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Berman ZT, Pianka K, Qaseem Y, Redmond J, Minocha J. Single-Session Ablative Transarterial Radioembolization for Patients with Hepatocellular Carcinoma to Streamline Care: An Initial Experience. Cardiovasc Intervent Radiol 2024:10.1007/s00270-024-03799-6. [PMID: 38977445 DOI: 10.1007/s00270-024-03799-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 06/22/2024] [Indexed: 07/10/2024]
Abstract
PURPOSE Transarterial radioembolization (TARE) for hepatocellular carcinoma (HCC) is performed after a mapping angiogram involving infusion of radiolabeled macroaggregated albumin to assess for non-target embolization and pulmonary shunting. The purpose of this case series was to evaluate the safety and feasibility of single-session TARE without the initial procedure. MATERIALS AND METHODS A single-institution case series of 16 consecutive procedures on 15 patients with 18 tumors who underwent an attempted single-session TARE procedures with glass microspheres are presented. A lung shunt fraction (LSF) of 5% was assumed for planning purposes. RESULTS Sixty-seven percent (10/15) of patients were male with a median age of 72 years. Median tumor size was 2.5 cm (IQR 2.0-3.2 cm). Sixteen of the 18 targeted tumors were untreated prior to the single-session TARE. Rate of technical success was 88% (14/16). Two patients did not ultimately receive a single-session TARE due to intraprocedural findings. The mean administered activity was 2.0 GBq, and the mean MIRD dose was 464 Gy based on pre-treatment anatomic imaging and 800 Gy based on cone-beam CT. There were no cases of radiation pneumonitis. Mean post-procedural calculated lung dose was 4.9 Gy (range 3.1-9.3) based on SPECT. CONCLUSIONS An initial experience with single-session TARE using Y-90 glass microspheres without pre-procedural mapping angiography and lung shunt estimation demonstrates that it is a feasible and safe treatment option for select patients with small (< 5 cm) HCC. LEVEL OF EVIDENCE IV Level 4 case series.
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Affiliation(s)
- Zachary T Berman
- Division of Vascular and Interventional Radiology, Department of Radiology, University of California, 200 West Arbor Dr, San Diego, California, 92103, USA.
| | - Kurt Pianka
- Division of Vascular and Interventional Radiology, Department of Radiology, University of California, 200 West Arbor Dr, San Diego, California, 92103, USA
| | - Yousuf Qaseem
- Division of Vascular and Interventional Radiology, Department of Radiology, University of California, 200 West Arbor Dr, San Diego, California, 92103, USA
| | - Jonas Redmond
- Division of Vascular and Interventional Radiology, Department of Radiology, University of California, 200 West Arbor Dr, San Diego, California, 92103, USA
| | - Jeet Minocha
- Division of Vascular and Interventional Radiology, Department of Radiology, University of California, 200 West Arbor Dr, San Diego, California, 92103, USA
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Rice SL, Muñoz FG, Benjamin J, Alnablsi MW, Pillai A, Osborne JR, Beets-Tan R. Transcatheter pseudo-vascular isolation for localization and concentration of a large molecule theranostic probe into a transgenic OncoPIG kidney tumor. Nucl Med Biol 2024; 136-137:108939. [PMID: 39003976 DOI: 10.1016/j.nucmedbio.2024.108939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 05/09/2024] [Accepted: 07/02/2024] [Indexed: 07/16/2024]
Abstract
