1
|
Taswell CS, Studenski M, Pennix T, Stover B, Georgiou M, Venkat S, Jones P, Zikria J, Thornton L, Yechieli R, Mohan P, Portelance L, Spieler B. For Hepatocellular Carcinoma Treated with Yttrium-90 Microspheres, Dose Volumetrics on Post-Treatment Bremsstrahlung SPECT/CT Predict Clinical Outcomes. Cancers (Basel) 2023; 15:cancers15030645. [PMID: 36765603 PMCID: PMC9913422 DOI: 10.3390/cancers15030645] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 01/11/2023] [Accepted: 01/17/2023] [Indexed: 01/22/2023] Open
Abstract
In transarterial radioembolization (TARE) of hepatocellular carcinoma (HCC) with Yttrium-90 (Y-90) microspheres, recent studies correlate dosimetry from bremsstrahlung single photon emission tomography (SPECT/CT) with treatment outcomes; however, these studies focus on measures of central tendency rather than volumetric coverage metrics commonly used in radiation oncology. We hypothesized that three-dimensional (3D) isodose coverage of gross tumor volume (GTV) is the driving factor in HCC treatment response to TARE and is best assessed using advanced dosimetry techniques applied to nuclear imaging of actual Y-90 biodistribution. We reviewed 51 lobar TARE Y-90 treatments of 43 HCC patients. Dose prescriptions were 120 Gy for TheraSpheres and 85 Gy for SIR-Spheres. All patients underwent post-TARE Y-90 bremsstrahlung SPECT/CT imaging. Commercial software was used to contour gross tumor volume (GTV) and liver on post-TARE SPECT/CT. Y-90 dose distributions were calculated using the Local Deposition Model based on post-TARE SPECT/CT activity maps. Median gross tumor volume (GTV) dose; GTV receiving less than 100 Gy, 70 Gy and 50 Gy; minimum dose covering the hottest 70%, 95%, and 98% of the GTV (D70, D95, D98); mean dose to nontumorous liver, and disease burden (GTV/liver volume) were obtained. Clinical outcomes were collected for all patients by chart and imaging review. HCC treatment response was assessed according to the modified response criteria in solid tumors (mRECIST) guidelines. Kaplan-Meier (KM) survival estimates and multivariate regression analyses (MVA) were performed using STATA. Median survival was 22.5 months for patients achieving objective response (OR) in targeted lesions (complete response (CR) or partial response (PR) per mRECIST) vs. 7.6 months for non-responders (NR, stable disease or disease progression per mRECIST). On MVA, the volume of underdosed tumor (GTV receiving less than 100 Gy) was the only significant dosimetric predictor for CR (p = 0.0004) and overall survival (OS, p = 0.003). All targets with less than CR (n = 39) had more than 20 cc of underdosed tumor. D70 (p = 0.038) correlated with OR, with mean D70 of 95 Gy for responders and 60 Gy for non-responders (p = 0.042). On MVA, mean dose to nontumorous liver trended toward significant association with grade 3+ toxicity (p = 0.09) and correlated with delivered activity (p < 0.001) and burden of disease (p = 0.05). Dosimetric models supplied area under the curve estimates of > 0.80 predicting CR, OR, and ≥grade 3 acute toxicity. Dosimetric parameters derived from the retrospective analysis of post-TARE Y-90 bremsstrahlung SPECT/CT after lobar treatment of HCC suggest that volumetric coverage of GTV, not a high mean or median dose, is the driving factor in treatment response and that this is best assessed through the analysis of actual Y-90 biodistribution.
Collapse
Affiliation(s)
- Crystal Seldon Taswell
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami, 1475 NW 12th Ave, Miami, FL 33136, USA
| | - Matthew Studenski
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami, 1475 NW 12th Ave, Miami, FL 33136, USA
| | - Thomas Pennix
- Miller School of Medicine, University of Miami, 1600 NW 10th Ave, Miami, FL 33136, USA
| | - Bryan Stover
- Department of Radiology, Sylvester Comprehensive Cancer Center, University of Miami, 1475 NW 12th Ave, Miami, FL 33136, USA
| | - Mike Georgiou
- Department of Radiology, Sylvester Comprehensive Cancer Center, University of Miami, 1475 NW 12th Ave, Miami, FL 33136, USA
| | - Shree Venkat
- Department of Radiology, Sylvester Comprehensive Cancer Center, University of Miami, 1475 NW 12th Ave, Miami, FL 33136, USA
| | - Patricia Jones
- Department of Medicine, Division of Digestive Health and Liver Diseases, Sylvester Comprehensive Cancer Center, University of Miami, 1475 NW 12th Ave, Miami, FL 33136, USA
| | - Joseph Zikria
- Department of Radiology, Sylvester Comprehensive Cancer Center, University of Miami, 1475 NW 12th Ave, Miami, FL 33136, USA
| | - Lindsay Thornton
- Department of Radiology, Sylvester Comprehensive Cancer Center, University of Miami, 1475 NW 12th Ave, Miami, FL 33136, USA
| | - Raphael Yechieli
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami, 1475 NW 12th Ave, Miami, FL 33136, USA
| | - Prasoon Mohan
- Department of Radiology, Sylvester Comprehensive Cancer Center, University of Miami, 1475 NW 12th Ave, Miami, FL 33136, USA
| | - Lorraine Portelance
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami, 1475 NW 12th Ave, Miami, FL 33136, USA
| | - Benjamin Spieler
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami, 1475 NW 12th Ave, Miami, FL 33136, USA
- Correspondence:
| |
Collapse
|
2
|
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]
|
3
|
Roosen J, Klaassen NJM, Westlund Gotby LEL, Overduin CG, Verheij M, Konijnenberg MW, Nijsen JFW. To 1000 Gy and back again: a systematic review on dose-response evaluation in selective internal radiation therapy for primary and secondary liver cancer. Eur J Nucl Med Mol Imaging 2021; 48:3776-3790. [PMID: 33839892 PMCID: PMC8484215 DOI: 10.1007/s00259-021-05340-0] [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: 12/08/2020] [Accepted: 03/25/2021] [Indexed: 12/21/2022]
Abstract
Purpose To systematically review all current evidence into the dose-response relation of yttrium-90 and holmium-166 selective internal radiation therapy (SIRT) in primary and secondary liver cancer. Methods A standardized search was performed in PubMed (MEDLINE), Embase, and the Cochrane Library in order to identify all published articles on dose-response evaluation in SIRT. In order to limit the results, all articles that investigated SIRT in combination with other therapy modalities (such as chemotherapy) were excluded. Results A total of 3038 records were identified of which 487 were screened based on the full text. Ultimately, 37 studies were included for narrative analysis. Meta-analysis could not be performed due to the large heterogeneity in study and reporting designs. Out of 37 studies, 30 reported a ‘mean dose threshold’ that needs to be achieved in order to expect a response. This threshold appears to be higher for hepatocellular carcinoma (HCC, 100–250 Gy) than for colorectal cancer metastases (CRC, 40–60 Gy). Reported thresholds tend to be lower for resin microspheres than when glass microspheres are used. Conclusion Although the existing evidence demonstrates a dose-response relationship in SIRT for both primary liver tumours and liver metastases, many pieces of the puzzle are still missing, hampering the definition of standardized dose thresholds. Nonetheless, most current evidence points towards a target mean dose of 100–250 Gy for HCC and 40–60 Gy for CRC. The field would greatly benefit from a reporting standard and prospective studies designed to elucidate the dose-response relation in different tumour types. Supplementary Information The online version contains supplementary material available at 10.1007/s00259-021-05340-0.
Collapse
Affiliation(s)
- Joey Roosen
- Department of Medical Imaging, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Nienke J M Klaassen
- 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
| | - Christiaan G Overduin
- Department of Medical Imaging, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marcel Verheij
- Department of Radiation Oncology, 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 Medical Center, Rotterdam, The Netherlands
| | - J Frank W Nijsen
- Department of Medical Imaging, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.
| |
Collapse
|
4
|
Stephens RW, Tredwell GD, Bell JL, Knox KJ, Philip LA, Senden TJ, Tapner MJ, Bickley SA, Tanudji MR, Jones SK. In vivo tumour imaging employing regional delivery of novel gallium radiolabelled polymer composites. Biomater Res 2021; 25:7. [PMID: 33789768 PMCID: PMC8011123 DOI: 10.1186/s40824-021-00210-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 03/16/2021] [Indexed: 11/23/2022] Open
Abstract
Background Understanding the regional vascular delivery of particles to tumour sites is a prerequisite for developing new diagnostic and therapeutic composites for treatment of oncology patients. We describe a novel imageable 67Ga-radiolabelled polymer composite that is biocompatible in an animal tumour model and can be used for preclinical imaging investigations of the transit of different sized particles through arterial networks of normal and tumour-bearing organs. Results Radiolabelling of polymer microspheres with 67Ga was achieved using a simple mix and wash method, with tannic acid as an immobilising agent. Final in vitro binding yields after autoclaving averaged 94.7%. In vivo stability of the composite was demonstrated in New Zealand white rabbits by intravenous administration, and intrahepatic artery instillations were made in normal and VX2 tumour implanted rabbit livers. Stability of radiolabel was sufficient for rabbit lung and liver imaging over at least 3 hours and 1 hour respectively, with lung retention of radiolabel over 91%, and retention in both normal and VX2 implanted livers of over 95%. SPECT-CT imaging of anaesthetised animals and planar imaging of excised livers showed visible accumulation of radiolabel in tumours. Importantly, microsphere administration and complete liver dispersal was more easily achieved with 8 μm diameter MS than with 30 μm MS, and the smaller microspheres provided more distinct and localised tumour imaging. Conclusion This method of producing 67Ga-radiolabelled polymer microspheres is suitable for SPECT-CT imaging of the regional vascular delivery of microspheres to tumour sites in animal models. Sharper distinction of model tumours from normal liver was obtained with smaller MS, and tumour resolution may be further improved by the use of 68Ga instead of 67Ga, to enable PET imaging.
Collapse
Affiliation(s)
- Ross W Stephens
- The Biomedical Radiochemistry Laboratory, Department of Applied Mathematics, Research School of Physics, Australian National University, Canberra, ACT, Australia.
| | - Gregory D Tredwell
- The Biomedical Radiochemistry Laboratory, Department of Applied Mathematics, Research School of Physics, Australian National University, Canberra, ACT, Australia
| | - Jessica L Bell
- The Biomedical Radiochemistry Laboratory, Department of Applied Mathematics, Research School of Physics, Australian National University, Canberra, ACT, Australia
| | - Karen J Knox
- The Biomedical Radiochemistry Laboratory, Department of Applied Mathematics, Research School of Physics, Australian National University, Canberra, ACT, Australia
| | - Lee A Philip
- The Biomedical Radiochemistry Laboratory, Department of Applied Mathematics, Research School of Physics, Australian National University, Canberra, ACT, Australia
| | - Tim J Senden
- The Biomedical Radiochemistry Laboratory, Department of Applied Mathematics, Research School of Physics, Australian National University, Canberra, ACT, Australia
| | | | | | | | | |
Collapse
|
5
|
Abstract
The current review documents the major hallmarks in the history and development of radioembolization, the origins of which date back to the late 1940s. Radioembolization was initially abandoned because of the increased incidence of adverse effects and lack of commercial interest; however, it regained avid interest in clinical trials and has achieved established clinical utility in the last 15 years. This review focuses on the main stations of the evolution of radioembolization, namely, initial animal and human experimental studies, production of Y-microspheres, development of current therapeutic agents (resin and glass spheres and labeled Lipiodol), prediction and prevention of inadvertent, extrahepatic shunt side effects, initial prospective studies, and large randomized trials till final approval from the relevant official bodies. The historical knowledge of the initial concepts of the method and the limitations encountered may pave the way toward further evolution and possible new applications.
