The Insider summarizes important, recent and pertinent publications to the SIO community.
An international expert study sought to define a textbook outcome (TO) for selective internal radiation therapy (SIRT) of hepatocellular carcinoma. First, a steering committee consisting of four interventional radiologists conducted a literature review to create a list of possible relevant items indicating an optimal SIRT intervention. Second, to set the final TO, they conducted an international and multidisciplinary survey. The online survey included three consecutive rounds with predefined settings and experts in interventional radiology, nuclear medicine, hepatology, and oncology from 11 countries. The first round included 50 potential TO items. The third round narrowed that list down to 11 parameters in six domains: pre-intervention workup, tumor targeting and dosimetry, intervention, post-90Y imaging, length of hospital stay, and complications. All but one of these items were applied in the institutions for more than 80% of the experts. "This multidimensional indicator is a comprehensive standardization tool, suitable for routine care, clinical round, and research," the researchers concluded.
European Journal of Nuclear Medicine and Molecular Imaging (10/22) J Gregory; L Tselikas; C Allimant; et al.
Researchers used univariate and multivariate analyses to identify risk factors for recurrence-free survival (RFS) and overall survival (OS) in patients who have hepatocellular carcinoma (HCC) with cirrhosis. For the study, HCC patients with and without cirrhosis who tested positive for hepatitis B surface antigen and had capable liver reserve function were compared in a large cohort of 1,003 cases. The Ishak Fibrosis Scale was used to determine fibrosis status. Patients with cirrhosis (67.3%) were then randomized into a training cohort and a validation cohort. Five clinical variables — hepatitis B e antigen (HBeAg) positivity, alpha-fetoprotein (AFP) level, tumour diameter, microvascular invasion (MVI), and satellite lesions — were significantly associated with RFS, while seven variables — HBeAg positivity, AFP level, tumour diameter, MVI, satellite lesions, gamma-glutamyl transpeptidase level, and histological differentiation — had significant associations with OS. Using these factors, nomograms were constructed. In the training cohort, the C-indices of the nomograms for RFS and OS were 0.739 and 0.789, respectively, while in the validation cohort they were 0.752 and 0.813, respectively. Compared with conventional staging systems, the C-indices of the nomograms were significantly higher. The calibration plots for the training cohort demonstrated optimal consistency between the nomogram-predicted RFS and OS and the observed three- and five-year prognoses. Based on the data, the researchers concluded that "[t]he nomograms developed in the present study showed good performance in predicting the prognoses of HCC patients with hepatitis B virus-associated cirrhosis."
BMC Surgery (09/13/22) L Xu; F Dai; P Wang; et al.
For patients undergoing transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC), using transradial access (TRA) resulted in a significant increase in activities of daily living and health-related quality of life compared with transfemoral access (TFA). Researchers randomly assigned 130 patients undergoing TACE for HCC to receive either TRA (n=65) or TFA (n=65); vascular closure devices were not used after TFA-TACE. Procedural variables such as the technical success rate, crossover rate, contrast agent dose, fluoroscopy time, procedure time, air kerma, dose-area product, length of hospital stay, and total cost were similar between the TRA and TFA groups, as were the incidence and severity of adverse events. Meanwhile, compared with the TFA group, overall discomfort, difficulty in going to the bathroom, difficulty feeding or self-caring, difficulty walking, general health, physical function, role physical function, social function, mental health, and role emotional function were improved in the TRA group. As a result, 90.8% of the patients who underwent TRA said they preferred it for their next procedure, compared with 24.6% of patients in the TFA group.
European Radiology (08/22) X Zhang; Y Luo; J Tsauo; et al.
For patients with unresectable hepatocellular carcinoma, combined locoregional systemic therapy — particularly the combination of tyrosine kinase inhibitor (TKI), immune checkpoint inhibitor (ICI), and locoregional therapy (LRT) — may be the most effective conversion therapy regimen, according to a recent meta-analysis. The systematic literature review, which included 24 studies, focused on four conversion regimens: chemotherapy, transcatheter arterial chemoembolization (TACE), molecular therapy (targeted therapy, immunotherapy, or a combination of both), and combined locoregional-systemic therapy. The pooled conversion rates were 13%, 12%, 10%, and 25%, respectively, while the pooled objective response rates (ORR) were 19%, 32%, 30%, and 60%, respectively. Among the various regimens, chemotherapy had the highest rate of pooled grade 3 or higher adverse events at 67%, followed by locoregional-systemic therapy at 40%, 34% for TACE, and 30% for molecular therapy. In subgroup analyses, the conversion rate, ORR, and grade 3 or higher adverse event rate for TKI plus ICI and LRT were 33%, 73%, and 31%, respectively.
Frontiers in Oncology (09/13/2022) Y Pei; W Li; Z Wang; et al.
Sustained release bortezomib nanoparticles (BTZ-NP), created using a flash nanocomplexation/nanoprecipitation process, effectively controlled tumor size and improved overall survival in vivo in three animal models of hepatocellular carcinoma (HCC), new research shows. BTZ is a highly cytotoxic small molecule for HCC, according to high-throughput drug screening across 40 HCC patient-derived organoids. The BTZ-NP formulation was a potent and safe treatment of HCC — including when delivered via the hepatic artery, a possible means of delivery in patients. In addition, the formulation demonstrated a sustained release of BTZ over 30 days and was more effective than treatment with doxorubicin-drug eluting beads. Based on the findings, the researchers more further preclinical research to further this technology to human clinical studies.
Hepatology (05/21/22) L Li; Y Zhang; Y Zhou; et al.
A recent study investigated the concept of MRI response as a surrogate endpoint of treatment efficacy following transarterial Yttrium-90 radioembolization (TARE) for colorectal liver metastases (CRLM). The retrospective research included 50 (135) patients with TARE for CRLMs and peri-interventional MRIs within defined timeframes. Using vRECIST and qEASL criteria, pre- and post-treatment target lesion volumes were assessed, while Cox regression models were used to evaluate the effects of MR morphologic response, vascularity at baseline, and clinical variables on patient survival. Median survival was 337 days, the researchers report. Applying the qEASL criteria three months after treatment permitted a significant separation of the survival curves for partial response, stable disease, and progressive disease within a median survival of 412 days in responders, compared with 181 days for non-responders. The likelihood of survival were significantly reduced by tumor burden and Tc99m lung shunt. Neither imaging nor available clinical data helped to predict morphologic response (MR) at baseline. Compared with vRECIST, the researchers concluded that MR response according to qEASL was superior for measuring the biological effect of TARE and predicting patient survival. "In order to improve on current prescribed activity calculation methods, future research needs to elicit the relationship of baseline metabolic activity and tumour absorbed-dose requirements and identify novel biomarkers of radiosensitivity for [colorectal carcinoma]," the researchers recommend.
Journal of Vascular and Interventional Radiology (10/22) L Willie; W Gero; F Klaus; 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.

November Case Spotlight - Pulmonary Lipiodol Deposition
Crossword Puzzle
This month's puzzle is titled "TARE" 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

AJ Gunn, MD
SIO Publications Vice 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
Giovanni Mauri, 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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