Rhenium-188 Lipiodol for the Treatment of Hepatocellular Carcinoma (HCC)

Abstract

Hepatocellular carcinoma (HCC) is one of the world’s most common malignancies, causing almost one million deaths annually. About 550,000 new cases of HCC are reported every year. Worldwide, HCC accounts for approximately 5.4% of all cancers. This major health problem is the third cause of cancer-related deaths. It is the most frequent primary liver cancer and the most severe complication of chronic liver disease. Various forms of therapy such as surgical resection, orthotopic liver transplantation (OLT), percutaneous injection to induce coagulative necrosis of the tumour have been considered as radical treatment of HCC, aiming at curing the disease. However, these have been found to be of benefit only in patients with smaller and fewer tumours, good liver function and without vascular invasion or extrahepatic spread. Unfortunately, except in patients undergoing OLT, recurrence rate has remained extremely high. In most series the curative treatment options are represented mainly by surgery (resection or transplantation), but most patients are not candidates for a curative option and only palliative treatment could be given to such patients. Radionuclide therapy using radio-conjugates have been used in the palliative treatment of inoperable HCC. However, the costs of commercially available radiopharmaceuticals like I-131 Lipiodol, Y-90 SIR spheres and Y-90 Therasphere are prohibitively high. As a result, hundreds of thousands of needy and deserving patients of HCC are deprived of this treatment option. Development of Rhenium 188 Lipiodol and its use in an IAEA sponsored multicentre study for the treatment of HCC has been a big step forward in meeting the demands for making available a low cost and effective radio-conjugate for therapy of inoperable HCC. There are several advantages of the use of intra-arterial Re-188 Lipiodol injection as compared to other intraarterial treatments. It is easier to deliver compared to chemo-embolisation. In fact, in the IAEA study the technique was feasible in all the participating countries after a short learning period. Good tolerance of Re-188 Lipiodol therapy by the patients avoids a long hospitalisation period and expensive care. It is cheaper than I-131-Lipiodol, Y-90 glass-based or resin-based microspheres, which are now available commercially. Re-188 is available onsite from an in-house generator system, on demand. One generator system can be effectively used for over 6 months. The treatment procedure does not require patient isolation and finally the multimodality applications of Rhenium-188 ensures optimal utilisation of the radionuclide in a variety of other clinical conditions like rheumatoid arthritis, haemophilic bleeding joints (Radiosynovectomy), metastatic bone pain, intravascular radionuclide therapy to prevent restenosis of coronary artery following revascularisation, etc. This chapter provides a brief overview of the available radio-conjugates for the treatment of HCC, discusses their merits and demerits and comprehensively reviews the outcome of the phase-II study conducted by the IAEA on the treatment of HCC using Re-188 Lipiodol in the developing country setting.