Collapse
|
6
|
How Wong Y, Yee Tan H, Kasbollah A, Johan Jeet Abdullah B, Nazri Md Shah M, Hong Yeong C. Biodegradable Samarium-153–labelled microspheres for hepatic radioembolization: preparation, characterization and radiolabelling evaluation after neutron activation. ACTA ACUST UNITED AC 2019. [DOI: 10.1088/1742-6596/1248/1/012066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
|
7
|
Kessler J, Park JJ. Yttrium-90 Radioembolization After Local Hepatic Therapy: How Prior Treatments Impact Patient Selection, Dosing, and Toxicity. Tech Vasc Interv Radiol 2019; 22:112-116. [PMID: 31079707 DOI: 10.1053/j.tvir.2019.02.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Numerous local treatment strategies now exist for patients with primary and metastatic liver tumors. Increasingly, patients who cannot be adequately treated with a single form of focal therapy, go on to receive a variety of sequential treatments. However, the impact of each prior therapy on subsequent treatments and the cumulative toxicity of these therapies remains uncertain. Yttrium-90 radioembolization is becoming an increasingly common treatment for patients with hepatic malignancies. Though the baseline toxicity of radioembolization is low, greater care must be taken when treating patients who have undergone prior hepatic treatments. While this population can be treated safely, additional measures should be taken to ensure that patients are carefully screened and all effort is made to minimize liver toxicity.
Collapse
Affiliation(s)
- Jonathan Kessler
- Division of Interventional Radiology, Department of Radiology, City of Hope Comprehensive Cancer Center, Duarte, CA.
| | - John J Park
- Division of Interventional Radiology, Department of Radiology, City of Hope Comprehensive Cancer Center, Duarte, CA
| |
Collapse
|
8
|
Stephens RW, Tredwell GD, Knox KJ, Philip LA, King DW, Debono KM, Bell JL, Senden TJ, Tanudji MR, Winter JG, Bickley SA, Tapner MJ, Jones SK. 99mTc-radiolabeled composites enabling in vivo imaging of arterial dispersal and retention of microspheres in the vascular network of rabbit lungs, liver, and liver tumors. Int J Nanomedicine 2019; 14:889-900. [PMID: 30774340 PMCID: PMC6362927 DOI: 10.2147/ijn.s187153] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Purpose Selective internal radiation therapy (SIRT) is an effective treatment option for liver tumors, using Y-90-loaded polymer microspheres that are delivered via catheterization of the hepatic artery. Since Y-90 is a beta emitter and not conveniently imaged by standard clinical instrumentation, dosimetry is currently evaluated in each patient using a surrogate particle, 99mTechnetium-labeled macroaggregated albumin (99mTc-MAA). We report a new composite consisting of 99mTc-labeled nanoparticles attached to the same polymer microspheres as used for SIRT, which can be imaged with standard SPECT. Methods Carbon nanoparticles with an encapsulated core of 99mTc were coated with the polycation protamine sulfate to provide electrostatic attachment to anionic polystyrene sulfonate microspheres of different sizes (30, 12, and 8 µm). The in vivo stability of these composites was determined via intravenous injection and entrapment in the capillary network of normal rabbit lungs for up to 3 hours. Furthermore, we evaluated their biodistribution in normal rabbit livers, and livers implanted with VX2 tumors, following intrahepatic artery instillation. Results We report distribution tests for three different sizes of radiolabeled microspheres and compare the results with those obtained using 99mTc-MAA. Lung retention of the radiolabeled microspheres ranged from 72.8% to 92.9%, with the smaller diameter microspheres showing the lowest retention. Liver retention of the microspheres was higher, with retention in normal livers ranging from 99.2% to 99.8%, and in livers with VX2 tumors from 98.2% to 99.2%. The radiolabeled microspheres clearly demonstrated preferential uptake at tumor sites due to the increased arterial perfusion produced by angiogenesis. Conclusion We describe a novel use of radiolabeled carbon nanoparticles to generate an imageable microsphere that is stable in vivo under the shear stress conditions of arterial networks. Following intra-arterial instillation in the normal rabbit liver, they distribute in a distinct segmented pattern, with the smaller microspheres extending throughout the organ in finer detail, while still being well retained within the liver. Furthermore, in livers hosting an implanted VX2 tumor, they reveal the increased arterial perfusion of tumor tissue resulting from angiogenesis. These novel composites may have potential as a more representative mimic of the vascular distribution of therapeutic microspheres in patients undergoing SIRT.
Collapse
Affiliation(s)
- Ross W Stephens
- The Biomedical Radiochemistry Laboratory, Department of Applied Mathematics, Research School of Physics and Engineering, Australian National University, Canberra, ACT, Australia,
| | - Gregory D Tredwell
- The Biomedical Radiochemistry Laboratory, Department of Applied Mathematics, Research School of Physics and Engineering, Australian National University, Canberra, ACT, Australia,
| | - Karen J Knox
- The Biomedical Radiochemistry Laboratory, Department of Applied Mathematics, Research School of Physics and Engineering, Australian National University, Canberra, ACT, Australia,
| | - Lee A Philip
- The Biomedical Radiochemistry Laboratory, Department of Applied Mathematics, Research School of Physics and Engineering, Australian National University, Canberra, ACT, Australia,
| | - David W King
- The Biomedical Radiochemistry Laboratory, Department of Applied Mathematics, Research School of Physics and Engineering, Australian National University, Canberra, ACT, Australia,
| | - Kelly M Debono
- Animal Services Division, Research School of Biology, Australian National University, Canberra, ACT, Australia
| | - Jessica L Bell
- The Biomedical Radiochemistry Laboratory, Department of Applied Mathematics, Research School of Physics and Engineering, Australian National University, Canberra, ACT, Australia,
| | - Tim J Senden
- The Biomedical Radiochemistry Laboratory, Department of Applied Mathematics, Research School of Physics and Engineering, Australian National University, Canberra, ACT, Australia,
| | - Marcel R Tanudji
- Research and Development, Sirtex Medical Limited, Sydney, NSW, Australia
| | - Jillean G Winter
- Research and Development, Sirtex Medical Limited, Sydney, NSW, Australia
| | | | - Michael J Tapner
- Research and Development, Sirtex Medical Limited, Sydney, NSW, Australia
| | - Stephen K Jones
- Research and Development, Sirtex Medical Limited, Sydney, NSW, Australia
| |
Collapse
|
9
|
Kim HS, Shaib WL, Zhang C, Nagaraju GP, Wu C, Alese OB, Chen Z, Brutcher E, Renfroe M, El-Rayes BF. Phase 1b study of pasireotide, everolimus, and selective internal radioembolization therapy for unresectable neuroendocrine tumors with hepatic metastases. Cancer 2018; 124:1992-2000. [PMID: 29451701 DOI: 10.1002/cncr.31192] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Revised: 10/08/2017] [Accepted: 10/20/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND Neuroendocrine tumors (NETs) metastasize to the liver. Everolimus and selective internal radioembolization (SIRT) are approved treatments. Pasireotide is a somatostatin analogue with an affinity for somatostatin receptors 1, 2, 3, and 5. Everolimus and pasireotide may potentiate SIRT radiosensitization and inhibit rebound angiogenesis. This study evaluated the safety of pasireotide, everolimus, and SIRT. METHODS This 3 + 3 phase 1 trial evaluated 3 dose levels of everolimus (2.5, 5, and 10 mg/day), pasireotide (600 μg twice daily), and SIRT (SIR-Spheres dose on days 9 and 37). Eligibility criteria included well or moderately differentiated NETs, bilobar liver metastases, and progression on long-acting octreotide. Toxicities and responses were evaluated with the Common Terminology Criteria for Adverse Events and the Response Evaluation Criteria in Solid Tumors (version 1.1). Dose-limiting toxicities (DLTs) were defined in the first 28 days. Correlative markers-angiopoietin 1, angiopoietin 2, basic fibroblast growth factor, collagen V, insulin-like growth factor binding protein 1, insulin-like growth factor binding protein 1, interleukin 8, M30, M65, placenta growth factor, and vascular endothelial growth factor receptor 2-were assessed. The Norfolk Quality of Life-Neuroendocrine Tumor Questionnaire was used to assess the quality of life (QOL). RESULTS Thirteen patients were enrolled; 1 was not evaluable for the primary endpoint. Eleven patients had well-differentiated tumors. The primary sites included small bowel (4), pancreas (3), lung (2), colon (1), gastric (1), and unknown primary (2) were unknown. Four had liver-only disease; 12 completed the planned treatment. No DLTs were observed. There was no treatment-related mortality. The most common toxicity was hyperglycemia. Clinically significant liver toxicity was not observed. One patient had liver progression. QOL improved on treatment. The median progression-free survival and overall survival were 18.6 and 46.3 months, respectively. CONCLUSIONS The recommended phase 2 dose of everolimus is 10 mg daily in combination with pasireotide and SIRT. The regimen is well tolerated. Preliminary activity appears promising. Cancer 2018;124:1992-2000. © 2018 American Cancer Society.
Collapse
Affiliation(s)
- Hyun S Kim
- Division of Interventional Radiology, Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut
| | - Walid L Shaib
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Chao Zhang
- Department of Biostatistics, Emory University, Atlanta, Georgia
| | | | - Christina Wu
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Olatunji B Alese
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Zhengjia Chen
- Department of Biostatistics, Emory University, Atlanta, Georgia
| | - Edith Brutcher
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Meredith Renfroe
- Clinical Trials Office, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Bassel F El-Rayes
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| |
Collapse
|
10
|
Abstract
Radioembolization (RE) is a relatively novel treatment modality for primary and secondary hepatic malignancies. Microspheres embedded with a β-emitting radioisotope are injected into the hepatic artery, resulting in microsphere deposition in the tumor arterioles and normal portal triads. Microsphere deposition in nontumorous parenchyma can result in radiation-induced liver injury, with lethal RE-induced liver disease (REILD) at the outer end of the spectrum. The primary aim of this study was to evaluate RE-related hepatotoxicity and present an overview of the currently applied definitions and clinically relevant characteristics of REILD. A systematic literature search on REILD was performed. Studies after the introduction of the term REILD (2008) were screened for definitions of REILD. Hepatotoxicity and applied definitions of REILD were compared. Liver biochemistry test abnormalities occur in up to 100% of patients after RE, mostly self-limiting. The incidence of symptomatic REILD varied between 0 and 31%, although in most reports, the incidence was 0-8%, with a lethal outcome in 0-5%. With the exception of bilirubin, the presentation of hepatotoxicity and REILD was similar for cirrhotic and noncirrhotic patients. No uniform definition of REILD was established in the current literature. Here, we propose a unifying definition and grading system for REILD. RE-related hepatotoxicity is a common phenomenon; symptomatic REILD, however, is rare. Currently, reporting of REILD is highly variable, precluding reliable comparison between studies, identification of risk factors, and treatment developments.
