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Trobiani C, Ubaldi N, Teodoli L, Tipaldi MA, Cappelli F, Ungania S, Vallati G. The Deterioration of Sarcopenia Post-Transarterial Radioembolization with Holmium-166 Serves as a Predictor for Disease Progression at 3 Months in Patients with Advanced Hepatocellular Carcinoma: A Pilot Study. J Pers Med 2024; 14:511. [PMID: 38793093 PMCID: PMC11122513 DOI: 10.3390/jpm14050511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Revised: 05/01/2024] [Accepted: 05/09/2024] [Indexed: 05/26/2024] Open
Abstract
PURPOSE The aim of this pilot study is to explore the relationship between changes in sarcopenia before and after one to three months of Transarterial Radioembolization (TARE) treatment with Holmium-166 (166Ho) and its effect on the rate of local response. Our primary objective is to assess whether the worsening of sarcopenia can function as an early indicator of a subgroup of patients at increased risk of disease progression in cases of hepatocellular carcinoma (HCC). METHODS A single-center retrospective analysis was performed on 25 patients with HCC who underwent 166Ho-TARE. Sarcopenia status was defined according to the measurement of the psoas muscle index (PMI) at baseline, one month, and three months after TARE. Radiological response according to mRECIST criteria was assessed and patients were grouped into responders and non-responders. The loco-regional response rate was evaluated for all patients before and after treatment, and was compared with sarcopenia status to identify any potential correlation. RESULTS A total of 20 patients were analyzed. According to the sarcopenia status at 1 month and 3 months, two groups were defined as follows: patients in which the deltaPMI was stable or increased (No-Sarcopenia group; n = 12) vs. patients in which the deltaPMI decreased (Sarcopenia group; n = 8). Three months after TARE, a significant difference in sarcopenia status was noted (p = 0.041) between the responders and non-responders, with the non-responder group showing a decrease in the sarcopenia values with a median deltaPMI of -0.57, compared to a median deltaPMI of 0.12 in the responder group. Therefore, deltaPMI measured three months post-TARE can be considered as a predictive biomarker for the local response rate (p = 0.028). Lastly, a minor deltaPMI variation (>-0.293) was found to be indicative of positive treatment outcomes (p = 0.0001). CONCLUSION The decline in sarcopenia three months post-TARE with Holmium-166 is a reliable predictor of worse loco-regional response rate, as evaluated radiologically, in patients with HCC. Sarcopenia measurement has the potential to be a valuable assessment tool in the management of HCC patients undergoing TARE. However, further prospective and randomized studies involving larger cohorts are necessary to confirm and validate these findings.
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Affiliation(s)
- Claudio Trobiani
- Interventional Radiology Unit, “IRCCS Istituto Nazionale Tumori Regina Elena”, 00144 Rome, Italy; (C.T.); (L.T.); (F.C.); (G.V.)
| | - Nicolò Ubaldi
- Department of Medical Surgical Sciences and Translational Medicine, Sapienza-University of Rome, Radiology Unit–Sant’Andrea Hospital, 1035 Via Di Grottarossa, 00189 Rome, Italy;
| | - Leonardo Teodoli
- Interventional Radiology Unit, “IRCCS Istituto Nazionale Tumori Regina Elena”, 00144 Rome, Italy; (C.T.); (L.T.); (F.C.); (G.V.)
| | - Marcello Andrea Tipaldi
- Department of Medical Surgical Sciences and Translational Medicine, Sapienza-University of Rome, Radiology Unit–Sant’Andrea Hospital, 1035 Via Di Grottarossa, 00189 Rome, Italy;
| | - Federico Cappelli
- Interventional Radiology Unit, “IRCCS Istituto Nazionale Tumori Regina Elena”, 00144 Rome, Italy; (C.T.); (L.T.); (F.C.); (G.V.)
| | - Sara Ungania
- Medical Physics Department, “IRCCS Istituto Nazionale Tumori Regina Elena”, 00144 Rome, Italy;
| | - Giulio Vallati
- Interventional Radiology Unit, “IRCCS Istituto Nazionale Tumori Regina Elena”, 00144 Rome, Italy; (C.T.); (L.T.); (F.C.); (G.V.)
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Serhal M, Gordon AC, Brown DB, Toskich BB, Lewandowski RJ. Transarterial Radioembolization: Overview of Radioembolic Devices. Semin Intervent Radiol 2023; 40:461-466. [PMID: 37927522 PMCID: PMC10622244 DOI: 10.1055/s-0043-1772814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Affiliation(s)
- Muhamad Serhal
- Section of Interventional Radiology, Department of Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, Illinois
| | - Andrew C. Gordon
- Section of Interventional Radiology, Department of Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, Illinois
| | - Daniel B. Brown
- Division of Interventional Radiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Beau B. Toskich
- Division of Interventional Radiology, Mayo Clinic Florida, Jacksonville, Florida
| | - Robert J. Lewandowski
- Section of Interventional Radiology, Department of Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, Illinois
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Roosen J, van Wijk MWM, Westlund Gotby LEL, Arntz MJ, Janssen MJR, Lobeek D, van de Maat GH, Overduin CG, Nijsen JFW. Improving MRI-based dosimetry for holmium-166 transarterial radioembolization using a nonrigid image registration for voxelwise Δ R 2 ∗ $\Delta R_2^*$ calculation. Med Phys 2023; 50:935-946. [PMID: 36202392 DOI: 10.1002/mp.16014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 08/16/2022] [Accepted: 09/12/2022] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Transarterial radioembolization (TARE) is a treatment modality for liver tumors during which radioactive microspheres are injected into the hepatic arterial system. These microspheres distribute throughout the liver as a result of the blood flow until they are trapped in the arterioles because of their size. Holmium-166 (166 Ho)-loaded microspheres used for TARE can be visualized and quantified with MRI, as holmium is a paramagnetic metal and locally increases the transverse relaxation rate R 2 ∗ $R_2^*$ . The current 166 Ho quantification method does not take regional differences in baseline R 2 ∗ $R_2^*$ values (such as between tumors and healthy tissue) into account, which intrinsically results in a systematic error in the estimated absorbed dose distribution. As this estimated absorbed dose distribution can be used to predict response to treatment of tumors and potential toxicity in healthy tissue, a high accuracy of absorbed dose estimation is required. PURPOSE To evaluate pre-existing differences in R 2 ∗ $R_2^*$ distributions between tumor tissue and healthy tissue and assess the feasibility and accuracy of voxelwise subtraction-based Δ R 2 ∗ $\Delta R_2^*$ calculation for MRI-based dosimetry of holmium-166 transarterial radioembolization (166 Ho TARE). METHODS MRI data obtained in six patients who underwent 166 Ho TARE of the liver as part of a clinical study was retrospectively evaluated. Pretreatment differences in R 2 ∗ $R_2^*$ distributions between tumor tissue and healthy tissue were characterized. Same-day pre- and post-treatment R 2 ∗ $R_2^*$ maps were aligned using a deformable registration algorithm and subsequently subtracted to generate voxelwise Δ R 2 ∗ $\Delta R_2^*$ maps and resultant absorbed dose maps. Image registration accuracy was quantified using the dice similarity coefficient (DSC), relative overlay (RO), and surface dice (≤4 mm; SDSC). Voxelwise subtraction-based absorbed dose maps were quantitatively (root-mean-square error, RMSE) and visually compared to the current MRI-based mean subtraction method and routinely used SPECT-based dosimetry. RESULTS Pretreatment R 2 ∗ $R_2^*$ values were lower in tumors than in healthy liver tissue (mean 36.8 s-1 vs. 55.7 s-1 , P = 0.004). Image registration improved the mean DSC of 0.83 (range: 0.70-0.88) to 0.95 (range: 0.92-0.97), mean RO of 0.71 (range 0.53-0.78) to 0.90 (range: 0.86-0.94), and mean SDSC ≤4 mm of 0.47 (range: 0.28-0.67) to 0.97 (range: 0.96-0.98). Voxelwise subtraction-based absorbed dose maps yielded a higher tumor-absorbed dose (median increase of 9.0%) and lower healthy liver-absorbed dose (median decrease of 13.8%) compared to the mean subtraction method. Voxelwise subtraction-based absorbed dose maps corresponded better to SPECT-based absorbed dose maps, reflected by a lower RMSE in three of six patients. CONCLUSIONS Voxelwise subtraction presents a robust alternative method for MRI-based dosimetry of 166 Ho microspheres that accounts for pre-existing R 2 ∗ $R_2^*$ differences, and appears to correspond better with SPECT-based dosimetry compared to the currently implemented mean subtraction method.
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Affiliation(s)
- Joey Roosen
- Department of Medical Imaging, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Meike W M van Wijk
- Department of Medical Imaging, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lovisa E L Westlund Gotby
- Department of Medical Imaging, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Mark J Arntz
- Department of Medical Imaging, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marcel J R Janssen
- Department of Medical Imaging, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Daphne Lobeek
- Department of Medical Imaging, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Christiaan G Overduin
- Department of Medical Imaging, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J Frank W Nijsen
- Department of Medical Imaging, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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A Theranostic Approach in SIRT: Value of Pre-Therapy Imaging in Treatment Planning. J Clin Med 2022; 11:jcm11237245. [PMID: 36498819 PMCID: PMC9736029 DOI: 10.3390/jcm11237245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 11/24/2022] [Accepted: 12/02/2022] [Indexed: 12/12/2022] Open
Abstract
Selective internal radiation therapy (SIRT) is one of the treatment options for liver tumors. Microspheres labelled with a therapeutic radionuclide (90Y or 166Ho) are injected into the liver artery feeding the tumor(s), usually achieving a high tumor absorbed dose and a high tumor control rate. This treatment adopts a theranostic approach with a mandatory simulation phase, using a surrogate to radioactive microspheres (99mTc-macroaggregated albumin, MAA) or a scout dose of 166Ho microspheres, imaged by SPECT/CT. This pre-therapy imaging aims to evaluate the tumor targeting and detect potential contraindications to SIRT, i.e., digestive extrahepatic uptake or excessive lung shunt. Moreover, the absorbed doses to the tumor(s) and the healthy liver can be estimated and used for planning the therapeutic activity for SIRT optimization. The aim of this review is to evaluate the accuracy of this theranostic approach using pre-therapy imaging for simulating the biodistribution of the microspheres. This review synthesizes the recent publications demonstrating the advantages and limitations of pre-therapy imaging in SIRT, particularly for activity planning.
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Reinders MT, van Erpecum KJ, Smits ML, Braat AJ, de Bruijne J, Bruijnen R, Sprengers D, de Man RA, Vegt E, IJzermans JN, Moelker A, Lam MG. Safety and Efficacy of 166Ho Radioembolization in Hepatocellular Carcinoma: The HEPAR Primary Study. J Nucl Med 2022; 63:1891-1898. [PMID: 35589409 PMCID: PMC9730925 DOI: 10.2967/jnumed.122.263823] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 04/18/2022] [Indexed: 01/11/2023] Open
Abstract
The safety and efficacy of 166Ho radioembolization was first determined in the HEPAR and HEPAR II studies, which, however, excluded patients with hepatocellular carcinoma (HCC). The aim of this prospective clinical early phase II study was to establish the toxicity profile of 166Ho radioembolization in patients with measurable, liver-dominant HCC; Barcelona clinic liver cancer stage B or C; a Child-Pugh score of no more than B7; and an Eastern Cooperative Oncology Group performance status of 0-1 without curative treatment options. Methods: The primary endpoint was a rate of unacceptable toxicity defined as grade 3 hyperbilirubinemia (Common Terminology Cancer Adverse Events, version 4.03) in combination with a low albumin or ascites level in the absence of disease progression or treatment-related serious adverse events. Secondary endpoints included overall toxicity, response, survival, change in α-fetoprotein, and quality of life. Thirty-one patients with Barcelona clinic liver cancer stage B (71%) or C (29%) HCC were included, mostly multifocal (87%) or bilobar (55%) disease. Results: Common grade 1 or 2 clinical toxicity included fatigue (71%), back pain (55%), ascites (32%), dyspnea (23%), nausea (23%), and abdominal pain (23%), with no more than 10% grade 3-5 toxicity. Grade 3 laboratory toxicity (>10%) included an aspartate transaminase and γ-glutamyltransferase increase (16%), hyperglycemia (19%), and lymphopenia (29%). Treatment-related unacceptable toxicity occurred in 3 of 31 patients. At 3 mo, 54% of target lesions showed a complete or partial response according to modified RECIST. Median overall survival was 14.9 mo (95% CI, 10.4-24.9 mo). No significant changes in quality of life or pain were observed. Conclusion: The safety of 166Ho radioembolization was confirmed in HCC, with less than 10% unacceptable toxicity. Efficacy data support further evaluation.
