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• W2605062129 abstract "We read with interest the recent study by Salem et al1Salem R. et al.Gastroenterology. 2016; 151: 1155-1163Abstract Full Text Full Text PDF PubMed Scopus (311) Google Scholar providing evidence from a randomized phase II trial of patients with hepatocellular carcinoma (HCC) that Y90 radioembolization is associated with significantly longer median time to progression (TTP) than conventional transarterial chemoembolization (TACE). Both Y90 radioembolization and TACE are widely used as “bridge” therapies that can postpone the need for other treatments, such as liver resection or transplantation, in patients with numerous or bulky HCC tumors.2Mosconi C. et al.World J Hepatol. 2015; 7: 738-752Crossref PubMed Scopus (38) Google Scholar How the 2 bridge therapies compare directly is unclear, and the European Organization for Research and Treatment of Cancer, the European Association for the Study of the Liver, and the American Association for the Study of Liver Diseases do not include Y90 radioembolization in their guidelines. We congratulate Salem et al1Salem R. et al.Gastroenterology. 2016; 151: 1155-1163Abstract Full Text Full Text PDF PubMed Scopus (311) Google Scholar for designing a trial to help compare treatment options for patients with HCC who may not be considered for resection or ablation therapy. However, we believe that they go too far beyond the evidence in concluding that, “Y90 radioembolization provides better tumor control [than TACE] and could reduce dropout from transplant waitlists.” The patients in their study receiving Y90 radioembolization or TACE showed similar therapy response rates, median survival times (with censoring upon liver transplantation), and liver transplantation rates. In fact, patients receiving transplants in the 2 groups underwent the procedure a similar number of months after study enrollment, indicating that the significantly longer TTP associated with radioembolization did not translate to a significantly higher transplantation rate or longer time before transplantation. The trial designed by Salem et al may not even represent best clinical practice according to the bulk of medical evidence. Their patients had HCC in Barcelona Clinic Liver Cancer (BCLC) stage A or B, Child-Pugh A/B liver function, and no vascular invasion; and they were eligible to receive TACE or Y90 radioembolization. Such patients may best be served by hepatic resection as first-line therapy, based on results from Western and Asian studies.3Dhir M. et al.Ann Surg. 2016; 263: 1112-1125Crossref PubMed Scopus (185) Google Scholar, 4Zhong J.H. et al.Medicine (Baltimore). 2015; 94: e396Crossref PubMed Scopus (105) Google Scholar These studies further suggest that resection may be an appropriate and effective option also for patients whose tumors cannot be resected or ablated because of their proximity to major vessels. This careful use of resection may help provide effective treatment in the face of chronic liver shortages worldwide.3Dhir M. et al.Ann Surg. 2016; 263: 1112-1125Crossref PubMed Scopus (185) Google Scholar, 4Zhong J.H. et al.Medicine (Baltimore). 2015; 94: e396Crossref PubMed Scopus (105) Google Scholar Other issues that weaken the conclusions of Salem et al1Salem R. et al.Gastroenterology. 2016; 151: 1155-1163Abstract Full Text Full Text PDF PubMed Scopus (311) Google Scholar are the relatively small sample and short follow-up time of approximately 18 months. This is too short for comparing radioembolization with TACE, because the median survival after TACE can reach 40 months in patients with early stage HCC.5Hsu K.F. et al.Eur J Radiol. 2012; 81: 466-471Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar The authors also failed to compare the 2 therapies in terms of cost effectiveness or quality of life. A systematic review has already suggested that Y90 radioembolization may not be cost effective in patients with BCLC stage A or B disease such as those in the study by Salem et al.6Rostambeigi N. et al.J Vasc Interv Radiol. 2014; 25: 1075-1084Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar It is also unclear whether radioembolization or TACE is associated with better quality of life; a pilot randomized trial found similar health-related quality of life for the 2 techniques.7Kolligs F.T. et al.Liver Int. 2015; 35: 1715-1721Crossref PubMed Scopus (109) Google Scholar Together, these issues render the results of Salem et al1Salem R. et al.Gastroenterology. 2016; 151: 1155-1163Abstract Full Text Full Text PDF PubMed Scopus (311) Google Scholar preliminary until they can be verified in large studies with sufficiently long follow-up that compare Y90 radioembolization and TACE across all clinically relevant outcomes, including cost effectiveness and quality of life. Such work may help to clarify the inconsistent results from retrospective studies comparing the 2 techniques in terms of TTP, response rate, overall survival, and complications.8Zhang Y. et al.Biosci Trends. 2015; 9: 289-299Crossref PubMed Scopus (43) Google Scholar Y90 Radioembolization Significantly Prolongs Time to Progression Compared With Chemoembolization in Patients With Hepatocellular CarcinomaGastroenterologyVol. 151Issue 6PreviewConventional transarterial chemoembolization (cTACE) is used to treat patients with hepatocellular carcinoma (HCC). Radioembolization is a minimally invasive procedure that involves implantation of radioactive micron-sized particles loaded with yttrium-90 (Y90) inside the blood vessels that supply a tumor. We performed a randomized, phase 2 study to compare the effects of cTACE and Y90 radioembolization in patients with HCC. Full-Text PDF ReplyGastroenterologyVol. 152Issue 6PreviewThe 2008 Journal of the National Cancer Institute guidelines recommend time to progression (TTP) in the randomized phase II setting for intermediate hepatocellular carcinoma (HCC).1 PREMIERE complied with the recommendation and was initiated in 2009. It is the first real-life comparative effectiveness randomized study comparing Y90 with the standard of care conventional transarterial chemoembolization (cTACE).2 We acknowledge the limitations of our trial and are happy reply to the comments. Full-Text PDF" @default.
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• W2605062129 title "Is Y90 Radioembolization Superior or Comparable to Transarterial Chemoembolization for Treating Hepatocellular Carcinoma?" @default.
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