Collapse
|
11
|
Hsieh TC, Wu YC, Sun SS, Yen KY, Kao CH. Treating hepatocellular carcinoma with 90Y-bearing microspheres: a review. Biomedicine (Taipei) 2016; 6:19. [PMID: 27848114 PMCID: PMC5138159 DOI: 10.7603/s40681-016-0019-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Accepted: 08/06/2016] [Indexed: 12/21/2022] Open
Abstract
Hepatocellular carcinoma (HCC) is a disease usually diagnosed in its advanced-stage, and is frequently not amenable to curative surgical treatment. Also, HCC is resistant to chemotherapy and less vulnerable to radiation therapy compared to normal hepatic parenchyma. Both of these facts render the efficacy of adjuvant and palliative treatments problematic. Selective internal radiation therapy (SIRT) with 90Y-bearing microspheres is characterized by preferentially delivering substantially high doses of radiation to a liver tumor dose simultaneously limiting the damage to its non-tumorous cells, providing an opportunity for effective local tumor control and even tumor regression therapy. The current article reviews the specific characters, dosimetry, possible applications, and special considerations toward the pre-existing radiation therapy of 90Y microsphere SIRT in treating HCC.
Collapse
Affiliation(s)
- Te-Chun Hsieh
- Department of Nuclear Medicine and PET Center, China Medical University Hospital, No. 2, Yuh-Der Rd., North Dist., Taichung, 404, Taiwan.,Department of Biomedical Imaging and Radiological Science, China Medical University, 404, Taichung, Taiwan
| | - Yu-Chin Wu
- Department of Nuclear Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu Branch, No. 25, Ln. 442. Sec. 1, Jingguo Rd., East Dist.,, Hsinchu City, 300, Taiwan.
| | - Shung-Shung Sun
- Department of Nuclear Medicine and PET Center, China Medical University Hospital, No. 2, Yuh-Der Rd., North Dist., Taichung, 404, Taiwan.,Department of Biomedical Imaging and Radiological Science, China Medical University, 404, Taichung, Taiwan
| | - Kuo-Yang Yen
- Department of Nuclear Medicine and PET Center, China Medical University Hospital, No. 2, Yuh-Der Rd., North Dist., Taichung, 404, Taiwan.,Department of Biomedical Imaging and Radiological Science, China Medical University, 404, Taichung, Taiwan
| | - Chia-Hung Kao
- Department of Nuclear Medicine and PET Center, China Medical University Hospital, No. 2, Yuh-Der Rd., North Dist., Taichung, 404, Taiwan. .,School of Medicine, China Medical University, 404, Taichung, Taiwan.
| |
Collapse
|
12
|
Högberg J, Rizell M, Hultborn R, Svensson J, Henrikson O, Mölne J, Gjertsson P, Bernhardt P. Simulation Model of Microsphere Distribution for Selective Internal Radiation Therapy Agrees With Observations. Int J Radiat Oncol Biol Phys 2016; 96:414-421. [DOI: 10.1016/j.ijrobp.2016.05.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 04/19/2016] [Accepted: 05/05/2016] [Indexed: 01/07/2023]
|
13
|
Westcott MA, Coldwell DM, Liu DM, Zikria JF. The development, commercialization, and clinical context of yttrium-90 radiolabeled resin and glass microspheres. Adv Radiat Oncol 2016; 1:351-364. [PMID: 28740906 PMCID: PMC5514171 DOI: 10.1016/j.adro.2016.08.003] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 08/02/2016] [Accepted: 08/03/2016] [Indexed: 12/14/2022] Open
Abstract
Selective internal radiation therapy has emerged as a well-accepted therapeutic for primary and metastatic hepatic malignancies. This therapeutic modality requires the combined efforts of multiple medical disciplines to ensure the safe delivery of yttrium-90 (90Y)-labeled microspheres. The development of this therapy followed decades of clinical research involving tumor vascularity and microsphere development. Today, it is essential that treating physicians have a thorough understanding of hepatic tumor vascularity and 90Y microsphere characteristics before undertaking this complex intervention. This review explores the contributions of early investigators of this therapy, as well as the development, US Food and Drug Administration approval, manufacturing process, and attributes of the 2 commercially available 90Y radiolabeled microsphere device to clarify the key physical differences between the products.
Collapse
Affiliation(s)
- Mark A. Westcott
- Department of Radiology, Lenox Hill Hospital, New York, New York
| | | | - David M. Liu
- Department of Radiology, University of British Columbia, Vancouver, British Columbia
| | - Joseph F. Zikria
- Department of Radiology, Memorial Regional Hospital, Hollywood, Florida
| |
Collapse
|
14
|
The role of 90Y-radioembolization in downstaging primary and secondary hepatic malignancies: a systematic review. Clin Transl Imaging 2016; 4:283-295. [PMID: 27512689 PMCID: PMC4960274 DOI: 10.1007/s40336-016-0172-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 03/14/2016] [Indexed: 12/11/2022]
Abstract
Radioembolization (RE) is an emerging treatment strategy for patients with primary hepatic malignancies and metastatic liver disease. Though RE is primarily performed in the palliative setting, a shift toward the curative setting is seen. Currently, hepatic resection and in selected cases liver transplantation are the only curative options for patients with a hepatic malignancy. Unfortunately, at diagnosis most patients are not eligible for liver surgery due to the imbalance between the necessary liver resection and the remaining liver remnant. However, in borderline resectable cases, tumor volume reduction and/or increasing the future liver remnant can lead to a resectable situation. The combination of selective tumor treatment, the induction of hypertrophy of untreated liver segments, and its favourable toxicity profile make RE an appealing strategy for downstaging. The present review discusses the possibilities for RE in the preoperative setting as a downstaging tool or as a bridge to liver transplantation.
Collapse
|
15
|
PET/MRI of Hepatic 90Y Microsphere Deposition Determines Individual Tumor Response. Cardiovasc Intervent Radiol 2015; 39:855-64. [PMID: 26721589 PMCID: PMC4858549 DOI: 10.1007/s00270-015-1285-y] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Accepted: 12/06/2015] [Indexed: 12/13/2022]
Abstract
Purpose The purpose of our study is to determine if there is a relationship between dose deposition measured by PET/MRI and individual lesion response to yttrium-90 (90Y) microsphere radioembolization. Materials and Methods 26 patients undergoing lobar treatment with 90Y microspheres underwent PET/MRI within 66 h of treatment and had follow-up imaging available. Adequate visualization of tumor was available in 24 patients, and contours were drawn on simultaneously acquired PET/MRI data. Dose volume histograms (DVHs) were extracted from dose maps, which were generated using a voxelized dose kernel. Similar contours to capture dimensional and volumetric change of tumors were drawn on follow-up imaging. Response was analyzed using both RECIST and volumetric RECIST (vRECIST) criteria. Results A total of 8 hepatocellular carcinoma (HCC), 4 neuroendocrine tumor (NET), 9 colorectal metastases (CRC) patients, and 3 patients with other metastatic disease met inclusion criteria. Average dose was useful in predicting response between responders and non-responders for all lesion types and for CRC lesions alone using both response criteria (p < 0.05). D70 (minimum dose to 70 % of volume) was also useful in predicting response when using vRECIST. No significant trend was seen in the other tumor types. For CRC lesions, an average dose of 29.8 Gy offered 76.9 % sensitivity and 75.9 % specificity for response. Conclusions PET/MRI of 90Y microsphere distribution showed significantly higher DVH values for responders than non-responders in patients with CRC. DVH analysis of 90Y microsphere distribution following treatment may be an important predictor of response and could be used to guide future adaptive therapy trials.
Collapse
|
16
|
Semi-Quantitative Analysis of Post-Transarterial Radioembolization (90)Y Microsphere Positron Emission Tomography Combined with Computed Tomography (PET/CT) Images in Advanced Liver Malignancy: Comparison With (99m)Tc Macroaggregated Albumin (MAA) Single Photon Emission Computed Tomography (SPECT). Nucl Med Mol Imaging 2015; 50:63-9. [PMID: 26941861 DOI: 10.1007/s13139-015-0366-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Accepted: 08/24/2015] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVES The purpose of this study is to evaluate the correlation between pretreatment planning technetium-99m ((99m)Tc) macroaggregated albumin (MAA) SPECT images and posttreatment transarterial radioembolization (TARE) yttirum-90 ((90)Y) PET/CT images by comparing the ratios of tumor-to-normal liver counts. METHODS Fifty-two patients with advanced hepatic malignancy who underwent (90)Y microsphere radioembolization from January 2010 to December 2012 were retrospectively reviewed. Patients had undergone (99m)Tc MAA intraarterial injection SPECT for a pretreatment evaluation of microsphere distribution and therapy planning. After the administration of (90)Y microspheres, the patients underwent posttreatment (90)Y PET/CT within 24 h. For semiquantitative analysis, the tumor-to-normal uptake ratios in (90)Y PET/CT (TNR-yp) and (99m)Tc MAA SPECT (TNR-ms) as well as the tumor volumes measured in angiographic CT were obtained and analyzed. The relationship of TNR-yp and TNR-ms was evaluated by Spearman's rank correlation and Wilcoxon's matched pairs test. RESULTS In a total of 79 lesions of 52 patients, the distribution of microspheres was well demonstrated in both the SPECT and PET/CT images. A good correlation was observed of between TNR-ms and TNR-yp (rho value = 0.648, p < 0.001). The TNR-yp (median 2.78, interquartile range 2.43) tend to show significantly higher values than TNR-ms (median 2.49, interquartile range of 1.55) (p = 0.012). The TNR-yp showed weak correlation with tumor volume (rho = 0.230, p = 0.041). CONCLUSIONS The (99m)Tc MAA SPECT showed a good correlation with (90)Y PET/CT in TNR values, suggesting that (99m)Tc MAA can be used as an adequate pretreatment evaluation method. However, the (99m)Tc MAA SPECT image consistently shows lower TNR values compared to (90)Y PET/CT, which means the possibility of underestimation of tumorous uptake in the partition dosimetry model using (99m)Tc MAA SPECT. Considering that (99m)Tc MAA is the only clinically available surrogate marker for distribution of microsphere, we recommend measurement of tumorous uptake using (90)Y PET/CT should be included routinely in the posttherapeutic evaluation.