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Affiliation(s)
- Margot T.M. Reinders
- Department of Radiology and Nuclear Medicine, University Medical Centre, Utrecht University, Utrecht, The Netherlands
| | - Karel J. van Erpecum
- Department of Gastroenterology and Hepatology University Medical Centre, Utrecht University, Utrecht, The Netherlands
| | - Maarten L.J. Smits
- Department of Radiology and Nuclear Medicine, University Medical Centre, Utrecht University, Utrecht, The Netherlands
| | - Arthur J.A.T. Braat
- Department of Radiology and Nuclear Medicine, University Medical Centre, Utrecht University, Utrecht, The Netherlands
| | - Joep de Bruijne
- Department of Gastroenterology and Hepatology University Medical Centre, Utrecht University, Utrecht, The Netherlands
| | - Rutger Bruijnen
- Department of Radiology and Nuclear Medicine, University Medical Centre, Utrecht University, Utrecht, The Netherlands
| | - Dave Sprengers
- Department of Gastroenterology and Hepatology, Erasmus MC–University Medical Centre, Rotterdam, The Netherlands
| | - Robert A. de Man
- Department of Gastroenterology and Hepatology, Erasmus MC–University Medical Centre, Rotterdam, The Netherlands
| | - Erik Vegt
- Department of Radiology and Nuclear Medicine, Erasmus MC–University Medical Centre, Rotterdam, The Netherlands; and
| | - Jan N.M. IJzermans
- Department of Surgery, Erasmus MC–University Medical Centre, Rotterdam, The Netherlands
| | - Adriaan Moelker
- Department of Radiology and Nuclear Medicine, Erasmus MC–University Medical Centre, Rotterdam, The Netherlands; and
| | - Marnix G.E.H. Lam
- Department of Radiology and Nuclear Medicine, University Medical Centre, Utrecht University, Utrecht, The Netherlands
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Morsink NC, Nijsen JFW, Grinwis GCM, Hesselink JW, Kirpensteijn J, van Nimwegen SA. Intratumoral injection of holmium-166 microspheres as neoadjuvant therapy of soft tissue sarcomas in dogs. Front Vet Sci 2022; 9:1015248. [PMID: 36387397 PMCID: PMC9664058 DOI: 10.3389/fvets.2022.1015248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 10/10/2022] [Indexed: 01/24/2023] Open
Abstract
INTRODUCTION Minimally invasive microbrachytherapy is in development to treat solid tumors by intratumoral injection of (radioactive) holmium-166 (166Ho) microspheres (MS). A high local dose can be administered with minimal damage to surrounding tissue because of the short soft tissue penetration depth of 166Ho beta radiation. We aimed to prospectively evaluate the safety and efficacy of 166Ho microbrachytherapy in client-owned canine patients with soft tissue sarcomas (STS). METHODS We included seven dogs with STS not suitable for local excision due to tumor size and/or location. 166HoMS were suspended in a carrier fluid and multiple needle-injections were performed in predetermined tumor segments to maximize tumor coverage. Tumor response was evaluated using 3D caliper and CT measurements. Follow-up further included monitoring for potential side effects and registration of subsequent treatments and survival, until at least two years after treatment. RESULTS Delivered radioactive doses ranged from 70 to 969 Gy resulting in a mean tumor volume reduction of 49.0 ± 21.3% after 33 ± 25 days. Treatment-related side effects consisted of local necrosis (n = 1) and ulceration of the skin covering the tumor (n = 1), which resolved with basic wound care, and surgical excision of residual tumor, respectively. Residual tumor was surgically resected in six patients after 22-93 days. After a mean follow-up of 1,005 days, four patients were alive, two patients were euthanized because of unrelated causes, and one patient was euthanized because of disease progression after the owner(s) declined subsequent surgical treatment. CONCLUSION 166Ho microbrachytherapy was a safe and effective neoadjuvant treatment option for canine patients with STS.
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Affiliation(s)
- Nino Chiron Morsink
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, Utrecht, Netherlands,*Correspondence: Nino Chiron Morsink
| | - Johannes Frank Wilhelmus Nijsen
- Department of Medical Imaging, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | | | - Jan Willem Hesselink
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, Utrecht, Netherlands
| | - Jolle Kirpensteijn
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, Utrecht, Netherlands
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Roosen J, Westlund Gotby LEL, Arntz MJ, Fütterer JJ, Janssen MJR, Konijnenberg MW, van Wijk MWM, Overduin CG, Nijsen JFW. Intraprocedural MRI-based dosimetry during transarterial radioembolization of liver tumours with holmium-166 microspheres (EMERITUS-1): a phase I trial towards adaptive, image-controlled treatment delivery. Eur J Nucl Med Mol Imaging 2022; 49:4705-4715. [PMID: 35829749 DOI: 10.1007/s00259-022-05902-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 06/30/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE Transarterial radioembolization (TARE) is a treatment for liver tumours based on injection of radioactive microspheres in the hepatic arterial system. It is crucial to achieve a maximum tumour dose for an optimal treatment response, while minimizing healthy liver dose to prevent toxicity. There is, however, no intraprocedural feedback on the dose distribution, as nuclear imaging can only be performed after treatment. As holmium-166 (166Ho) microspheres can be quantified with MRI, we investigate the feasibility and safety of performing 166Ho TARE within an MRI scanner and explore the potential of intraprocedural MRI-based dosimetry. METHODS Six patients were treated with 166Ho TARE in a hybrid operating room. Per injection position, a microcatheter was placed under angiography guidance, after which patients were transported to an adjacent 3-T MRI system. After MRI confirmation of unchanged catheter location, 166Ho microspheres were injected in four fractions, consisting of 10%, 30%, 30% and 30% of the planned activity, alternated with holmium-sensitive MRI acquisition to assess the microsphere distribution. After the procedures, MRI-based dose maps were calculated from each intraprocedural image series using a dedicated dosimetry software package for 166Ho TARE. RESULTS Administration of 166Ho microspheres within the MRI scanner was feasible in 9/11 (82%) injection positions. Intraprocedural holmium-sensitive MRI allowed for tumour dosimetry in 18/19 (95%) of treated tumours. Two CTCAE grade 3-4 toxicities were observed, and no adverse events were attributed to treatment in the MRI. Towards the last fraction, 4/18 tumours exhibited signs of saturation, while in 14/18 tumours, the microsphere uptake patterns did not deviate from the linear trend. CONCLUSION This study demonstrated feasibility and preliminary safety of a first in-human application of TARE within a clinical MRI system. Intraprocedural MRI-based dosimetry enabled dynamic insight in the microsphere distribution during TARE. This proof of concept yields unique possibilities to better understand microsphere distribution in vivo and to potentially optimize treatment efficacy through treatment personalization. REGISTRATION Clinicaltrials.gov, identifier NCT04269499, registered on February 13, 2020 (retrospectively registered).
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Affiliation(s)
- Joey Roosen
- Department of Medical Imaging, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Lovisa E L Westlund Gotby
- Department of Medical Imaging, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Mark J Arntz
- Department of Medical Imaging, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jurgen J Fütterer
- Department of Medical Imaging, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marcel J R Janssen
- Department of Medical Imaging, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Mark W Konijnenberg
- Department of Medical Imaging, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Meike W M van Wijk
- Department of Medical Imaging, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Christiaan G Overduin
- Department of Medical Imaging, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J Frank W Nijsen
- Department of Medical Imaging, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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Stella M, Braat AJAT, van Rooij R, de Jong HWAM, Lam MGEH. Holmium-166 Radioembolization: Current Status and Future Prospective. Cardiovasc Intervent Radiol 2022; 45:1634-1645. [PMID: 35729423 PMCID: PMC9626412 DOI: 10.1007/s00270-022-03187-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 05/22/2022] [Indexed: 12/05/2022]
Abstract
Since its first suggestion as possible option for liver radioembolization treatment, the therapeutic isotope holmium-166 (166Ho) caught the experts’ attention due to its imaging possibilities. Being not only a beta, but also a gamma emitter and a lanthanide, 166Ho can be imaged using single-photon emission computed tomography and magnetic resonance imaging, respectively. Another advantage of 166Ho is the possibility to perform the scout and treatment procedure with the same particle. This prospect paves the way to an individualized treatment procedure, gaining more control over dosimetry-based patient selection and treatment planning. In this review, an overview on 166Ho liver radioembolization will be presented. The current clinical workflow, together with the most relevant clinical findings and the future prospective will be provided.
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Affiliation(s)
- Martina Stella
- Department of Radiology and Nuclear Medicine, UMC Utrecht, Heidelberglaan 100, 3584CX, Utrecht, The Netherlands.
| | - Arthur J A T Braat
- Department of Radiology and Nuclear Medicine, UMC Utrecht, Heidelberglaan 100, 3584CX, Utrecht, The Netherlands
| | - Rob van Rooij
- Department of Radiology and Nuclear Medicine, UMC Utrecht, Heidelberglaan 100, 3584CX, Utrecht, The Netherlands
| | - Hugo W A M de Jong
- Department of Radiology and Nuclear Medicine, UMC Utrecht, Heidelberglaan 100, 3584CX, Utrecht, The Netherlands
| | - Marnix G E H Lam
- Department of Radiology and Nuclear Medicine, UMC Utrecht, Heidelberglaan 100, 3584CX, Utrecht, The Netherlands
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Ahmadzadehfar H, Ilhan H, Lam MGEH, Sraieb M, Stegger L. Radioembolization, Principles and indications. Nuklearmedizin 2022; 61:262-272. [PMID: 35354218 DOI: 10.1055/a-1759-4238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Radioembolization is the selective application of radionuclide-loaded microspheres into liver arteries for the therapy of liver tumours and metastases. In this review, we focused on therapy planning and dosimetry, as well as the main indications of 90Y-glass and resin microspheres and 166Ho-microspheres.
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Affiliation(s)
| | - Harun Ilhan
- Department of Nuclear Medicine, Klinikum der Universität München, Munich, Germany.,Die Radiologie, Practice for Radiology, Nuclear Medicine, and Radiation Oncology, Munich, Germany
| | - Marnix G E H Lam
- Radiology and Nuclear Medicine, University of Utrecht Faculty of Medicine, Utrecht, Netherlands
| | - Miriam Sraieb
- Nuclear Medicine, University Hospital Essen, Germany
| | - Lars Stegger
- Nuclear Medicine, University Hospital Münster, Germany
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Weber M, Lam M, Chiesa C, Konijnenberg M, Cremonesi M, Flamen P, Gnesin S, Bodei L, Kracmerova T, Luster M, Garin E, Herrmann K. EANM procedure guideline for the treatment of liver cancer and liver metastases with intra-arterial radioactive compounds. Eur J Nucl Med Mol Imaging 2022; 49:1682-1699. [PMID: 35146577 PMCID: PMC8940802 DOI: 10.1007/s00259-021-05600-z] [Citation(s) in RCA: 69] [Impact Index Per Article: 34.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 10/19/2021] [Indexed: 12/15/2022]
Abstract
Primary liver tumours (i.e. hepatocellular carcinoma (HCC) or intrahepatic cholangiocarcinoma (ICC)) are among the most frequent cancers worldwide. However, only 10-20% of patients are amenable to curative treatment, such as resection or transplant. Liver metastases are most frequently caused by colorectal cancer, which accounts for the second most cancer-related deaths in Europe. In both primary and secondary tumours, radioembolization has been shown to be a safe and effective treatment option. The vast potential of personalized dosimetry has also been shown, resulting in markedly increased response rates and overall survival. In a rapidly evolving therapeutic landscape, the role of radioembolization will be subject to changes. Therefore, the decision for radioembolization should be taken by a multidisciplinary tumour board in accordance with the current clinical guidelines. The purpose of this procedure guideline is to assist the nuclear medicine physician in treating and managing patients undergoing radioembolization treatment. PREAMBLE: The European Association of Nuclear Medicine (EANM) is a professional non-profit medical association that facilitates communication worldwide among individuals pursuing clinical and research excellence in nuclear medicine. The EANM was founded in 1985. These guidelines are intended to assist practitioners in providing appropriate nuclear medicine care for patients. They are not inflexible rules or requirements of practice and are not intended, nor should they be used, to establish a legal standard of care. The ultimate judgment regarding the propriety of any specific procedure or course of action must be made by medical professionals taking into account the unique circumstances of each case. Thus, there is no implication that an approach differing from the guidelines, standing alone, is below the standard of care. To the contrary, a conscientious practitioner may responsibly adopt a course of action different from that set out in the guidelines when, in the reasonable judgment of the practitioner, such course of action is indicated by the condition of the patient, limitations of available resources or advances in knowledge or technology subsequent to publication of the guidelines. The practice of medicine involves not only the science but also the art of dealing with the prevention, diagnosis, alleviation and treatment of disease. The variety and complexity of human conditions make it impossible to always reach the most appropriate diagnosis or to predict with certainty a particular response to treatment. Therefore, it should be recognised that adherence to these guidelines will not ensure an accurate diagnosis or a successful outcome. All that should be expected is that the practitioner will follow a reasonable course of action based on current knowledge, available resources and the needs of the patient to deliver effective and safe medical care. The sole purpose of these guidelines is to assist practitioners in achieving this objective.
