Caren van Roekel

56 Chapter 2 Tohme et al. describe 20 patients with HCC who were treated with radioembolization as a bridge to transplantation. Radioembolization induced a complete or partial response in 9 of 16 evaluable patients. Histopathologic analysis of the explanted livers showed complete tumor necrosis in 5 cases, 50-99% necrosis in 6 cases and <50% necrosis in 9 cases. Median survival was 75.1 months and there were 4 patients with disease recurrence, of whom one had cancer in the new liver (113). Mohamed et al. have reported their center’s experience in using several therapeutic modalities before liver transplantation. In comparison with stereotactic radiotherapy, TACE and RFA, treatment with radioembolization yielded the highest radiologic complete response rate (33% versus 25% for TACE, 8.6% for stereotactic radiotherapy and 22% for RFA) and also the highest proportion of pathologic necrosis (75%, versus 41% for TACE, 28.5% for stereotactic radiotherapy and 60% for RFA). There were 7 patients with disease recurrence after transplantation, but none of them was treated with radioembolization (114). These findings show that radioembolization can enable patients to remain on the waiting list for transplantation by stabilizing or even down-staging their disease. To date, several trials with radioembolization have been performed with BCLC stage B and C patients. Transarterial chemoembolization (TACE), the gold standard for BCLC stage B, is not always possible because of a large portal vein main branch tumor thrombus (BCLC stage C). However, this is not an absolute contra-indication for treatment with radioembolization. Furthermore, large tumor size (>10 cm) can be a contra-indication for TACE, whereas for radioembolization, it is not (2). In a small randomized controlled trial, Kolligs et al. have compared the effectiveness of radioembolization versus TACE as first-line treatment. The disease control rates were slightly higher for radioembolization than for TACE: 76.9% versus 73.3%. The impact on quality of life was comparable (115). The PREMIERE trial is a prospective randomized phase 2 study of TACE versus radioembolization in HCC. Forty-five patients with BCLC stage A/B were included and randomly assigned to TACE (n=21) or radioembolization (n=24). Clinical toxicities and objective response rates were similar in both patient