Safety of Radioembolization in the Setting of Angiographically Apparent Arterioportal Shunting

Radioembolization for Hepatocellular Carcinoma: The Effects of Arterioportal Shunts on Nontargeted Liver Hypertrophy

PURPOSE

To determine whether arterioportal shunting to the contralateral lobe attenuates the liver function and the hypertrophy of the nontargeted liver after radioembolization in patients with hepatocellular carcinoma (HCC) MATERIALS AND METHODS: This retrospective study included 46 patients who received radioembolization for HCC contained within the right lobe between 2012 and 2020. The patients were divided into the following groups based on the presence and extent of arterioportal shunt : patients with retrograde arterioportal shunting to the left lobe (contralateral group) and patients with arterioportal shunt limited to the right lobe or no arterioportal shunt (control group). Safety profiles including adverse events, tumor response and overall survival were compared. With the volume of left lateral segment used as a surrogate marker for nontarget liver, degree of hypertrophy was compared between two groups at 3 and 6 months.

RESULTS

Liver function significantly deteriorated in contralateral group in a month (p=<0.05). Tumor response and overall survival did not significantly differ between two groups. Degree of hypertrophy was significantly higher in the control group compared with the contralateral group at 3 months [10.6% vs 3.5% (p = 0.008)] and at 6 months [20.7% vs 2.4% (p < 0.001)].

CONCLUSION

In patients with arterioportal shunting to the contralateral lobe, hypertrophy of the nontarget liver may not occur and the liver function may be worsened.

Streamlining radioembolization in UNOS T1/T2 hepatocellular carcinoma by eliminating lung shunt estimation

BACKGROUND & AIMS

Pre-treatment Tc-99m macroaggregated albumin (MAA) scans are routinely performed prior to transarterial radioembolization (TARE) to estimate lung shunt fraction (LSF) and lung dose. In this study, we investigate LSF observed in early hepatocellular carcinoma (HCC) and provide the scientific rationale for eliminating this step from routine practice.

METHODS

Patients with HCC who underwent Y90 from 2004 to 2018 were reviewed. Inclusion criteria were early stage HCC (UNOS T1/T2/Milan criteria: solitary ≤5 cm, 3 nodules ≤3 cm). LSF was determined using MAA in all patients. Associations between LSF and baseline characteristics were investigated. A "no-MAA" paradigm was then proposed based on a homogenous group that expressed very low LSF.

RESULTS

Of 1,175 patients with HCC treated with TARE, 448 patients met inclusion criteria. Mean age was 65.6 years and 303 (68%) were males. A total of 352 (79%) had solitary lesions and 406 (91%) unilobar disease. Two-hundred and forty-three (54%), 178 (40%) and 27 (6%) patients were Child-Pugh class A, B and C, respectively. Median LSF was 3.9% (IQR 2.4-6%). Median administered activity was 0.9 GBq (IQR 0.6-1.4), for a median segmental volume of 170 cm³ (range: 60-530). Median lung dose was 1.9 Gy (IQR: 1.0-3.3). The presence of a transjugular intrahepatic portosystemic shunt (TIPS; n = 38) was associated with LSF >10% (odds ratio 12.2; 95% CI 5.2-28.6; p <0.001). Median LSF was 3.8% (IQR: 2.4-5.7%) and 6% (IQR: 3.8-15.3%) in no-TIPS vs. TIPS patients (p <0.001).

CONCLUSION

LSF is clinically negligible in patients with UNOS T1/T2 HCC without TIPS. When segmental injections are planned, this step can be eliminated, thereby reducing time-to-treatment, number of procedures, and improving convenience for patients traveling from faraway.

LAY SUMMARY

Transarterial radioembolization is a microembolic transarterial treatment for hepatocellular carcinoma. In our study, we found that early stage patients, where segmental injections are planned, exhibited low lung shunting, effectively eliminating the risk of radiation pneumonitis. We propose that the lung shunt study be eliminated in this subgroup, thus leading to fewer procedures, a cost reduction and improved convenience for patients.

Angiographic Findings Relevant to Prostatic Artery Embolization in Patients with Prostate Cancer

The 2014-2018 angiograms of 58 patients with prostate cancer were retrospectively analyzed to illustrate angiographic findings during prostatic artery embolization. Arteriovenous fistulae were observed in 6 patients (6/58, 10.3%), with no difference between patients with or without prior iodine-125 seeds implantation (5/48, 10.4% vs 1/10, 10.0%; P > .05); tumor staining was not detected. The origins of the prostatic arteries included the internal pudendal artery (n = 45, 32.4%), the superior vesical artery (n = 38, 27.3%), the obturator artery (n = 28, 20.1%), the gluteal-pudendal trunk (n = 21, 15.1%), the inferior gluteal artery (n = 3, 2.2%), the accessory pudendal artery (n = 3, 2.2%), and the superior gluteal artery (n = 1, 0.7%).

Iatrogenic Arterioportal Fistula Caused by Radiofrequency Ablation of Hepatocellular Carcinoma: Clinical Course and Treatment Outcomes

PURPOSE

To analyze the clinical course and treatment outcomes of patients with iatrogenic arterioportal fistula (APF) caused by radiofrequency (RF) ablation of hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

Among the 1,620 hepatocellular carcinoma patients treated by RF ablation between January 2012 and August 2017, 99 who developed APF after RF ablation were included in this retrospective study. Depending on the extent of portal vein enhancement on arterial phase images, APF was classified as massive or nonmassive. The patients' clinical course was investigated and statistically evaluated by univariable and multivariable analyses.

RESULTS

Thrombocytopenia (odds ratio [OR] = 3.939; 95% confidence interval [CI], 1.141-13.598) was the only risk factor for developing massive APF. Eleven patients underwent embolotherapy (technical success rate, 90.9%) and no patients experienced serious adverse events within 30 days of the procedure. Patients with massive APF (66.7%) had a significantly higher chance of a Child-Pugh score increase than did the patients with nonmassive APF (13.6%) (P < .001). Massive APF had a significantly lower chance of natural regression than did nonmassive APF (P < .001). Child-Pugh B (OR = 17.739; 95% confidence interval, 2.361-133.279) and massive APF without treatment (OR = 11.061; 95% confidence interval, 1.257-97.341) were independent risk factors for liver failure that led to death of liver transplant within 1 year after RF ablation.

CONCLUSIONS

Massive APF caused by RF ablation is mostly irreversible and significantly worsens patients' outcomes, but may be effectively treated with embolotherapy.