Comparison of PET/CT and PET/MR imaging and dosimetry of yttrium-90 (90Y) in patients with unresectable hepatic tumors who have received intra-arterial radioembolization therapy with 90Y microspheres

Y-90 PET/MR imaging optimization with a Bayesian penalized likelihood reconstruction algorithm

Positron Emission Tomography (PET) imaging after90 Y liver radioembolization is used for both lesion identification and dosimetry. Bayesian penalized likelihood (BPL) reconstruction algorithms are an alternative to ordered subset expectation maximization (OSEM) with improved image quality and lesion detectability. The investigation of optimal parameters for90 Y image reconstruction of Q.Clear, a commercial BPL algorithm developed by General Electric (GE), in PET/MR is a field of interest and the subject of this study. The NEMA phantom was filled at an 8:1 sphere-to-background ratio. Acquisitions were performed on a PET/MR scanner for clinically relevant activities between 0.7 and 3.3 MBq/ml. Reconstructions with Q.Clear were performed varying the β penalty parameter between 20 and 6000, the acquisition time between 5 and 20 min and pixel size between 1.56 and 4.69 mm. OSEM reconstructions of 28 subsets with 2 and 4 iterations with and without Time-of-Flight (TOF) were compared to Q.Clear with β = 4000. Recovery coefficients (RC), their coefficient of variation (COV), background variability (BV), contrast-to-noise ratio (CNR) and residual activity in the cold insert were evaluated. Increasing β parameter lowered RC, COV and BV, while CNR was maximized at β = 4000; further increase resulted in oversmoothing. For quantification purposes, β = 1000-2000 could be more appropriate. Longer acquisition times resulted in larger CNR due to reduced image noise. Q.Clear reconstructions led to higher CNR than OSEM. A β of 4000 was obtained for optimal image quality, although lower values could be considered for quantification purposes. An optimal acquisition time of 15 min was proposed considering its clinical use.

The American Brachytherapy Society consensus statement for permanent implant brachytherapy using Yttrium-90 microsphere radioembolization for liver tumors

PURPOSE

To develop a multidisciplinary consensus for high quality multidisciplinary implementation of brachytherapy using Yttrium-90 (90Y) microspheres transarterial radioembolization (90Y TARE) for primary and metastatic cancers in the liver.

METHODS AND MATERIALS

Members of the American Brachytherapy Society (ABS) and colleagues with multidisciplinary expertise in liver tumor therapy formulated guidelines for 90Y TARE for unresectable primary liver malignancies and unresectable metastatic cancer to the liver. The consensus is provided on the most recent literature and clinical experience.

RESULTS

The ABS strongly recommends the use of 90Y microsphere brachytherapy for the definitive/palliative treatment of unresectable liver cancer when recommended by the multidisciplinary team. A quality management program must be implemented at the start of 90Y TARE program development and follow-up data should be tracked for efficacy and toxicity. Patient-specific dosimetry optimized for treatment intent is recommended when conducting 90Y TARE. Implementation in patients on systemic therapy should account for factors that may enhance treatment related toxicity without delaying treatment inappropriately. Further management and salvage therapy options including retreatment with 90Y TARE should be carefully considered.

CONCLUSIONS

ABS consensus for implementing a safe 90Y TARE program for liver cancer in the multidisciplinary setting is presented. It builds on previous guidelines to include recommendations for appropriate implementation based on current literature and practices in experienced centers. Practitioners and cooperative groups are encouraged to use this document as a guide to formulate their clinical practices and to adopt the most recent dose reporting policies that are critical for a unified outcome analysis of future effectiveness studies.