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Affiliation(s)
- M Weber
- Department of Nuclear medicine, University clinic Essen, Essen, Germany.
| | - M Lam
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, The Netherlands
| | - C Chiesa
- Nuclear Medicine, Foundation IRCCS National Tumour Institute, Milan, Italy
| | - M Konijnenberg
- Nuclear Medicine Department, Erasmus MC, Rotterdam, The Netherlands
| | - M Cremonesi
- Radiation Research Unit, IEO European Institute of Oncology IRCCS, Via Giuseppe Ripamonti, 435, 20141, Milan, MI, Italy
| | - P Flamen
- Department of Nuclear Medicine, Institut Jules Bordet-Université Libre de Bruxelles (ULB), 1000, Brussels, Belgium
| | - S Gnesin
- Institute of Radiation physics, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - L Bodei
- Molecular Imaging and Therapy Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - T Kracmerova
- Department of Medical Physics, Motol University Hospital, Prague, Czech Republic
| | - M Luster
- Department of Nuclear medicine, University hospital Marburg, Marburg, Germany
| | - E Garin
- Department of Nuclear Medicine, Cancer, Institute Eugène Marquis, Rennes, France
| | - K Herrmann
- Department of Nuclear medicine, University clinic Essen, Essen, Germany
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Gulec SA, McGoron AJ. Radiomicrosphere Dosimetry: Principles and Current State of the Art. Semin Nucl Med 2022; 52:215-228. [DOI: 10.1053/j.semnuclmed.2021.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Pettinato C, Richetta E, Cremonesi M. Dosimetry with single photon emission tomography (SPECT). Nucl Med Mol Imaging 2022. [DOI: 10.1016/b978-0-12-822960-6.00173-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Morsink NC, Klaassen NJM, Meij BP, Kirpensteijn J, Grinwis GCM, Schaafsma IA, Hesselink JW, Nijsen JFW, van Nimwegen SA. Case Report: Radioactive Holmium-166 Microspheres for the Intratumoral Treatment of a Canine Pituitary Tumor. Front Vet Sci 2021; 8:748247. [PMID: 34805338 PMCID: PMC8600255 DOI: 10.3389/fvets.2021.748247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 09/27/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: In this case study, a client-owned dog with a large pituitary tumor was experimentally treated by intratumoral injection of radioactive holmium-166 microspheres (166HoMS), named 166Ho microbrachytherapy. To our knowledge, this is the first intracranial intratumoral treatment through needle injection of radioactive microspheres. Materials and Methods: A 10-year-old Jack Russell Terrier was referred to the Clinic for Companion Animal Health (Faculty of Veterinary Medicine, Utrecht University, The Netherlands) with behavioral changes, restlessness, stiff gait, and compulsive circling. MRI and CT showed a pituitary tumor with basisphenoid bone invasion and marked mass effect. The tumor measured 8.8 cm3 with a pituitary height-to-brain area (P/B) ratio of 1.86 cm-1 [pituitary height (cm) ×10/brain area (cm2)]. To reduce tumor volume and neurological signs, 166HoMS were administered in the tumor center by transsphenoidal CT-guided needle injections. Results: Two manual CT-guided injections were performed containing 0.6 ml of 166HoMS suspension in total. A total of 1097 MBq was delivered, resulting in a calculated average tumor dose of 1866 Gy. At 138 days after treatment, the tumor volume measured 5.3 cm3 with a P/B ratio of 1.41 cm-1, revealing a total tumor volume reduction of 40%. Debulking surgery was performed five months after 166HoMS treatment due to recurrent neurological signs. The patient was euthanized two weeks later at request of the owners. Histopathological analysis indicated a pituitary adenoma at time of treatment, with more malignant characteristics during debulking surgery. Conclusion: The 40% tumor volume reduction without evident severe periprocedural side effects demonstrated the feasibility of intracranial intratumoral 166HoMS treatment in this single dog.
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Affiliation(s)
- Nino Chiron Morsink
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, Utrecht, Netherlands
| | - Nienke Johanna Maria Klaassen
- Department of Medical Imaging, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Björn Petrus Meij
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, Utrecht, Netherlands
| | - Jolle Kirpensteijn
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, Utrecht, Netherlands
| | | | - Irene Afra Schaafsma
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, Utrecht, Netherlands
| | - Jan Willem Hesselink
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, Utrecht, Netherlands
| | - Johannes Frank Wilhelmus Nijsen
- Department of Medical Imaging, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
- Quirem Medical, Deventer, Netherlands
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Development of an MRI-Guided Approach to Selective Internal Radiation Therapy Using Holmium-166 Microspheres. Cancers (Basel) 2021; 13:cancers13215462. [PMID: 34771626 PMCID: PMC8582586 DOI: 10.3390/cancers13215462] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 10/27/2021] [Accepted: 10/28/2021] [Indexed: 11/30/2022] Open
Abstract
Simple Summary Selective internal radiation therapy (SIRT) is a treatment for patients with liver cancer that involves the injection of radioactive microspheres into the liver artery. For a successful treatment, it is important that tumours are adequately covered with these microspheres; however, there is currently no method to assess this intraoperatively. As holmium microspheres are paramagnetic, MRI can be used to visualize the holmium deposition directly after administration, and possibly to adapt the treatment if necessary. In order to exploit this advantage and provide a personally optimized approach to SIRT, the administration could ideally be performed within a clinical MRI scanner. It is, however, unclear whether all materials (catheters, administration device) used during the procedure are safe for use in the MRI suite. Additionally, we explore the capability of MRI to visualize the microspheres in near real-time during injection, which would be a requirement for successful MRI-guided treatment. We further illustrate our findings with an initial patient case. Abstract Selective internal radiation therapy (SIRT) is a treatment modality for liver tumours during which radioactive microspheres are injected into the hepatic arterial tree. Holmium-166 (166Ho) microspheres used for SIRT can be visualized and quantified with MRI, potentially allowing for MRI guidance during SIRT. The purpose of this study was to investigate the MRI compatibility of two angiography catheters and a microcatheter typically used for SIRT, and to explore the detectability of 166Ho microspheres in a flow phantom using near real-time MRI. MR safety tests were performed at a 3 T MRI system according to American Society for Testing of Materials standard test methods. To assess the near real-time detectability of 166Ho microspheres, a flow phantom was placed in the MRI bore and perfused using a peristaltic pump, simulating the flow in the hepatic artery. Dynamic MR imaging was performed using a 2D FLASH sequence during injection of different concentrations of 166Ho microspheres. In the safety assessment, no significant heating (ΔTmax 0.7 °C) was found in any catheter, and no magnetic interaction was found in two out of three of the used catheters. Near real-time MRI visualization of 166Ho microsphere administration was feasible and depended on holmium concentration and vascular flow speed. Finally, we demonstrate preliminary imaging examples on the in vivo catheter visibility and near real-time imaging during 166Ho microsphere administration in an initial patient case treated with SIRT in a clinical 3 T MRI. These results support additional research to establish the feasibility and safety of this procedure in vivo and enable the further development of a personalized MRI-guided approach to SIRT.
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Hesse M, d'Abadie P, Lhommel R, Jamar F, Walrand S. Yttrium-90 TOF-PET-Based EUD Predicts Response Post Liver Radioembolizations Using Recommended Manufacturer FDG Reconstruction Parameters. Front Oncol 2021; 11:592529. [PMID: 34676157 PMCID: PMC8523947 DOI: 10.3389/fonc.2021.592529] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 09/07/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose Explaining why 90Y TOF-PET based equivalent uniform dose (EUD) using recommended manufacturer FDG reconstruction parameters has been shown to predict response. Methods The hot rods insert of a Jaszczak deluxe phantom was partially filled with a 2.65 GBq 90Y - 300ml DTPA water solution resulting in a 100 Gy mean absorbed dose in the 6 sectors. A two bed 20min/position acquisition was performed on a 550ps- and on a 320ps- TOF-PET/CT and reconstructed with recommended manufacturer FDG reconstruction parameters, without and with additional filtering. The whole procedure was repeated on both PET after adding 300ml of water (50Gy setup). The phantom was acquired again after decay by a factor of 10 (5Gy setup), but with 200min per bed position. For comparison, the phantom was also acquired with 18F activity corresponding to a clinical FDG whole body acquisition. Results The 100Gy-setup provided a hot rod sectors image almost as good as the 18F phantom. However, despite acquisition time compensation, the 5Gy-setup provides much lower quality imaging. TOF-PET based sectors EUDs for the three large rod sectors agreed with the actual EUDs computed with a radiosensitivity of 0.021Gy-1 well in the range observed in external beam radiotherapy (EBRT), i.e. 0.01-0.04Gy-1. This agreement explains the reunification of the dose-response relationships of the glass and resin spheres in HCC using the TOF-PET based EUD. Additional filtering reduced the EUDs agreement quality. Conclusions Recommended manufacturer FDG reconstruction parameters are suitable in TOF-PET post 90Y liver radioembolization for accurate tumour EUD computation. The present results rule out the use of low specific activity phantom studies to optimize reconstruction parameters.
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Affiliation(s)
- Michel Hesse
- Nuclear Medicine, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Philipe d'Abadie
- Nuclear Medicine, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Renaud Lhommel
- Nuclear Medicine, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Francois Jamar
- Nuclear Medicine, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Stephan Walrand
- Nuclear Medicine, Cliniques universitaires Saint-Luc, Brussels, Belgium
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de Vries M, Klaassen NJM, Morsink NC, van Nimwegen SA, Nijsen JFW, van den Dobbelsteen JJ. Dedicated holmium microsphere administration device for MRI-guided interstitial brain microbrachytherapy. Med Eng Phys 2021; 96:13-21. [PMID: 34565548 DOI: 10.1016/j.medengphy.2021.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 07/15/2021] [Accepted: 07/21/2021] [Indexed: 01/22/2023]
Abstract
Microbrachytherapy with radioactive holmium-166 (166Ho) microspheres (MS) has the potential to be an effective treatment method for brain malignancies. Direct intratumoural delivery of 166Ho-MS and dose coverage of the whole tumour are crucial requirements. However, currently no dedicated instruments for controlled intratumoural delivery exist. This study presents an administration device that facilitates this novel magnetic resonance imaging (MRI) -guided intervention. The bioceramic alumina oxide cannula creates a straight channel for a superelastic nitinol precurved stylet to control spatial deposition of Ho-MS. End-point accuracy of the stylet was measured during insertions in phantoms. Imaging tests were performed in a 3 Tesla MRI-scanner to quantify instrument-induced artefacts. Additionally, the feasibility of non-radioactive holmium-165 (165Ho)-MS delivery with the administration device was evaluated in a brain tumour simulant. Absolute stylet tip error was 0.88 ± 0.61 mm, instrument distortion in MRI depended on needle material and orientation and dose delivery of 165Ho-MS in a brain tumour phantom was possible. This study shows that the administration device can accurately place the stylet for injection of Ho-MS and that visualization can be performed with MRI.
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Affiliation(s)
- M de Vries
- Department of BioMechanical Engineering, Faculty of Mechanical, Maritime and Materials Engineering, Delft University of Technology, Mekelweg 2, Delft 2628 CD, the Netherlands.
| | - N J M Klaassen
- Department of Medical Imaging, Radboud Institute for Health Sciences, Radboud university Medical Center, Geert Grooteplein Zuid 10, Nijmegen 6525 GA, the Netherlands
| | - N C Morsink
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, Yalelaan 108, Utrecht 3508 TD, the Netherlands
| | - S A van Nimwegen
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, Yalelaan 108, Utrecht 3508 TD, the Netherlands
| | - J F W Nijsen
- Department of Medical Imaging, Radboud Institute for Health Sciences, Radboud university Medical Center, Geert Grooteplein Zuid 10, Nijmegen 6525 GA, the Netherlands; Quirem Medical B.V., Zutphenseweg 55, Deventer 7418 AH, the Netherlands
| | - J J van den Dobbelsteen
- Department of BioMechanical Engineering, Faculty of Mechanical, Maritime and Materials Engineering, Delft University of Technology, Mekelweg 2, Delft 2628 CD, the Netherlands
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d’Abadie P, Hesse M, Louppe A, Lhommel R, Walrand S, Jamar F. Microspheres Used in Liver Radioembolization: From Conception to Clinical Effects. Molecules 2021; 26:3966. [PMID: 34209590 PMCID: PMC8271370 DOI: 10.3390/molecules26133966] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 06/22/2021] [Accepted: 06/23/2021] [Indexed: 01/31/2023] Open
Abstract
Inert microspheres, labeled with several radionuclides, have been developed during the last two decades for the intra-arterial treatment of liver tumors, generally called Selective Intrahepatic radiotherapy (SIRT). The aim is to embolize microspheres into the hepatic capillaries, accessible through the hepatic artery, to deliver high levels of local radiation to primary (such as hepatocarcinoma, HCC) or secondary (metastases from several primary cancers, e.g., colorectal, melanoma, neuro-endocrine tumors) liver tumors. Several types of microspheres were designed as medical devices, using different vehicles (glass, resin, poly-lactic acid) and labeled with different radionuclides, 90Y and 166Ho. The relationship between the microspheres' properties and the internal dosimetry parameters have been well studied over the last decade. This includes data derived from the clinics, but also computational data with various millimetric dosimetry and radiobiology models. The main purpose of this paper is to define the characteristics of these radiolabeled microspheres and explain their association with the microsphere distribution in the tissues and with the clinical efficacy and toxicity. This review focuses on avenues to follow in the future to optimize such particle therapy and benefit to patients.