INTRODUCTION Great strides have been made identifying molecular and genetic changes expressed by various tumor types. These molecular and genetic changes are used as pharmacologic targets for precision treatment using large molecule (LM) proteins with high specificity. Theranostics exploits these LM biomolecules via radiochemistry, creating sensitive diagnostic and therapeutic agents. Intravenous (i.v.) LM drugs have an extended biopharmaceutical half-life thus resulting in an insufficient therapeutic index, permitting only palliative brachytherapy due to unacceptably high rates of systemic nontarget radiation doses to normal tissue. We employ tumor arteriole embolization isolating a tumor from the systemic circulation, and local intra-arterial (i.a.) infusion to improve uptake of a LM drug within a porcine renal tumor (RT). METHODS In an oncopig RT we assess the in vivo biodistribution of 99mTc-labeled macroaggregated albumin (MAA) a surrogate for a LM theranostics agent in the RT, kidney, liver, spleen, muscle, blood, and urine. Control animals underwent i.v. infusion and experimental group undergoing arteriography with pseudovascular isolation (PVI) followed by direct i.a. injection. RESULTS Injected dose per gram (%ID/g) of the LM at 1 min was 86.75 ± 3.76 and remained elevated up to 120 min (89.35 ± 5.77) with i.a. PVI, this increase was statistically significant (SS) compared to i.v. (13.38 ± 1.56 and 12.02 ± 1.05; p = 0.0003 p = 0.0006 at 1 and 120 min respectively). The circulating distribution of LM in the blood was less with i.a. vs i.v. infusion (2.28 ± 0.31 vs 25.17 ± 1.84 for i.v. p = 0.033 at 1 min). Other organs displayed a trend towards less exposure to radiation for i.a. with PVI compared to i.v. which was not SS. CONCLUSION PVI followed by i.a. infusion of a LM drug has the potential to significantly increase the first pass uptake within a tumor. This minimally invasive technique can be translated into clinical practice, potentially rendering monoclonal antibody based radioimmunotherapy a viable treatment for renal tumors.
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Affiliation(s)
- Samuel L Rice
- Netherlands Cancer Institute-Antoni van Leeuwenhoekziekenhuis, Department of Radiology, Plesmanlaan 121, 1066 CX Amsterdam, Netherlands; UT Southwestern Medical Center, Department of Radiology, Interventional Radiology Section, 5959 Harry Hines Blvd., Dallas, TX 75390-9061, Professional Office Building I (HP6.600) Mail Code 8834, United States of America.
| | - Fernando Gómez Muñoz
- Netherlands Cancer Institute-Antoni van Leeuwenhoekziekenhuis, Department of Radiology, Plesmanlaan 121, 1066 CX Amsterdam, Netherlands
| | - Jamaal Benjamin
- UT Southwestern Medical Center, Department of Radiology, Interventional Radiology Section, 5959 Harry Hines Blvd., Dallas, TX 75390-9061, Professional Office Building I (HP6.600) Mail Code 8834, United States of America
| | - Mhd Wisam Alnablsi
- UT Southwestern Medical Center, Department of Radiology, Interventional Radiology Section, 5959 Harry Hines Blvd., Dallas, TX 75390-9061, Professional Office Building I (HP6.600) Mail Code 8834, United States of America
| | - Anil Pillai
- UT Southwestern Medical Center, Department of Radiology, Interventional Radiology Section, 5959 Harry Hines Blvd., Dallas, TX 75390-9061, Professional Office Building I (HP6.600) Mail Code 8834, United States of America
| | - Joseph R Osborne
- New York-Presbyterian Weill Cornell Medical Center, Department of Radiology, 1305 York Avenue 3rd Floor, New York, NY 10021, United States of America
| | - Regina Beets-Tan
- Netherlands Cancer Institute-Antoni van Leeuwenhoekziekenhuis, Department of Radiology, Plesmanlaan 121, 1066 CX Amsterdam, Netherlands
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Brunson CP, McGregor HJ, Hennemeyer CT, Patel MV, Woodhead GJ, Young SJ. Measurement of the Tumor-to-Normal Ratio for Radioembolization of Hepatocellular Carcinoma: A Prospective Study Comparing 2-Dimensional Perfusion Angiography, Technetium-99m Macroaggregated Albumin, and Yttrium-90 SPECT/CT. J Vasc Interv Radiol 2024; 35:94-101. [PMID: 37783268 DOI: 10.1016/j.jvir.2023.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 08/11/2023] [Accepted: 09/23/2023] [Indexed: 10/04/2023] Open
Abstract
