The Insider summarizes important, recent and pertinent publications to the SIO community.
Researchers explored the role of chemotherapy plus concurrent irreversible electroporation (IRE) for the treatment of unresectable hilar cholangiocarcinoma (UHC). Treatments for this common malignant tumor, which has a relatively poor prognosis, are limited. In all, 47 patients with UHC were randomized to receive chemotherapy plus IRE (23) or chemotherapy alone (24). The chemotherapy regimen consisted mainly of gemcitabine with cisplatin or oxaliplatin or S1 (only prescribed for Asian patients); a total of 1,000 mg/m2 of gemcitabine (at day 1 and day 8) was administered and each I.V. infusion time was >30 min. Each patient received six four-week courses of chemotherapy. Using computed tomography (CT) or magnetic resonance imaging (MRI) to assess treatment response one month after treatment and then every three months, the researchers found the combination therapy group had a lower rate of local tumor progression (LTP) compared with the chemotherapy only group, at 16.7% vs. 39.5%. The complete response rate in the chemotherapy plus IRE group was 52.2%, compared with 12.5% in the chemotherapy only group. At 11.2 months, time to LTP in the combination treatment group was much longer than the 4.2 months seen in the chemotherapy alone group. Median overall survival was also longer for the chemotherapy plus IRE recipients, at 19.6% months vs. 10.2% months. There was one report of cholangitis in the chemotherapy plus IRE group, while minor complications in both groups included liver function injury, partial portal thrombosis, abdominal pain, vomiting, myelosuppression, and self-limiting pleural effusion. "Our data suggested that IRE ablation can be used as an adjunct to improve the efficacy of chemotherapy and reduce the rate of LTP in patients with UHC," the researchers conclude.
International Journal of Hyperthermia (10/21) Vol. 38, No. 1, P. 1512 Y Ma; Z Chen; W Zhu; et al.
Selective internal radiotherapy (SIRT) is a treatment option for the downstaging of patients with unresectable intrahepatic cholangiocarcinoma (ICC), research shows. The Phase II clinical trial, which was conducted between November 2013 and June 2016, involved 41 patients who had never received chemotherapy or intra-arterial therapy; 26 (63%) were male, with a mean age of 64 years. Patients received concomitant first-line chemotherapy with cisplatin, 25 mg/m2, and gemcitabine, 1000 mg/m2 (gemcitabine reduced to 300 mg/m2 for the cycles just before and after SIRT), on days 1 and 8 of a 21-day cycle for 8 cycles. Selective internal radiotherapy was administered during cycle 1 (1 hemiliver disease) or cycles 1 and 3 (disease involving both hemilivers) using glass Y90 microspheres. At 3 months, the Response Evaluation Criteria in Solid Tumors (RECIST) 1.1 response rate was 39%, while the disease control rate was 98%. After a median of 36 months of follow-up, the median progression-free survival was 14 months, and median overall survival was 22 months. In all, 71% (29) of the patients had grades 3-4 toxic effects. In addition, 22% (9) patients were downstaged to surgical intervention, and 20% (8) achieved R0 surgical resection. The researchers note that following a median 46 months after surgery, patients who underwent resection did not achieve median relapse-free survival. Although further study is needed, the authors report that "the high disease control and downstaging rates suggest that this treatment can be an option in initially unresectable ICC. The postsurgical outcomes suggest that SIRT is a potentially curative strategy as downstaging treatment among patients otherwise considered for palliative-intent medical treatment."
JAMA Oncology (10/19) J Edeline; Y Touchefeu; B Guiu; et al.
A new report demonstrates a proof of concept that prostatic artery embolization (PAE) in men who have lower urinary tract symptoms (LUTS) from benign prostatic hyperplasia prior to definitive radiation therapy (RT) for prostate cancer (PCa) lowers the rate of gastrointestinal/genitourinary (GU) toxicity. For the study, nine patients with PCa underwent PAE to treat LUTS stemming from benign prostatic hyperplasia with concurrent PCa. For the five patients who completed treatment and follow-up, the mean International Prostate Symptom Score reduction following PAE was 13.8, while the mean prostatic volume reduction was 23.1%. During treatment, there were no Common Terminology Criteria for Adverse Events of grade 3 or higher. A comparison of pre- and post-PAE plans for patients 1 and 2, who had prostate RT alone, found they had on average 23.2%, 39.8%, and 22.9% reductions in mean dose across the bladder, rectum, and penile bulb. For patients 3, 4, and 5, who had prostate with elective nodal coverage RT, there were no meaningful differences in dosimetry. No patients experienced biochemical failure, with a median follow-up of 18 months.