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Affiliation(s)
- Philippe d’Abadie
- Department of Nuclear Medicine, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, 1200 Brussels, Belgium; (M.H.); (A.L.); (R.L.); (S.W.); (F.J.)
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Gutjahr R, Bakker RC, Tiessens F, van Nimwegen SA, Schmidt B, Nijsen JFW. Quantitative dual-energy CT material decomposition of holmium microspheres: local concentration determination evaluated in phantoms and a rabbit tumor model. Eur Radiol 2020; 31:139-148. [PMID: 32767101 PMCID: PMC7755872 DOI: 10.1007/s00330-020-07092-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 06/03/2020] [Accepted: 07/20/2020] [Indexed: 12/21/2022]
Abstract
Objectives The purpose of this study was to assess the feasibility of dual-energy CT-based material decomposition using dual-X-ray spectra information to determine local concentrations of holmium microspheres in phantoms and in an animal model. Materials and methods A spectral calibration phantom with a solution containing 10 mg/mL holmium and various tube settings was scanned using a third-generation dual-energy CT scanner to depict an energy-dependent and material-dependent enhancement vectors. A serial dilution of holmium (microspheres) was quantified by spectral material decomposition and compared with known holmium concentrations. Subsequently, the feasibility of the spectral material decomposition was demonstrated in situ in three euthanized rabbits with injected (radioactive) holmium microspheres. Results The measured CT values of the holmium solutions scale linearly to all measured concentrations and tube settings (R2 = 1.00). Material decomposition based on CT acquisitions using the tube voltage combinations of 80/150 Sn kV or 100/150 Sn kV allow the most accurate quantifications for concentrations down to 0.125 mg/mL holmium. Conclusion Dual-energy CT facilitates image-based material decomposition to detect and quantify holmium microspheres in phantoms and rabbits. Key Points • Quantification of holmium concentrations based on dual-energy CT is obtained with good accuracy. • The optimal tube-voltage pairs for quantifying holmium were 80/150 Sn kV and 100/150 Sn kV using a third-generation dual-source CT system. • Quantification of accumulated holmium facilitates the assessment of local dosimetry for radiation therapies.
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Affiliation(s)
- Ralf Gutjahr
- Computed Tomography, Siemens Healthcare GmbH, Forchheim, Germany.,CAMP, Technical University of Munich, Munich, Germany
| | - Robbert C Bakker
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Oral and Maxillofacial Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Feiko Tiessens
- R&D Imaging & Software, Quirem Medical BV, Deventer, The Netherlands
| | - Sebastiaan A van Nimwegen
- Department of Clinical Sciences of Companion Animals, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
| | - Bernhard Schmidt
- Computed Tomography, Siemens Healthcare GmbH, Forchheim, Germany
| | - Johannes Frank Wilhelmus Nijsen
- R&D Imaging & Software, Quirem Medical BV, Deventer, The Netherlands. .,Department of Medical Imaging, Radboudumc, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, The Netherlands.
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Radioactive Microspheres. Clin Nucl Med 2020. [DOI: 10.1007/978-3-030-39457-8_35] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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van Roekel C, Braat AJAT, Smits MLJ, Bruijnen RCG, de Keizer B, Lam MGEH. Radioembolization. Clin Nucl Med 2020. [DOI: 10.1007/978-3-030-39457-8_36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Hesse M, Walrand S. Significant artefactual noise in 90Y TOF-PET imaging of low specific activity phantoms arises despite increased acquisition time. EJNMMI Phys 2019; 6:20. [PMID: 31781879 PMCID: PMC6882976 DOI: 10.1186/s40658-019-0259-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 10/31/2019] [Indexed: 11/24/2022] Open
Abstract
Volumes of usual PET phantoms are about four to sixfold that of a human liver. In order to avoid count rate saturation and handling of very high 90Y activity, reported TOF-PET phantom studies are performed using specific activities lower than those observed in liver radioembolization. However, due to the constant random coincidence rate induced by the natural crystal radioactivity, reduction of 90Y specific activity in TOF-PET imaging cannot be counterbalanced by increasing the acquisition time. As a result, most 90Y phantom studies reported images noisier than those obtained in whole-body 18F-FDG, and thus advised to use dedicated noise control in TOF-PET imaging post 90Y liver radioembolization. We performed acquisitions of the Jaszczak Deluxe phantom in which the hot rod insert was only partially filled with 2.6 GBq of 90Y. Standard reconstruction parameters recommended by the manufacturer for whole-body 18F-FDG PET were used. Low specific activity setups, although exactly compensated by increasing the acquisition time in order to get the same number of detected true coincidences per millilitre, were impacted by significant noise. On the other hand, specific activity and acquisition time setup similar to that used in post 90Y liver radioembolization provided image quality very close to that of whole-body 18F-FDG. This result clearly discards the use of low specific activity phantoms intended to TOF-PET reconstruction parameter optimization. Volume reduction of large phantoms can be achieved by vertically setting the phantoms or by adding Styrofoam inserts.
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Affiliation(s)
- Michel Hesse
- Universite Catholique de Louvain, Brussels, Brabant, Belgium
| | - Stephan Walrand
- Universite Catholique de Louvain, Brussels, Brabant, Belgium.
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Peltek OO, Muslimov AR, Zyuzin MV, Timin AS. Current outlook on radionuclide delivery systems: from design consideration to translation into clinics. J Nanobiotechnology 2019; 17:90. [PMID: 31434562 PMCID: PMC6704557 DOI: 10.1186/s12951-019-0524-9] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 08/14/2019] [Indexed: 02/06/2023] Open
Abstract
Radiopharmaceuticals have proven to be effective agents, since they can be successfully applied for both diagnostics and therapy. Effective application of relevant radionuclides in pre-clinical and clinical studies depends on the choice of a sufficient delivery platform. Herein, we provide a comprehensive review on the most relevant aspects in radionuclide delivery using the most employed carrier systems, including, (i) monoclonal antibodies and their fragments, (ii) organic and (iii) inorganic nanoparticles, and (iv) microspheres. This review offers an extensive analysis of radionuclide delivery systems, the approaches of their modification and radiolabeling strategies with the further prospects of their implementation in multimodal imaging and disease curing. Finally, the comparative outlook on the carriers and radionuclide choice, as well as on the targeting efficiency of the developed systems is discussed.
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Affiliation(s)
- Oleksii O Peltek
- Russian Research Center of Radiology and Surgical Technologies (RRCRST) of Ministry of Public Health, Leningradskaya Street 70 Pesochny, Saint-Petersburg, 197758, Russian Federation
| | - Albert R Muslimov
- Russian Research Center of Radiology and Surgical Technologies (RRCRST) of Ministry of Public Health, Leningradskaya Street 70 Pesochny, Saint-Petersburg, 197758, Russian Federation
| | - Mikhail V Zyuzin
- Faculty of Physics and Engineering, ITMO University, St. Petersburg, 197101, Russia
| | - Alexander S Timin
- Russian Research Center of Radiology and Surgical Technologies (RRCRST) of Ministry of Public Health, Leningradskaya Street 70 Pesochny, Saint-Petersburg, 197758, Russian Federation.
- Research School of Chemical and Biomedical Engineering, National Research Tomsk Polytechnic University, Lenin Avenue 30, Tomsk, 634050, Russia.
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Smits MLJ, Dassen MG, Prince JF, Braat AJAT, Beijst C, Bruijnen RCG, de Jong HWAM, Lam MGEH. The superior predictive value of 166Ho-scout compared with 99mTc-macroaggregated albumin prior to 166Ho-microspheres radioembolization in patients with liver metastases. Eur J Nucl Med Mol Imaging 2019; 47:798-806. [PMID: 31399801 PMCID: PMC7075844 DOI: 10.1007/s00259-019-04460-y] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 07/23/2019] [Indexed: 12/11/2022]
Abstract
Purpose As an alternative to technetium-99m-macroaggregated albumin (99mTc-MAA), a scout dose of holmium-166 (166Ho) microspheres can be used prior to 166Ho-radioembolization. The use of identical particles for pre-treatment and treatment procedures may improve the predictive value of pre-treatment analysis of distribution. The aim of this study was to analyze the agreement between 166Ho-scout and 166Ho-therapeutic dose in comparison with the agreement between 99mTc-MAA and 166Ho-therapeutic dose. Methods Two separate scout dose procedures were performed (99mTc-MAA and 166Ho-scout) before treatment in 53 patients. First, qualitative assessment was performed by two blinded nuclear medicine physicians who visually rated the agreement between the 99mTc-MAA, 166Ho-scout, and 166Ho-therapeutic dose SPECT-scans (i.e., all performed in the same patient) on a 5-point scale. Second, agreement was measured quantitatively by delineating lesions and normal liver on FDG-PET/CT. These volumes of interest (VOIs) were co-registered to the SPECT/CT images. The predicted absorbed doses (based on 99mTc-MAA and 166Ho-scout) were compared with the actual absorbed dose on post-treatment SPECT. Results A total of 23 procedures (71 lesions, 22 patients) were included for analysis. In the qualitative analysis, 166Ho-scout was superior with a median score of 4 vs. 2.5 for 99mTc-MAA (p < 0.001). The quantitative analysis showed significantly narrower 95%-limits of agreement for 166Ho-scout in comparison with 99mTc-MAA when evaluating lesion absorbed dose (− 90.3 and 105.3 Gy vs. − 164.1 and 197.0 Gy, respectively). Evaluation of normal liver absorbed dose did not show difference in agreement between both scout doses and 166Ho-therapeutic dose (− 2.9 and 5.5 Gy vs − 3.6 and 4.1 Gy for 99mTc-MAA and 166Ho-scout, respectively). Conclusions In this study, 166Ho-scout was shown to have a superior predictive value for intrahepatic distribution in comparison with 99mTc-MAA.
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Affiliation(s)
- Maarten L J Smits
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Mathijs G Dassen
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Jip F Prince
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Arthur J A T Braat
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Casper Beijst
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Rutger C G Bruijnen
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Hugo W A M de Jong
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Marnix G E H Lam
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
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Klaassen NJM, Arntz MJ, Gil Arranja A, Roosen J, Nijsen JFW. The various therapeutic applications of the medical isotope holmium-166: a narrative review. EJNMMI Radiopharm Chem 2019; 4:19. [PMID: 31659560 PMCID: PMC6682843 DOI: 10.1186/s41181-019-0066-3] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 07/05/2019] [Indexed: 12/17/2022] Open
Abstract
Over the years, a broad spectrum of applications of the radionuclide holmium-166 as a medical isotope has been established. The isotope holmium-166 is attractive as it emits high-energy beta radiation which can be used for a therapeutic effect and gamma radiation which can be used for nuclear imaging purposes. Furthermore, holmium-165 can be visualized by MRI because of its paramagnetic properties and by CT because of its high density. Since holmium-165 has a natural abundance of 100%, the only by-product is metastable holmium-166 and no costly chemical purification steps are necessary for production of nuclear reactor derived holmium-166. Several compounds labelled with holmium-166 are now used in patients, such Ho166-labelled microspheres for liver malignancies, Ho166-labelled chitosan for hepatocellular carcinoma (HCC) and [166Ho]Ho DOTMP for bone metastases. The outcomes in patients are very promising, making this isotope more and more interesting for applications in interventional oncology. Both drugs as well as medical devices labelled with radioactive holmium are used for internal radiotherapy. One of the treatment possibilities is direct intratumoural treatment, in which the radioactive compound is injected with a needle directly into the tumour. Numerous other applications have been developed, like patches for treatment of skin cancer and holmium labelled antibodies and peptides. The second major application that is currently clinically applied is selective internal radiation therapy (SIRT, also called radioembolization), a novel treatment option for liver malignancies. This review discusses medical drugs and medical devices based on the therapeutic radionuclide holmium-166.
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Affiliation(s)
- Nienke J M Klaassen
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Radboud Institute for Health Sciences, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands
| | - Mark J Arntz
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Radboud Institute for Health Sciences, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands
| | - Alexandra Gil Arranja
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Radboud Institute for Health Sciences, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands.,Department of Pharmaceutics, Utrecht Institute for Pharmaceutical Sciences (UIPS), Science for Life, Faculty of Science, Utrecht University, 3508, TB, Utrecht, The Netherlands.,Department of Radiation Science and Technology, Delft University of Technology, Mekelweg 15, 2629, JB, Delft, The Netherlands
| | - Joey Roosen
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Radboud Institute for Health Sciences, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands
| | - J Frank W Nijsen
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Radboud Institute for Health Sciences, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands.
