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Baloji A, Kalra N, Chaluvashetty S, Bhujade H, Chandel K, Duseja A, Taneja S, Gorsi U, Kumar R, Singh H, Sood A, Bhattacharya A, Singh B, Mittal BR, Singh V, Sandhu MS. Efficacy of Yttrium-90 Transarterial Radioembolisation in Advanced Hepatocellular Carcinoma: An Experience With Hybrid Angio-Computed Tomography and Glass Microspheres. J Clin Exp Hepatol 2024; 14:101342. [PMID: 38283702 PMCID: PMC10819781 DOI: 10.1016/j.jceh.2023.101342] [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: 10/16/2022] [Accepted: 12/23/2023] [Indexed: 01/30/2024] Open
Abstract
Background Hepatocellular carcinoma is one of the most common malignancies worldwide. Transarterial radioembolisation (TARE) involves selective intra-arterial administration of microspheres loaded with a radioactive compound like Yttrium-90 (Y-90). Conventionally, C-arm-based cone-beam computed tomography has been extensively used during TARE. However, angio-computed tomography (CT) is a relatively new modality which combines the advantages of both fluoroscopy and fCT. There is scarce literature detailing the use of angio-CT in Y90 TARE. Methods This was a retrospective study of primary liver cancer cases in which the TARE procedure was done from November 2017 to December 2021. Glass-based Y-90 microspheres were used in all these cases. All the cases were performed in the hybrid angio-CT suite. A single photon emission computed tomography-computed comography (SPECT-CT) done postplanning session determined the lung shunt fraction and confirmed the accurate targeting of the lesion. Postdrug delivery, positron emission tomography-computed tomography (PET-CT) was obtained to confirm the distribution of the Y-90 particles. The technical success, median follow-up, objective response rate (ORR), progression-free survival (PFS), and overall survival (OS) were recorded. Results A total of 56 hepatocellular carcinoma patients underwent TARE during this period, out of which 36 patients (30 males and 6 females) underwent Y90 TARE. The aetiology of cirrhosis included non-alcoholic steatohepatitis (NASH) (11), hepatitis C (HCV) (11), hepatitis B (HBV) (9), metabolic dysfunction and alcohol-associated liver disease (MetALD) (2), alcoholic liver disease (ALD) (1), cryptogenic (1), and autoimmune hepatitis (AIH) (1). The technical success was 100 % and the median follow-up was 7 months (range: 1-32 months). The median OS was 15 months (range 10.73-19.27 months; 95 % CI) and the median local PFS was 4 months (range 3.03-4.97 months; 95 % CI). The ORR (best response, CR + PR) was 58 %. No major complications were seen in this study. Conclusion TARE is a viable option for liver cancer in all stages, but more so in the advanced stages. The use of angio-CT in TARE aids in the precise delivery of the particles to the tumour and avoids non-target embolisation.
