Chemorefractory liver metastasis from cervical cancer successfully treated with a combination of yttrium-90 and immunotherapy

Abstract

Liver metastases in cervical cancer is rare and can be difficult-to-treat. The current guidelines established by the Gynecologic Oncology Group recommend platinum-based systemic chemotherapy in combination with an anti-angiogenic agent such as bevacizumab, however, overall survival remains poor following diagnosis and options for patients who fail chemotherapy are limited. Yttrium-90 (Y90) radioembolization (RE) has shown great promise in the treatment of chemo-refractory colorectal liver metastases. We describe a 30-year-old female with a history of stage IB endocervical adenocarcinoma who later developed metastases to the liver, that were unresponsive to multiple chemotherapeutics and chemoembolization, and was successfully treated with Y90 RE with concurrent systemic Pembrolizumab. The Y90 RE treatment resulted in positive clinical and imaging responses with improvement in her quality of life, all of which continue to persist at the time of writing this manuscript about 8-months into her RE treatment.

Keywords: Endocervical carcinoma; Liver metastasis; Pembrolizumab; Radioembolization; Yttrium 90 microspheres.

Fig. 1

8 months after the initiating chemotherapy (cisplatin, followed by carboplatin + Avastin), a TACE was performed to treat the new right lobe liver lesion, that was not responding to systemic therapy. The axial cone beam CT obtained in the IR suite, at the end of the TACE procedure to confirm drug localization, demonstrates Lipiodol accumulation (white arrows) around the segment 5 tumor (black arrows), suggesting a technically successful procedure.

Figure 2

Axial fused PET/CT (a and b) obtained 6 months following TACE to the right lobe and completion of 6 cycles of carboplatin + Avastin, showing a larger FDG avid lesion in segment V and a new lesion in segment 7 (black arrows), suggesting poor response to the TACE and systemic chemotherapy.

Fig. 3

Axial (a and b) and coronal (c and d) contrast enhanced MRI of the abdomen obtained concurrently with the PET/CT, to better characterize and evaluate for additional smaller liver lesions, showing heterogeneously enhancing masses in the segment 5 and 7 of the liver (black arrows).

Fig. 4

Mapping Y90 digital subtraction angiogram of the replaced right hepatic artery performed 2 weeks after the MRI and PET/CT, showing tumor blush in the segment 5 and 7 (black circles). The microcatheter is in the replaced right hepatic artery (white arrows).

Fig. 5

Planar image following Tc 99 MAA injection into the right hepatic artery, obtained as a part of the mapping angiogram, shows localization of the isotope to the segment 5 of the liver (black arrow).

Fig. 6

Axial (a and b) and coronal (c and d) contrast enhanced MRI of the abdomen obtained 3 months after the Y90 treatment showing much smaller and nonenhancing lesions in segment 5 and 7 (black arrows).

Fig. 7

PET/CT 8 months following the Y-90 RE showing continued shrinkage of the lesions without FDG activity.