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Degrauwe N, Hocquelet A, Digklia A, Schaefer N, Denys A, Duran R. Theranostics in Interventional Oncology: Versatile Carriers for Diagnosis and Targeted Image-Guided Minimally Invasive Procedures. Front Pharmacol 2019; 10:450. [PMID: 31143114 PMCID: PMC6521126 DOI: 10.3389/fphar.2019.00450] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 04/08/2019] [Indexed: 12/12/2022] Open
Abstract
We are continuously progressing in our understanding of cancer and other diseases and learned how they can be heterogeneous among patients. Therefore, there is an increasing need for accurate characterization of diseases at the molecular level. In parallel, medical imaging and image-guided therapies are rapidly developing fields with new interventions and procedures entering constantly in clinical practice. Theranostics, a relatively new branch of medicine, refers to procedures combining diagnosis and treatment, often based on patient and disease-specific features or molecular markers. Interventional oncology which is at the convergence point of diagnosis and treatment employs several methods related to theranostics to provide minimally invasive procedures tailored to the patient characteristics. The aim is to develop more personalized procedures able to identify cancer cells, selectively reach and treat them, and to assess drug delivery and uptake in real-time in order to perform adjustments in the treatment being delivered based on obtained procedure feedback and ultimately predict response. Here, we review several interventional oncology procedures referring to the field of theranostics, and describe innovative methods that are under development as well as future directions in the field.
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Affiliation(s)
- Nils Degrauwe
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Arnaud Hocquelet
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Antonia Digklia
- Department of Oncology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Niklaus Schaefer
- Department of Nuclear Medicine and Molecular Imaging, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Alban Denys
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Rafael Duran
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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Abstract
Radiation therapy has made tremendous progress in oncology over the last decades due to advances in engineering and physical sciences in combination with better biochemical, genetic and molecular understanding of this disease. Local delivery of optimal radiation dose to a tumor, while sparing healthy surrounding tissues, remains a great challenge, especially in the proximity of vital organs. Therefore, imaging plays a key role in tumor staging, accurate target volume delineation, assessment of individual radiation resistance and even personalized dose prescription. From this point of view, radiotherapy might be one of the few therapeutic modalities that relies entirely on high-resolution imaging. Magnetic resonance imaging (MRI) with its superior soft-tissue resolution is already used in radiotherapy treatment planning complementing conventional computed tomography (CT). Development of systems integrating MRI and linear accelerators opens possibilities for simultaneous imaging and therapy, which in turn, generates the need for imaging probes with therapeutic components. In this review, we discuss the role of MRI in both external and internal radiotherapy focusing on the most important examples of contrast agents with combined therapeutic potential.
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Reinders MTM, Smits MLJ, van Roekel C, Braat AJAT. Holmium-166 Microsphere Radioembolization of Hepatic Malignancies. Semin Nucl Med 2019; 49:237-243. [PMID: 30954190 DOI: 10.1053/j.semnuclmed.2019.01.008] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Holmium microspheres have recently become available in the European market as the third type of microspheres for radioembolization of unresectable liver malignancies. Holmium microspheres come with a dedicated administration system, and since these microspheres contain holmium-166 (166Ho) instead of yttrium-90, unique dosing and imaging possibilities have become available as well. In addition, a scout dose of 166Ho microspheres (Conformité Européenne mark is now granted and not pending anymore) can be used instead of 99mTc-macroaggragated albumin during the preparatory angiography procedure. So far, two prospective phase I and phase II clinical studies have been performed on 166Ho radioembolization in a population of liver metastases from mixed origins. These studies showed that a mean whole-liver dose of 60 Gy is safe and induces tumor response. Ongoing trials investigate the effect of 166Ho radioembolization in patients with neuroendocrine tumor metastases, hepatocellular carcinoma, and colorectal cancer metastases. Data derived from these studies will be used to refine the dosing schedule of 60 Gy to the whole liver and determine the optimal level of activity for each patient. This paper discusses several basics and provides an overview of relevant dosing aspects, technical aspects of performing holmium radioembolization, as well as a summary of completed and ongoing clinical studies and the upcoming developments regarding these microspheres.
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Abstract
Dosimetry for yttrium-90 radioembolization continues to generate interest and controversy, as multiple approaches have been used effectively. Traditionally, simple formulas primarily based on patients' body weight or perfused liver volume were used. Over the past several years, dosimetry refinements have led to marked improvements in this therapy from both a safety and efficacy standpoint. Technetium-99m macroaggregated albumin single photon emission computed tomography (SPECT) optimizes pretreatment dosimetry to ensure delivery of a therapeutic radiation dose to the tumor while minimizing nontarget radiation to healthy hepatic tissue. Post-treatment yttrium-90 PET utilizing the inherent internal pair production of yttrium-90 accurately calculates the absorbed dose to tumors and to the normal hepatic parenchyma, which correlates with patient outcomes. As dosimetric calculations become more complex, quantitative imaging with Tc-99m SPECT and Y-90 PET may set the new standard for radioembolization dosimetry.
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Affiliation(s)
- Bashir A Tafti
- Section of Interventional Radiology, Department of Radiology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA
| | - Siddharth A Padia
- Section of Interventional Radiology, Department of Radiology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA.
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Radosa CG, Radosa JC, Grosche-Schlee S, Zöphel K, Plodeck V, Kühn JP, Kotzerke J, Hoffmann RT. Holmium-166 Radioembolization in Hepatocellular Carcinoma: Feasibility and Safety of a New Treatment Option in Clinical Practice. Cardiovasc Intervent Radiol 2019; 42:405-412. [PMID: 30603976 DOI: 10.1007/s00270-018-2133-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Accepted: 11/22/2018] [Indexed: 12/18/2022]
Abstract
PURPOSE To investigate clinical feasibility, technical success and toxicity of 166Ho-radioembolization (166Ho-RE) as new approach for treatment of hepatocellular carcinomas (HCC) and to assess postinterventional calculation of exact dosimetry through quantitative analysis of MR images. MATERIALS AND METHODS From March 2017 to April 2018, nine patients suffering from HCC were treated with 166Ho-RE. To calculate mean doses on healthy liver/tumor tissue, MR was performed within the first day after treatment. For evaluation of hepatotoxicity and to rule out radioembolization-induced liver disease (REILD), the Model for End-Stage Liver Disease (MELD) Score, the Common Terminology Criteria for Adverse Events and specific laboratory parameters were used 1-day pre- and posttreatment and after 60 days. After 6 months, MR/CT follow-up was performed. RESULTS In five patients the right liver lobe, in one patient the left liver lobe and in three patients both liver lobes were treated. Median administered activity was 3.7 GBq (range 1.7-5.9 GBq). Median dose on healthy liver tissue was 41 Gy (21-55 Gy) and on tumor tissue 112 Gy (61-172 Gy). Four patients suffered from mild postradioembolization syndrome. No significant differences in median MELD-Score were observed pre-, posttherapeutic and 60 days after 166Ho-RE. No deterioration of liver function and no indicators of REILD were observed. One patient showed a complete response, four a partial response, three a stable disease and one a progressive disease at the 6 months follow-up. CONCLUSION 166Ho-RE seems to be a feasible and safe treatment option with no significant hepatotoxicity for treatment of HCC.
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Affiliation(s)
- Christoph G Radosa
- Institute and Policlinic for Diagnostic and Interventional Radiology, University Hospital Carl Gustav Carus, TU Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Julia C Radosa
- Department of Gynecology and Obstetrics, Saarland University Hospital, Kirrbergerstraße 100, 66421, Homburg, Germany
| | - Sabine Grosche-Schlee
- Department of Nuclear Medicine, University Hospital Carl Gustav Carus, TU Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Klaus Zöphel
- Department of Nuclear Medicine, University Hospital Carl Gustav Carus, TU Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Verena Plodeck
- Institute and Policlinic for Diagnostic and Interventional Radiology, University Hospital Carl Gustav Carus, TU Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Jens P Kühn
- Institute and Policlinic for Diagnostic and Interventional Radiology, University Hospital Carl Gustav Carus, TU Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Jörg Kotzerke
- Department of Nuclear Medicine, University Hospital Carl Gustav Carus, TU Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Ralf-Thorsten Hoffmann
- Institute and Policlinic for Diagnostic and Interventional Radiology, University Hospital Carl Gustav Carus, TU Dresden, Fetscherstraße 74, 01307, Dresden, Germany.
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Bastiaannet R, Kappadath SC, Kunnen B, Braat AJAT, Lam MGEH, de Jong HWAM. The physics of radioembolization. EJNMMI Phys 2018; 5:22. [PMID: 30386924 PMCID: PMC6212377 DOI: 10.1186/s40658-018-0221-z] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 06/19/2018] [Indexed: 12/11/2022] Open
Abstract
Radioembolization is an established treatment for chemoresistant and unresectable liver cancers. Currently, treatment planning is often based on semi-empirical methods, which yield acceptable toxicity profiles and have enabled the large-scale application in a palliative setting. However, recently, five large randomized controlled trials using resin microspheres failed to demonstrate a significant improvement in either progression-free survival or overall survival in both hepatocellular carcinoma and metastatic colorectal cancer. One reason for this might be that the activity prescription methods used in these studies are suboptimal for many patients.In this review, the current dosimetric methods and their caveats are evaluated. Furthermore, the current state-of-the-art of image-guided dosimetry and advanced radiobiological modeling is reviewed from a physics' perspective. The current literature is explored for the observation of robust dose-response relationships followed by an overview of recent advancements in quantitative image reconstruction in relation to image-guided dosimetry.This review is concluded with a discussion on areas where further research is necessary in order to arrive at a personalized treatment method that provides optimal tumor control and is clinically feasible.
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Affiliation(s)
- Remco Bastiaannet
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Room E01.132, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
| | - S. Cheenu Kappadath
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, 1155 Pressler St, Unit 1352, Houston, TX 77030 USA
| | - Britt Kunnen
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Room E01.132, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
| | - Arthur J. A. T. Braat
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Room E01.132, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
| | - Marnix G. E. H. Lam
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Room E01.132, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
| | - Hugo W. A. M. de Jong
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Room E01.132, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
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32
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Preparation of Chitosan microspheres containing 166Dy/166Ho in vivo generators and their theranostic potential. J Radioanal Nucl Chem 2018. [DOI: 10.1007/s10967-018-5984-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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33
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Braat AJAT, Kwekkeboom DJ, Kam BLR, Teunissen JJM, de Herder WW, Dreijerink KMA, van Rooij R, Krijger GC, de Jong HWAM, van den Bosch MAAJ, Lam MGEH. Additional hepatic 166Ho-radioembolization in patients with neuroendocrine tumours treated with 177Lu-DOTATATE; a single center, interventional, non-randomized, non-comparative, open label, phase II study (HEPAR PLUS trial). BMC Gastroenterol 2018; 18:84. [PMID: 29902988 PMCID: PMC6003090 DOI: 10.1186/s12876-018-0817-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 06/05/2018] [Indexed: 12/18/2022] Open
Abstract
Background Neuroendocrine tumours (NET) consist of a heterogeneous group of neoplasms with various organs of origin. At diagnosis 21% of the patients with a Grade 1 NET and 30% with a Grade 2 NET have distant metastases. Treatment with peptide receptor radionuclide therapy (PRRT) shows a high objective response rate and long median survival after treatment. However, complete remission is almost never achieved. The liver is the most commonly affected organ in metastatic disease and is the most incriminating factor for patient survival. Additional treatment of liver disease after PRRT may improve outcome in NET patients. Radioembolization is an established therapy for liver metastasis. To investigate this hypothesis, a phase 2 study was initiated to assess effectiveness and toxicity of holmium-166 radioembolization (166Ho-RE) after PRRT with lutetium-177 (177Lu)-DOTATATE. Methods The HEPAR PLUS trial (“HolmiumEmbolizationParticles forArterialRadiotherapyPlus177Lu-DOTATATE inSalvage NET patients”) is a single centre, interventional, non-randomized, non-comparative, open label study. In this phase 2 study 30–48 patients with > 3 measurable liver metastases according to RECIST 1.1 will receive additional 166Ho-RE within 20 weeks after the 4th and last cycle of PRRT with 7.4 GBq 177Lu-DOTATATE. Primary objectives are to assess tumour response, complete and partial response according to RECIST 1.1, and toxicity, based on CTCAE v4.03, 3 months after 166Ho-RE. Secondary endpoints include biochemical response, quality of life, biodistribution and dosimetry. Discussion This is the first prospective study to combine PRRT with 177Lu-DOTATATE and additional 166Ho-RE in metastatic NET. A radiation boost on intrahepatic disease using 166Ho-RE may lead to an improved response rate without significant additional side-effects. Trial registration Clinicaltrials.gov NCT02067988, 13 February 2014. Protocol version: 6, 30 november 2016.