PURPOSE To calculate the preradioembolic tumor-to-normal (T:N) ratio in hepatocellular carcinoma (HCC) using 2-dimensional (2D) perfusion angiography and compare it with that calculated using technetium-99m macroaggregated albumin (99mTc MAA) single-photon emission computed tomography (SPECT)/computed tomography (CT). MATERIALS AND METHODS This prospective single-arm study enrolled 15 participants with HCC who underwent 2D perfusion angiography immediately before the enrollment and with the microcatheter located at the same location as 99mTc MAA injection, after which SPECT/CT was performed. Quantitative digital subtraction angiography was used to calculate the area under the curve for the tumor and normal hepatic parenchyma and subsequently calculate the T:N ratio. The T:N ratio was calculated from the 99mTc MAA SPECT/CT and post-yttrium-90 bremsstrahlung SPECT/CT using dosimetry software. RESULTS The mean participant age was 64.1 years ± 9.8, and the study included 14 (93%) men and 1 (7%) woman. The mean tumor size was 4.1 cm (SD ± 2.4), and all participants received segmental treatments with glass microspheres. The mean T:N ratio calculated by 99mTc MAA SPECT/CT was 2.28 (SD ± 0.89) vs 2.25 (SD ± 0.99) calculated by 2D perfusion angiography (P = .45). For the 13 participants who underwent selective internal radiation therapy (transarterial radioembolization), there was no significant difference between the T:N ratios calculated by 2D perfusion angiography and post-90Y SPECT/CT (2.25 [SD ± 1.05] vs 1.91 [SD ± 0.39]; P = .12). CONCLUSIONS The T:N ratio calculated by 2D perfusion angiography correlated well with that calculated by 99mTc MAA SPECT/CT.
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Affiliation(s)
- Christopher P Brunson
- Department of Radiology & Biomedical Imaging, University of California-San Francisco, San Francisco, California.
| | - Hugh J McGregor
- Department of Vascular and Interventional Radiology, University of Washington, Seattle, Washington
| | | | - Mikin V Patel
- Department of Vascular and Interventional Radiology, University of Chicago, Chicago, Illinois
| | | | - Shamar J Young
- Division of Interventional Radiology, University of Arizona, Tucson, Arizona
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Lee JH, Lee CH, Kim M, Song YS, Yoon CJ, Lee WW. CT texture features and lung shunt fraction measured using 99mTc-macroaggregated albumin SPECT/CT before trans-arterial radioembolization for hepatocellular carcinoma patients. Sci Rep 2023; 13:22288. [PMID: 38097801 PMCID: PMC10721865 DOI: 10.1038/s41598-023-49787-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 12/12/2023] [Indexed: 12/17/2023] Open
Abstract
The aim of this study is to determine whether contrast-enhanced computed tomography (CECT)-based texture parameters can predict high (> 30 Gy) expected lung dose (ELD) calculated using 99mTc macroaggregated albumin single-photon emission computed tomography/computed tomography (SPECT/CT) for pre-trans-arterial radioembolization (TARE) dosimetry. 35 patients were analyzed, with a treatable planned dose of ≥ 200 Gy for unresectable hepatocellular carcinoma (HCC). Lung shunt fraction (LSF) was obtained from planar and SPECT/CT scans. Texture features of the tumor lesion on CECT before TARE were analyzed. Univariate and multivariate linear regression analyses were performed to determine potential ELD > 30 Gy predictors. Among the 35 patients, nine (25.7%) had ELD > 30 Gy, and had a higher LSF than the ELD ≤ 30 Gy group using the planar (20.7 ± 8.0% vs. 6.3 ± 3.3%; P < 0.001) and SPECT/CT (12.4 ± 5.1% vs. 3.5 ± 2.0%; P < 0.001) scans. The tumor integral total (HU × L) value was a predictor for high LSF using SPECT/CT, with an area under the curve, sensitivity, and specificity of 0.983 (95% confidence interval: 0.869-1.000, P < 0.001), 100%, and 88.5%, respectively. The tumor integral total value is an imaging marker for predicting ELD > 30 Gy. Applying CECT texture analysis may assist in reducing time and cost in patient selection and modifying TARE treatment plans.
