Transarteriyel Radyoembolizasyon (TARE)
Özet
Transarteriyel Radyoembolizasyon (TARE), cerrahi olarak çıkarılamayan primer karaciğer tümörlerinde veya kemoterapiye dirençli karaciğer baskın metastazlarda kullanılan, Ytriyum-90 (Y-90) yüklü cam veya reçine mikrokürelerin hepatik arter yoluyla doğrudan tümör dokusuna enjekte edildiği bir internal radyoterapi yöntemidir. Bu teknik, normal karaciğer parankimini korurken, lokal radyasyon etkisiyle tümör yatağında yüksek dozda mikrosfer birikimi sağlayarak apoptozu tetikler ve tümör boyutunu küçültür. TARE uygulaması, hepatik vasküler anatominin belirlenmesi ve Tc-99m MAA sintigrafisi ile hepatopulmoner şant oranının ölçülmesini içeren iki aşamalı anjiyografik planlama ve enjeksiyon sürecinden oluşur. Çok disiplinli bir konsey kararıyla seçilen uygun hastalarda, portal ven trombozu varlığında dahi güvenle uygulanabilen bu yöntem, yan etki profilinin düşüklüğü ve kısa hastane yatış süresiyle öne çıkar. Tedavi sonrasında, hastaların takibi laboratuvar testleri ile metabolik (PET/BT) ve radyolojik (MR/BT) görüntüleme modaliteleri kullanılarak 3-4. aylarda gerçekleştirilir.
Transarterial Radioembolization (TARE) is an internal radiation therapy method used for unresectable primary liver tumors or chemotherapy-resistant liver-dominant metastases, where Yttrium-90 (Y-90) loaded glass or resin microspheres are injected directly into the tumor tissue via the hepatic artery. This technique preserves the normal liver parenchyma while triggering apoptosis and reducing tumor size by ensuring a high concentration of microspheres in the tumor bed through localized radiation. The TARE procedure consists of a two-stage angiographic planning and injection process, which includes defining the hepatic vascular anatomy and measuring the hepatopulmonary shunt ratio using Tc-99m MAA scintigraphy. Selected by a multidisciplinary board, this method can be safely applied even in the presence of portal vein thrombosis in eligible patients, standing out with its low side-effect profile and short hospital stay. Following the treatment, patient follow-up is performed at 3-4 months using laboratory tests alongside metabolic (PET/CT) and radiological (MR/CT) imaging modalities.
Referanslar
Lanza E, Donadon M, Paretti D, et al. Transarterial therapies for hcpatocellular carcinoma. Liver Cancer. 2016; 6:27-33.
Braat A.J.A.T., Smits M.L.J, Al E. 90Y hepatic radioembolization: An update on current practice and recent developments. J Nucl Med 2015; 56:1079-87.
Guice SA SJ. Postthcrapy radiation safety considerations in radiomicrosphere treatment with 90Y-microspheres. J Nucl Med 2007; 48:2080-6.
Kennedy A, Coldwell D, Sangro B, et al. Radioembolization for the treatment of liver tumors general principles. Am J Clin Oncol 2012; 35:91-9.
Jernigan, S.R., Osborne, J.A., Mirek CJ, et al. Selective internal radiation therapy: Quantifying distal penetration and distribution of resin and glass microsphcres in a surrogate arterial model. J Vase Interv Radiol 2015; 26:897-904.
Kennedy A, Nag S, Salem R, et al. Recommendations for radioembolization of hepatic malignancies using yttrium-90 microsphere brachytherapy: a consensus panel report from the radioembolization brachytherapy oncology consortium. Int J Radiat Oncol Biol Phys. 2007;68(1):13-23.
Liu DM, Salem R, Bui JT, et al. Angiographic considerations in patients undergoing liver-directed therapy. J Vasc Interv Radiol. 2005; 16(7):911-35.
