Biliary Sequelae following Radioembolization with Yttrium-90 Microspheres

Atassi, Bassel; Bangash, Affaan K.; Lewandowski, Robert J.; Ibrahim, Saad M.; Kulik, Laura; Mulcahy, Mary F.; Murthy, Ravi; Ryu, Robert K.; Sato, Kent T.; Miller, Frank H.; Omary, Reed A.; Salem, Riad

doi:10.1016/j.jvir.2008.01.003

Cited by 148 publications

(87 citation statements)

References 37 publications

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“…The question still remains as to whether we need to take actions such as coiling the cystic artery or surgically removing the gallbladder to prevent radiationinduced cholecystitis. In a study performed at our institution, we saw only 2 cases (0.6%) of radiation-induced cholecystitis, which is similar to other published results (27,28). None of the patients in this study developed cholecystitis despite showing 99m Tc-MAA uptake within the gallbladder.…”

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confidence: 90%

Intraarterial Hepatic SPECT/CT Imaging Using ^99mTc-Macroaggregated Albumin in Preparation for Radioembolization

et al. 2015

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Current standard practice for radioembolization treatment planning makes use of nuclear medicine imaging (NMI) of 99m Tc-macroaggregated albumin ( 99m Tc-MAA) arterial distributions for the assessment of lung shunting and extrahepatic uptake. Our aim was to retrospectively compare NMI with mapping angiography in the detection and localization of extrahepatic 99m Tc-MAA and to evaluate the typical and atypical findings of NMI in association with catheter placement. Methods: One hundred seventy-four patients underwent diagnostic angiography in preparation for radioembolization. 99m Tc-MAA was administered to the liver via a microcatheter positioned in the desired hepatic artery. Planar scintigraphy imaging followed by SPECT/CT imaging was obtained within 2 h. All images were reviewed for hepatic and extrahepatic 99m Tc-MAA deposition and compared with the mapping angiogram. Results: Intrahepatic lobe shunting was present on NMI in only 2.9% of the cases but was present in 62.5% of the patients with portal vein thrombosis. Extrahepatic distributions included lungs (100%), the gallbladder (49%) if present, and locations involving hepaticoenteric arterial anatomy recognized on angiograms (16%). Free pertechnetate was identified on 38% of the nuclear medicine images. Three percent of nuclear medicine images showed alternative findings such as a thyroid nodule or metallic artifact. Conclusion: Patients being considered for radioembolization should undergo both angiography and scintigraphy for the assessment of hepaticoenteric arterial anatomy, hepatopulmonary shunting, and appropriate dosimetry considerations. Knowledge of the expected distribution of 99m Tc-MAA with normal variants and potential nontarget delivery to adjacent structures is critical in improving clinical outcomes. Cur rently, nuclear medicine imaging (NMI) of 99m Tc-labeled macroaggregated albumin ( 99m Tc-MAA) is performed routinely before radioembolization for the assessment of lung shunting and extrahepatic uptake. NMI is widely recognized to be important for minimizing the risk of potentially debilitating adverse events such as radiation-induced pneumonitis or radiation gastritis/duodenitis after radioembolization using 90 Y-microspheres for inoperable hepatic tumors (1,2). The seminal work in a canine liver model demonstrating the safety and feasibility of using 90 Y-microsphere therapy for hepatic malignancies was reported in the late 1980s. Human studies of 90 Y-microsphere therapy in liver applications followed from the late 1980s through the 1990s. These investigations established the safety of 90 Y for intrahepatic applications and the optimal dosimetry for tumor radiation kill, while minimizing exposure to normal liver tissue (3-8).Given the similarities in sizes of 90 Y-microspheres (20-40 mm) and 99m Tc-MAA (20-50 mm), the pattern of 99m Tc-MAA deposition as determined from a high-resolution SPECT/CT acquisition serves as a surrogate to demonstrate how 90 Y-microspheres will localize during treatment. Radioembolization has evolved for the ...

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Section: Figuresupporting

confidence: 90%

Intraarterial Hepatic SPECT/CT Imaging Using ^99mTc-Macroaggregated Albumin in Preparation for Radioembolization

et al. 2015

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“…The varying degrees of splenomegaly that have been observed after SIRT might suggest subclinical or low-grade portal hypertension (3,22). A predominance of biliary toxicity in RMILD has been emphasized in more recent publications (23,24). A clear definition of RMILD will require well-designed studies investigating the liver dose-toxicity relationship in a systematic manner.…”

Section: Discussionmentioning

confidence: 99%

Hepatic Structural Dosimetry in ⁹⁰Y Microsphere Treatment: A Monte Carlo Modeling Approach Based on Lobular Microanatomy