Post Yttrium-90 Imaging

Transarterial radioembolization with yttrium-90 ( ⁹⁰ Y) is a mainstay for the treatment of liver cancer. Imaging the distribution following delivery is a concept that dates back to the 1960s. As β particles are created during ⁹⁰ Y decay, bremsstrahlung radiation is created as the particles interact with tissues, allowing for imaging with a gamma camera. Inherent qualities of bremsstrahlung radiation make its imaging difficult. SPECT and SPECT/CT can be used but suffer from limitations related to low signal-to-noise bremsstrahlung radiation. However, with optimized imaging protocols, clinically adequate images can still be obtained. A finite but detectable number of positrons are also emitted during ⁹⁰ Y decay, and many studies have demonstrated the ability of commercial PET/CT and PET/MR scanners to image these positrons to understand ⁹⁰ Y distribution and help quantify dose. PET imaging has been proven to be superior to SPECT for quantitative imaging, and therefore will play an important role going forward as we try and better understand dose/response and dose/toxicity relationships to optimize personalized dosimetry. The availability of PET imaging will likely remain the biggest barrier to its use in routine post- ⁹⁰ Y imaging; thus, SPECT/CT imaging with optimized protocols should be sufficient for most posttherapy subjective imaging.

An estimate of 90Y dosimetry for bremsstrahlung SPECT/CT imaging in liver therapy with 90Y microspheres

OBJECTIVE

Bremsstrahlung SPECT/CT (bSPECT/CT) is one of the most common methods for post-therapy imaging in ⁹⁰Y microspheres selective internal radiation therapy (SIRT) of liver cancers. Here, we are proposing a simple approach using bSPECT/CT to estimate mean absorbed dose to the liver in patients undergoing treatment with ⁹⁰Y microspheres.

MATERIALS AND METHODS

In our previous study comparing ⁹⁰Y dosimetry obtained using bSPECT/CT vs PET/CT, we found that there was a large difference between the mean absorbed dose values to the whole-liver. However, there was a high linear correlation between the doses, which presented an opportunity for quantitative assessment using bSPECT/CT ⁹⁰Y imaging. In this study, after treatment with ⁹⁰Y microspheres, 43 patients were immediately imaged on a dual-head Infinia SPECT/CT gamma camera and on a mCT PET/CT system. Images from 25 of the patients, randomly selected, were used to calculate the correlation of mean liver doses obtained from bSPECT/CT vs. PET/CT. For the remaining 18 patients, the calculated correlation was used to estimate doses obtained from bSPECT/CT, and these estimations were then compared to the doses obtained from PET/CT, considered the gold standard for quantitative analysis.

RESULTS

From the 25 selected patients, the calculated linear correlation between bSPECT/CT and PET/CT ⁹⁰Y mean absorbed doses in whole liver was high (r^2 = 0.97), with a slope of 2.80 and an intercept of -0.63. This linear fit was used to calculate the bSPECT/CT doses for the remaining 18 patients. For these patients, the mean whole-liver dose obtained from bSPECT/CT fitted data vs that obtained from PET/CT were 50.59 Gy and 50.81 Gy, respectively. The average dose difference was 0.2 ± 5.4 Gy (range -18.2%-13.0%). The repeatability coefficient was 10.5 (20.8 % of the mean).

CONCLUSION

Although quantitative bremsstrahlung imaging is difficult, it is possible to calculate adequate estimates of whole-liver dosimetry from bSPECT/CT imaging that is calibrated using its correlation with post-therapy PET/CT ⁹⁰Y images.

Preclinical dosimetry models and the prediction of clinical doses of novel positron emission tomography radiotracers

Dosimetry models using preclinical positron emission tomography (PET) data are commonly employed to predict the clinical radiological safety of novel radiotracers. However, unbiased clinical safety profiling remains difficult during the translational exercise from preclinical research to first-in-human studies for novel PET radiotracers. In this study, we assessed PET dosimetry data of six ¹⁸F-labelled radiotracers using preclinical dosimetry models, different reconstruction methods and quantified the biases of these predictions relative to measured clinical doses to ease translation of new PET radiotracers to first-in-human studies. Whole-body PET images were taken from rats over 240 min after intravenous radiotracer bolus injection. Four existing and two novel PET radiotracers were investigated: [¹⁸F]FDG, [¹⁸F]AlF-NOTA-RGDfK, [¹⁸F]AlF-NOTA-octreotide ([¹⁸F]AlF-NOTA-OC), [¹⁸F]AlF-NOTA-NOC, [¹⁸F]ENC2015 and [¹⁸F]ENC2018. Filtered-back projection (FBP) and iterative methods were used for reconstruction of PET data. Predicted and true clinical absorbed doses for [¹⁸F]FDG and [¹⁸F]AlF-NOTA-OC were then used to quantify bias of preclinical model predictions versus clinical measurements. Our results show that most dosimetry models were biased in their predicted clinical dosimetry compared to empirical values. Therefore, normalization of rat:human organ sizes and correction for reconstruction method biases are required to achieve higher precision of dosimetry estimates.