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Affiliation(s)
- Abhiman Baloji
- Department of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Naveen Kalra
- Department of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sreedhara Chaluvashetty
- Department of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Harish Bhujade
- Department of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Karamvir Chandel
- Department of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ajay Duseja
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sunil Taneja
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ujjwal Gorsi
- Department of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajender Kumar
- Department of Nuclear Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Harmandeep Singh
- Department of Nuclear Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashwani Sood
- Department of Nuclear Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Anish Bhattacharya
- Department of Nuclear Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Baljinder Singh
- Department of Nuclear Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Bhagwant R. Mittal
- Department of Nuclear Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Virendra Singh
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Manavjit S. Sandhu
- Department of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Marquis H, Ocampo Ramos JC, Carter LM, Zanzonico P, Bolch WE, Laforest R, Kesner AL. MIRD Pamphlet No. 29: MIRDy90-A 90Y Research Microsphere Dosimetry Tool. J Nucl Med 2024; 65:jnumed.123.266743. [PMID: 38388514 PMCID: PMC11064830 DOI: 10.2967/jnumed.123.266743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 01/23/2024] [Indexed: 02/24/2024] Open
Abstract
90Y-microsphere radioembolization has become a well-established treatment option for liver malignancies and is one of the first U.S. Food and Drug Administration-approved unsealed radionuclide brachytherapy devices to incorporate dosimetry-based treatment planning. Several different mathematical models are used to calculate the patient-specific prescribed activity of 90Y, namely, body surface area (SIR-Spheres only), MIRD single compartment, and MIRD dual compartment (partition). Under the auspices of the MIRDsoft initiative to develop community dosimetry software and tools, the body surface area, MIRD single-compartment, MIRD dual-compartment, and MIRD multicompartment models have been integrated into a MIRDy90 software worksheet. The worksheet was built in MS Excel to estimate and compare prescribed activities calculated via these respective models. The MIRDy90 software was validated against available tools for calculating 90Y prescribed activity. The results of MIRDy90 calculations were compared with those obtained from vendor and community-developed tools, and the calculations agreed well. The MIRDy90 worksheet was developed to provide a vetted tool to better evaluate patient-specific prescribed activities calculated via different models, as well as model influences with respect to varying input parameters. MIRDy90 allows users to interact and visualize the results of various parameter combinations. Variables, equations, and calculations are described in the MIRDy90 documentation and articulated in the MIRDy90 worksheet. The worksheet is distributed as a free tool to build expertise within the medical physics community and create a vetted standard for model and variable management.
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Affiliation(s)
- Harry Marquis
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Juan C Ocampo Ramos
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Lukas M Carter
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Pat Zanzonico
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Wesley E Bolch
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, Florida; and
| | - Richard Laforest
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Adam L Kesner
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York;
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Mourad SN, De la Garza-Ramos C, Toskich BB. Radiation Segmentectomy for the Treatment of Hepatocellular Carcinoma: A Practical Review of Evidence. Cancers (Basel) 2024; 16:669. [PMID: 38339418 PMCID: PMC10854641 DOI: 10.3390/cancers16030669] [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: 01/18/2024] [Revised: 02/02/2024] [Accepted: 02/03/2024] [Indexed: 02/12/2024] Open
Abstract
Radiation segmentectomy is a versatile, safe, and effective ablative therapy for early-stage hepatocellular carcinoma. Advances in radiation segmentectomy patient selection, procedural technique, and dosimetry have positioned this modality as a curative-intent and guideline-supported treatment for patients with solitary HCC. This review describes key radiation segmentectomy concepts and summarizes the existing literary knowledgebase.
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Affiliation(s)
- Sophia N. Mourad
- College of Medicine, Florida State University, Orlando, FL 32301, USA
| | | | - Beau B. Toskich
- Division of Interventional Radiology, Mayo Clinic Florida, Jacksonville, FL 32224, USA
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Badar W, Yu Q, Patel M, Ahmed O. Transarterial Radioembolization for Management of Hepatocellular Carcinoma. Oncologist 2024; 29:117-122. [PMID: 38128565 PMCID: PMC10836303 DOI: 10.1093/oncolo/oyad327] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 11/17/2023] [Indexed: 12/23/2023] Open
Abstract
Transarterial radioembolization (TARE) with Yttrium-90 (Y90) is a growing area of study due to its benefits in early-, intermediate-, and late-stage hepatocellular carcinoma. Treatment intent, including curative therapy, bridging to transplant, and downstaging disease, informs treatment approach and dosimetry goals. Radiation lobectomy (RL) and radiation segmentectomy (RS) are the 2 main forms of Y90 administration which have shown improved survival outcomes with the development of personalized dosimetry. RS aims to achieve complete pathological necrosis with dose escalation and RL aims for local disease control as well as induction of contralateral lobe hypertrophy to improve hepatic reserve. Furthermore, TARE has been validated in head-to-head comparison to other locoregional and systemic therapies. Lastly, early potential exists for combination therapy between TARE and immune checkpoint inhibitors for advanced stage disease.
