Emmanuel Deshayes

Evaluation of response after SBRT for liver tumors

Stereotactic body radiotherapy (SBRT) has developed over the last few years for the treatment of primary and metastatic hepatic tumors. The tumoral and adjacent peritumoral modifications caused by this radiosurgery limit the evaluation of response by anatomic imaging and dimensional criteria alone, such as with RECIST. This suggests that it is of interest to also take into account the residual enhancement and hyper metabolism of these hepatic targets. We have reviewed the English language literature regarding the response of hepatic lesions treated by SBRT, and found that only seven articles were specifically concerned with this problem. The response of the hepatocellular carcinoma after SBRT has been studied specifically with multiphase enhanced CT-scan. Criteria set by the European Association of Study of the Liver better estimate response at each time point of follow up than RECIST does. Non-enhancement, reflecting tumor necrosis, is additionally an early indicator of response with extended response in time and a best non-enhancement percentage is observed at 12 months. The response after treatment by SBRT of cholangiocarcinoma has not yet generated a specific report. Use of RECIST criteria is also inadequate in the evaluation of response after SBRT for hepatic metastases. Response of liver metastases to SBRT is better assessed with a combination of size and enhancement pattern. The occurrence of a lobulated enhancement during follow up is efficient to predict local progression in a specific, reproducible, and sensitive way. Patients with FDG-avid hepatic metastases are also better evaluated with PET-CT and functional criteria than routine imaging and metric evaluation alone.

SBRT planning for liver metastases: A focus on immobilization, motion management and planning imaging techniques

AIM To evaluate the different techniques used for liver metastases Stereotactic Body Radiation Therapy (SBRT) planning. We especially focused on immobilization devices, motion management and imaging used for contouring. BACKGROUND Although some guidelines exist, there is no consensus regarding the minimal requirements for liver SBRT treatments. MATERIALS AND METHODS We reviewed the main liver metastases SBRT publications and guidelines; and compared the techniques used for immobilization, motion management, margins and imaging. RESULTS There is a wide variety of techniques used for immobilization, motion management and planning imaging. CONCLUSIONS We provide a subjective critical analysis of minimal requirements and ideal technique for liver SBRT planning.

Extended Liver Venous Deprivation Leads to a Higher Increase in Liver Function that ALPPS in Early Assessment: A comment to “Sparrelid, E. et al. Dynamic Evaluation of Liver Volume and Function in Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy. Journal of Gastrointestinal Surgery (2017)”

We read with great interest the study by Sparrelid et al. about assessment of volume (CT based) and function (with Tcmebrofenin hepatobiliary scintigraphy (HBS) of the future remnant liver (FRL) for 9 patients with colorectal liver metastasis (CRLM) undergoing associating liver partition and portal vein ligation for staged hepatectomy (ALPPS). This is the third study published so far to confirm that the increase in FLR volume in ALPPS does not keep pace with liver function within the short period of time between stages of ALPPS. While the Stockholm group’s restriction performing ALPPS only in patients with colorectal liver metastases (CRLM) in face of the worse outcomes for other indications and their thorough evaluation of patients with indocyanate green (ICG), mebrofenin and LimaX test has to be applauded, there may remain concern about the heterogeneity of the study population (among the 9 patients, 6 had previously undergone PVE and/or PVL) and the high heterogenity in measurements of liver function 6 days after the procedure (from −35.7% to +83.8%, leading to a median FRL function gain of 28.2%). With evidence from now three studies, it is becoming more difficult to turn the eyes away from the fact that ALPPS with its short time period between stages may have a real problem. It is important to emphasize that, while the extent of hypertrophy induced by ALPPS remains impressive, there is no need for hurry in the treatment of non-resected colorectal liver metastases that have responded appropriately to conversion chemotherapy. Second, the potential of inducing extensive hypertrophy through less invasive means than a two-stage hepatectomy with full or partial transection of the liver are far from exhausted. Recently, we developed a new percutaneous interventional procedure called BExtended Liver Venous Deprivation^ (eLVD) technique, which combined, during the same procedure, right portal vein embolization and right and middle hepatic vein embolizations. We showed that eLVD was safe and resulted in an increase in liver volume that is comparable to ALPPS. Additionally, a functional evaluation of the FLR was performed in 3 patients with CRLM using Tc-mebrofenin scanning 7 days after the procedure, similarly to Sparrelid et al. and based on the methodology developed by the Amsterdam group. Of note, we found comparable baseline liver function in our patients as Sparrelid et al. (respectively 1.95%/min/m [1.6–2.2] compared to 1.8%/min/ m [1.4–2.9]) suggesting that we are dealing with them same patient population. In the 3 patients undergoing eLVD with Tc-mebrofenin, a significant increase in FRL volume (+53.4%) as well as function (+65.7%) was observed 7 days * Emmanuel Deshayes emmanuel.deshayes@icm.unicancer.fr

Exogenous thyrotropin improves renal function in euthyroid patients, while serum creatinine levels are increased in hypothyroidism

Background There is evidence showing that the hypothyroid state results in increased serum creatinine levels. However, whether this is only due to the peripheral thyroid hormones or if thyroid-stimulating hormone (TSH) is also involved is not known. Methods Serum creatinine levels and estimated glomerular filtration rate (eGFR) were assessed in thyroidectomized patients with varying thyroid hormones and TSH levels. Blood samples from Group 1 (21 patients) were obtained 1 month after complete thyroidectomy, while under a hypothyroid state (t1) and a sufficient time after thyroid hormones initiation (euthyroid state, t2). Group 2 (20 euthyroid patients) were sampled after recombinant human thyrotropin injections (rhTSH, t1) and later after rhTSH extinction (t2). Results In Group 1, serum creatinine levels decreased after correction of hypothyroidism (85.3 ± 4.3 versus 78.0 ± 3.9 µmol/L; P = 0.04). In Group 2, serum creatinine levels increased after rhTSH withdrawal (70.6 ± 5.7 µmol/L versus 76.5 ± 5.8 µmol/L; P = 0.007). Between t1 and t2, eGFR varied accordingly [Group 1, 71.7 ± 3.5 versus 81.2 ± 4.5 mL/min/1.73 m² (P = 0.02); Group 2, 97.7 ± 7.4 versus 87.5 ± 5.9 (P = 0.007)]. The changes in TSH and eGFR following supplementation with thyroxine were significantly correlated (r = −0.6, P = 0.0041). Conclusions Iatrogenic hypothyroidism significantly increases serum creatinine and reversibly impairs eGFR, while treatment with rhTSH enhances renal function in euthyroid patients, supporting the existence of an influence of TSH level on renal function. The mechanisms by which peripheral thyroid hormones and TSH influence GFR need to be identified in physiology-orientated studies.