Advances in Radiation Oncology (06/01/21) Vol. 6, No. 3, P. 100619 J Peacock; D Sikaria; L Maun-Garcia; et al.
The results of a Phase II trial indicate that sorafenib plus 3cir-OFF hepatic arterial infusion chemotherapy (HAIC) increased survival for patients with hepatocellular carcinoma (HCC) with major portal vein tumor thrombosis (PVTT), compared with sorafenib alone. For the study, treatment-naive patients with HCC and major PVTT (portal vein invasion grade Vp3 [first branch] and Vp4 [main trunk]) were randomized on a 1:1 basis to receive sorafenib (400 mg twice daily) plus 3cir-OFF HAIC (35 mg/m2 oxaliplatin [hours 0–2] followed by 600 mg/m2 5-fluorouracil [hours 2–24], days 1–3) with a standardized percutaneous port catheter system or sorafenib alone (400 mg twice daily) every 4 weeks. The intent-to-treat population included 64 patients, 32 in each group. The median overall survival — the primary endpoint — was 16.3 months in the sorafenib plus HAIC group, compared with 6.5 months for sorafenib alone. The objective response rate in the sorafenib plus HAIC group was 41%, compared with 3% for sorafenib alone, while rates of progression-free survival were 9.0 months and 2.5 months, respectively. The sorafenib plus HAIC group did have more frequent grade 3 or 4 adverse events compared with the sorafenib-only group, including diarrhea, hand-foot syndrome, and thrombocytopenia. Given the increased survival and acceptable safety profile, the findings hold promise for patients with HCC and major PVTT.
Radiology (02/01/22) K Zheng; X Zhu; S Fu; et al.
New research highlights the safety and feasibility of image-guided intrapleural delivery of chimeric antigen receptor (CAR) T cells using intracavitary or intratumoral routes for patients with anatomically variable pleural cancers. The Phase I/II trial involved patients without a pleural catheter or who lacked effusion for insertion of a catheter, who received intrapleural CAR T cells using image guidance by computed tomography or ultrasound. Researchers administered the CAR T cells using a needle in an accessible pleural loculation (intracavitary) or after an induced loculated artificial pneumothorax. For patients in whom intracavitary infusion was not possible, CAR T cells were injected percutaneously, either surrounding and/or in the pleural nodule/thickening (intratumoral). In all, 31 patients successfully received intrapleural CAR T cells with a planned dose of 10-186 mL, and two received second doses. Fourteen (42%) of the 33 procedures were intracavitary, while 19 (58%) were intratumoral. All of the procedures were completed within two hours of the T cells being thawed, and procedure-related adverse events were mild. A common imaging finding, seen in 12 (36%) of the 33 procedures, was ground glass opacities with interlobular septal thickening and/or consolidation. No differences were seen between infusion methods in the incidence of fever, CRP, IL-6, and peak vector copy number in the peripheral blood.
Lung Cancer (03/01/22) Vol. 165, P. 1 M Ghosn; W Cheema; A Zhu; et al.
A recent study out of the Netherlands highlights the efficacy of radiofrequency ablation (RFA) as a treatment option for benign symptomatic thyroid nodules (SBTN), leading to significant volume reduction and improvements in both health-related and thyroid-related quality of life (QoL). The study included 72 SBTN from 67 patients (median age 50 years, 91% women). Eligibility for RFA included nodule size of 2.0 - 5.0 cm, solid component >20%, benign cytology on two separate cytological assessments, and unequivocal symptoms related to mechanical compression. At six weeks, the median volume reduction was 51.0%, increasing to 63.9%, 65.2%, 81.3%, and 90.3% at six months, one year, two years, and three years, respectively. There were significant increases for patients on the SF-36 physical component scale and the ThyPRO-39 overall OoL-impact scale, with an absolute improvement noted in the ThyPRO-39 goiter and cosmetic complaints. The complication rate was 9.0%, including 4.5% major complications.
Journal of Vascular and Interventional Radiology (02/22) I Loncar; SPJ van Dijk; EFS van Velsen; 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.

February Case Spotlight - Mesocaval Shunt Recanalization
Crossword Puzzle
Introducing a fun, new feature in the newsletter — an IR-related crossword puzzle. This month's puzzle is titled "Liver again" Click here for a printable version of the crossword puzzle. If you're stuck, the solution can be found below as well.

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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