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Affiliation(s)
- Jae Hwan Lee
- Department of Radiology, Seoul National University Bundang Hospital, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea
- Department of Radiology, Seoul National University College of Medicine, Jongno-gu, Seoul, Republic of Korea
- Institute of Radiation Medicine, Seoul National University Medical Research Center, Jongno-gu, Seoul, Republic of Korea
| | - Chong-Ho Lee
- Department of Radiology, Seoul National University Bundang Hospital, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Minuk Kim
- Department of Radiology, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Yoo Sung Song
- Department of Nuclear Medicine, Seoul National University Bundang Hospital, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea.
- Department of Nuclear Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - Chang Jin Yoon
- Department of Radiology, Seoul National University Bundang Hospital, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea
- Department of Radiology, Seoul National University College of Medicine, Jongno-gu, Seoul, Republic of Korea
- Institute of Radiation Medicine, Seoul National University Medical Research Center, Jongno-gu, Seoul, Republic of Korea
| | - Won Woo Lee
- Institute of Radiation Medicine, Seoul National University Medical Research Center, Jongno-gu, Seoul, Republic of Korea
- Department of Nuclear Medicine, Seoul National University Bundang Hospital, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea
- Department of Nuclear Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Health Science and Technology, The Graduate School of Convergence Science and Technology, Seoul National University, Suwon-si, Gyeonggi-do, Republic of Korea
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Chung S, Gogna A, Chandramohan S, Lo R, Irani FG, Venkatanarasimha N. Review of outcomes of combination therapy using yttrium 90 radioembolization and sorafenib/nivolumab for HCC with hepatic vein or IVC invasion. PROCEEDINGS OF SINGAPORE HEALTHCARE 2023. [DOI: 10.1177/20101058231154666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Background A systematic review of the outcomes of combination therapy using Yttrium 90 radioembolization (Y90) and sorafenib/nivolumab for patients with hepatocellular carcinoma (HCC), with hepatic vein (HV) or inferior vena cava (IVC) invasion. The aim of this study is to summarise the results of different studies that used the combination therapy for HCC patients with tumor thrombosis involving the HV or IVC. Method A literature search was performed using keywords in Medline and Google Scholar limited to publications from 2010 to 2021. There were 173 articles identified during the initial literature search. During abstract screening, 81 articles were excluded. Another 83 did not contain information on hepatic vein or IVC invasion. Therefore, 9 articles met the eligibility criteria and were included in the synthesis. Results In total, 37 patients with hepatic vein or IVC invasion were identified. There were 31 patients who were given sorafenib, 7 were given nivolumab and 1 was given both sorafenib and nivolumab. Among the 37 patients, 21 had hepatic vein invasion, 22 had IVC invasion and 6 had both HV and IVC invasion. The median OS was 20.55 months and median PFS was 8.18 months. For the results, 23 patients were evaluated via modified RECIST (mRECIST) criteria and 14 were evaluated via RECIST 1.1. Conclusion The combination of local and systemic therapies demonstrated potential results for increased response rates, OS and PFS benefits. Further studies are required to determine the long-term outcomes of the combination therapy for this group of patients.
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Affiliation(s)
| | - Apoorva Gogna
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Singapore
| | | | - Richard Lo
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Singapore
| | - Farah Gillan Irani
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Singapore
| | - Nanda Venkatanarasimha
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Singapore
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Su TH, Hsu SJ, Kao JH. Paradigm shift in the treatment options of hepatocellular carcinoma. Liver Int 2022; 42:2067-2079. [PMID: 34515412 DOI: 10.1111/liv.15052] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 08/31/2021] [Accepted: 09/03/2021] [Indexed: 01/27/2023]
Abstract
Hepatocellular carcinoma (HCC) is prevalent worldwide with suboptimal therapeutic outcomes. The advancement of therapeutic options and the development of new systemic therapies expand the armamentarium to tackle HCC. Treatment options should be provided based on the hierarchy of efficacy in a multidisciplinary perspective, instead of the traditional stage-guided scheme. In advanced HCC, lenvatinib has a comparable efficacy as sorafenib for the first-line therapy of HCC; while regorafenib, cabozantinib, and ramucirumab have been approved as second-line therapy after the failure of sorafenib. Immune checkpoint inhibitor therapy prolongs response rate and survival and enables long-term cure. Atezolizumab plus bevacizumab is superior to sorafenib as the first-line therapy for advanced HCC. Several emerging regimens by the combination of various systemic therapies are currently under clinical trials. Systemic therapy may be used in the neoadjuvant, adjuvant or even as initial therapy for intermediate-stage HCC. The paradigm shift of HCC treatment will improve patient outcomes.