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Affiliation(s)
- Arthur J A T Braat
- Department of Radiology and Nuclear Medicine, University Medical Centre Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, the Netherlands.
| | - Dik J Kwekkeboom
- Department of Nuclear Medicine, Erasmus Medical Centre, 's-Gravendijkwal 230, 3015, CE, Rotterdam, the Netherlands
| | - Boen L R Kam
- Department of Nuclear Medicine, Erasmus Medical Centre, 's-Gravendijkwal 230, 3015, CE, Rotterdam, the Netherlands
| | - Jaap J M Teunissen
- Department of Nuclear Medicine, Erasmus Medical Centre, 's-Gravendijkwal 230, 3015, CE, Rotterdam, the Netherlands
| | - Wouter W de Herder
- Department of Endocrinology, Erasmus Medical Centre, 's-Gravendijkwal 230, 3015, CE, Rotterdam, the Netherlands
| | - Koen M A Dreijerink
- Department of Endocrinology, VU University Medical Centre Amsterdam, De Boelelaan 117, 1081, HV, Amsterdam, the Netherlands
| | - Rob van Rooij
- Department of Radiology and Nuclear Medicine, University Medical Centre Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, the Netherlands
| | - Gerard C Krijger
- Department of Radiology and Nuclear Medicine, University Medical Centre Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, the Netherlands
| | - Hugo W A M de Jong
- Department of Radiology and Nuclear Medicine, University Medical Centre Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, the Netherlands
| | - Maurice A A J van den Bosch
- Department of Radiology and Nuclear Medicine, University Medical Centre Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, the Netherlands
| | - Marnix G E H Lam
- Department of Radiology and Nuclear Medicine, University Medical Centre Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, the Netherlands
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Bakker RC, van Es RJ, Rosenberg AJ, van Nimwegen SA, Bastiaannet R, de Jong HW, Nijsen JF, Lam MG. Intratumoral injection of radioactive holmium-166 microspheres in recurrent head and neck squamous cell carcinoma: preliminary results of first use. Nucl Med Commun 2018; 39:213-221. [PMID: 29309367 PMCID: PMC5815636 DOI: 10.1097/mnm.0000000000000792] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 11/28/2017] [Accepted: 12/05/2017] [Indexed: 01/29/2023]
Abstract
BACKGROUND Limited treatment options exist for patients with locoregional recurrences of head and neck squamous cell carcinoma (HNSCC). In the palliative setting, a single session, minimally invasive, and relatively safe therapy is desirable. This case series illustrates the feasibility of a direct intratumoral injection of radioactive holmium-166 microspheres (HoMS) in patients as a palliative treatment for recurrent HNSCC. PATIENTS AND METHODS In this retrospective analysis, patients with already reirradiated irresectable recurrent HNSCC, for whom palliative chemotherapy was unsuccessful or impossible, were offered microbrachytherapy with HoMS. The intratumoral injection was administered manually under ultrasound guidance. Parameters scored were technical feasibility (i.e. administration, leakage, and distribution), clinical response (response evaluation criteria in solid tumors 1.1), and complications (Common Terminology Criteria for Adverse Events 4.3). RESULTS From 2015 to 2017, three patients were treated. None of the patients experienced adverse events; however, therapeutic effects were minimal. Technical difficulties, including precipitating of microspheres and high intratumoral pressure, resulted in suboptimal distribution of the microspheres. CONCLUSION Intratumoral injections with HoMS are minimally invasive and relatively safe in palliation of HNSCC patients. Careful patient selection and improved administration techniques are required to provide a more effective treatment. Further investigation of this novel treatment modality should be carried out because of the absence of side effects and lack of other treatment options.
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Affiliation(s)
- Robbert C. Bakker
- Department of Radiology and Nuclear Medicine
- Department of Oral and Maxillofacial Surgery, University Medical Center Utrecht
| | - Robert J.J. van Es
- Department of Head and Neck Surgical Oncology, UMC Utrecht Cancer Center
| | | | - Sebastiaan A. van Nimwegen
- Department of Clinical Sciences of Companion Animals, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
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D'Arienzo M, Pimpinella M, Capogni M, De Coste V, Filippi L, Spezi E, Patterson N, Mariotti F, Ferrari P, Chiaramida P, Tapner M, Fischer A, Paulus T, Pani R, Iaccarino G, D'Andrea M, Strigari L, Bagni O. Phantom validation of quantitative Y-90 PET/CT-based dosimetry in liver radioembolization. EJNMMI Res 2017; 7:94. [PMID: 29185067 PMCID: PMC5705539 DOI: 10.1186/s13550-017-0341-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 10/29/2017] [Indexed: 12/20/2022] Open
Abstract
Background PET/CT has recently been shown to be a viable alternative to traditional post-infusion imaging methods providing good quality images of 90Y-laden microspheres after selective internal radiation therapy (SIRT). In the present paper, first we assessed the quantitative accuracy of 90Y-PET using an anthropomorphic phantom provided with lungs, liver, spine, and a cylindrical homemade lesion located into the hepatic compartment. Then, we explored the accuracy of different computational approaches on dose calculation, including (I) direct Monte Carlo radiation transport using Raydose, (II) Kernel convolution using Philips Stratos, (III) local deposition algorithm, (IV) Monte Carlo technique (MCNP) considering a uniform activity distribution, and (V) MIRD (Medical Internal Radiation Dose) analytical approach. Finally, calculated absorbed doses were compared with those obtained performing measurements with LiF:Mg,Cu,P TLD chips in a liquid environment. Results Our results indicate that despite 90Y-PET being likely to provide high-resolution images, the 90Y low branch ratio, along with other image-degrading factors, may produce non-uniform activity maps, even in the presence of uniform activity. A systematic underestimation of the recovered activity, both for the tumor insert and for the liver background, was found. This is particularly true if no partial volume correction is applied through recovery coefficients. All dose algorithms performed well, the worst case scenario providing an agreement between absorbed dose evaluations within 20%. Average absorbed doses determined with the local deposition method are in excellent agreement with those obtained using the MIRD and the kernel-convolution dose calculation approach. Finally, absorbed dose assessed with MC codes are in good agreement with those obtained using TLD in liquid solution, thus confirming the soundness of both calculation approaches. This is especially true for Raydose, which provided an absorbed dose value within 3% of the measured dose, well within the stated uncertainties. Conclusions Patient-specific dosimetry is possible even in a scenario with low true coincidences and high random fraction, as in 90Y–PET imaging, granted that accurate absolute PET calibration is performed and acquisition times are sufficiently long. Despite Monte Carlo calculations seeming to outperform all dose estimation algorithms, our data provide a strong argument for encouraging the use of the local deposition algorithm for routine 90Y dosimetry based on PET/CT imaging, due to its simplicity of implementation.
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Affiliation(s)
- Marco D'Arienzo
- ENEA, Italian National Institute of Ionizing Radiation Metrology, Via Anguillarese 301, 00123, Rome, Italy. .,Department of Anatomical, Histological, Forensic Medicine and Orthopedic Sciences, Sapienza University, Rome, Italy.
| | - Maria Pimpinella
- ENEA, Italian National Institute of Ionizing Radiation Metrology, Via Anguillarese 301, 00123, Rome, Italy
| | - Marco Capogni
- ENEA, Italian National Institute of Ionizing Radiation Metrology, Via Anguillarese 301, 00123, Rome, Italy
| | - Vanessa De Coste
- ENEA, Italian National Institute of Ionizing Radiation Metrology, Via Anguillarese 301, 00123, Rome, Italy
| | - Luca Filippi
- Nuclear Medicine Department, Santa Maria Goretti Hospital, Latina, Italy
| | - Emiliano Spezi
- School of Engineering, Cardiff University, Cardiff, CF24 3AA, United Kingdom.,Department of Medical Physics, Velindre Cancer Centre, Cardiff, UK
| | - Nick Patterson
- Department of Medical Physics, Velindre Cancer Centre, Cardiff, UK
| | - Francesca Mariotti
- ENEA, Radiation Protection Institute, Bologna Via Martiri di Monte Sole 4, 40129, Bologna, Italy
| | - Paolo Ferrari
- ENEA, Radiation Protection Institute, Bologna Via Martiri di Monte Sole 4, 40129, Bologna, Italy
| | | | | | - Alexander Fischer
- Philips Technologie GmbH Innovative Technologies, Research Laboratories Pauwelsstr, 17, 52074, Aachen, Germany
| | - Timo Paulus
- Philips Technologie GmbH Innovative Technologies, Research Laboratories Pauwelsstr, 17, 52074, Aachen, Germany
| | - Roberto Pani
- Depertment of Medico-surgical Sciences and Biotecnologies, Sapienza University of Rome, Rome, Italy
| | - Giuseppe Iaccarino
- Laboratory of Medical Physics and Expert Systems, Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144, Rome, Italy
| | - Marco D'Andrea
- Laboratory of Medical Physics and Expert Systems, Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144, Rome, Italy
| | - Lidia Strigari
- Laboratory of Medical Physics and Expert Systems, Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144, Rome, Italy
| | - Oreste Bagni
- Nuclear Medicine Department, Santa Maria Goretti Hospital, Latina, Italy
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Prince JF, van den Bosch MAAJ, Nijsen JFW, Smits MLJ, van den Hoven AF, Nikolakopoulos S, Wessels FJ, Bruijnen RCG, Braat MNGJA, Zonnenberg BA, Lam MGEH. Efficacy of Radioembolization with 166Ho-Microspheres in Salvage Patients with Liver Metastases: A Phase 2 Study. J Nucl Med 2017; 59:582-588. [PMID: 28916623 DOI: 10.2967/jnumed.117.197194] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 09/05/2017] [Indexed: 12/22/2022] Open
Abstract
Radioembolization of liver malignancies with 166Ho-microspheres has been shown to be safe in a phase 1 dose-escalation study. The purpose of this study was to investigate the efficacy of 166Ho radioembolization. Methods: In this prospective single-arm study, 56 patients were enrolled, all with liver metastases refractory to systemic therapy and ineligible for surgical resection. The primary outcome was a response by 2 target lesions on triphasic liver CT scans 3 mo after therapy, as assessed using RECIST, version 1.1. Secondary outcomes included overall tumor response, time to imaging progression, overall survival, toxicity, quality of life, and quantification of the microspheres on SPECT and MRI. Results: Between May 2012 and March 2015, 38 eligible patients were treated, one of whom was not evaluable. In 27 (73%) of 37 patients, the target lesions showed complete response, partial response, or stable disease (disease control) at 3 mo (95% confidence interval [CI], 57%-85%). The median overall survival was 14.5 mo (95% CI, 8.6-22.8 mo). For colorectal cancer patients (n = 23), the median overall survival was 13.4 mo (95% CI, 8.2-15.7 mo). Grade 3 or 4 toxic events after treatment (according to the Common Terminology Criteria for Adverse Events, version 4.03) included abdominal pain (in 18% of patients), nausea (8%), ascites (3%), fatigue (3%), gastric stenosis (3%), hepatic failure (3%), liver abscesses (3%), paroxysmal atrial tachycardia (3%), thoracic pain (3%), upper gastrointestinal hemorrhage (3%), and vomiting (3%). On SPECT, 166Ho could be quantified with high accuracy and precision, with a mean overestimation of 9.3% ± 7.1% in the liver. Conclusion: Radioembolization with 166Ho-microspheres induced a tumor response with an acceptable toxicity profile in salvage patients with liver metastases.
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Affiliation(s)
- Jip F Prince
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands; and
| | - Maurice A A J van den Bosch
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands; and
| | - Johannes F W Nijsen
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands; and
| | - Maarten L J Smits
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands; and
| | - Andor F van den Hoven
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands; and
| | - Stavros Nikolakopoulos
- Department of Biostatistics, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frank J Wessels
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands; and
| | - Rutger C G Bruijnen
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands; and
| | - Manon N G J A Braat
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands; and
| | - Bernard A Zonnenberg
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands; and
| | - Marnix G E H Lam
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands; and
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Braat AJAT, Prince JF, van Rooij R, Bruijnen RCG, van den Bosch MAAJ, Lam MGEH. Safety analysis of holmium-166 microsphere scout dose imaging during radioembolisation work-up: A cohort study. Eur Radiol 2017; 28:920-928. [PMID: 28786008 PMCID: PMC5811583 DOI: 10.1007/s00330-017-4998-2] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 05/21/2017] [Accepted: 07/18/2017] [Indexed: 12/18/2022]
Abstract
Objective Radioembolisation is generally preceded by a scout dose of technetium-99m-macroaggregated albumin to estimate extrahepatic shunting of activity. Holmium-166 microspheres can be used as a scout dose (±250 MBq) and as a therapeutic dose. The general toxicity of a holmium-166 scout dose (166Ho-SD) and safety concerns of an accidental extrahepatic deposition of 166Ho-SD were investigated. Methods All patients who received a 166Ho-SD in our institute were reviewed for general toxicity and extrahepatic depositions. The absorbed dose in extrahepatic tissue was calculated on SPECT/CT and correlated to clinical toxicities. Results In total, 82 patients were included. No relevant clinical toxicity occurred. Six patients had an extrahepatic deposition of 166Ho-SD (median administered activity 270 MBq). The extrahepatic depositions (median activity 3.7 MBq) were located in the duodenum (3x), gastric fundus, falciform ligament and the lesser curvature of the stomach, and were deposited in a median volume of 15.3 ml, which resulted in an estimated median absorbed dose of 3.6 Gy (range 0.3–13.8 Gy). No adverse events related to the extrahepatic deposition of the 166Ho-SD occurred after a median follow-up of 4 months (range 1–12 months). Conclusion These results support the safety of 250 MBq 166Ho-SD in a clinical setting. Key Points • A holmium-166 scout dose is safe in a clinical setting. • Holmium-166 scout dose is a safe alternative for99mTc-MAA for radioembolisation work-up. • Holmium-166 scout dose potentially has several benefits over99mTc-MAA for radioembolisation work-up.
