Perflutren Protein-Type A Microspheres and Contrast-Enhanced Ultrasound in Improving Response to Radioembolization Therapy in Patients With Liver Cancer

PRIMARY OBJECTIVE:

I. Characterize the ability of localized ultrasound contrast agent destruction to improve hepatocellular carcinoma (HCC) response to yttrium Y-90 (Y90) radioembolization.

SECONDARY OBJECTIVE:

I. Determine if contrast-enhanced ultrasound estimated tumor perfusion can reliably predict HCC response to radioembolization 1-14 days post treatment.

OUTLINE: Patients are randomized to 1 of 2 groups.

GROUP I: Patients receive perflutren protein-type A microspheres intravenously (IV) over 10 minutes and undergo contrast-enhanced ultrasound (CEUS) over 60 minutes at 1-6 hours and at approximately 7 and 14 days after yttrium Y-90 radioembolization.

GROUP II: Patients undergo standard of care yttrium Y-90 radioembolization.

After completion of study treatment, patients are followed up at 1 month and at 3-4 months.

• Yttrium-90 Microsphere Radioembolization (Procedure), also known as Yttrium Y 90 Microsphere Therapy, Yttrium-90 Radioembolization: Undergo standard of care Y-90 radioembolization
• Perflutren Protein-Type A Microspheres (Drug), also known as Optison: Given IV.
• Dynamic Contrast-Enhanced Ultrasound Imaging (Procedure): Undergo CEUS

Primary outcomes

• Treatment Response to Yttrium Y-90 Radioembolization [Up to 4 months]: Measured using the modified Response Evaluation Criteria in Solid Tumors. Will be tested with a non-parametric Mann- Whitney U-test of the difference in response distributions between control (radioembolization alone) and experimental group (ultrasound-triggered microbubble destruction \[UTMD\] + radioembolization). The outcome variable in this analysis, the modified Response Evaluation Criteria in Solid Tumors (mRECIST) score, is treated as an ordinal variable in this analysis. Tumor response assessed using modified Response Evaluation Criteria in Solid Tumors (mRECIST). The mRECIST scale includes four ordered categories: * Complete Response (best outcome) * Partial Response * Stable Disease * Progressive Disease (worst outcome)
• Tumor Perfusion Measured by Contrast-enhanced Ultrasound Between Ultrasound-triggered Microbubble Destruction Pulses [Up to 14 days]: Perfusion will be characterized in terms of contrast replenishment time intensity curves fit with a 2-parameter exponential recovery curve. The relationship between the normalized perfusion values from this image processing and the patients' subsequent mRECIST scores in the UTMD + radioembolization group will be evaluated with Spearman's rank order correlation. Tumor perfusion measured as fractional vascularity (%) using contrast-enhanced ultrasound (CEUS). Values range from 0% (no perfusion) to 100% (maximal perfusion).

Sex: All, ages: 18 Years to any

Inclusion Criteria:

* Be scheduled for sub-lobar radioembolization therapy of a previously untreated HCC mass < 6 cm visible on grayscale ultrasound
* Be medically stable
* If a female of child-bearing age, have a negative pregnancy test prior to each ultrasound exam
* Have signed informed consent to participate in the study

Exclusion Criteria:

* Females who are pregnant or nursing
* Patients who are medically unstable, patients who are seriously or terminally ill, and patients whose clinical course is unpredictable; for example:

  * Patients on life support or in a critical care unit
  * Patients with unstable occlusive disease (e.g., crescendo angina)
  * Patients with clinically unstable cardiac arrhythmias, such as recurrent ventricular tachycardia
  * Patients with uncontrolled congestive heart failure (New York heart Association \[NYHA\] class IV)
* Patients with recent cerebral hemorrhage
* Patients with known sensitivities to albumin, blood, or blood products
* Patients with known hypersensitivity to perflutren
* Patients with known cardiac shunts
* Patients with known congenital heart defects
* Patients with severe emphysema, pulmonary vasculitis, or a history of pulmonary embolism
* Patients with respiratory distress syndrome
* Patients with a history of bleeding disorders
* Patients with bilirubin levels > 2 mg/dL

Participant flow

Outcome results

• Treatment Response to Yttrium Y-90 Radioembolization (Primary), Count of participants, Participants: Group I (Perflutren Protein-type A Microspheres, CEUS) 2; Group II (Standard of Care) 17
• Tumor Perfusion Measured by Contrast-enhanced Ultrasound Between Ultrasound-triggered Microbubble Destruction Pulses (Primary), Mean, percentage of tumor vascularity: Group I (Perflutren Protein-type A Microspheres, CEUS) 62 +/- 28; Group II (Standard of Care)

Adverse events

Time frame: From enrollment through 3-4 months post-treatment

Other adverse events by term

• Results publication: Wessner CE, Forsberg F, Lyshchik A, O'Kane P, Bradigan K, Liu JB, Delaney LJ, Anton K, Topper SR, Civan J, Maley W, Keith SW, Shaw CM, Eisenbrey JR. Microbubble-based Radiosensitization of Hepatocellular Carcinoma: Evaluation of Safety and Efficacy in a Phase II Randomized Trial. Radiology. 2025 Sep;316(3):e250083. doi: 10.1148/radiol.250083. PMID 41025990

• Study Protocol and Statistical Analysis Plan (PDF, 2023-07-05)

• John Eisenbrey, PhD, Principal investigator, Sidney Kimmel Comprehensive Cancer Center at Thomas Jefferson University

NIH grants: R01CA238241