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Affiliation(s)
- Tung-Hung Su
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Hepatitis Research Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Shih-Jer Hsu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Hepatitis Research Center, National Taiwan University Hospital, Taipei, Taiwan.,Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Yunlin, Taiwan
| | - Jia-Horng Kao
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Hepatitis Research Center, National Taiwan University Hospital, Taipei, Taiwan.,Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan.,Department of Medical Research, National Taiwan University Hospital, Taipei, Taiwan
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7
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Abstract
Selective internal radiation therapy represents an endovascular treatment option for patients with primary liver malignancies, in different clinical stages. Potential applications of this treatment are in early-stage hepatocellular carcinoma, as a curative option, or in combination with systemic treatments in intermediate and advanced-stages. This review, based on existing literature and ongoing trials, will focus on the future of this treatment in patients with hepatocellular carcinoma, in combination with systemic treatments, or with the use of new devices and technological developments; it will also describe new potential future indications and structural and organizational perspectives.
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Williams SJ, Rilling WS, White SB. Quality of Life and Cost Considerations: Y-90 Radioembolization. Semin Intervent Radiol 2021; 38:482-487. [PMID: 34629718 DOI: 10.1055/s-0041-1735570] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Objective Transarterial radioembolization (TARE) offers a minimally invasive and safe treatment option for primary and metastatic hepatic malignancies. The benefits of TARE are manifold including prolonged overall survival, low associated morbidities, and improved time to progression allowing prolonged treatment-free intervals. The rapid development of new systemic therapies including immunotherapy has radically changed the treatment landscape for primary and metastatic liver cancer. Given the current climate, it is critical for interventional oncologists to understand the benefits of TARE relative to these other therapies. Therefore, this report aims to review quality-of-life outcomes and the cost comparisons of TARE as compared with systemic therapies.
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Affiliation(s)
- Stephen J Williams
- Division of Vascular and Interventional Radiology, Department of Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - William S Rilling
- Division of Vascular and Interventional Radiology, Department of Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Sarah B White
- Division of Vascular and Interventional Radiology, Department of Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin
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9
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Elsayed M, Loya M, Galt J, Schuster DM, Bercu ZL, Newsome J, Brandon D, Benenati S, Behbahani K, Duszak R, Sethi I, Kokabi N. Same day yttrium-90 radioembolization with single photon emission computed tomography/computed tomography: An opportunity to improve care during the COVID-19 pandemic and beyond. World J Gastrointest Oncol 2021; 13:440-452. [PMID: 34040704 PMCID: PMC8131908 DOI: 10.4251/wjgo.v13.i5.440] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 03/21/2021] [Accepted: 04/23/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The coronavirus disease 2019 (COVID-19) pandemic has made it more challenging for patients to undergo yttrium-90 (Y-90) radioembolization (RE). Same day Y-90 RE provides an opportunity to minimize logistical challenges and infection risk associated with COVID-19, thus improving patient access.
AIM To describe the use of same day Y-90 RE with routine single photon emission computed tomography/computed tomography (SPECT/CT) in order to optimize therapy.
METHODS All patients were selected for Y-90 RE through a multidisciplinary tumor board, and were screened and tested for COVID-19 infection per institutional protocol. A same day procedure was developed, consisting of angiography, imaging, and Y-90 resin particle delivery. Routine SPECT/CT after technetium-99m macroaggregated albumin (Tc-99m MAA) administration was performed for assessment of arterial supply, personalized dosimetry, and extrahepatic activity. Post-treatment Y-90 bremsstrahlung SPECT/CT was performed for confirmation of particle delivery, by utilization of energy windowing to limit signal from previously administered Tc-99m MAA particles.