Collapse
|
17
|
Ahmadzadehfar H, Duan H, Haug AR, Walrand S, Hoffmann M. The role of SPECT/CT in radioembolization of liver tumours. Eur J Nucl Med Mol Imaging 2014; 41 Suppl 1:S115-24. [PMID: 24442600 DOI: 10.1007/s00259-013-2675-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Accepted: 12/17/2013] [Indexed: 01/14/2023]
Abstract
Radioembolization (RE) with (90)Y microspheres is a promising catheter-based therapeutic option for patients with unresectable primary and metastatic liver tumours. Its rationale arises from the dual blood supply of liver tissue through the hepatic artery and the portal vein. Metastatic hepatic tumours measuring >3 mm derive 80 - 100 % of their blood supply from the arterial rather than the portal hepatic circulation. Typically, an angiographic evaluation combined with (99m)Tc-macroaggregated albumin ((99m)Tc-MAA) scan precedes therapy to map the tumour feeding vessels as well as to avoid the inadvertent deposition of microspheres in organs other than the liver. Prior to administration of (99m)Tc-MAA, prophylactic coil embolization of the gastroduodenal artery is recommended to avoid extrahepatic deposition of the microspheres. SPECT/CT allows direct correlation of anatomic and functional information in patients with unresectable liver disease. SPECT/CT is recommended to assess intrahepatic distribution as well as extrahepatic gastrointestinal uptake in these patients. Pretherapeutic SPECT/CT is an important component of treatment planning including catheter positioning and dose finding. A post-therapy bremsstrahlung (BS) scan should follow RE to verify the distribution of the administered tracer. BS SPECT/CT imaging enables better localization and definition of intrahepatic and possible extrahepatic sphere distribution and to a certain degree allows posttreatment dosimetry. In this paper we address the usefulness and significance of SPECT/CT in therapy planning and therapy monitoring of RE.
Collapse
|
18
|
Ha EJ, Gwak HS, Rhee CH, Youn SM, Choi CW, Cheon GJ. Intracavitary radiation therapy for recurrent cystic brain tumors with holmium-166-chico : a pilot study. J Korean Neurosurg Soc 2013; 54:175-82. [PMID: 24278644 PMCID: PMC3836922 DOI: 10.3340/jkns.2013.54.3.175] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Revised: 08/08/2013] [Accepted: 09/08/2013] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Intracavitary injection of beta-emitting radiation source for control of cystic tumors has been tried with a benefit of localized internal radiation. The authors treated cystic brain tumor patients with Holmium-166-chitosan complex (Ho-166-chico), composed of a beta-emitting radionuclide Holmium-166 and biodegradable chit polymer, and evaluated the safety and effective measurement for response. METHODS Twenty-two patients with recurrent cystic brain tumor and/or located in a deep or eloquent area were enrolled in this pilot study. The cyst volume and wall thickness were determined on CT or MRI to assess radiological response. The activity of Ho-166-chico injected via Ommaya reservoir was prescribed to be 10-25 Gy to the cyst wall in a depth of 4 mm. RESULTS There was neither complications related to systemic absorption nor leakage of Ho-166-chico in all 22 patients. But, two cases of oculomotor paresis were observed in patients with recurrent craniopharyngioma. Radiological response was seen in 14 of 20 available follow-up images (70%). Seven patients of 'evident' radiological response experienced more than 25% decrease of both cyst volume and wall thickness. Another 7 patients with 'suggestive' response showed decrease of cyst volume without definitive change of the wall thickness or vice versa. All patients with benign tumors or low grade gliomas experienced symptomatic improvement. CONCLUSION Ho-166-chico intracavitary radiation therapy for cystic tumor is a safe method of palliation without serious complications. The determination of both minimal effective dosage and time interval of repeated injection through phase 1 trial could improve the results in the future.
Collapse
Affiliation(s)
- Eun Jin Ha
- Neuro-Oncology Clinic, National Cancer Center, Ilsan, Korea
| | | | | | | | | | | |
Collapse
|
19
|
Ulrich G, Dudeck O, Furth C, Ruf J, Grosser OS, Adolf D, Stiebler M, Ricke J, Amthauer H. Predictive Value of Intratumoral 99mTc-Macroaggregated Albumin Uptake in Patients with Colorectal Liver Metastases Scheduled for Radioembolization with 90Y-Microspheres. J Nucl Med 2013; 54:516-22. [DOI: 10.2967/jnumed.112.112508] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
|
20
|
Abstract
Radioembolization aims to selectively target radiation to all liver tumors while limiting the dose to normal liver parenchyma. The deposition of yttrium-90 ((90)Y) microspheres delivered through the hepatic artery are preferentially implanted within liver tumors in a 3:1 to 20:1 ratio compared with a normal liver. The principles and mode of action of radioembolization are fundamentally different from the conventional embolization of liver tumors through transarterial embolization or chemoembolization. A meticulous work-up, involving computed tomography scanning, contrast-enhanced magnetic resonance imaging, and transfemoral hepatic angiogram, is essential to assess the appropriateness of the patient for treatment. A simulation of the treatment, done with technetium-99m-labeled macroaggregated albumin particles, which approximate the size of microspheres, is used to identify the shunting of microparticles to the lungs or gastrointestinal tract, thus helping to determine patient selection. Whole-liver or unilobar treatment approaches are chosen according to the anatomic distribution of the tumors, concomitant factors affecting liver function, and institutional preferences. Optimal periprocedural care, discharge planning, and follow-up care are essential to assess treatment response and ensure that short-term side effects of radioembolization are adequately managed. The expanding literature on radioembolization shows that this is an effective treatment for the management of both primary and metastatic tumors.
Collapse
|
21
|
Comparison of transcatheter arterial chemoembolization and microsphere embolization for treatment of unresectable hepatocellular carcinoma: a meta-analysis. J Cancer Res Clin Oncol 2011; 138:455-62. [DOI: 10.1007/s00432-011-1117-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2011] [Accepted: 12/05/2011] [Indexed: 12/13/2022]
|
22
|
Liu CS, Lin KH, Lee RC, Tseng HS, Wang LW, Huang PI, Chao LS, Chang CY, Yen SH, Tung CJ, Wang SJ, Oliver Wong CY, Liu RS. Model-based radiation dose correction for yttrium-90 microsphere treatment of liver tumors with central necrosis. Int J Radiat Oncol Biol Phys 2011; 81:660-8. [PMID: 20932691 DOI: 10.1016/j.ijrobp.2010.06.045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2009] [Revised: 06/07/2010] [Accepted: 06/17/2010] [Indexed: 01/18/2023]
Abstract
PURPOSE The objectives of this study were to model and calculate the absorbed fraction ϕ of energy emitted from yttrium-90 ((90)Y) microsphere treatment of necrotic liver tumors. METHODS AND MATERIALS The tumor necrosis model was proposed for the calculation of ϕ over the spherical shell region. Two approaches, the semianalytic method and the probabilistic method, were adopted. In the former method, the range--energy relationship and the sampling of electron paths were applied to calculate the energy deposition within the target region, using the straight-ahead and continuous-slowing-down approximation (CSDA) method. In the latter method, the Monte Carlo PENELOPE code was used to verify results from the first method. RESULTS The fraction of energy, ϕ, absorbed from (90)Y by 1-cm thickness of tumor shell from microsphere distribution by CSDA with complete beta spectrum was 0.832 ± 0.001 and 0.833 ± 0.001 for smaller (r(T) = 5 cm) and larger (r(T) = 10 cm) tumors (where r is the radii of the tumor [T] and necrosis [N]). The fraction absorbed depended mainly on the thickness of the tumor necrosis configuration, rather than on tumor necrosis size. The maximal absorbed fraction φ that occurred in tumors without central necrosis for each size of tumor was different: 0.950 ± 0.000, and 0.975 ± 0.000 for smaller (r(T) = 5 cm) and larger (r(T) = 10 cm) tumors, respectively (p < 0.0001). CONCLUSIONS The tumor necrosis model was developed for dose calculation of (90)Y microsphere treatment of hepatic tumors with central necrosis. With this model, important information is provided regarding the absorbed fraction applicable to clinical (90)Y microsphere treatment.
Collapse
Affiliation(s)
- Ching-Sheng Liu
- National PET/Cyclotron Center, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
23
|
Kawashita M, Matsui N, Li Z, Miyazaki T, Kanetaka H. Preparation, structure, and in vitro chemical durability of yttrium phosphate microspheres for intra-arterial radiotherapy. J Biomed Mater Res B Appl Biomater 2011; 99:45-50. [DOI: 10.1002/jbm.b.31870] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2011] [Revised: 04/19/2011] [Accepted: 04/20/2011] [Indexed: 01/27/2023]
|
24
|
Kao YH, Tan EH, Ng CE, Goh SW. Clinical implications of the body surface area method versus partition model dosimetry for yttrium-90 radioembolization using resin microspheres: a technical review. Ann Nucl Med 2011; 25:455-61. [PMID: 21643807 DOI: 10.1007/s12149-011-0499-6] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2011] [Accepted: 05/16/2011] [Indexed: 12/25/2022]
Abstract
Yttrium-90 (Y-90) radioembolization is becoming established as an effective therapeutic modality for inoperable liver tumors. For resin microspheres, the 'body surface area (BSA)' method and the partition model can both be used for Y-90 activity calculation. The BSA method is semi-empirical, but more commonly used due its simplicity. The partition model is more accurate, scientifically sound and personalized, but less popular due to its complexity. This article provides a technical comparison of both methods with an emphasis on its clinical implications. Future dosimetric techniques for Y-90 radioembolization based on emerging technologies are also discussed.
Collapse
Affiliation(s)
- Yung Hsiang Kao
- Department of Nuclear Medicine and PET, Singapore General Hospital.
| | | | | | | |
Collapse
|
25
|
Rajekar H, Bogammana K, Stubbs RS. Selective internal radiation therapy for gastrointestinal neuroendocrine tumour liver metastases: a new and effective modality for treatment. Int J Hepatol 2011; 2011:404916. [PMID: 22164335 PMCID: PMC3227504 DOI: 10.4061/2011/404916] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2011] [Revised: 09/03/2011] [Accepted: 09/03/2011] [Indexed: 01/28/2023] Open
Abstract
Background. Nonresectable neuroendocrine tumour (NET) liver metastases respond poorly to most widely available and used therapies. Selective Internal Radiation Therapy (SIRT) is becoming recognized as a new modality for selectively treating non-resectable liver tumours. This paper presents an experience of 14 patients with non-resectable NET liver metastases treated with SIRT. Methods. Between September 1997 and October 2009 14 patients with extensive NET liver metastases were treated with 2.0 to 3.0 GBq of (90)Yttrium microspheres. Repeat SIRT was undertaken in three patients after 16, 27, and 48 months, respectively. Responses were assessed clinically, biochemically, and with serial CT scans. Survival was measured from initial SIRT. Results. Some response was seen in all 14 patients. Carcinoid syndrome improved or resolved in 10/10 instances. 24-hour urinary 5-HIAA or serum chromogranin A levels fell dramatically in 5/7 patients following SIRT. Serial CT scans revealed partial response or stable disease in all 14 patients. Repeat treatment in three patients experiencing progression was associated with a further response. Median survival after SIRT is 25 months with 6 patients being alive (and 3 patients still asymptomatic), at 19, 22, 23, 23, 58, and 60 months. Conclusions. SIRT is an effective and well-tolerated treatment for non-resectable NET liver metastases capable of both alleviating the carcinoid syndrome and achieving significant tumour regression. Repeat treatment is an option and liver resection after downstaging may also become possible.
