Pharmacological treatment of hepatocellular carcinoma with cavoatrial tumor thrombus – case series and literature review

Hepatocellular carcinomas (HCC) that extend into the vena cava and the right atrium have a poor prognosis. Surgical approaches including partial hepatectomy and thrombectomy are the most frequently reported treatment options. However, most patients with advanced HCC are not eligible for complex surgical interventions due to reduced liver function, comorbidities, and metastases. At the same time, systemic treatment options of HCC have expanded in recent years. Here, we report 3 cases of patients with advanced HCC who developed a cavoatrial tumor thrombus (CATT) after initial surgical or interventional therapy. The patients were consequently treated with sorafenib or nivolumab. In all cases, the tumor responded to systemic treatment with disease stabilization or partial regression. Overall survival after diagnosis of CATT was 3 and 17 months for sorafenib and 7 + months for nivolumab. Compared to survival rates of alternative treatment options, systemic therapies demonstrated comparable outcomes. In summary, pharmacotherapy is an efficient and well worth option to treat patients with HCC and CATT and should be an integral part of a multimodal therapy concept.

Which patient is going to benefit from surgical cytoreduction with intraperitoneal chemotherapy (for manifest peritoneal metastases)?

The gastric cancer with peritoneal metastases still represents a serious problem in the oncological surgery, whereas the peritoneal metastases arising from colorectal cancer can be successfully treated using a multimodal therapy concept consisting of systemic chemotherapy, cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. The best survival rates in patients suffering from peritoneal metastases of gastric cancer have been reported by the ToGa trial, in patients with HER-2 positive expression who received standard chemotherapy and trastuzumab. Cytoreductive surgery and HIPEC are increasingly wining a place in the multimodal therapy of gastric cancer with peritoneal metastases, the criteria for such an aggressive therapy are strict and the operability needs to be previously assessed by laparoscopic exploration. Interesting new data are awaited from the German GASTRIPEC study and from the French GASTRICHIP study.

High-Activity Samarium-153-EDTMP Therapy in Unresectable Osteosarcoma

SummaryDespite highly efficacious chemotherapy, patients with osteosarcomas still have a poor prognosis if adequate surgical control cannot be obtained. We applied high-activity Sm-153-EDTMP therapy within a multimodal therapy concept to improve local control of an unresectable osteosarcoma with poor response to initial polychemotherapy. A 21-yearold woman with an extended, unresectable pelvic osteosarcoma and multiple pulmonary metastases was treated with high-activity of Sm-153- EDTMP (150 MBq/kg BW, total 8.1 GBq). Afterwards external radiotherapy of the primary tumor site was performed and polychemotherapy was continued, followed by autologous peripheral blood stem cell reinfusion. Within 48 h after Sm-153-EDTMP application the patient had complete pain relief. After three weeks the response was documented by 3-phase Tc-99m-MDP bone scintigraphy (primary tumor and metastases: decreased tracer uptake), whole-body F-18-FDG-PET (primary tumor and metastases: diminution of glucose metabolism) and thoracic CT (metastases: reduction of size). The present case warrants further evaluation of feasibility and efficacy of this multimodal therapy combination of high-activity Sm-153-EDTMP therapy, external radiation, polychemotherapy and stem cell support for unresectable osteosarcomas.