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Affiliation(s)
- Wali Badar
- Division of Interventional Radiology, Department of Radiology, University of Illinois Hospital and Health Sciences System, Chicago, IL, USA
| | - Qian Yu
- Division of Interventional Radiology, Department of Radiology, University of Chicago, Chicago, IL, USA
| | - Mikin Patel
- Division of Interventional Radiology, Department of Radiology, University of Chicago, Chicago, IL, USA
| | - Osman Ahmed
- Division of Interventional Radiology, Department of Radiology, University of Chicago, Chicago, IL, USA
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Villalobos A, Pisanie JLD, Gandhi RT, Kokabi N. Yttrium-90 Radioembolization Dosimetry: Dose Considerations, Optimization, and Tips. Semin Intervent Radiol 2024; 41:63-78. [PMID: 38495257 PMCID: PMC10940044 DOI: 10.1055/s-0044-1779715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Affiliation(s)
- Alexander Villalobos
- Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Johannes L. du Pisanie
- Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Ripal T. Gandhi
- Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Nima Kokabi
- Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Villalobos A, Dabbous HH, Little O, Gbolahan OB, Akce M, Lilly MA, Bercu Z, Kokabi N. Safety and Efficacy of Concurrent Atezolizumab/Bevacizumab or Nivolumab Combination Therapy with Yttrium-90 Radioembolization of Advanced Unresectable Hepatocellular Carcinoma. Curr Oncol 2023; 30:10100-10110. [PMID: 38132368 PMCID: PMC10742675 DOI: 10.3390/curroncol30120734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 11/06/2023] [Accepted: 11/11/2023] [Indexed: 12/23/2023] Open
Abstract
To evaluate the safety and efficacy of combining yttrium-90 radioembolization (Y90-RE) with immune checkpoint inhibitor therapy, consecutive advanced unresectable hepatocellular carcinoma (HCC) patients treated between 2016 and 2022 with atezolizumab/bevacizumab or nivolumab within three-months pre- and post-Y90-RE were retrospectively evaluated. Tumor response and treatment-related clinical/laboratory adverse events (AE) were assessed at 1 and 6 months, as well as differences in clinical and laboratory variables and median overall survival (OS) from initial treatment (whether it was Y90-RE or systemic therapy) between the two cohorts. A total of 19 patients (10 atezolizumab/bevacizumab; 9 nivolumab), comprising 84% males with median age 69 years, met the inclusion criteria. Compared to the atezolizumab/bevacizumab group, there were less males (100% vs. 67%; p = 0.02) and more ECOG ≥ 2 patients in the nivolumab group (0% vs. 33%; p = 0.02). Baseline characteristics or incidence of 6-month post-treatment any-grade AE (60% vs. 56%; p = 0.7), grade ≥ 3 AE (0% vs. 11%; p = 0.3), objective response (58% total, 60% vs. 56%; p = 0.7), and complete response (16% total; 10% vs. 22%; p = 0.8) were similar between the atezolizumab/bevacizumab and the nivolumab cohorts. Median OS was 12.9 months for the whole cohort, 16.4 months for nivolumab, and 10.7 months for atezolizumab/bevacizumab. Among patients with advanced unresectable HCC, the utilization of Y90-RE concurrently or within 90 days of nivolumab or atezolizumab/bevacizumab immunotherapy, appears to be well-tolerated and with a low incidence of severe AE.