Collapse
|
26
|
Kim YC, Kim YH, Um SH, Seo YS, Park EK, Oh SY, Han YM, Choe JG. Usefulness of Bremsstrahlung Images after Intra-arterial Y-90 Resin Microphere Radioembolization for Hepatic Tumors. Nucl Med Mol Imaging 2010; 45:59-67. [PMID: 24899979 DOI: 10.1007/s13139-010-0066-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2010] [Accepted: 10/27/2010] [Indexed: 02/07/2023] Open
Abstract
PURPOSE Y-90 resin microsphere radioembolization is used to treat inoperable hepatic tumors. After injection of Y-90 resin microsphere, the only method to visualize the distribution of Y-90 is the scintigraphic imaging of bremsstrahlung radiation. The purpose of this study was to evaluate the characteristics and usefulness of bremsstrahlung imaging in Y-90 resin microsphere treatment. METHODS Twenty patients (22 administrations) underwent intra-arterial Y-90 resin microsphere treatment. For pre-treatment planning, images of Tc-99m albumin macroaggregate (MAA) arterial injection and hepatic contrast angiography were obtained. Post-treatment bremsstrahlung images were taken and compared with pre-treatment images. The extrahepatic activity was evaluated on bremsstrahlung images. To correlate the size and vascularity of the tumors with tumor visualization on bremsstrahlung images, the individual tumors were grouped according to visualization on each image and compared with one another by size and tumor-to-normal ratio. RESULTS All post-therapeutic bremsstrahlung images showed similar contours of the liver with pre-treatment angiography. No extrahepatic activity was seen in all cases. The visualized tumors on bremsstrahlung images were significantly larger than the non-visualized tumors. Tumor-to-normal ratios of the visualized tumors on bremsstrahlung images were significantly higher than those of the non-visualized tumors. CONCLUSIONS Bremsstrahlung images after intra-arterial Y-90 resin microsphere treatment are useful in evaluating the intrahepatic distribution of radioisotope and detecting possible extrahepatic activity.
Collapse
Affiliation(s)
- Young Chul Kim
- Department of Nuclear Medicine, College of Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Yun Hwan Kim
- Department of Radiology, College of Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Soon Ho Um
- Department of Internal Medicine, College of Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Yeon Seok Seo
- Department of Internal Medicine, College of Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Eun Kyung Park
- Department of Nuclear Medicine, College of Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Sun Young Oh
- Department of Nuclear Medicine, College of Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - You Mie Han
- Department of Radiology, College of Medicine, Hallym University Hangang Sacred Heart Hospital, Seoul, Republic of Korea
| | - Jae-Gol Choe
- Department of Nuclear Medicine, College of Medicine, Korea University Anam Hospital, Seoul, Republic of Korea ; Department of Nuclear Medicine, Korea University Anam Hospital, 126-1 Anam-dong 5-ga, Seongbuk-gu, Seoul, 136-705 South Korea
| |
Collapse
|
27
|
Radiation safety issues in y-90 microsphere selective hepatic radioembolization therapy: possible radiation exposure from the patients. Nucl Med Mol Imaging 2010; 44:252-60. [PMID: 24899961 DOI: 10.1007/s13139-010-0047-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2010] [Revised: 07/28/2010] [Accepted: 08/04/2010] [Indexed: 12/31/2022] Open
Abstract
PURPOSE The purpose of this study was to estimate the possible external radiation dose to other individuals from patients treated with Y-90 resin microspheres for unresectable hepatocellular carcinoma. METHODS We designed the study prospectively to estimate the possible radiation dose to other individuals from patients who had been treated with Y-90 microspheres for unresectable hepatocellular carcinoma. We estimated the total effective dose equivalent (TEDE) using two methods: 'theoretical' TEDEs according to the administered activity and 'measured' TEDE based on the 'measured' ambient radiation exposure rate. We compared the results from each method to determine when we can release patients from confinement at the earliest time complying with the patient release criteria. RESULTS A total of 20 administrations of Y-90 resin microspheres were done in 18 patients. The average administered activity was 1.2 ± 0.77 (0.28-2.97) GBq. The 'theoretical' TEDEs were in the range of 0.8-10 μSv. The 'measured' TEDEs were in the range of 2.31-185 μSv. The measured TEDEs tend to be higher than the theoretical TEDEs. The values of theoretical and measured TEDE were both far less than 1 mSv, the upper limit at which the licensee can release a patient without any written documents. CONCLUSION The effective dose equivalent caused by the Y-90 microsphere administered patient is very low. It is safe in terms of radiation safety to the other individuals when Y-90 microsphere radioembolization therapy is done with dose less than 3 GBq. Because the measured TEDE tends to be higher than the theoretical TEDE, it is recommended to use 'measured' TEDE for determining patient release.
Collapse
|
28
|
Strigari L, Sciuto R, Rea S, Carpanese L, Pizzi G, Soriani A, Iaccarino G, Benassi M, Ettorre GM, Maini CL. Efficacy and toxicity related to treatment of hepatocellular carcinoma with 90Y-SIR spheres: radiobiologic considerations. J Nucl Med 2010; 51:1377-85. [PMID: 20720056 DOI: 10.2967/jnumed.110.075861] [Citation(s) in RCA: 170] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
UNLABELLED Radioactive (90)Y-selective internal radiation (SIR) sphere therapy is increasingly used for the treatment of nonresectable hepatocellular carcinoma (HCC). However, the maximum delivered dose is limited by severe injury to the nontarget tissue, including liver parenchyma. Our study aimed to implement radiobiologic models for both tumor control probability (TCP) and normal-tissue complication probability (NTCP) to describe more effectively local response and the liver toxicity rate, respectively. METHODS Patients with documented HCC, adequate bone marrow parameters, and regular hepatic and pulmonary function were eligible for the study. Patients who had pulmonary shunt greater than 20% of (99m)Tc-labeled macroaggregated albumin or any uncorrectable delivery to the gastrointestinal tract, reverse blood flow out of the liver, or complete portal vein thrombosis were excluded. Patients received a planned activity of the (90)Y-SIR spheres, determined using the empiric body surface area method. The dose distribution was determined using posttreatment (3-dimensional) activity distribution and Monte Carlo dose voxel kernel calculations, and the mean doses to healthy liver and tumor were calculated for each patient. Response was defined according to Response Evaluation Criteria in Solid Tumors (RECIST) and recommendations of the European Association for the Study of the Liver (EASL). Criteria were used to assess possible liver toxicities. The parameters of TCP and NTCP models were established by direct maximization of the likelihood. RESULTS Seventy-three patients were treated. With an average dose of 110 Gy to the tumor, complete or partial response was observed in 74% and 55% of patients according to the EASL guideline and RECIST, respectively, and the predicted TCPs were 73% and 55%, respectively. With a median liver dose of 36 Gy (range, 6-78 Gy), the >or=grade 2 (G2), >or=grade 3 (G3), and >or=grade 4 (G4) liver toxicities were observed in 32% (23/73), 21% (15/73), and 11% (8/73) of patients, respectively. The parameters describing the >or=G2 liver toxicity data using the NTCP model were a tolerance dose of the whole organ leading to a 50% complication probability of 52 Gy (95% confidence interval, 44-61 Gy) and a slope of NTCP versus dose of 0.28 (95% confidence interval, 0.18-0.60), assuming n = 1. CONCLUSION The radiobiologic approach, based on patient-specific dosimetry, could improve the (90)Y-microsphere therapeutic approach of HCC, maintaining an acceptable liver toxicity.
Collapse
Affiliation(s)
- Lidia Strigari
- Laboratory of Medical Physics and Expert Systems, Regina Elena National Cancer Institute, Rome, Italy.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
29
|
Wang SC, Bester L, Burnes JP, Clouston JE, Hugh TJ, Little AF, Padbury RTA, Price D. Clinical care and technical recommendations for 90yttrium microsphere treatment of liver cancer. J Med Imaging Radiat Oncol 2010; 54:178-87. [DOI: 10.1111/j.1754-9485.2010.02167.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
|
30
|
Kooby DA, Egnatashvili V, Srinivasan S, Chamsuddin A, Delman KA, Kauh J, Staley CA, Kim HS. Comparison of yttrium-90 radioembolization and transcatheter arterial chemoembolization for the treatment of unresectable hepatocellular carcinoma. J Vasc Interv Radiol 2009; 21:224-30. [PMID: 20022765 DOI: 10.1016/j.jvir.2009.10.013] [Citation(s) in RCA: 143] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2008] [Revised: 10/01/2009] [Accepted: 10/01/2009] [Indexed: 12/11/2022] Open
Abstract
PURPOSE To compare the effectiveness and toxicity of transcatheter arterial chemoembolization (chemoembolization) and yttrium-90-labeled microspheres (radioembolization) in patients with unresectable hepatocellular carcinoma (HCC). MATERIALS AND METHODS Outcomes from patients who underwent radioembolization or chemoembolization as the only treatment for unresectable HCC from 1996 to 2006 were compared. Response was assessed with Response Evaluation Criteria in Solid Tumors, survival was assessed with the Kaplan-Meier method, and toxicity was graded with National Cancer Institute criteria. Multivariate analysis for factors affecting survival was performed. RESULTS Seventy-one patients were treated with either chemoembolization (n = 44, 62%) or radioembolization (n = 27, 38%). Treatment groups were similar in age, sex, Child class, Model for End-Stage Liver Disease score, tumor size, and vascular invasion. Progressive disease at 3 months was observed in 16 (36%) of the 44 patients treated with chemoembolization and nine (33%) of the 27 patients treated with radioembolization (P = not statistically significant). The median overall survival was similar for both groups (6 months with chemoembolization vs 6 months with radioembolization, P= .7). Grade 3 or higher toxicity was observed in 24 of the 71 patients (34%). Tumor multifocality, vascular invasion, and hepatitis C seropositivity were independently associated with worse survival, whereas method of treatment was not. CONCLUSIONS In this single-center study, preliminary evidence suggests that chemoembolization and radioembolization provided similar effectiveness and toxicity in patients with unresectable HCC.