RESULTS A total of 14 patients underwent same day Y-90 RE between March and June 2020. Mean lung shunt fraction was 6.13% (range 3.5%-13.1%). Y-90 RE was performed for a single lesion in 7 patients, while the remaining 7 patients had treatment of multifocal lesions. The largest lesion measured 8.3 cm. All patients tolerated the procedure well and were discharged the same day.
CONCLUSION Same day Y-90 RE with resin-based microspheres is feasible, and provides an opportunity to mitigate infection risk and logistical challenges associated with the COVID-19 pandemic and beyond. We recommend consideration of SPECT/CT, especially among patients with complex malignancies, for the potential to improve outcomes and eligibility of patients to undergo same day Y-90 RE.
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Affiliation(s)
- Mohammad Elsayed
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA 30322, United States
| | - Mohammad Loya
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA 30322, United States
| | - James Galt
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA 30322, United States
| | - David M Schuster
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA 30322, United States
| | - Zachary L Bercu
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA 30322, United States
| | - Janice Newsome
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA 30322, United States
| | - David Brandon
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA 30322, United States
| | - Sonia Benenati
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA 30322, United States
| | - Keywan Behbahani
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA 30322, United States
| | - Richard Duszak
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA 30322, United States
| | - Ila Sethi
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA 30322, United States
| | - Nima Kokabi
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA 30322, United States
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Abstract
Hepatocellular carcinoma is one of the leading causes of cancer related death in the world. Biannual surveillance for the disease in patients with cirrhosis and in high risk carriers of hepatitis B virus allows early stage cancer detection and treatment with good long term outcomes. Liver ultrasonography and serum α fetoprotein are the most commonly used surveillance tests. If suspicious results are found on the surveillance test, multiphasic computed tomography or magnetic resonance imaging should be undertaken to confirm the diagnosis of hepatocellular carcinoma. If radiologic tests show inconclusive results, liver biopsy or repeat imaging could be considered for confirmation of hepatocellular carcinoma. Management of the disease is complex. Patients should be evaluated by a multidisciplinary team, and the selection of treatment should consider factors such as tumor burden, severity of liver dysfunction, medical comorbidities, local expertise, and preference of patients. Early stage hepatocellular carcinoma is best managed by curative treatment, which includes resection, ablation, or transplantation. Patients with intermediate stage disease often receive locoregional treatment. Systemic treatment is reserved for patients with advanced disease. Several positive, phase III, randomized controlled trials have expanded the systemic treatment options for advanced hepatocellular carcinoma with promising long term outcomes, especially trials using combination treatments, which could also have eventual implications for the treatment of earlier stage disease.
