TheraSphere® For Treatment of Metastases in Liver

Johns Hopkins Medicine

Status

Completed

Conditions

Colorectal Cancer Metastatic

Colorectal Cancer

Treatments

Other: Therasphere Therapy

Study type

Interventional

Funder types

Other

Identifiers

NCT04517643

J2006

National Institute Of Health (Other Grant/Funding Number)

Details and patient eligibility

About

To investigate whether the dose predicted by pre-therapy 99mTc MAA SPECT predicts the dose to the liver from the 90Y microspheres as assessed by post-therapy 90Y SPECT/CT or positron emission tomography (PET)/CT.

Full description

This study will acquire imaging information from 3-5 patients that will demonstrate feasibility of future implementation of personal dosimetry-based treatment planning for Trans-arterial Radio-embolization (TARE).

TARE therapy of liver neoplasia using 90Y-theraspheres has a long history. The device is FDA approved for the treatment of hepatocellular carcinoma, but has been used extensively for treatment of secondary liver neoplasia, including metastatic colorectal lesions under Humanitarian Device Exemption protocols such as this one.

As a targeted radioactive therapy, the current TARE implementation suffers from a lack of efficiency characteristic of radiopharmaceutical therapy (RPT) in general; namely, that the activity determined to treat the patient is not optimized according to normal organ tolerated absorbed dose and tumor efficacy thresholds. The amount of activity to be administered is determined from volumetrics established from associated imaging, either MRI or X-ray CT, where the total volume of irradiated tissue is considered as irrigated by the artery selected for administration, including both tumor and normal organ tissue. From this volume determination, the activity necessary to deliver an average pre-determined safe absorbed dose (120 Gy) to the entire irradiated region is calculated and administered.

In RPT, in the theranostic paradigm, a pre-therapeutic, or surrogate, quantity of activity is administered to the patient; 3D imaging (SPECT/CT or PET/CT) is then acquired at several time points and the individual patient's pharmacokinetics are determined, the normal organ and tumor dosimetry are performed and the optimal administered activity calculated that will deliver safe and efficacious treatment for the individual patient is determined, generally limited by the normal organ at risk maximum tolerated dose.

TARE presents a number of unique characteristics that enable a simpler version of this approach than is typical for most RPT. The method of administration means that only the normal liver and lungs need to be considered as potential organs at risk as the microspheres embolize and do not circulate systemically; the lack of associated photons in the 90Y decay chain means that a simple activity-to-dose-rate conversion can be used; the embolization means that only a single imaging time point is necessary as there is no redistribution of activity over time and the dose rate is converted to absorbed dose using the physical decay parameters of 90Y. These natural simplifications are already exploited in the current volumetric paradigm, where a 99mTc-macro albumin aggregate (MAA) surrogate and planar imaging are used to determine the fraction of total activity that is shunted to the lung and where a derived conversion factor is used to convert activity to absorbed dose.

The technical complication in TARE is that the surrogate (99mTc-MAA) has a different nature from the therapeutic device (90Y-theraspheres), and thus the reliability of the predictive quality of the surrogate is disputed. However, with precise and advanced imaging reconstruction and dosimetry the investigators have shown the ability to accurately and precisely predict normal liver and tumor average 90Y-therasphere uptake and absorbed dose from 99mTc-MAA.

This protocol seeks to acquire the imaging information from 3-5 patients that will demonstrate feasibility of future implementation of personal dosimetry-based treatment planning for TARE. In addition to the clinical standard of care assessments: 1. a single SPECT/CT instead of the current planar image will be acquired of the surrogate 99mTc-MAA; 2. An additional single 3D image (either SPECT/CT or PET/CT, depending on machine availability) will be acquired up to 6 hours post-administration of the therapeutic 90Y-microspheres for comparison. Informed consent will be obtained.

Enrollment

4 patients

Sex

All

Ages

18 to 100 years old

Volunteers

No Healthy Volunteers

Inclusion criteria

The Diagnosis of metastatic colorectal cancer to the liver
Patients with a diagnosis of metastatic colorectal cancer to the liver
Liver metastases are unresectable
Tumors are hypervascular based on visual estimation by the Investigator
Target tumors are measurable using standard imaging techniques
Performance Status Score 0 - 2
Age ≥18 years
Life expectancy ≥3 months
>4 weeks since prior radiation, surgery or chemotherapy
Able to comprehend and provide written informed consent in accordance with institutional and federal guidelines
At least one month has elapsed since most recent prior cancer therapy with the following exception:
Patient is willing to participate in the study and has signed the study informed consent

Exclusion criteria

Patients may not be treated with TheraSphere® if patients have any of the following exclusions:

Any pre-treatment laboratory findings within 15 days of treatment demonstrating liver dysfunction:
Blood test result levels outside of the normal range
Any history of hepatic encephalopathy
Any contraindications to angiography and hepatic artery catheterization such as:
History of severe allergy or intolerance to any contrast media, narcotics, sedatives or atropine that cannot be corrected or premedicated
Bleeding diathesis, not correctable by usual forms of therapy
Severe peripheral vascular disease that would preclude catheterization.
Evidence of pulmonary insufficiency
Significant extrahepatic disease representing an imminent life-threatening outcome
Active uncontrolled infection
Significant underlying medical or psychiatric illness
Co-morbid disease or condition that would preclude safe delivery of TheraSphere® treatment or, in the judgment of the physician, place the patient at undue risk
Pregnancy
Special Categories of Patients: Not applicable
Research in Mentally Disabled People: No. All participants or legal guardians will be fully able to give informed consent.