Comparison of posttherapy 90Y positron emission tomography/computed tomography dosimetry methods in liver therapy with 90Y microspheres

The aim of our study was to compare dosimetry methods for yttrium-90 (⁹⁰Y) positron emission tomography/computed tomography (PET/CT). Twenty-five patients were taken to a PET/CT suite following therapy with ⁹⁰Y microspheres. The low mA, nondiagnostic CT images were used for attenuation correction and localization of the ⁹⁰Y microspheres. The acquisition time was 15 min, the reconstruction matrix size was 200 mm × 200 mm × 75 mm, and voxel size was 4.07 mm × 4.07 mm × 3.00 mm. Two software packages, MIM 6.8 and Planet Dose, were utilized to calculate ⁹⁰Y dosimetry. Three methods were used for voxel-based dosimetry calculations: the local deposition method (LDM), LDM with scaling (LDMwS) for known injected activity, and a dose point kernel (DPK) method using the MIRD kernel. Only the DPK approach was applied to the Planet Dose software. LDM and LDMwS were only applied to the MIM software. The average total liver dosimetry values (mean ± standard deviation) were 60.93 ± 28.62 Gy, 53.59 ± 23.47 Gy, 55.33 ± 24.80 Gy, and 54.25 ± 23.70 Gy for LDMwS, LDM, DPK with MIM, and DPK with Planet Dose (DOSI), respectively. In most cases, the LDMwS method produced slightly higher dosimetry values than the other methods. The MIM and Planet Dose DPK dosimetry values (i.e., DPK vs. DOSI) were highly comparable. Bland–Altman analysis calculated a mean difference of 1.1 ± 2.2 Gy. The repeatability coefficient was 4.4 (7.9% of the mean). The MIM and Planet Dose DPK dosimetry values were practically interchangeable. ⁹⁰Y dosimetry values obtained by all methods were similar, but LDMwS tended to produce slightly higher values.

Current Status of Radiopharmaceutical Therapy

In radiopharmaceutical therapy (RPT), a radionuclide is systemically or locally delivered with the goal of targeting and delivering radiation to cancer cells while minimizing radiation exposure to untargeted cells. Examples of current RPTs include thyroid ablation with the administration of ¹³¹I, treatment of liver cancer with ⁹⁰Y microspheres, the treatment of bony metastases with ²²³Ra, and the treatment of neuroendocrine tumors with ¹⁷⁷Lu-DOTATATE. New RPTs are being developed where radionuclides are incorporated into systemic targeted therapies. To assure that RPT is appropriately implemented, advances in targeting need to be matched with advances in quantitative imaging and dosimetry methods. Currently, radiopharmaceutical therapy is administered by intravenous or locoregional injection, and the treatment planning has typically been implemented like chemotherapy, where the activity administered is either fixed or based on a patient's body weight or body surface area. RPT pharmacokinetics are measurable by quantitative imaging and are known to vary across patients, both in tumors and normal tissues. Therefore, fixed or weight-based activity prescriptions are not currently optimized to deliver a cytotoxic dose to targets while remaining within the tolerance dose of organs at risk. Methods that provide dose estimates to individual patients rather than to reference geometries are needed to assess and adjust the injected RPT dose. Accurate doses to targets and organs at risk will benefit the individual patients and decrease uncertainties in clinical trials. Imaging can be used to measure activity distribution in vivo, and this information can be used to determine patient-specific treatment plans where the dose to the targets and organs at risk can be calculated. The development and adoption of imaging-based dosimetry methods is particularly beneficial in early clinical trials. In this work we discuss dosimetric accuracy needs in modern radiation oncology, uncertainties in the dosimetry in RPT, and best approaches for imaging and dosimetry of internal radionuclide therapy.