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Affiliation(s)
- Alexander Villalobos
- Department of Radiology, University of North Carolina at Chapel Hill, Alexander Villalobos 101 Manning Drive, Chapel Hill, NC 27514, USA;
| | - Howard Hussein Dabbous
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA 30322, USA; (H.H.D.); (M.A.L.); (Z.B.)
| | - Olivia Little
- Department of Radiology and Imaging Sciences, Mercer University School of Medicine, Savannah, GA 31404, USA;
| | - Olumide Babajide Gbolahan
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA 30322, USA;
| | - Mehmet Akce
- Department of Hematology and Medical Oncology, University of Alabama School of Medicine, Birmingham, AL 35294, USA;
| | - Meghan Allegra Lilly
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA 30322, USA; (H.H.D.); (M.A.L.); (Z.B.)
| | - Zachary Bercu
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA 30322, USA; (H.H.D.); (M.A.L.); (Z.B.)
| | - Nima Kokabi
- Department of Radiology, University of North Carolina at Chapel Hill, Alexander Villalobos 101 Manning Drive, Chapel Hill, NC 27514, USA;
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Serhal M, Gordon AC, Brown DB, Toskich BB, Lewandowski RJ. Transarterial Radioembolization: Overview of Radioembolic Devices. Semin Intervent Radiol 2023; 40:461-466. [PMID: 37927522 PMCID: PMC10622244 DOI: 10.1055/s-0043-1772814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Affiliation(s)
- Muhamad Serhal
- Section of Interventional Radiology, Department of Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, Illinois
| | - Andrew C. Gordon
- Section of Interventional Radiology, Department of Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, Illinois
| | - Daniel B. Brown
- Division of Interventional Radiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Beau B. Toskich
- Division of Interventional Radiology, Mayo Clinic Florida, Jacksonville, Florida
| | - Robert J. Lewandowski
- Section of Interventional Radiology, Department of Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, Illinois
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Villalobos A, Arndt L, Cheng B, Dabbous H, Loya M, Majdalany B, Bercu Z, Kokabi N. Yttrium-90 Radiation Segmentectomy of Hepatocellular Carcinoma: A Comparative Study of the Effectiveness, Safety, and Dosimetry of Glass-Based versus Resin-Based Microspheres. J Vasc Interv Radiol 2023; 34:1226-1234. [PMID: 36958669 DOI: 10.1016/j.jvir.2023.02.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 01/29/2023] [Accepted: 02/02/2023] [Indexed: 03/25/2023] Open
Abstract
PURPOSE To evaluate the differences in safety, effectiveness, and dosimetry between glass-based and resin-based ablative yttrium-90 (90Y) transarterial radioembolization (TARE) of hepatocellular carcinoma (HCC). MATERIALS AND METHODS Using the modified Response Evaluation Criteria in Solid Tumors and Common Terminology Criteria for Adverse Events, both tumor response and adverse events (AEs) were assessed at 3 months after 90Y-TARE. Post procedure 90Y-bremsstrahlung single-photon emission computed tomography/computed tomography voxel-based dosimetry analysis was used to create tumor dose (TD) and normal tissue dose (NTD) volume histograms, and to calculate tumor particle loading and specific activity. The TD and NTD receiver operating characteristic curves evaluated the dose threshold able to predict objective (partial or complete) and complete tumor responses in addition to any-grade and grade ≥3 AE incidences. The chi-square test and Student t-test were used to assess variable differences where appropriate. RESULTS Between 2019 and 2020, 81 patients with HCC (20 in the resin-based cohort and 61 in the glass-based cohort) underwent ablative 90Y-TARE. The resin-based cohort had more males (89% vs 65%, P = .03), lower tumor-to-normal ratio (1.81 ± 0.39 vs 2.22 ± 0.94, P = .03), higher tumor particle loading (40,172 particles/mL ± 28,039 vs 17,081 particles/mL ± 12,555, P = .0001), lower specific activity (158 Bq/particle ± 3 vs 1,058 Bq/particle ± 331, P = .001), and lower mean TD (308 Gy ± 210 vs 794 Gy ± 523, P = .0002) than the glass-based cohort. No significant differences in baseline characteristics or posttreatment AEs were noted. The overall objective and complete response rates were 85% (95% resin-based vs 82% glass-based; P = .1) and 65% (95% resin-based vs 56% glass-based; P = .003), respectively. The mean TD thresholds able to predict the objective and complete responses were 176 Gy and 247 Gy for resin-based radioembolization and 290 Gy and 481 Gy for glass-based radioembolization, respectively. A maximum NTD of 999 Gy predicted any-grade AEs in glass-based ablative 90Y-TARE. CONCLUSIONS Compared with glass-based ablative 90Y-TARE, resin-based ablative 90Y-TARE can offer comparable safety and effectiveness profiles for patients with HCC. The impact of the significantly different tumor particle loading, particle specific activities, and delivered TDs on tumor response outcomes merits further investigation.
