Treatment of HCC with Re-188 lipiodol: Initial experience in Mongolia

Full text: The aim of this study was to assess the safety and efficacy, in patients with inoperable hepatocellular carcinoma (IHCC) of intra-arterial 188Re-lipiodol given at an amount of radioactivity calculated to deliver acceptable radiation absorbed doses to critical normal organs (liver, lung and bone marrow). Rhenium-188 was eluted from a tungsten/rhenium generator system from ORNL. Conjugation of 188Re to lipiodol was carried out using a HDD kit from Korea. Both were provided through the IAEA. Thirty nine patients with HCC were studied. Patients had acceptable hematopoietic and hepatic parameters at baseline. All patients had measurable disease on CT. A transmission whole body scan was carried out on the morning of the study. A 'scout' activity 207 ± 57 MBq of 188Re-lipiodol was administered into the relevant hepatic arterial tree accessed in the interventional suite, and static images were obtained in Nuclear Medicine to provide quantitative images of the liver (including tumor), lungs and whole body. The maximum tolerated activity (MTA) was defined as that which would deliver no more than 30 Gy to liver, 12 Gy to lungs or 1.5 Gy to red marrow, calculated using a MIRD-based spreadsheet developed at MSKCC, New York, USA. An amount of 188Re-lipiodol not more than the MTA was then administered under identical conditions. Patients were followed for toxicity and efficacy until death or disease progression. Twenty one patients were treated twice, and two patient three times. The therapy was well tolerated with no major side-effects observed. Logistic and other constraints prevented delivery of the MTA in all patients, with 35.5% (1.33-2.7GBq) of MTA being administered. Despite this, 16.6% had major (PR+CR) response and 56.6% had stabilization of disease. Quality of life was improved in 12/39 patients, with a median overall survival of 14 (4-24) months and a median progression-free survival of 9 months. We conclude that intra-arterial therapy with 188Re-lipiodol is feasible in Mongolia. The therapy is safe and preliminary efficacy results are encouraging. The inability to treat at MTA suggests that other methods, including multiple treatments cumulatively less than MTA, may be considered. The study is ongoing, as is analysis of tumor radiation absorbed dose and treatment efficacy. (author)