Collapse
Affiliation(s)
- David A Kooby
- Department of Surgery, Emory University, 1365C Clifton Rd, NE, 2nd Fl, Atlanta, GA 30322, USA.
| | | | | | | | | | | | | | | |
Collapse
|
31
|
Novel treatments for hepatocellular cancer. Cancer Lett 2009; 286:114-20. [DOI: 10.1016/j.canlet.2009.07.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2008] [Revised: 06/22/2009] [Accepted: 07/02/2009] [Indexed: 11/22/2022]
|
32
|
van Hazel GA, Pavlakis N, Goldstein D, Olver IN, Tapner MJ, Price D, Bower GD, Briggs GM, Rossleigh MA, Taylor DJ, George J. Treatment of Fluorouracil-Refractory Patients With Liver Metastases From Colorectal Cancer by Using Yttrium-90 Resin Microspheres Plus Concomitant Systemic Irinotecan Chemotherapy. J Clin Oncol 2009; 27:4089-95. [DOI: 10.1200/jco.2008.20.8116] [Citation(s) in RCA: 130] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Purpose Liver metastases are the principal cause of death in patients with advanced colorectal cancer (CRC). Irinotecan is a chemotherapeutic agent used in the treatment of CRC and has demonstrated synergistic potential when used with radiation. Radioembolization with yttrium-90 microspheres has demonstrated increased response and survival rates when given with fluorouracil chemotherapy. This study's goal was to evaluate the maximum-tolerated dose of concomitant irinotecan and radioembolization in fluorouracil-refractory patients with CRC hepatic metastases. Patients and Methods Twenty-five irinotecan-naïve patients who had experienced relapse after previous chemotherapy were enrolled onto three dose-escalating groups. Irinotecan was administered at 50, 75, or 100 mg/m2 on days 1 and 8 of a 3-week cycle for the first two cycles, and full irinotecan doses (ie, 100 mg/m2) were administered during cycles 3 to 9. Radioembolization was administered during the first chemotherapy cycle. Results Most patients experienced acute, self-limiting abdominal pain and nausea. Mild lethargy and anorexia were common. Grades 3 to 4 events were seen in three of six patients at 50 mg/m2 (obstructive jaundice, thrombocytopenia, diarrhea), in five of 13 patients at 75 mg/m2 (neutropenia, leukopenia, thrombocytopenia, elevated alkaline phosphatase, abdominal pain, ascites, fatigue) and in four of six patients at 100 mg/m2 (diarrhea, deep vein thrombosis, constipation, leukopenia). Eleven (48%) of 23 patients had a partial response, and nine patients (39%) had stable disease. The median progression-free survival was 6.0 months; the median survival was 12.2 months. Conclusion Concomitant use of radioembolization plus irinotecan did not reach a maximum-tolerated dose. The recommended dose of irinotecan in this setting is 100 mg/m2 on days 1 and 8 of a 3-week cycle.
Collapse
Affiliation(s)
- Guy A. van Hazel
- From Perth Oncology; Mount Nuclear Medicine; and Perth Radiologic Clinic, Mount Medical Centre, Perth, Western Australia; Departments of Medical Oncology and Radiology, Royal North Shore Hospital, St Leonards; Departments of Oncology and Nuclear Medicine, Prince of Wales Hospital, Randwick; Storr Liver Unit, Westmead Millennium Institute, Westmead; Sirtex Technology Pty, Lane Cove, Sydney, New South Wales; and Departments of Medical Oncology and Radiology, Royal Adelaide Hospital, Adelaide, South
| | - Nick Pavlakis
- From Perth Oncology; Mount Nuclear Medicine; and Perth Radiologic Clinic, Mount Medical Centre, Perth, Western Australia; Departments of Medical Oncology and Radiology, Royal North Shore Hospital, St Leonards; Departments of Oncology and Nuclear Medicine, Prince of Wales Hospital, Randwick; Storr Liver Unit, Westmead Millennium Institute, Westmead; Sirtex Technology Pty, Lane Cove, Sydney, New South Wales; and Departments of Medical Oncology and Radiology, Royal Adelaide Hospital, Adelaide, South
| | - David Goldstein
- From Perth Oncology; Mount Nuclear Medicine; and Perth Radiologic Clinic, Mount Medical Centre, Perth, Western Australia; Departments of Medical Oncology and Radiology, Royal North Shore Hospital, St Leonards; Departments of Oncology and Nuclear Medicine, Prince of Wales Hospital, Randwick; Storr Liver Unit, Westmead Millennium Institute, Westmead; Sirtex Technology Pty, Lane Cove, Sydney, New South Wales; and Departments of Medical Oncology and Radiology, Royal Adelaide Hospital, Adelaide, South
| | - Ian N. Olver
- From Perth Oncology; Mount Nuclear Medicine; and Perth Radiologic Clinic, Mount Medical Centre, Perth, Western Australia; Departments of Medical Oncology and Radiology, Royal North Shore Hospital, St Leonards; Departments of Oncology and Nuclear Medicine, Prince of Wales Hospital, Randwick; Storr Liver Unit, Westmead Millennium Institute, Westmead; Sirtex Technology Pty, Lane Cove, Sydney, New South Wales; and Departments of Medical Oncology and Radiology, Royal Adelaide Hospital, Adelaide, South
| | - Michael J. Tapner
- From Perth Oncology; Mount Nuclear Medicine; and Perth Radiologic Clinic, Mount Medical Centre, Perth, Western Australia; Departments of Medical Oncology and Radiology, Royal North Shore Hospital, St Leonards; Departments of Oncology and Nuclear Medicine, Prince of Wales Hospital, Randwick; Storr Liver Unit, Westmead Millennium Institute, Westmead; Sirtex Technology Pty, Lane Cove, Sydney, New South Wales; and Departments of Medical Oncology and Radiology, Royal Adelaide Hospital, Adelaide, South
| | - David Price
- From Perth Oncology; Mount Nuclear Medicine; and Perth Radiologic Clinic, Mount Medical Centre, Perth, Western Australia; Departments of Medical Oncology and Radiology, Royal North Shore Hospital, St Leonards; Departments of Oncology and Nuclear Medicine, Prince of Wales Hospital, Randwick; Storr Liver Unit, Westmead Millennium Institute, Westmead; Sirtex Technology Pty, Lane Cove, Sydney, New South Wales; and Departments of Medical Oncology and Radiology, Royal Adelaide Hospital, Adelaide, South
| | - Geoffrey D. Bower
- From Perth Oncology; Mount Nuclear Medicine; and Perth Radiologic Clinic, Mount Medical Centre, Perth, Western Australia; Departments of Medical Oncology and Radiology, Royal North Shore Hospital, St Leonards; Departments of Oncology and Nuclear Medicine, Prince of Wales Hospital, Randwick; Storr Liver Unit, Westmead Millennium Institute, Westmead; Sirtex Technology Pty, Lane Cove, Sydney, New South Wales; and Departments of Medical Oncology and Radiology, Royal Adelaide Hospital, Adelaide, South
| | - Gregory M. Briggs
- From Perth Oncology; Mount Nuclear Medicine; and Perth Radiologic Clinic, Mount Medical Centre, Perth, Western Australia; Departments of Medical Oncology and Radiology, Royal North Shore Hospital, St Leonards; Departments of Oncology and Nuclear Medicine, Prince of Wales Hospital, Randwick; Storr Liver Unit, Westmead Millennium Institute, Westmead; Sirtex Technology Pty, Lane Cove, Sydney, New South Wales; and Departments of Medical Oncology and Radiology, Royal Adelaide Hospital, Adelaide, South
| | - Monica A. Rossleigh
- From Perth Oncology; Mount Nuclear Medicine; and Perth Radiologic Clinic, Mount Medical Centre, Perth, Western Australia; Departments of Medical Oncology and Radiology, Royal North Shore Hospital, St Leonards; Departments of Oncology and Nuclear Medicine, Prince of Wales Hospital, Randwick; Storr Liver Unit, Westmead Millennium Institute, Westmead; Sirtex Technology Pty, Lane Cove, Sydney, New South Wales; and Departments of Medical Oncology and Radiology, Royal Adelaide Hospital, Adelaide, South
| | - D. James Taylor
- From Perth Oncology; Mount Nuclear Medicine; and Perth Radiologic Clinic, Mount Medical Centre, Perth, Western Australia; Departments of Medical Oncology and Radiology, Royal North Shore Hospital, St Leonards; Departments of Oncology and Nuclear Medicine, Prince of Wales Hospital, Randwick; Storr Liver Unit, Westmead Millennium Institute, Westmead; Sirtex Technology Pty, Lane Cove, Sydney, New South Wales; and Departments of Medical Oncology and Radiology, Royal Adelaide Hospital, Adelaide, South
| | - Jacob George
- From Perth Oncology; Mount Nuclear Medicine; and Perth Radiologic Clinic, Mount Medical Centre, Perth, Western Australia; Departments of Medical Oncology and Radiology, Royal North Shore Hospital, St Leonards; Departments of Oncology and Nuclear Medicine, Prince of Wales Hospital, Randwick; Storr Liver Unit, Westmead Millennium Institute, Westmead; Sirtex Technology Pty, Lane Cove, Sydney, New South Wales; and Departments of Medical Oncology and Radiology, Royal Adelaide Hospital, Adelaide, South
| |
Collapse
|
33
|
|
34
|
|
35
|
Welsh JS, Kennedy AS, Thomadsen B. Selective Internal Radiation Therapy (SIRT) for liver metastases secondary to colorectal adenocarcinoma. Int J Radiat Oncol Biol Phys 2006; 66:S62-73. [PMID: 16979443 DOI: 10.1016/j.ijrobp.2005.09.011] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2005] [Revised: 08/31/2005] [Accepted: 09/06/2005] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Selective internal radiation therapy (SIRT) is a relatively new commercially available microbrachytherapy technique for treatment of malignant hepatic lesions using (90)Y embedded in resin microspheres, which are infused directly into the hepatic arterial circulation. It is FDA approved for liver metastases secondary to colorectal carcinoma and is under investigation for treatment of other liver malignancies, such as hepatocellular carcinoma and neuroendocrine malignancies. MATERIALS/METHODS A modest number of clinical trials, preclinical animal studies, and dosimetric studies have been reported. Here we review several of the more important results. RESULTS High doses of beta radiation can be selectively delivered to tumors, resulting in impressive local control and survival rates. Ex vivo analyses have shown that microspheres preferentially cluster around the periphery of tumor nodules with a high tumor:normal tissue ratio of up to 200:1. Toxicity is usually mild, featuring fatigue, anorexia, nausea, abdominal discomfort, and slight elevations of liver function tests. CONCLUSIONS Selective internal radiation therapy represents an effective means of controlling liver metastases from colorectal adenocarcinoma. Clinical trials have demonstrated improved local control of disease and survival with relatively low toxicity. Investigations of SIRT for other hepatic malignancies and in combination with newer chemotherapy agents and targeted biologic therapies are under way or in planning. A well-integrated team involving interventional radiology, nuclear medicine, medical oncology, surgical oncology, medical physics, and radiation oncology is essential for a successful program. Careful selection of patients through the combined expertise of the team can maximize therapeutic efficacy and reduce the potential for adverse effects.
