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Evidence With SIRT in HCC

Insights From: Arndt Vogel, MD, Hannover Medical School; Oliver Waidmann, MD, Goethe-Universitat Frankfurt am Main
Published: Thursday, Sep 14, 2017



Transcript: 

Oliver Waidmann, MD: SIRT is a new and different kind of technique to do local treatment in HCC. Of course, you have some advantages and you have some disadvantages. SIRT is more of a treatment for specialized centers. So, not every center has a possibility to do SIRT. And the really big advantage of SIRT is that you just have to do it once or twice normally, so you don’t have many cycles to do. And, of course, you can also do it in patients who have infiltration of the portal vein and even complete thrombosis of the portal vein. In such patients, you should not do the TACE, so this is a big advantage. Of course, it’s much more expensive. If you have problems with the money, it might be a bit problematic.

Arndt Vogel, MD: We have a few trials that have shown that TACE is evidence of effective treatment for HCC. More recently, more and more centers have used Y-90 as an additional therapy for the treatment of HCC. In contrast to TACE, which is more of a treatment that leads to a block of blood flow into the tumor, Y-90 is a radiotherapy within the liver. When we use a high dose of radiation, we can really destroy the tumors. And because many of us have seen really impressive responses with Y-90, everybody assumes that Y-90 needs to be a very effective therapy and should be part of the treatment of HCC. However, we never really had a prospective trial that confirmed that we not only are effective against the tumor, but that we also increase and prolong the survival of our patients. The effort was really required that we need a prospective trial to look at the efficacy of TACE in comparison to systemic therapies.

And now, very recently, 2 trials have been reported. One has been performed in France, the SARAH study, comparing Y-90 to sorafenib. And very recently at the ASCO this year, the SIRveNIB study was published. It’s the same design, Y-90 versus sorafenib, but in an Asian population. In both studies, the investigators were convinced that Y-90 was a very effective therapy, and the design was to show superiority compared to sorafenib. Very interestingly, both trials are completely negative. In terms of overall survival, there was no significant benefit for patients treated with Y-90.

Personally, I think these are very disappointing results. Of course, you can notice there are some secondary endpoints that are positive, such as a minimal prolongation of PFS or TTP (time to progression), and maybe that there are also less side effects with Y-90 compared to treatment with sorafenib. Although, I think these data clearly indicate that we should be careful to integrate Y-90 in our treatment schedule. It can be a very effective treatment, I have no doubt about this. We also use Y-90 in our patients, but with these data now, we should really be careful to increase the use of local therapies for our patients. And we have now more and more systemic therapies available. So, the discussion really needs to be in that direction: that we do not overuse local therapies but do an early switch to systemic therapies.

Oliver Waidmann, MD: We’ve learned from recent trials that SIRT is an effusive treatment in patients with HCC, especially in patients who have really big tumors—bigger than 7 cm—who have local infiltration of the portal vein or of the complete branches of the portal vein and in patients who had progressed after TACE. In such patients, you also can use SIRT.

Transcript Edited for Clarity 

Brought to you in part by Eisai
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Transcript: 

Oliver Waidmann, MD: SIRT is a new and different kind of technique to do local treatment in HCC. Of course, you have some advantages and you have some disadvantages. SIRT is more of a treatment for specialized centers. So, not every center has a possibility to do SIRT. And the really big advantage of SIRT is that you just have to do it once or twice normally, so you don’t have many cycles to do. And, of course, you can also do it in patients who have infiltration of the portal vein and even complete thrombosis of the portal vein. In such patients, you should not do the TACE, so this is a big advantage. Of course, it’s much more expensive. If you have problems with the money, it might be a bit problematic.

Arndt Vogel, MD: We have a few trials that have shown that TACE is evidence of effective treatment for HCC. More recently, more and more centers have used Y-90 as an additional therapy for the treatment of HCC. In contrast to TACE, which is more of a treatment that leads to a block of blood flow into the tumor, Y-90 is a radiotherapy within the liver. When we use a high dose of radiation, we can really destroy the tumors. And because many of us have seen really impressive responses with Y-90, everybody assumes that Y-90 needs to be a very effective therapy and should be part of the treatment of HCC. However, we never really had a prospective trial that confirmed that we not only are effective against the tumor, but that we also increase and prolong the survival of our patients. The effort was really required that we need a prospective trial to look at the efficacy of TACE in comparison to systemic therapies.

And now, very recently, 2 trials have been reported. One has been performed in France, the SARAH study, comparing Y-90 to sorafenib. And very recently at the ASCO this year, the SIRveNIB study was published. It’s the same design, Y-90 versus sorafenib, but in an Asian population. In both studies, the investigators were convinced that Y-90 was a very effective therapy, and the design was to show superiority compared to sorafenib. Very interestingly, both trials are completely negative. In terms of overall survival, there was no significant benefit for patients treated with Y-90.

Personally, I think these are very disappointing results. Of course, you can notice there are some secondary endpoints that are positive, such as a minimal prolongation of PFS or TTP (time to progression), and maybe that there are also less side effects with Y-90 compared to treatment with sorafenib. Although, I think these data clearly indicate that we should be careful to integrate Y-90 in our treatment schedule. It can be a very effective treatment, I have no doubt about this. We also use Y-90 in our patients, but with these data now, we should really be careful to increase the use of local therapies for our patients. And we have now more and more systemic therapies available. So, the discussion really needs to be in that direction: that we do not overuse local therapies but do an early switch to systemic therapies.

Oliver Waidmann, MD: We’ve learned from recent trials that SIRT is an effusive treatment in patients with HCC, especially in patients who have really big tumors—bigger than 7 cm—who have local infiltration of the portal vein or of the complete branches of the portal vein and in patients who had progressed after TACE. In such patients, you also can use SIRT.

Transcript Edited for Clarity 

Brought to you in part by Eisai
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