Salem R, Thurston KG. Radioembolization with 90Yttrium microspheres: a state-of-theart brachytherapy treatment for primary and secondary liver malignancies. Part 1: Technical and methodologic considerations. J Vasc Interv Radiol. 2006;17(8):1251-78
Forner, A, Gilabert M, Bruix J, ct al. Treatment of intermediate-stage hepatocellular carcinoma. Nat Rev Clin Oncol 2014; 11 :525-35
Brown DB. Hepatic artery dissection in a patient on bevacizumab resulting in pseudoaneurysm formation. Semin Intervent Radiol 2011;28:142-146.
Rode A, Bancel B, Douek P, et al. Small nodule detection in cirrhotic livers: evaluation with US, spiral CT, and MRI and correlation with pathologic examination of explanted liver. J Comput Assist Tomogr 2001;25:327-336.
Chandarana H, Taouli B. Diffusion and perfusion imaging of the liver. Eur J Radiol 2010;76:348-58.
Gulec SA, Fong Y. Yttrium 90 microsphere selective internal radiation treatment of hepatic colorectal metastases. Arch Surg 2007;142:675-682.
Nelson TM, Pollak R, Jonasson O, et al. Anatomic variants of the celiac, superior mesenteric, and inferior mesenteric arteries and their clinical relevance. Clinical Anatomy: The Official Journal of the American Association of Clinical Anatomists and the British Association of Clinical Anatomists 1988;1:75- 91.
Liu DM, Salem R, Bui JT, et al. Angiographic considerations in patients undergoing liver directed therapy. J Vasc Interv Radiol 2005;16:911-935.
Liu DM, Salem R, Bui JT, et al. Angiographic considerations in patients undergoing liver-directed therapy. J Vasc Interv Radiol. 2005; 16(7):911-35
Hamoui N, Minocha J, Memon K, et al. Prophylactic embolization of the gastroduodenal and right gastric arteries is not routinely necessary before radioembolization with glass microspheres. J Vasc Interv Radiol. 2013;24(11): 1743-5
Lam MG, Banerjee S, Louie JD, et al. Root cause analysis of gastroduodenal ulceration after yttrium-90 radioembolization. Cardiovasc Intervent Radiol. 2013;36(6):1536-47
Lam MG, Banerjee S, Louie JD, et al. Root cause analysis of gastroduodenal ulceration after yttrium-90 radioembolization. Cardiovasc Intervent Radiol. 2013;36(6):1536-47
McWilliams JP, Kee ST, Loh CT, et al. Prophylactic embolization of the cystic artery before radioembolization: feasibility, safety, and outcomes. Cardiovasc Intervent Radiol. 2011; 34(4):786-92
Morante A, Romano M, Cuomo A, et al. Massive gastric ulceration after transarterial chemoembolization for hepatocellular carcinoma. Gastrointest Endosc. 2006;63(4):718- 20.
Salem R, Thurston KG. Radioembolization with 90Yttrium microspheres: a state-of-theart brachytherapy treatment for primary and secondary liver malignancies. Part 1: Technical and methodologic considerations. J Vasc Interv Radiol. 2006;17(8):1251-78
Atassi B, Bangash AK, Lewandowski RJ, Ibrahim S, Kulik L, Mulcahy MF, et al. Biliary sequelae following radioembolization with Yttrium-90 microspheres. J Vasc Interv Radiol. 2008;19:691-7
Tong AK, Kao YH, Too CW, Chin KF, Ng D, Chow PK. Yttrium-90 hepatic radioembolization: clinical review and current techniques in interventional radiology and personalized dosimetry. Br J Radiol. 2016;24:20150943.
Kulik LM, Atassi B, van Holsbeeck L, Souman T, Lewandowski RJ, Mulcahy MF, et al. Yttrium-90 microspheres (TheraSphere(R)) treatment of unresectable hepatocellular carcinoma: Downstaging to resection, RFA and bridge to transplantation. J Surg Oncol. 2006 17;94(7):572-86.