Collapse
Affiliation(s)
- James S Welsh
- Department of Human Oncology, University of Wisconsin-Madison, Madison, WI, USA.
| | | | | |
Collapse
|
36
|
Kennedy AS, Coldwell D, Nutting C, Murthy R, Wertman DE, Loehr SP, Overton C, Meranze S, Niedzwiecki J, Sailer S. Resin 90Y-microsphere brachytherapy for unresectable colorectal liver metastases: modern USA experience. Int J Radiat Oncol Biol Phys 2006; 65:412-25. [PMID: 16690429 DOI: 10.1016/j.ijrobp.2005.12.051] [Citation(s) in RCA: 265] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2005] [Revised: 12/16/2005] [Accepted: 12/19/2005] [Indexed: 12/12/2022]
Abstract
PURPOSE Salvage therapy for patients with unresectable colorectal liver metastases that were refractory to oxaliplatin and irinotecan was performed via radioactive microspheres. High doses of radiation were delivered to tumors from permanently implanted 90Y microspheres, delivered through the hepatic arterial vessels. METHODS AND MATERIALS Patients from 7 institutions were selected for treatment after screening-defined vascular access to all the tumors, and imaging-confirmed microspheres would be implanted only in the liver tumors. All patients were followed with laboratory and imaging studies at regular intervals until death. Toxicities, both acute and late, were recorded, and actuarial survival determined. RESULTS A total of 208 patients were treated from April 2002 to April 2005. Median follow-up of the 129 men and 79 women is 13 months (range, 1-42 months). Median survival is 10.5 months for responders but only 4.5 months in nonresponders. No treatment-related procedure deaths or radiation-related venoocclusive liver failures were found. Computed tomography partial response was 35%; positron emission tomography response of 91% and reduction in carcinoembryonic antigen of 70% were achieved. CONCLUSIONS In this group of heavily pretreated patients, radioactive microspheres produced an encouraging median survival, with acceptable toxicity, and a significant objective response rate, which suggests that further investigation of this approach is warranted.
Collapse
|
37
|
Dass CR, Choong PFM. Targeting of small molecule anticancer drugs to the tumour and its vasculature using cationic liposomes: lessons from gene therapy. Cancer Cell Int 2006; 6:17. [PMID: 16792817 PMCID: PMC1524816 DOI: 10.1186/1475-2867-6-17] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2006] [Accepted: 06/23/2006] [Indexed: 12/02/2022] Open
Abstract
Cationic (positively charged) liposomes have been tested in various gene therapy clinical trials for neoplastic and other diseases. They have demonstrated selectivity for tumour vascular endothelial cells raising hopes for both antiangiogenic and antivascular therapies. They are also capable of being selectively delivered to the lungs and liver when administered intravenously. These vesicles are being targeted to the tumour in various parts of the body by using advanced liposomal systems such as ligand-receptor and antibody-antigen combinations. At present, the transferrin receptor is commonly used for cancer-targeted drug delivery systems including cationic liposomes. This review looks at the growing utility of these vesicles for delivery of small molecule anticancer drugs.
Collapse
Affiliation(s)
- Crispin R Dass
- Department of Orthopaedics, University of Melbourne, St. Vincent's Hospital Melbourne, Australia
| | - Peter FM Choong
- Department of Orthopaedics, University of Melbourne, St. Vincent's Hospital Melbourne, Australia
- Bone and Soft Tissue Sarcoma Service, Peter MacCallum Cancer Institute, Melbourne, Australia
| |
Collapse
|
38
|
Petriev VM, Skvortsov VG, Smakhtin LA, Shutova IN. Monitoring of Radionuclide Impurities in 166Ho-Albumin Microspheres Prepared by Neutron Activation with Thermal Neutrons. RADIOCHEMISTRY 2005. [DOI: 10.1007/s11137-005-0093-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
39
|
Seppenwoolde JH, Nijsen JFW, Bartels LW, Zielhuis SW, van Het Schip AD, Bakker CJG. Internal radiation therapy of liver tumors: qualitative and quantitative magnetic resonance imaging of the biodistribution of holmium-loaded microspheres in animal models. Magn Reson Med 2005; 53:76-84. [PMID: 15690505 DOI: 10.1002/mrm.20320] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
In internal radiation therapy of unresectable liver tumors, microspheres containing a radionuclide are injected in the hepatic artery to achieve a preferential deposition of microspheres in the lesions. In this study, MR imaging techniques for qualitative and quantitative assessment of the biodistribution of holmium-loaded microspheres (HoMS) were investigated for their use in selective internal radiation therapy of liver tumors. To achieve this goal, the relaxivity of HoMS was first investigated in gel experiments. The resultant calibration curve was subsequently employed to quantify the biodistribution of HoMS administered to 13 excised rabbit livers and to the livers of 3 live rabbits with an implanted tumor. Finally, the feasibility of MR imaging of the biodistribution during treatment of a large animal was investigated by MR imaging of hepatic administration of HoMS to a live pig. Overall, the study showed that MRI can clearly depict the biodistribution of HoMS, but that quantification by means of the gel calibration curve yields an underestimation that increases for higher amounts of HoMS. The observed underestimation is tentatively attributed to accumulations of HoMS in larger liver vessels. The exploratory quantification experiments suggest the feasibility of MR dosimetry.
Collapse
Affiliation(s)
- Jan-Henry Seppenwoolde
- Image Sciences Institute, Department of Radiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands.
| | | | | | | | | | | |
Collapse
|
40
|
Seong SK, Ryu JM, Shin DH, Bae EJ, Shigematsu A, Hatori Y, Nishigaki J, Kwak C, Lee SE, Park KB. Biodistribution and excretion of radioactivity after the administration of 166Ho-chitosan complex (DW-166HC) into the prostate of rat. Eur J Nucl Med Mol Imaging 2005; 32:910-7. [PMID: 15841375 DOI: 10.1007/s00259-005-1792-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2004] [Accepted: 02/07/2005] [Indexed: 11/30/2022]
Abstract
PURPOSE The objective of this study was to determine the fate of the 166Ho-chitosan complex (DW-166HC) in rats by examining its absorption, distribution and excretion after administration into the prostate. METHODS About 100 microCi of DW-166HC [containing 0.1875 mg of Ho(NO3)3.5H2O and 0.25 mg of chitosan] was administered intraprostatically. The level of radioactivity in blood, urinary and faecal excretion, and radioactivity distribution were examined. To determine the effect of chitosan in DW-166HC, 166Ho nitrate alone [0.1875 mg of Ho(NO3)3.5H2O] was administered into the prostate of male rats, and radioactivity distribution was examined using whole-body autoradiography. RESULTS After administration of DW-166HC into the prostate, cumulative urinary and faecal excretion over the period 0-72 h was 0.35% and 0.11%, respectively. The radioactivity at the administration site was extremely high at all time points up to 144 h (>98% of injected dose). The small amount of radioactivity which did transfer from the administration site distributed mainly to the liver, spleen, kidney cortex and bone. Compared with the DW-166HC group, the group that received 166Ho nitrate alone displayed three- to fourfold higher levels of radioactivity in the main tissues, including liver, spleen, kidney cortex and bone, at 24 h after administration (P < 0.05). CONCLUSION The results of this study show clearly that most of the administered DW-166HC remained at the administration site. It is concluded that the chitosan complex may be used to retain 166Ho within a limited area in cancer of the prostate.
Collapse
Affiliation(s)
- Seung Kyoo Seong
- Pharmacology and Toxicology Lab, Central Research Laboratories, Dong Wha Pharmaceutical Co., Ltd., Anyang, South Korea
| | | | | | | | | | | | | | | | | | | |
Collapse
|
41
|
Kennedy AS, Nutting C, Coldwell D, Gaiser J, Drachenberg C. Pathologic response and microdosimetry of (90)Y microspheres in man: review of four explanted whole livers. Int J Radiat Oncol Biol Phys 2005; 60:1552-63. [PMID: 15590187 DOI: 10.1016/j.ijrobp.2004.09.004] [Citation(s) in RCA: 298] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2004] [Revised: 08/30/2004] [Accepted: 09/07/2004] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Radioactive microsphere (90)Y therapy is increasingly used for primary and metastatic solid tumors in the liver. We present an analysis of 4 explanted livers previously treated with (90)Y microsphere agents (glass or resin). One tumor nodule was analyzed with submillimeter three-dimensional microdosimetry. METHODS AND MATERIALS Four patients received hepatic artery delivery of (90)Y microspheres for unresectable hepatocellular and colon cancers. Whole livers were explanted as part of lifesaving cadaveric transplant in 2 patients with hepatoma. These patients had received glass microspheres as a procedural bridge to transplant. Autopsy was performed on 2 patients with colon cancer who died of progressive metastatic disease and who had been treated with resin microspheres. Complete pathologic review was performed on each whole liver, including estimation of the response of the tumor to therapy, distribution of microspheres in the tumor and normal liver tissues, and normal-tissue radiation response. A biopsy taken from the edge of a tumor nodule was sectioned serially for three-dimensional radiation dosimetry analyses. Three-dimensional microsphere coordinates within the biopsy specimen were used to calculate dosage using a three-dimensional dose kernel. Isodose coverage of tumor and normal liver areas and total dose delivered were determined. RESULTS Preferential and heterogeneous deposition of microspheres was noted at the edge of tumor nodules compared with the center portion of the tumor or normal liver parenchyma. Both glass and resin microspheres delivered high cumulative doses to the tumor, which varied from 100 Gy to more than 3000 Gy. No veno-occlusive disease or widespread radiation hepatitis was seen. CONCLUSION Microsphere ((90)Y) therapy delivers high numbers of spheres with resulting high total doses of radiation, preferentially in the periphery of tumors. Normal liver parenchyma showed little radiation effect away from the tumors. Heterogeneous high-dose regions in the tumor were produced by both glass and resin microspheres.
