligoprogressive distant metastases to achieve local tumor control or pain palliation. TA should also be considered, in conjunction with bone consolidation and external beam radiation therapy, for painful bone metastases not amenable to other established therapies. European Thyroid Journal (06/01/21) Vol. 10, No. 3, P. 185 G Mauri; L Hegedüs; S Bandula; et al.
The Society of Interventional Oncology presents an opportunity to share key findings from interesting patient cases within the interventional oncology community. Access to these cases and engaging in the discussion surrounding their content is a benefit of SIO membership. New cases will be released in the SIO Insider.

October Case Spotlight - Malignant Transformation of Inflammatory Hepatic Adenoma
CROSSWORD PUZZLE
Crossword Puzzle
Introducing a fun, new feature in the newsletter — an IR-related crossword puzzle. This month's puzzle, written by Christos Georgiades MD, PhD, FSIR, FCIRSE, is titled "Liver" Click here for a printable version of the crossword puzzle. If you're stuck, the solution can be found below as well.

Solution
This newsletter is supported by an educational grant from Varian, A Siemens Healthineers Company
Publications Committee
Christos Georgiades, MD, PhD, FSIR, FCIRSE
SIO Publications Chair

Edward Kim, MD, FSIR
SIO Board Liaison
Yilun Koethe, MD, RPVI
Christine E. Boone, MD, PhD
Ji Buethe, MD
Andrew Kolarich, MD
Juan C. Camacho, MD
Anish Ghodadra, MD
Alex J. Solomon, MD
Elena Violari, MD
Maria Tsitskari, MD
Chiara Zini, MD
This newsletter is brought to you by the Society of Interventional Oncology (SIO) and supported by an educational grant from Varian, A Siemens Healthineers Company. SIO's mission is to advance interventional oncology by developing evidence supporting IO therapies, educating IO practitioners, and improving patient access to IO therapies.

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