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Affiliation(s)
- Arthur J A T Braat
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, Huispostnummer E01.132, 3584 CX, Utrecht, The Netherlands.
| | - Jip F Prince
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, Huispostnummer E01.132, 3584 CX, Utrecht, The Netherlands
| | - Rob van Rooij
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, Huispostnummer E01.132, 3584 CX, Utrecht, The Netherlands
| | - Rutger C G Bruijnen
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, Huispostnummer E01.132, 3584 CX, Utrecht, The Netherlands
| | - Maurice A A J van den Bosch
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, Huispostnummer E01.132, 3584 CX, Utrecht, The Netherlands
| | - Marnix G E H Lam
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, Huispostnummer E01.132, 3584 CX, Utrecht, The Netherlands
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de Baere T, Tselikas L, Yevich S, Boige V, Deschamps F, Ducreux M, Goere D, Nguyen F, Malka D. The role of image-guided therapy in the management of colorectal cancer metastatic disease. Eur J Cancer 2017; 75:231-242. [DOI: 10.1016/j.ejca.2017.01.010] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 11/29/2016] [Accepted: 01/14/2017] [Indexed: 02/07/2023]
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Buckle T, van der Wal S, van Malderen SJ, Müller L, Kuil J, van Unen V, Peters RJ, van Bemmel ME, McDonnell LA, Velders AH, Koning F, Vanhaeke F, van Leeuwen FWB. Hybrid Imaging Labels: Providing the Link Between Mass Spectrometry-Based Molecular Pathology and Theranostics. Theranostics 2017; 7:624-633. [PMID: 28255355 PMCID: PMC5327638 DOI: 10.7150/thno.17484] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 11/16/2016] [Indexed: 01/28/2023] Open
Abstract
Background: Development of theranostic concepts that include inductively coupled plasma mass spectrometry (ICP-MS) and laser ablation ICP-MS (LA-ICP-MS) imaging can be hindered by the lack of a direct comparison to more standardly used methods for in vitro and in vivo evaluation; e.g. fluorescence or nuclear medicine. In this study a bimodal (or rather, hybrid) tracer that contains both a fluorescent dye and a chelate was used to evaluate the existence of a direct link between mass spectrometry (MS) and in vitro and in vivo molecular imaging findings using fluorescence and radioisotopes. At the same time, the hybrid label was used to determine whether the use of a single isotope label would allow for MS-based diagnostics. Methods: A hybrid label that contained both a DTPA chelate (that was coordinated with either 165Ho or 111In) and a Cy5 fluorescent dye was coupled to the chemokine receptor 4 (CXCR4) targeting peptide Ac-TZ14011 (hybrid-Cy5-Ac-TZ4011). This receptor targeting tracer was used to 1) validate the efficacy of (165Ho-based) mass-cytometry in determining the receptor affinity via comparison with fluorescence-based flow cytometry (Cy5), 2) evaluate the microscopic binding pattern of the tracer in tumor cells using both fluorescence confocal imaging (Cy5) and LA-ICP-MS-imaging (165Ho), 3) compare in vivo biodistribution patterns obtained with ICP-MS (165Ho) and radiodetection (111In) after intravenous administration of hybrid-Cy5-Ac-TZ4011 in tumor-bearing mice. Finally, LA-ICP-MS-imaging (165Ho) was linked to fluorescence-based analysis of excised tissue samples (Cy5). Results: Analysis with both mass-cytometry and flow cytometry revealed a similar receptor affinity, respectively 352 ± 141 nM and 245 ± 65 nM (p = 0.08), but with a much lower detection sensitivity for the first modality. In vitro LA-ICP-MS imaging (165Ho) enabled clear discrimination between CXCR4 positive and negative cells, but fluorescence microscopy was required to determine the intracellular distribution. In vivo biodistribution patterns obtained with ICP-MS (165Ho) and radiodetection (111In) of the hybrid peptide were shown to be similar. Assessment of tracer distribution in excised tissues revealed the location of tracer uptake with both LA-ICP-MS-imaging and fluorescence imaging. Conclusion: Lanthanide-isotope chelation expands the scope of fluorescent/radioactive hybrid tracers to include MS-based analytical tools such as mass-cytometry, ICP-MS and LA-ICP-MS imaging in molecular pathology. In contradiction to common expectations, MS detection using a single chelate imaging agent was shown to be feasible, enabling a direct link between nuclear medicine-based imaging and theranostic methods.
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de Baere T, Tselikas L, Deschamps F, Boige V, Ducreux M, Hollebecque A. Advances in transarterial therapies for hepatocellular carcinoma: is novel technology leading to better outcomes? Hepat Oncol 2016; 3:109-118. [PMID: 30191032 DOI: 10.2217/hep-2015-0001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 12/15/2015] [Indexed: 02/06/2023] Open
Abstract
Conventional transarterial chemoembolization (c-TACE) was validated in 2002 for intermediate stage hepatocellular carcinoma (HCC). Recent improvements in overall survival after c-TACE in HCC is linked to both better patient selection, and improvement in treatment technologies: catheter, image guidance and new drug delivery platforms. Drug eluting beads (DEBs) demonstrated a benefit over c-TACE in pharmacokinetic studies; however, two randomized studies comparing c-TACE and DEB-TACE demonstrated no benefit of DEB-TACE in response rate or overall survival. Delivery platforms loaded with yttrium-90 deliver selective internal radiation therapy, which opens a new field of therapy for HCC. Future improvement in intra-arterial therapies will include resorbable loadable embolic material, new emulsion used for c-TACE and platforms releasing multikinase inhibitors.
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Affiliation(s)
- Thierry de Baere
- Department of Image Guided Therapy, Gustave Roussy-Cancer Campus, Villejuif, France.,Université Paris-Sud XI, UFR Médecine Le Kremlin-Bicêtre, Le Kremlin Bicêtre, France.,Department of Image Guided Therapy, Gustave Roussy-Cancer Campus, Villejuif, France.,Université Paris-Sud XI, UFR Médecine Le Kremlin-Bicêtre, Le Kremlin Bicêtre, France
| | - Lambros Tselikas
- Department of Image Guided Therapy, Gustave Roussy-Cancer Campus, Villejuif, France.,Université Paris-Sud XI, UFR Médecine Le Kremlin-Bicêtre, Le Kremlin Bicêtre, France.,Department of Image Guided Therapy, Gustave Roussy-Cancer Campus, Villejuif, France.,Université Paris-Sud XI, UFR Médecine Le Kremlin-Bicêtre, Le Kremlin Bicêtre, France
| | - Frederic Deschamps
- Department of Image Guided Therapy, Gustave Roussy-Cancer Campus, Villejuif, France.,Université Paris-Sud XI, UFR Médecine Le Kremlin-Bicêtre, Le Kremlin Bicêtre, France.,Department of Image Guided Therapy, Gustave Roussy-Cancer Campus, Villejuif, France.,Université Paris-Sud XI, UFR Médecine Le Kremlin-Bicêtre, Le Kremlin Bicêtre, France
| | - Valerie Boige
- Department of Image Guided Therapy, Gustave Roussy-Cancer Campus, Villejuif, France.,Université Paris-Sud XI, UFR Médecine Le Kremlin-Bicêtre, Le Kremlin Bicêtre, France.,Department of Image Guided Therapy, Gustave Roussy-Cancer Campus, Villejuif, France.,Université Paris-Sud XI, UFR Médecine Le Kremlin-Bicêtre, Le Kremlin Bicêtre, France
| | - Michel Ducreux
- Department of Image Guided Therapy, Gustave Roussy-Cancer Campus, Villejuif, France.,Université Paris-Sud XI, UFR Médecine Le Kremlin-Bicêtre, Le Kremlin Bicêtre, France.,Department of Image Guided Therapy, Gustave Roussy-Cancer Campus, Villejuif, France.,Université Paris-Sud XI, UFR Médecine Le Kremlin-Bicêtre, Le Kremlin Bicêtre, France
| | - Antoine Hollebecque
- Department of Image Guided Therapy, Gustave Roussy-Cancer Campus, Villejuif, France.,Université Paris-Sud XI, UFR Médecine Le Kremlin-Bicêtre, Le Kremlin Bicêtre, France.,Department of Image Guided Therapy, Gustave Roussy-Cancer Campus, Villejuif, France.,Université Paris-Sud XI, UFR Médecine Le Kremlin-Bicêtre, Le Kremlin Bicêtre, France
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Prince JF, van Rooij R, Bol GH, de Jong HWAM, van den Bosch MAAJ, Lam MGEH. Safety of a Scout Dose Preceding Hepatic Radioembolization with 166Ho Microspheres. J Nucl Med 2015; 56:817-23. [PMID: 25931477 DOI: 10.2967/jnumed.115.155564] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Accepted: 04/15/2015] [Indexed: 12/11/2022] Open
Abstract
UNLABELLED Before (166)Ho radioembolization, a small batch of the same type of microspheres is administered as a scout dose instead of the conventional (99m)Tc-macroaggregated albumin ((99m)Tc-MAA). The (166)Ho scout dose provides a more accurate and precise lung shunt assessment. However, in contrast to (99m)Tc-MAA, an unintended extrahepatic deposition of this β-emitting scout dose could inflict radiation damage, the extent of which we aimed to quantify in this study. METHODS All patients eligible for radioembolization in our institute between January 2011 and March 2014 were reviewed. Of the extrahepatic depositions of (99m)Tc-MAA on SPECT, the amount and volume were measured. These were used to calculate the theoretic absorbed dose in the case a (166)Ho scout dose had been used. The extrahepatic activity was measured as the sum of all voxels of the deposition. Volumes were measured using a threshold technique including all voxels from the maximum voxel intensity up to a certain percentage. The threshold needed to obtain the true volume was studied in a phantom study. RESULTS In the phantom study, a threshold of 40% was found to overestimate the volume, with the consequence of underestimating the absorbed dose. Of 160 patients, 32 patients (34 cases) of extrahepatic deposition were identified. The depositions contained a median of 1.3% (range, 0.1%-19.5%) of the administered activity in a median volume of 6.8 mL (range, 1.1-42 mL). The use of a scout dose of 250 MBq of (166)Ho microspheres in these cases would theoretically have resulted in a median absorbed dose of 6.0 Gy (range, 0.9-374 Gy). The dose exceeded a limit of 49 Gy (reported in 2013) in 2 of 34 cases (5.9%; 95% confidence interval, 0.7%-20.1%) or 2 of 160 (1.3%; 95% confidence interval, 0.1%-4.7%) of all patients. In these 2 patients with a large absorbed dose (112 and 374 Gy), the culprit vessel was identified in 1 case. CONCLUSION Extrahepatic deposition of a (166)Ho scout dose seems to be theoretically safe in most patients. Its safety in clinical practice is being evaluated in ongoing clinical trials.
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Affiliation(s)
- Jip F Prince
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Rob van Rooij
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gijsbert H Bol
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Hugo W A M de Jong
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Marnix G E H Lam
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
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Radioembolization Dosimetry: The Road Ahead. Cardiovasc Intervent Radiol 2014; 38:261-9. [DOI: 10.1007/s00270-014-1042-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Accepted: 10/28/2014] [Indexed: 12/25/2022]
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Prince JF, Smits MLJ, Krijger GC, Zonnenberg BA, van den Bosch MAAJ, Nijsen JFW, Lam MGEH. Radiation emission from patients treated with holmium-166 radioembolization. J Vasc Interv Radiol 2014; 25:1956-1963.e1. [PMID: 25311966 DOI: 10.1016/j.jvir.2014.09.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Revised: 09/04/2014] [Accepted: 09/04/2014] [Indexed: 02/06/2023] Open
Abstract
PURPOSE To assess the radiation exposure to individuals coming from patients after treatment with holmium-166 ((166)Ho) microspheres. MATERIALS AND METHODS Holmium-166 radioembolization (RE) with escalating whole-liver doses of 20 Gy, 40 Gy, 60 Gy, and 80 Gy was administered to 15 patients. Exposure rates (μSv/h) from patients were measured at 1.0 m distance from a lateral and frontal position at 0, 3, 6, 24, and 48 hours after infusion. The total effective dose equivalent (TEDE) to a maximally exposed contact was calculated in accordance with guidelines of the U.S. Nuclear Regulatory Commission (NRC). Results were extrapolated to a whole-liver dose of 60 Gy used in future treatments. RESULTS The median exposure rate at discharge, 48 hours after infusion, measured from a lateral position was 26 μSv/h (range, 7-45 μSv/h). Extrapolated to a whole-liver dose of 60 Gy, none of the exposure rates for the NRC contact scenario, at any time, frontal or lateral, would lead to a TEDE > 5 mSv; all patients may be released directly after treatment. Release after 6 hours is possible without contact restrictions for patients who received up to 7 GBq. CONCLUSIONS The TEDE to a contact of patients treated with (166)Ho RE would not exceed the NRC limit of 5 mSv. Contact restrictions 6 hours after treatment are unnecessary for infused activities < 7 GBq.