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Affiliation(s)
- Alexander Villalobos
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia.
| | - Linzi Arndt
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Bernard Cheng
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Howard Dabbous
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Mohammed Loya
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Bill Majdalany
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Zachary Bercu
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Nima Kokabi
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
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Wagstaff WV, Villalobos A, Gichoya J, Kokabi N. Using Deep Learning to Predict Treatment Response in Patients with Hepatocellular Carcinoma Treated with Y90 Radiation Segmentectomy. J Digit Imaging 2023; 36:1180-1188. [PMID: 36629989 PMCID: PMC10287849 DOI: 10.1007/s10278-022-00762-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 06/27/2022] [Accepted: 12/15/2022] [Indexed: 01/12/2023] Open
Abstract
Treatment of hepatocellular carcinoma (HCC) with Y90 radioembolization segmentectomy (Y90-RE) demonstrates a tumor dose-response threshold, where dose estimates are highly dependent on accurate SPECT/CT acquisition, registration, and reconstruction. Any error can result in distorted absorbed dose distributions and inaccurate estimates of treatment success. This study improves upon the voxel-based dosimetry model, one of the most accurate methods available clinically, by using a deep convolutional network ensemble to account for the spatially variable uptake of Y90 within a treated lesion. A retrospective analysis was conducted in patients with HCC who received Y90-RE at a single institution. Seventy-seven patients with 103 lesions met the inclusion criteria: three or fewer tumors, pre- and post treatment MRI, and no prior Y90-RE. Lesions were labeled as complete (n = 57) or incomplete response (n = 46) based on 3-month post treatment MRI and divided by medical record number into a 20% hold-out test set and 80% training set with 5-fold cross-validation. Slice-wise predictions were made from an average ensemble of models and thresholds from the highest accuracy epochs across all five folds. Lesion predictions were made by thresholding all slice predictions through the lesion. When compared to the voxel-based dosimetry model, our model had a higher F1-score (0.72 vs. 0.2), higher accuracy (0.65 vs. 0.60), and higher sensitivity (1.0 vs. 0.11) at predicting complete treatment response. This algorithm has the potential to identify patients with treatment failure who may benefit from earlier follow-up or additional treatment.
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Affiliation(s)
- William V Wagstaff
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA.
| | - Alexander Villalobos
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Judy Gichoya
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Nima Kokabi
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
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Kokabi N, Arndt-Webster L, Chen B, Brandon D, Sethi I, Davarpanahfakhr A, Galt J, Elsayed M, Bercu Z, Cristescu M, Kappadath SC, Schuster DM. Voxel-based dosimetry predicting treatment response and related toxicity in HCC patients treated with resin-based Y90 radioembolization: a prospective, single-arm study. Eur J Nucl Med Mol Imaging 2023; 50:1743-1752. [PMID: 36650357 PMCID: PMC10119065 DOI: 10.1007/s00259-023-06111-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 01/05/2023] [Indexed: 01/19/2023]
Abstract
BACKGROUND There is an increasing body of evidence indicating Y90 dose thresholds for tumor response and treatment-related toxicity. These thresholds are poorly studied in resin Y90, particularly in hepatocellular carcinoma (HCC). PURPOSE To evaluate the efficacy of prospective voxel-based dosimetry for predicting treatment response and adverse events (AEs) in patients with HCC undergoing resin-based Y90 radioembolization. MATERIALS AND METHODS This correlative study was based on a prospective single-arm clinical trial (NCT04172714), which evaluated the efficacy of low/scout (555 MBq) activity of resin-based Y90 for treatment planning. Partition model was used with goal of tumor dose (TD) > 200 Gy and non-tumoral liver dose (NTLD) < 70 Gy for non-segmental therapies. Single compartment dose of 200 Gy was used for segmentectomies. Prescribed Y90 activity minus scout activity was administered for therapeutic Y90 followed by Y90-PET/CT. Sureplan® (MIM Software, Cleveland, OH) was used for dosimetry analysis. Treatment response was evaluated at 3 and 6 