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Affiliation(s)
- Ju Dong Yang
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Julie K Heimbach
- Division of Transplant Surgery, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
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Comparison of perfused volume segmentation between cone-beam CT and 99mTc-MAA SPECT/CT for treatment dosimetry before selective internal radiation therapy using 90Y-glass microspheres. Diagn Interv Imaging 2020; 102:45-52. [PMID: 33032960 DOI: 10.1016/j.diii.2020.09.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 08/29/2020] [Accepted: 09/10/2020] [Indexed: 02/03/2023]
Abstract
PURPOSE To compare the reliability and accuracy of the pre-treatment dosimetry predictions using cone-beam computed tomography (CBCT) versus 99mTc-labeled macroaggregated albumin (MAA) SPECT/CT for perfused volume segmentation in patients with hepatocellular carcinoma treated by selective internal radiation therapy (SIRT) using 90Y-glass microspheres. MATERIALS AND METHODS Fifteen patients (8 men, 7 women) with a mean age of 68.3±10.5 (SD) years (range: 47-82 years) who underwent a total of 17 SIRT procedures using 90Y-glass microspheres for unresectable hepatocellular carcinoma were retrospectively included. Pre-treatment dosimetry data were calculated from 99mTc-MAA SPECT/CT using either CBCT or 99mTc-MAA SPECT/CT to segment the perfused volumes. Post-treatment dosimetry data were calculated using 90Y imaging (SPECT/CT or PET/CT). The whole liver, non-tumoral liver, and tumor volumes were segmented on CT or MRI data. The mean absorbed doses of the tumor (DT), non-tumoral liver, perfused liver (DPL) and perfused non-tumoral liver were calculated. Intra- and interobserver reliabilities were investigated by calculating Lin's concordant correlation coefficients (ρc values). The differences (biases) between pre- and post-treatment dosimetry data were assessed using the modified Bland-Altman method (for non-normally distributed variables), and systematic bias was evaluated using Passing-Bablok regression. RESULTS The intra- and interobserver reliabilities were good-to-excellent (ρc: 0.80-0.99) for all measures using both methods. Compared with 90Y imaging, the median differences were 5.8Gy (IQR: -12.7; 16.1) and 5.6Gy (IQR: -13.6; 10.2) for DPL-CBCT and DPL-99mTc-MAA SPECT/CT, respectively. The median differences were 1.6Gy (IQR: -29; 7.53) and 9.8Gy (IQR: -28.4; 19.9) for DT-CBCT and DT-99mTc-MAA SPECT/CT respectively. Passing-Bablok regression analysis showed that both CBCT and 99mTc-MAA SPECT/CT had proportional biases and thus tendencies to overestimate DT and DPL at higher post-treatment doses. CONCLUSION CBCT may be a reliable segmentation method, but it does not significantly increase the accuracy of dose prediction compared with that of 99mTc-MAA SPECT/CT. At higher doses both methods tend to overestimate the doses to tumors and perfused livers.
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Gabr A, Entezari P, Riaz A, Salem R, Lewandowski RJ. Contemporary Techniques and Applications of Radioembolization in Patients with Hepatocellular Carcinoma. ACTA ACUST UNITED AC 2020. [DOI: 10.1016/j.yacr.2020.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Gabr A, Ranganathan S, Mouli SK, Riaz A, Gates VL, Kulik L, Ganger D, Maddur H, Moore C, Hohlastos E, Katariya N, Caicedo JC, Kalyan A, Lewandowski RJ, Salem R. Streamlining radioembolization in UNOS T1/T2 hepatocellular carcinoma by eliminating lung shunt estimation. J Hepatol 2020; 72:1151-1158. [PMID: 32145255 DOI: 10.1016/j.jhep.2020.02.024] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 02/04/2020] [Accepted: 02/09/2020] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Ahmed Gabr
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Srirajkumar Ranganathan
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Samdeep K Mouli
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Ahsun Riaz
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Vanessa L Gates
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Laura Kulik
- Department of Medicine, Division of Hepatology, Northwestern University, Chicago, IL
| | - Daniel Ganger
- Department of Medicine, Division of Hepatology, Northwestern University, Chicago, IL
| | - Haripriya Maddur
- Department of Medicine, Division of Hepatology, Northwestern University, Chicago, IL
| | - Christopher Moore
- Department of Medicine, Division of Hepatology, Northwestern University, Chicago, IL
| | - Elias Hohlastos
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Nitin Katariya
- Department of Surgery, Division of Transplantation, Comprehensive Transplant Center, Northwestern University, Chicago, IL
| | - Juan Carlos Caicedo
- Department of Surgery, Division of Transplantation, Comprehensive Transplant Center, Northwestern University, Chicago, IL
| | - Aparna Kalyan
- Department of Medicine, Division of Medical Oncology, Northwestern University, Chicago, IL
| | - Robert J Lewandowski
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL; Department of Surgery, Division of Transplantation, Comprehensive Transplant Center, Northwestern University, Chicago, IL
| | - Riad Salem
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL; Department of Surgery, Division of Transplantation, Comprehensive Transplant Center, Northwestern University, Chicago, IL; Department of Medicine, Division of Medical Oncology, Northwestern University, Chicago, IL.
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