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Affiliation(s)
- Jip F Prince
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands..
| | - Maarten L J Smits
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Gerard C Krijger
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Bernard A Zonnenberg
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Maurice A A J van den Bosch
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Johannes F W Nijsen
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Marnix G E H Lam
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
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Elschot M, Smits MLJ, Nijsen JFW, Lam MGEH, Zonnenberg BA, van den Bosch MAAJ, Viergever MA, de Jong HWAM. Quantitative Monte Carlo-based holmium-166 SPECT reconstruction. Med Phys 2014; 40:112502. [PMID: 24320461 DOI: 10.1118/1.4823788] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
PURPOSE Quantitative imaging of the radionuclide distribution is of increasing interest for microsphere radioembolization (RE) of liver malignancies, to aid treatment planning and dosimetry. For this purpose, holmium-166 ((166)Ho) microspheres have been developed, which can be visualized with a gamma camera. The objective of this work is to develop and evaluate a new reconstruction method for quantitative (166)Ho SPECT, including Monte Carlo-based modeling of photon contributions from the full energy spectrum. METHODS A fast Monte Carlo (MC) simulator was developed for simulation of (166)Ho projection images and incorporated in a statistical reconstruction algorithm (SPECT-fMC). Photon scatter and attenuation for all photons sampled from the full (166)Ho energy spectrum were modeled during reconstruction by Monte Carlo simulations. The energy- and distance-dependent collimator-detector response was modeled using precalculated convolution kernels. Phantom experiments were performed to quantitatively evaluate image contrast, image noise, count errors, and activity recovery coefficients (ARCs) of SPECT-fMC in comparison with those of an energy window-based method for correction of down-scattered high-energy photons (SPECT-DSW) and a previously presented hybrid method that combines MC simulation of photopeak scatter with energy window-based estimation of down-scattered high-energy contributions (SPECT-ppMC+DSW). Additionally, the impact of SPECT-fMC on whole-body recovered activities (A(est)) and estimated radiation absorbed doses was evaluated using clinical SPECT data of six (166)Ho RE patients. RESULTS At the same noise level, SPECT-fMC images showed substantially higher contrast than SPECT-DSW and SPECT-ppMC+DSW in spheres ≥ 17 mm in diameter. The count error was reduced from 29% (SPECT-DSW) and 25% (SPECT-ppMC+DSW) to 12% (SPECT-fMC). ARCs in five spherical volumes of 1.96-106.21 ml were improved from 32%-63% (SPECT-DSW) and 50%-80% (SPECT-ppMC+DSW) to 76%-103% (SPECT-fMC). Furthermore, SPECT-fMC recovered whole-body activities were most accurate (A(est) = 1.06 × A - 5.90 MBq, R(2) = 0.97) and SPECT-fMC tumor absorbed doses were significantly higher than with SPECT-DSW (p = 0.031) and SPECT-ppMC+DSW (p = 0.031). CONCLUSIONS The quantitative accuracy of (166)Ho SPECT is improved by Monte Carlo-based modeling of the image degrading factors. Consequently, the proposed reconstruction method enables accurate estimation of the radiation absorbed dose in clinical practice.
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Affiliation(s)
- Mattijs Elschot
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
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Vouche M, Habib A, Ward TJ, Kim E, Kulik L, Ganger D, Mulcahy M, Baker T, Abecassis M, Sato KT, Caicedo JC, Fryer J, Hickey R, Hohlastos E, Lewandowski RJ, Salem R. Unresectable solitary hepatocellular carcinoma not amenable to radiofrequency ablation: multicenter radiology-pathology correlation and survival of radiation segmentectomy. Hepatology 2014; 60:192-201. [PMID: 24691943 DOI: 10.1002/hep.27057] [Citation(s) in RCA: 210] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Accepted: 02/01/2014] [Indexed: 12/17/2022]
Abstract
UNLABELLED Resection and radiofrequency ablation (RFA) are treatment options for hepatocellular carcinoma (HCC) <3 cm; there is interest in expanding the role of ablation to 3-5 cm. RFA is considered high-risk when the lesion is in close proximity to critical structures. Combining microcatheter technology and the localized emission properties of Y90, highly selective radioembolization is a possible alternative to RFA in such cases. We assessed the efficacy (response, radiology-pathology correlation, survival) of radiation segmentectomy in solitary HCC not amenable to RFA or resection. Patients with treatment-naïve, unresectable, solitary HCC ≤ 5 cm not amenable to RFA were included in this multicenter study. Administered dose, response rate, time-to-progression (modified Response Evaluation Criteria in Solid Tumors [mRECIST]), radiology-pathology correlation and long-term survival were assessed. In all, 102 patients were included in this study. mRECIST complete response (CR), partial response (PR), and stable disease (SD) were 47/99 (47%), 39/99 (39%), and 12/99 (12%), respectively. Median time-to-disease-progression was 33.1 months. In all, 33/102 (32%) patients were transplanted with a median (interquartile range [IQR]) time-to-transplantation of 6.3 months (3.6-9.7). Pathology revealed 100% and 50-99% necrosis in 17/33 (52%) and 16/33 (48%), respectively. Median overall survival was 53.4 months. Univariate analysis demonstrated a survival benefit for Eastern Cooperative Oncology Group (ECOG) 0 patients. In the multivariate model, age <65, ECOG 0, and Child-Pugh A were characteristics associated with longer survival. CONCLUSION Radiation segmentectomy is an effective technique with a favorable risk profile and radiology-pathology outcomes for solitary HCC ≤ 5 cm. This approach may allow for treatment of HCC in difficult locations. Since RFA and resection are not options given tumor location, there appears to be a strong rationale for this technique as second choice.
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Affiliation(s)
- Michael Vouche
- Department of Radiology, Section of Interventional Radiology and Division of Interventional Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL
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van de Maat GH, de Leeuw H, Seevinck PR, van den Bosch MAAJ, Nijsen JFW, Bakker CJG. Simultaneous R2*, R2, and R2′ quantification by combining S0estimation of the free induction decay with a single spin echo: A single acquisition method for R2insensitive quantification of holmium-166-loaded microspheres. Magn Reson Med 2014; 73:273-83. [DOI: 10.1002/mrm.25138] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Revised: 12/19/2013] [Accepted: 12/31/2013] [Indexed: 01/14/2023]
Affiliation(s)
- G. H. van de Maat
- Image Sciences Institute; University Medical Center Utrecht; Utrecht The Netherlands
| | - H. de Leeuw
- Image Sciences Institute; University Medical Center Utrecht; Utrecht The Netherlands
| | - P. R. Seevinck
- Image Sciences Institute; University Medical Center Utrecht; Utrecht The Netherlands
| | - M. A. A. J. van den Bosch
- Department of Radiology and Nuclear Medicine; University Medical Center Utrecht; Utrecht The Netherlands
| | - J. F. W. Nijsen
- Department of Radiology and Nuclear Medicine; University Medical Center Utrecht; Utrecht The Netherlands
| | - C. J. G. Bakker
- Department of Radiology and Nuclear Medicine; University Medical Center Utrecht; Utrecht The Netherlands
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Smits MLJ, Elschot M, van den Bosch MAAJ, van de Maat GH, van het Schip AD, Zonnenberg BA, Seevinck PR, Verkooijen HM, Bakker CJ, de Jong HWAM, Lam MGEH, Nijsen JFW. In vivo dosimetry based on SPECT and MR imaging of 166Ho-microspheres for treatment of liver malignancies. J Nucl Med 2013; 54:2093-100. [PMID: 24136931 DOI: 10.2967/jnumed.113.119768] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
UNLABELLED (166)Ho-poly(l-lactic acid) microspheres allow for quantitative imaging with MR imaging or SPECT for microsphere biodistribution assessment after radioembolization. The purpose of this study was to evaluate SPECT- and MR imaging-based dosimetry in the first patients treated with (166)Ho radioembolization. METHODS Fifteen patients with unresectable, chemorefractory liver metastases of any origin were enrolled in this phase 1 study and were treated with (166)Ho radioembolization according to a dose escalation protocol (20-80 Gy). The contours of all liver segments and all discernible tumors were manually delineated on T2-weighted posttreatment MR images and registered to the posttreatment SPECT images (n = 9) or SPECT/CT images (n = 6) and MR imaging-based R2* maps (n = 14). Dosimetry was based on SPECT (n = 15) and MR imaging (n = 9) for all volumes of interest, tumor-to-nontumor (T/N) activity concentration ratios were calculated, and correlation and agreement of MR imaging- and SPECT-based measurements were evaluated. RESULTS The median overall T/N ratio was 1.4 based on SPECT (range, 0.9-2.8) and 1.4 based on MR imaging (range, 1.1-3.1). In 6 of 15 patients (40%), all tumors had received an activity concentration equal to or higher than the normal liver (T/N ratio ≥ 1). Analysis of SPECT and MR imaging measurements for dose to liver segments yielded a high correlation (R(2) = 0.91) and a moderate agreement (mean bias, 3.7 Gy; 95% limits of agreement, -11.2 to 18.7). CONCLUSION With the use of (166)Ho-microspheres, in vivo dosimetry is feasible on the basis of both SPECT and MR imaging, which enables personalized treatment by selective targeting of inadequately treated tumors.
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Affiliation(s)
- Maarten L J Smits
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands; and
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Wondergem M, Smits MLJ, Elschot M, de Jong HWAM, Verkooijen HM, van den Bosch MAAJ, Nijsen JFW, Lam MGEH. 99mTc-macroaggregated albumin poorly predicts the intrahepatic distribution of 90Y resin microspheres in hepatic radioembolization. J Nucl Med 2013; 54:1294-301. [PMID: 23749996 DOI: 10.2967/jnumed.112.117614] [Citation(s) in RCA: 160] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
UNLABELLED In hepatic (90)Y radioembolization, pretreatment (99m)Tc-macroaggregated albumin ((99m)Tc-MAA) nuclear imaging is used for lung shunt analysis, evaluation of extrahepatic deposition, and sometimes for treatment planning, using a partition model. A high level of agreement between pretreatment (99m)Tc-MAA distribution and final (90)Y-microsphere distribution is assumed. The aim of this study was to investigate the value of pretreatment (99m)Tc-MAA SPECT to predict intrahepatic posttreatment (90)Y-microsphere distribution. METHODS Volumes of interest (VOIs) were delineated on pretreatment contrast-enhanced CT or MR images according to Couinaud liver segmentation. All VOIs were registered to the (99m)Tc-MAA SPECT and (90)Y SPECT images. The (99m)Tc-MAA SPECT and (90)Y SPECT activity counts were normalized to the total administered activity of (90)Y. For each VOI, this practice resulted in a predictive amount of (90)Y (MBq/cm(3)) based on (99m)Tc-MAA SPECT in comparison with an actual amount of (90)Y based on (90)Y SPECT. Bland-Altman analysis was used to investigate the agreement of the activity distribution between (99m)Tc-MAA SPECT and (90)Y SPECT. RESULTS A total of 39 procedures (225 VOIs) in 31 patients were included for analysis. The overall mean difference between pretreatment and posttreatment distribution of activity concentration for all segments was -0.022 MBq/cm(3) with 95% limits of agreement of -0.581 to 0.537 MBq/cm(3) (-28.9 to 26.7 Gy absorbed dose). A difference of >10%, >20%, and >30% of the mean activity per milliliter was found in, respectively, 153 (68%), 97 (43%), and 72 (32%) of the 225 segments. In every (99m)Tc-MAA procedure, at least 1 segment showed an under- or overestimation of >10%. The position of the catheter tip during administrations, as well as the tumor load of the liver segments, significantly influenced the disagreement. CONCLUSION In current clinical practice, (99m)Tc-MAA distribution does not accurately predict final (90)Y activity distribution. Awareness of the importance of catheter positioning and adherence to specific recommendations may lead to optimization of individualized treatment planning based on pretreatment imaging.
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Affiliation(s)
- Maurits Wondergem
- Department of Radiology and Nuclear Medicine, UMC Utrecht, Utrecht, The Netherlands
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