months. Receiver operating characteristic curve determined TD response threshold for objective response (OR) and complete response (CR) as well as non-tumor liver dose (NTLD) threshold that predicted AEs. RESULTS N = 30 patients were treated with 33 tumors (19 segmental and 14 non-segmental). One patient died before the first imaging, and clinical follow-up was excluded from this analysis. Overall, 26 (81%) of the tumors had an OR and 23 (72%) had a CR. A mean TD of 253 Gy predicted an OR with 92% sensitivity and 83% specificity (area under the curve (AUC = 0.929, p < 0.001). A mean TD of 337 Gy predicted a CR with 83% sensitivity and 89% specificity (AUC = 0.845, p < 0.001). A mean NTLD of 81 and 87 Gy predicted grade 3 AEs with 100% sensitivity and 100% specificity in the non-segmental cohort at 3- and 6-month post Y90, respectively. CONCLUSION In patients with HCC undergoing resin-based Y90, there are dose response and dose toxicity thresholds directly affecting outcomes. CLINICAL TRIAL NUMBER NCT04172714.
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Affiliation(s)
- Nima Kokabi
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA.
| | - Linzi Arndt-Webster
- Division of Interventional Radiology, Department of Radiology, Mount Sinai School of Medicine, New York, NY, USA
| | - Bernard Chen
- Division of Interventional Radiology, Department of Radiology, University of Texas at San Antonio, San Antonio, TX, USA
| | - David Brandon
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Ila Sethi
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Amir Davarpanahfakhr
- Division of Abdominal Imaging, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - James Galt
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Mohammad Elsayed
- Division of Interventional Radiology, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Zachary Bercu
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Mircea Cristescu
- Division of Interventional Radiology, Department of Radiology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - S Cheenu Kappadath
- Division of Interventional Radiology, Department of Radiology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David M Schuster
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
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Wu R, Gogineni K, Meisel J, Szabo S, Thirunavu M, Friend S, Bercu Z, Sethi I, Natarajan N, Switchenko J, Levy J, Abdalla E, Weakland L, Kalinsky K, Kokabi N. Study Protocol: Efficacy and Safety of Radioembolization (REM) as an Early Modality (EM) Therapy for Metastatic Breast Cancer (BR) to the Liver with Y90 (REMEMBR Y90). Cardiovasc Intervent Radiol 2022; 45:1725-1734. [PMID: 36008574 DOI: 10.1007/s00270-022-03254-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 08/09/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE The primary objective of the REMEMBR Y90 study is to evaluate the efficacy of Yttrium-90 (Y90) radioembolization in patients with breast cancer metastases to the liver as a 2nd or 3rd line treatment option with systemic therapy by assessing liver-specific and overall progression-free survival. Secondary objectives include quality of life, overall survival benefit, and toxicity in relation to patients' tumor biology. MATERIALS AND METHODS This trial is a multi-center, prospective, Phase 2, open-label, IRB-approved, randomized control trial in the final phases of activation. Eligible patients include those over 18 years of age with metastatic breast cancer to the liver with liver-only or liver-dominant disease, and history of tumor progression on 1-2 lines of chemotherapy. 60 patients will be randomized to radioembolization with chemotherapy versus chemotherapy alone. Permissible regimens include capecitabine, eribulin, vinorelbine, and gemcitabine within 2 weeks of enrollment for every patient. Patients receiving radioembolization will receive lobar or segmental treatment within 1-6 weeks of enrollment depending on their lesion. After final radioembolization, patients will receive clinical and imaging follow-up every 12-16 weeks for two years, including contrast-enhanced computed tomography or magnetic resonance imaging of the abdomen and whole-body positron emission tomography/computed tomography. DISCUSSION This study seeks to elucidate the clinical benefit and toxicity of Y90 in patients with metastatic breast cancer to the liver who are receiving minimal chemotherapy. Given previous data, it is anticipated that the use of Y90 and chemotherapy earlier in the metastatic disease course would improve survival outcomes and reduce toxicity. LEVEL OF EVIDENCE Level 1b, Randomized Controlled Trial. TRIAL REGISTRATION NUMBER NCT05315687 on clinicaltrials.gov.
