Prognostic factors and prevention of radioembolization-induced liver..
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Thanks, Jason. Wish I had seen that before my RE — I can see that waiting on a return to chemo is a good idea and I can see that steroids would help. It just makes sense, doesn’t it? So if and when I have another RE go-around, I’ll ask after this protocol.
I have had a chance to read the paper, and here is my layman take on the research:
This institute in Spain does a fair number of RE procedures (260 analyzed), and they notice that a significant number of patients develop RadioEmbolozation-Induced Liver Disease (REILD). They analyze their patient data to try and figure out what correlates with REILD. They find that evidence of cirrhosis prior to the procedure is a big risk factor. Most interesting to me is that they also find significant risk factors in the non-cirrhosis group.
For non-cirrhosis patients, they find that the important factors include radiation dosage, chemotherapy (both before and after), and age.
Radiation dosage:
Dosage only seemed to matter when the RE was a “whole liver” RE instead of a partial liver RE. They look at dosage relative to the volume of the liver and find that REILD primarily occurs when this value is high.Based on this finding, they suggest a modified protocol that includes a 10%-20% reduction in the radiation used compared to standard dosing formulas.
Chemotherapy:
They found that chemotherapy prior (especially with capecitabine) and/or chemotherapy within 2 months after RE was associated with REILD. They seem to argue that the combination of chemotherapy and radiation put so much stress on the liver that the chance of REILD is increased.They related REILD to another identified liver reaction to chemo + radiation (CMILD — combined modality-induced liver disease). With CMILD, the liver disease comes from “whole body irradiation together with ablative doses of chemotherapy” They note similarities between REILD and CMILD that are not associated with liver reactions to other procedures suggesting that the chemo + radiation combo is the key.
In any event, taking a steroid combo is helpful in avoiding CMILD. The modified protocol advocated for in this paper adopts a low-dose steroid regime as well for RE procedures (daily steroids starting the day of RE and continuing for two months).
Age:
They note a surprising result that was previously identified…younger patients (<60) had a HIGHER risk of REILD. They are not sure why.Modified protocol:
They found that non-cirrohsis patients following the modified protocol had a substantially lower likelihood of developing REILD compared to the standard protocol (3.3% vs. 19.6%). They also found that the effectiveness of the RE treatment for disease control was not statistically different between the protocols.All in all, lots of interesting data analysis that I had not seen before. I scanned the paper and made it into a .pdf. Send me an email if you want a copy.
Jason
Hi,
Another recent link for radioembo. if interested.
But they did not tell us the “may be risk factors “of prior to or after chemotherapy and radiation treatment.http://www.ncbi.nlm.nih.gov/pubmed/23602420
God bless.
thebompie4:
That is what it sounds like to me, but there are two major caveats:
#1 – I am neither a doctor nor an expert in this field, so please keep that in mind.
#2 – I have only seen the abstract not the full paper.
The abstract talks about a “modified protocol” that greatly mitigated the risks, so understanding that protocol better is, in my opinion, critical.
Jason
Thanks Jason–
so our Dr is talking about doing this to my husband (radioemb.) AFTER he
completes one more cycle of gem/cis as another alternate treatment.either that or chemoemb.
if i am understanding this correctly (which it’s possible i am NOT) my husband
would have a higher chance of devoloping REILD because of chemo previous
to radioemb.is that correct? or possibly a higher chance?
he has been responding so well to this chemo with (so far) ZERO side effects
other than “tired”. We are not so keen on moving on to something else
that we know nothing about.when it’s working, it is hard to think about trying something else that
we are unsure HOW IT WILL work.
Prognostic factors and prevention of radioembolization-induced liver disease
The abstract:
Radioembolization (RE)-induced liver disease (REILD) has been defined as jaundice and ascites appearing 1 to 2 months after RE in the absence of tumor progression or bile duct occlusion. Our aims were to study the incidence of REILD in a large cohort of patients and the impact of a series of changes introduced in the processes of treatment design, activity calculation, and the routine use of ursodeoxycholic acid and low-dose steroids (modified protocol). Between 2003 and 2011, 260 patients with liver tumors treated by RE were studied (standard protocol: 75, modified protocol: 185). REILD appeared only in patients with cirrhosis or in noncirrhosis patients exposed to systemic chemotherapy prior to RE. Globally, the incidence of REILD was reduced in the modified protocol group from 22.7% to 5.4% and the incidence of severe REILD from 13.3% to 2.2% (P < 0.0001). Treatment efficacy was not jeopardized since 3-month disease control rates were virtually identical in both groups (66.7% and 67.2%, P = 0.93). Exposure to chemotherapy in the 2-month period following RE and being treated by the standard protocol were independent predictors of REILD among noncirrhosis patients. In cirrhosis, the presence of a small liver (total volume <1.5 L), an abnormal bilirubin (>1.2 mg/dL), and treatment in a selective fashion were independently associated with REILD. Conclusion: REILD is an uncommon but relevant complication that appears when liver tissue primed by cirrhosis or prior and subsequent chemotherapy is exposed to the radiation delivered by radioactive microspheres. We designed a comprehensive treatment protocol that reduces the frequency and the severity of REILD.
(bold mine)
I am not sure yet what the modified protocol was, but I should be able to get the paper from the library on Wednesday.
Jason
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