Salem R, Lewandowski RJ, Kulik L, Wang E, Riaz A. Radioembolization results in longer time-to-progression and reduced toxicity compared with chemoembolization in patients with hepatocellular carcinoma. Gastroenterology. 2011;140:497-507
Gramenzi A, Golfieri R, Mosconi C, Cappelli A, Granito A. Yttrium-90 radioembolization vs sorafenib for intermediate-locally advanced hepatocellular carcinoma: a cohort study with propensity score analysis. Liver Int. 2015;35: 1036-47.
Galle P, Blanc J, Van Laethem JL. Efficacy and safety of sorafenib in patients with advanced hepatocellular carcinoma and prior antitumor therapy: a subanalysis from the SHARP trial. J Hepatol. 2008;20:372.
Cheng AL, Kang YK, Chen Z, Tsao CJ, Qin S. Efficacy and safety of sorafenib in patients in the Asia-Pacific region with advanced hepatocellular carcinoma: a phase III randomise double-blind, placebo-controlled trial. Lancet Oncol. 2009;10:25-34.
Bruix J, Raoul JL, Sherman M, Mazzaferro V, Bolondi L, Craxi A, et al. Efficacy and safety of sorafenib in patients with hepatocellular carcinoma (HCC): subanalysis of Sharp trial based on Barcelona Clinic Liver Cancer (BCLC) stage. J Hepatol. 2012;50:28
Ricke J, Bulla K, Kolligs F, Peck-Radosavljevic M, Reimer P. Safety and toxicity of radioembolization plus Sorafenib in advanced hepatocellular carcinoma: analysis of the European multicentre trial SORAMIC. Liver Int. 2015;35:620-6
. Lewandowski RJ, Kulik LM, Riaz A, Senthilnathan S, Mulcahy MF. A comparative analysis of transarterial downstaging for hepatocellular carcinoma: chemoembolization versus radioembolization. Am J Transplant. 2009;9:1920-28.
Gaba RC, Lewandowski RJ, Kulik LM, Riaz A, Ibrahim SM, Mulcahy MF, et al. Radiation lobectomy: preliminary findings of hepatic volumetric response to lobar yttrium-90 radioembolization. Ann Surg Oncol. 2009;16:1587-96
Al-Adra DP, Gill RS, Axford SJ, Shi X, Kneteman N, Liau SS. Treatment of unresectable intrahepatic cholangiocarcinoma with yttrium90 radioembolization: A systematic review and pooled analysis. Eur J Surg Oncol 2015;41(1):120-7.
Rhee TK, Omary RA, Gates V, Mounajjed T, Larson AC, Barakat O, et al. The effect of catheter-directed CT angiography on yttrium90 radioembolization treatment of hepatocellular carcinoma. J Vasc Interv Radiol 2005;16:1085-91.
Salem R, Lewandowski RJ, Atassi B, Gordon SC, Gates VL, Barakat O, et al. Treatment of unresectable hepatocellular carcinoma with use of 90Y microspheres (TheraSphere): safety, tumor response, and survival. J Vasc Interv Radiol. 2005;16:1627-39.
Kalinowski M, Dressler M, König A, El-Sheik M, Rinke A, Höffken H, et al. Selective internal radiotherapy with Yttrium-90 microspheres for hepatic metastatic neuroendocrine tumors: a prospective single center study. Digestion. 2009;79:137-42.
Rhee TK, Lewandowski RJ, Liu DM, Mulcahy MF, Takahashi G, Hansen PD, et al. 90Y Radioembolization for metastatic neuroendocrine liver tumors: preliminary results from a multiinstitutional experience. Ann Surg. 2008;247: 1029-35.
Eldredge-Hindy H, Ohri N, Anne PR, Eschelman D, Gonsalves C, Intenzo C, et al. Ytrium-90 Microsphere brachytherapy for liver metastases from uveal melanoma: clinical out-comes and the predictive value of fluorodeoxyglucose positron emission tomography. Am J Clin Oncol. 2014 Jan 16.