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Affiliation(s)
- Richard Wu
- School of Medicine, Emory University, Atlanta, GA, USA
| | - Keerthi Gogineni
- Department of Hematology and Medical Oncology, Emory University, Atlanta, GA, USA
| | - Jane Meisel
- Department of Hematology and Medical Oncology, Emory University, Atlanta, GA, USA
| | - Stephen Szabo
- Department of Hematology and Medical Oncology, Emory University, Atlanta, GA, USA
| | - Meenakshi Thirunavu
- Department of Hematology and Medical Oncology, Emory University, Atlanta, GA, USA
| | - Sarah Friend
- Department of Hematology and Medical Oncology, Emory University, Atlanta, GA, USA
| | - Zachary Bercu
- Division of Interventional Radiology and Image Guided Medicine, Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA, USA
| | - Ila Sethi
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA, USA
| | - Neela Natarajan
- Department of Hematology and Medical Oncology, Emory University, Atlanta, GA, USA
| | - Jeffrey Switchenko
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, GA, USA
| | - Jason Levy
- Northside Hospital Cancer Institute, Atlanta, GA, USA
| | - Eddie Abdalla
- Northside Hospital Cancer Institute, Atlanta, GA, USA
| | | | - Kevin Kalinsky
- Department of Hematology and Medical Oncology, Emory University, Atlanta, GA, USA
| | - Nima Kokabi
- Division of Interventional Radiology and Image Guided Medicine, Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA, USA.
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Role of nanoparticles in transarterial radioembolization with glass microspheres. Ann Nucl Med 2022; 36:479-487. [PMID: 35199286 DOI: 10.1007/s12149-022-01727-7] [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: 09/21/2021] [Accepted: 02/06/2022] [Indexed: 11/01/2022]
Abstract
OBJECTIVE Transarterial Radioembolization (TARE) with 90Y-loaded glass microspheres is a locoregional treatment option for Hepatocellular Carcinoma (HCC). Post-treatment 90Y bremsstrahlung imaging using Single-Photon Emission Tomography (SPECT) is currently a gold-standard imaging modality for quantifying the delivered dose. However, the nature of bremsstrahlung photons causes difficulty for dose estimation using SPECT imaging. This work aimed to investigate the possibility of using glass microspheres loaded with 90Y and Nanoparticles (NPs) to improve the quantification of delivered doses. METHODS The Monte Carlo codes were used to simulate the post-TARE 90Y planar imaging. Planar images from bremsstrahlung photons and characteristic X-rays are acquired when 0, 1.2 mol/L, 2.4 mol/L, and 4.8 mol/L of Gold (Au), Hafnium (Hf), and Gadolinium (Gd) NPs are incorporated into the glass microspheres. We evaluated the quality of acquired images by calculating sensitivity and Signal-to-Background Ratio (SBR). Therapeutic effects of NPs were evaluated by calculation of Dose Enhancement Ratio (DER) in tumoral and non-tumoral liver tissues. RESULTS The in silico results showed that the sensitivity values of bremsstrahlung and characteristic X-ray planar images increased significantly as the NPs concentration increased in the glass microspheres. The SBR values decreased as the NPs concentration increased for the bremsstrahlung planar images. In contrast, the SBR values increased for the characteristic X-ray planar images when Hf and Gd were incorporated into the glass microspheres. The DER values decreased in the tumoral and non-tumoral liver tissues as the NPs concentration increased. The maximum dose reduction was observed at the NPs concentration of 4.8 mol/L (≈ 7%). CONCLUSIONS The incorporation of Au, Hf, and Gd NPs into the glass microspheres improved the quality and quantity of post-TARE planar images. Also, treatment efficiency was decreased significantly at NPs concentration > 4.8 mol/L.
