Bilobar Radioembolization Carries the Risk of Radioembolization-Induced Liver Disease in the Treatment of Advanced Hepatocellular Carcinoma: Safety and Efficacy Comparison to Systemic Therapy with Atezolizumab/ Bevacizumab

Background & Aims Recommended treatment options for advanced stage hepatocellular carcinoma (HCC) include Yttrium-90 (Y90) radioembolization (RE) and systemic therapy (ST). Before the approval of immune-checkpoint inhibitors as new first-line treatments, a similar safety profile was reported for both RE and ST. However, whole-liver treatment and underlying cirrhosis were identified as risk factors for potentially lethal radioembolization-induced liver disease (REILD). We performed a retrospective analysis to compare the safety and efficacy of RE and ST in patients with advanced HCC involving at least both liver lobes.

Methods In this study, we included 77 patients with new or recurrent HCC, who were either treated with bilobar RE (n=35) or systemic combination therapy with atezolizumab and bevacizumab (n=42) between January 2019 and October 2021 at the University Hospital Essen. Treatment decisions were made by a multidisciplinary oncological team based on the BCLC scheme. RE was performed according to the standard dosimetric approach, administering a mean dose of 117 Gy (range 97 to 140 Gy) to the perfused volume of treated hepatic tissue. Outcomes of interest included overall survival, safety and response rates.

Results Mean age of the population was 69.9 years (SD 10.8 years) and 21 of them were women. Most patients had compensated liver function (90% were classified as Child Pugh Score A, 74% as ALBI Grade 1) at baseline. Although not significant, patients treated with ST showed longer overall survival as compared to those treated with Y90 RE (7.3 months vs 13.2 months, p= 0.07). No differences were observed in disease control rate (47.2% in RE group and 40.5% in ST group, p=0.65). Within the RE group, there was a significant association of cirrhosis and REILD, with 21 of 28 cirrhotic patients experiencing REILD following bilobar RE. Liver function at baseline, as measured by ALBI-Score, was a predictor for occurrence of REILD. In patients without cirrhosis, a mean progression-free survival of 9.1 months was achieved with RE compared to 6.2 months in patients with similar BCLC B tumor stage in the ST group.

Conclusion Bilobar RE is suitable to achieve durable tumor response in a selected group of patients. In patients with liver cirrhosis, however, bilobar RE has an unfavorable risk profile. When liver function is impaired (ALBI grade≥ 2), a switch of treatment paradigm from local to systemic therapy should be considered to prevent REILD.

Publication History

Article published online:
19 August 2022