Collapse
|
42
|
Van Hazel G, Blackwell A, Anderson J, Price D, Moroz P, Bower G, Cardaci G, Gray B. Randomised phase 2 trial of SIR-Spheres plus fluorouracil/leucovorin chemotherapy versus fluorouracil/leucovorin chemotherapy alone in advanced colorectal cancer. J Surg Oncol 2004; 88:78-85. [PMID: 15499601 DOI: 10.1002/jso.20141] [Citation(s) in RCA: 367] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE Selective internal radiation therapy (SIRT) with SIR-Spheres(R) is a new technique for selectively targeting high doses of radiation to tumours within the liver. The primary objectives of this randomised trial were to compare the response rate, time to progressive disease (PD), and toxicity of a regimen of systemic fluorouracil/leucovorin chemotherapy versus the same chemotherapy plus a single administration of SIR-Spheres in patients with advanced colorectal liver metastases. The trial was designed to presage a larger trial that would have survival as the primary outcome. PATIENTS AND METHODS Twenty-one patients with previously untreated advanced colorectal liver metastases, with or without extrahepatic metastases, were randomised into the study. RESULTS Using RECIST criteria, the response rate for 11 patients receiving the combination treatment was significantly greater than for 10 patients receiving chemotherapy alone (First Integrated Response; 10 PR, 1 SD vs. 0 PR, 6 SD, 4 PD, P < 0.001 and Best Confirmed Response; 8 PR, 3 SD vs. 0 PR, 6 SD, 4 PD P < 0.001). The time to PD was greater for patients receiving the combination treatment (18.6 months vs. 3.6 months, P < 0.0005). Median survival was significantly longer for patients receiving the combination treatment (29.4 months vs. 12.8 months, P = 0.02). One patient in the combination arm died from chemotherapy induced neutropenic sepsis after the fourth chemotherapy cycle. There were more Grade 3 and 4 toxicity events in patients receiving the combination treatment. There was no difference in quality-of-life over a 3 month period between the two treatments when rated by patients (P = 0.96) or physicians (P = 0.98). CONCLUSIONS This small phase 2 randomised trial demonstrated that the addition of a single administration of SIR-Spheres to a regimen of systemic fluorouracil/leucovorin chemotherapy significantly increased both treatment related response, time to PD, and survival with acceptable toxicity. The combination of SIR-Spheres plus systemic chemotherapy is now the subject of ongoing trials to further define patient benefit.
Collapse
|
43
|
Moroz P, Pardoe H, Jones SK, St Pierre TG, Song S, Gray BN. Arterial embolization hyperthermia: hepatic iron particle distribution and its potential determination by magnetic resonance imaging. Phys Med Biol 2002; 47:1591-602. [PMID: 12043822 DOI: 10.1088/0031-9155/47/9/312] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Arterial embolization hyperthermia (AEH) consists of arterially embolizing liver tumours with ferromagnetic particles that generate hysteretic heating on exposure to an alternating magnetic field. A critical component of AEH is the concentration and distribution of ferromagnetic particles in the normal hepatic parenchyma (NHP), as well as in the tumour tissue. If the distribution of particles in NHP is heterogeneous, with areas of high concentration, then unwanted areas of necrosis may result during AEH. Using an in vivo rabbit liver tumour model, this study showed that hepatic arterial infusion of ferromagnetic particles does indeed result in a heterogeneous distribution of iron in NHP. The radiological technique of magnetic resonance imaging (MRI) was then evaluated as a potential tool for non-invasively and prospectively determining the concentration and distribution of particles within the hepatic tumour and NHP following hepatic arterial infusion. A preliminary in vitro experiment showed that although the concentration of iron within the tumour tissue (1.92-3.50 mg of iron per gram of tissue) was too great to measure, MRI was able to accurately determine the lower iron concentration (0.10-0.53 mg of iron per gram of tissue) in NHP. Further work is needed to evaluate MRI under in vivo conditions. If successful, MRI could become an important component of an emerging novel treatment for advanced hepatic malignancies.
Collapse
Affiliation(s)
- Paul Moroz
- Centre for Applied Cancer Studies, The University of Western Australia, Perth, Australia.
| | | | | | | | | | | |
Collapse
|
44
|
Jones SK, Winter JG. Experimental examination of a targeted hyperthermia system using inductively heated ferromagnetic microspheres in rabbit kidney. Phys Med Biol 2001; 46:385-98. [PMID: 11229721 DOI: 10.1088/0031-9155/46/2/308] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
It is known that significant heating can be generated by magnetic hysteresis effects in small ferromagnetic particles exposed to a rapidly alternating magnetic field. If such particles can be made to infiltrate the vascular bed surrounding a tumour by intravascular infusion then it may be possible to generate sufficient heating to destroy the tumour by hyperthermia. One of the constraints on such a technique is the limited amount of magnetic material that can be delivered to a tumour via the intravascular route and the consequent heating that can be induced by this material. Here, we report on a series of experiments in which doses of microspheres containing different amounts of ferromagnetic material were infused into rabbit kidneys via the renal artery with the aim of testing whether adequate tissue heating could be achieved using realistic concentrations of the embolised material. Heating rates were measured for each infused quantity under similar conditions with the animal alive and dead to examine the role of blood flow in the heating process. The results show that tissue temperatures above the therapeutic threshold of 42 degrees C can be readily achieved using this method with clinically relevant concentrations of microspheres in living tissue.
Collapse
Affiliation(s)
- S K Jones
- Cancer Research Institute Incorporated, Victoria Park, WA, Australia.
| | | |
Collapse
|
45
|
Nayak D, Lahiri S. Application of radioisotopes in the field of nuclear medicine. J Radioanal Nucl Chem 1999. [DOI: 10.1007/bf02345573] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
46
|
|
47
|
Abstract
Therapy with intraarterial microspheres is a technique which involves incorporation of radioisotope-labelled microspheres into a capillary bed of tumour and normal tissue. Betaemitters such as 90Y and 166Ho are used for this purpose. This technique provides tumour to normal tissue (TNT) dose ratios in the range of 2-10 and demonstrates significant clinical benefit, which could potentially be increased with more accurate dose predictions and delivery. However, dose calculations in this modality face the difficulties associated with nonuniform and inhomogeneous activity distribution. Most of the dose calculations used clinically do not account for the nonuniformity and assume uniform activity distribution. This paper is devoted to the development of a model which would allow more accurate prediction of dose distributions from microspheres. The model calculates dose assuming that microspheres are aggregated into randomly distributed clusters, and using precomputed dose kernels for the clusters. The dose kernel due to a microsphere cluster was found by numerical integration of a point source dose kernel over the volume of the cluster. It is shown that a random distribution of clusters produces an intercluster distance distribution which agrees well with the one measured by Pillai et al in liver. Dose volume histograms (DVHs) predicted by the model agree closely with the results of Roberson et al for normal tissue and tumour. Dose distributions for different concentrations and types of radioisotope as well as for tumours of different radii, have been calculated to demonstrate the model's possible applications.
Collapse
Affiliation(s)
- S F Zavgorodni
- Department of Medical Physics, Royal Adelaide Hospital, Australia
| |
Collapse
|
48
|
Khakoo SI, Grellier LF, Soni PN, Bhattacharya S, Dusheiko GM. Etiology, screening, and treatment of hepatocellular carcinoma. Med Clin North Am 1996; 80:1121-45. [PMID: 8804377 DOI: 10.1016/s0025-7125(05)70482-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The prognosis with large hepatocellular carcinomas is poor, and only palliative treatment is available. Small tumors are amenable to several modes of treatment, including liver transplantation, resection, or alcohol injection, with acceptable 5-year survival rates. Although the value of screening for hepatocellular carcinoma has yet to be shown, these data, coupled with the recognition of at-risk groups and useful diagnostic techniques, might encourage the clinician to screen at-risk patients in the clinic. New imaging techniques such as ultrasonographic angiography enhanced with CO2 microbubbles, or color Doppler ultrasound, may clarify the intratumoral blood flow of small tumors.
Collapse
Affiliation(s)
- S I Khakoo
- University Department of Medicine, Royal Free Hospital and School of Medicine, London, United Kingdom
| | | | | | | | | |
Collapse
|
49
|
Ho S, Lau WY, Leung TW, Chan M, Ngar YK, Johnson PJ, Li AK. Partition model for estimating radiation doses from yttrium-90 microspheres in treating hepatic tumours. EUROPEAN JOURNAL OF NUCLEAR MEDICINE 1996; 23:947-52. [PMID: 8753684 DOI: 10.1007/bf01084369] [Citation(s) in RCA: 217] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
A uniform distribution of yttrium-90 (90Y) microspheres throughout the entire liver has always been assumed for dose calculation in treating hepatic tumours. A simple mathematical model was formulated which allows estimation of the activities of a therapeutic dose of 90Y microspheres partitioned between the lungs, the tumour and the normal liver, and hence the radiation doses to them. The doses to the tumour and normal liver were verified by intra-operative direct beta-probing. The percentage of activity shunted to the lung and the tumour-to-normal tissue ratio (T/N) were obtained from gamma scintigraphy using technetium-99m-labelled macroaggregated albumin (MAA) which simulates the 90Y microspheres used in subsequent treatment. The intrahepatic activity was partitioned between the tumour and the normal liver based on the T/N and their masses determined from computerized tomography slices. The corresponding radiation doses were computed using the MIRD formula. The estimated radiation doses were correlated with the doses directly measured using a calibrated beta-probe at laparotomy by linear regression. The radiation doses to the tumour and the normal liver, estimated using the partition model, were close to that measured directly with coefficients of correlation for linear regression: 0.862 for the tumours and 0.804 for the normal liver compartment (P<0.001). The partition model permits a distinction between the radiation doses received by the tumour and the normal liver to be made and the doses thus estimated are close to the actual doses received. The optimal doses to the tumour and normal liver and hence the required quantity of 90Y microspheres to be administered can be easily predetermined.
Collapse
Affiliation(s)
- S Ho
- Department of Surgery, Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong
| | | | | | | | | | | | | |
Collapse
|
50
|
Chang D, Jenkins SA, Grime SJ, Nott DM, Cooke T. Increasing hepatic arterial flow to hypovascular hepatic tumours using degradable starch microspheres. Br J Cancer 1996; 73:961-5. [PMID: 8611432 PMCID: PMC2075812 DOI: 10.1038/bjc.1996.188] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
The effect of degradable starch microspheres (DSM) on the intrahepatic distribution of a low molecular weight marker, 99Tcm-labelled methylene diphosphonate (MDP), was studied in rats with hypovascular HSN liver tumours. MDP was injected regionally, via the hepatic artery, alone or co-administered with DSM, with or without subsequent occlusion of either the hepatic artery or the portal vein. Tumour vascularity was measured with 57Co-labelled microspheres. Co-injection with DSM immediately significantly increased hepatic retention of marker in both tumour (T) (median 22.40 (range 16.82-39.58)% injected dose) and normal liver (N) (9.08 (4.85-12.59) %ID) the greater effect seen in T (P < 0.01). After DSM degradation, very little MDP remained in N (0.61 (0.28-1.40) %ID) but there was significant retention in T (10.01 (6.73-20.28) %ID, P < 0.01). Clamping the hepatic artery had minimal effect on the retention of MDP when administered alone. Regional injection of 16.5 microM 57Co microspheres resulted in a N:T ratio of 2.25:1. Concomitant injection of the 40 microM DSM was 57Co microspheres reversed this ratio to 1:2. The results indicate that DSM selectively enhances the retention of MDP to a hypovascular hepatic tumour, not by causing intra-tumour stasis, but by directing a greater arterial flow to hypovascular areas in the liver.
Collapse
Affiliation(s)
- D Chang
- University Departments of Surgery, Royal Liverpool Hospital, UK
| | | | | | | | | |
Collapse
|