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Webster LA, Villalobos A, Majdalany BS, Bercu ZL, Gandhi RT, Kokabi N. Standard Radiation Dosimetry Models: What Interventional Radiologists Need to Know. Semin Intervent Radiol 2021; 38:405-411. [PMID: 34629706 DOI: 10.1055/s-0041-1732323] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Thoughtful and accurate dosimetry is critical to obtain the safest and most efficacious yttrium-90 (Y90) radioembolization of primary and secondary liver cancers. Three dosimetry models are currently used in clinical practice, namely, body surface area model, medical internal radiation dose model, and the partition model. The objective of this review is to briefly outline the history behind Y90 dosimetry and the difference between the aforementioned models. When applying these three models to a single case, the differences between them are further demonstrated. Each dosimetry model in clinical practice has its own benefits and limitations. Therefore, it is incumbent upon practicing interventional radiologists to be aware of these differences to optimize treatment outcomes for their patients.
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Affiliation(s)
- Linzi Arndt Webster
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Alexander Villalobos
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Bill S Majdalany
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Zachary L Bercu
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Ripal T Gandhi
- Miami Cardiac and Vascular Institute, Miami Cancer Institute, Miami, FL
| | - Nima Kokabi
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Emory University School of Medicine, Atlanta, Georgia
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Predictors of Successful Yttrium-90 Radioembolization Bridging or Downstaging in Patients with Hepatocellular Carcinoma. Can J Gastroenterol Hepatol 2021; 2021:9926704. [PMID: 34336728 PMCID: PMC8324378 DOI: 10.1155/2021/9926704] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 04/28/2021] [Accepted: 07/01/2021] [Indexed: 02/08/2023] Open
Abstract
PURPOSE This study aims to identify clinical and imaging prognosticators associated with the successful bridging or downstaging to liver transplantation (LT) in patients undergoing Yttrium-90 radioembolization (Y90-RE) for hepatocellular carcinoma (HCC). METHODS Retrospectively, patients with Y90-RE naïve HCC who were candidates or potential candidates for LT and underwent Y90-RE were included. Patients were then divided into favorable (maintained or achieved Milan criteria (MC) eligibility) or unfavorable (lost eligibility or unchanged MC ineligibility) cohorts based on changes to their MC eligibility after Y90-RE. Penalized logistic regression analysis was performed to identify the significant baseline prognosticators. RESULTS Between 2013 and 2018, 135 patients underwent Y90-RE treatment. Among the 59 (42%) patients within MC, LT eligibility was maintained in 49 (83%) and lost in 10 (17%) patients. Within the 76 (56%) patients outside MC, eligibility was achieved in 32 (42%) and unchanged in 44 (58%). Among the 81 (60%) patients with a favorable response, 16 (20%) went on to receive LT. Analysis of the baseline characteristics revealed that lower Albumin-Bilirubin score, lower Child-Pugh class, lower Barcelona Clinic Liver Cancer stage, HCC diagnosis using dynamic contrast-enhanced imaging on CT or MRI, normal/higher albumin levels, decreased severity of tumor burden, left lobe HCC disease, and absence of HBV-associated cirrhosis, baseline abdominal pain, or fatigue were all associated with a higher likelihood of bridging or downstaging to LT eligibility (p's < 0.05). CONCLUSION Certain baseline clinical and tumor characteristics are associated with the successful bridging or downstaging of potential LT candidates with HCC undergoing Y90-RE.
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