Güleç¹,

Sztejnberg²,

Siegel³

et al. 2010

J Nucl Med

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Selective internal radiation treatment (SIRT) via intrahepatic arterial administration of 90 Y microspheres is an effective therapeutic modality. The conventional and generally applied MIRD schema is based on the premise that the distribution of microspheres in the liver parenchyma is uniform. In reality, however, the distribution of the microspheres follows a distinct pattern, requiring that a model be developed to more appropriately estimate radiation absorbed doses to the different structural/functional elements of the hepatic microanatomy. Methods: A systematic investigation was performed encompassing a conventional average absorbed dose assessment, a compartmental macrodosimetric approach that accounts for the anticipated higher tumor-to-normal liver activity concentration ratio, dose point-kernel convolution-derived estimates, and Monte Carlo dose estimates employing a spherical and 3-dimensional hexagonal liver model, including various subunits of the hepatic anatomy, down to the micrometer level. Results: Detailed specifics of the radiation dose deposition of 90 Y microspheres demonstrated a rapid decrease in absorbed dose in and around the portal tracts where the microspheres are deposited. The model also demonstrated that the hepatocellular parenchymal and central vein doses could be at significant levels because of a cross-fire effect. Conclusion: The reported microstructural dosimetry models can help in the detailed assessment of the dose distributions in the hepatic functional subunits and in relating these doses to their effects. These models have also revealed that the there is a consistent relationship between the average liver dose as calculated by MIRD macrodosimetry and the structural dosimetry estimates in support of the clinical utility of the MIRD methodology. This relationship could be used to more realistically assess patterns of hepatic toxicity associated with the 90 Y SIRT treatment.

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“…This occurs when the microspheres are inadvertently injected into small arteries supplying the gut, are misinterpreted as suppliers of the left lobe of the liver, or remain undetected in pretherapeutic tests. Reported complications include gastrointestinal ulceration or bleeding, gastritis or duodenitis, cholecystitis, pancreatitis, and radiation pneumonitis (10)(11)(12)(13)(14)(15)(16)(17)(18).…”

Section: Discussionmentioning

confidence: 99%

Significance of Oral Administration of Sodium Perchlorate in Planning Liver-Directed Radioembolization

et al. 2011

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99m Tc-macroaggregated albumin ( 99m Tc-MAA) scanning precedes radioembolization of the liver to detect extrahepatic shunting to the lung or gastrointestinal tract. Despite strict preventive measures in the production of 99m Tc-MAA and in scanning protocols, the images frequently show a gastric concentration of free 99m Tc-pertechnetate, hindering accurate evaluation of the gastroduodenal region. Our aim was to evaluate whether oral administration of sodium perchlorate (NaClO 4 ) before 99m Tc-MAA scanning will improve its accuracy by blocking free 99m Tc-pertechnetate gastric uptake. Methods: In 144 patients, 171 diagnostic hepatic angiograms combined with a 99m Tc-MAA scan were performed; 86 angiograms were performed after oral administration of NaClO 4 , and 85 were performed without this premedication. Clinical follow-up, esophagogastroduodenoscopy, and angiography served as reference standards. Results: 99m Tc-MAA studies showed tracer uptake in the gastric region of 25 patients who did not receive NaClO 4 . The uptake was interpreted as a free 99m Tc-pertechnetate concentration in 21 studies and as a 99m Tc-MAA accumulation in 4 studies. In 5 patients with a free 99m Tc-pertechnetate concentration, aberrant vessels were detected in angiographic reexamination, and 3 patients developed gastrointestinal ulcer. In 7 studies, gastric findings viewed pretherapeutically as free 99m Tc-pertechnetate were retrospectively classified as equivocal. Of the patients receiving NaClO 4 , 2 showed gastric accumulation of 99m Tc-MAA but no equivocal or free 99m Tc-pertechnetate. Oral administration of NaClO 4 increased the negative predictive value and accuracy of the test concerning the detection of gastric perfusion from 68% and 69%, respectively, to 93% and 94%, respectively. Conclusion: Oral administration of NaClO 4 before the test angiogram with 99m Tc-MAA resulted in effective avoidance of free 99m Tc-pertechnetate concentration and, consequently, of equivocal findings in the gastroduodenal region. This technique increased test accuracy and reporter confidence, saved time in reviewing the angiograms, and can improve treatment planning and reduce therapeutic side effects. Scanni ng with 99m Tc-macroaggregated albumin ( 99m Tc-MAA) generally precedes radioembolization of the liver to detect extrahepatic shunting to the lung or gastrointestinal tract (1). To avoid dissociated 99m Tc-pertechnetate, 99m Tc-MAA should be prepared under strict quality control assessments (2-4) and scintigraphy should be performed within 1 h of the radiopharmaceutical injection. Despite the preventive measures, a gastric concentration of free 99m Tc-pertechnetate is frequently seen in 99m Tc-MAA images and can hinder the accurate evaluation of the gastroduodenal region. Sodium perchlorate (NaClO 4 ) has a great affinity for the sodium-iodine symporter and is safely used for prophylaxis of iodine-induced hyperthyroidism due to iodinated contrast agents (5-7). Our aim was to evaluate whether oral administration of NaClO 4 before 99m Tc-MAA sca...

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Biliary Sequelae following Radioembolization with Yttrium-90 Microspheres

Cited by 148 publications

References 37 publications

Intraarterial Hepatic SPECT/CT Imaging Using ^99mTc-Macroaggregated Albumin in Preparation for Radioembolization

Intraarterial Hepatic SPECT/CT Imaging Using ^99mTc-Macroaggregated Albumin in Preparation for Radioembolization

Hepatic Structural Dosimetry in ⁹⁰Y Microsphere Treatment: A Monte Carlo Modeling Approach Based on Lobular Microanatomy

Significance of Oral Administration of Sodium Perchlorate in Planning Liver-Directed Radioembolization

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Biliary Sequelae following Radioembolization with Yttrium-90 Microspheres

Cited by 148 publications

References 37 publications

Intraarterial Hepatic SPECT/CT Imaging Using 99mTc-Macroaggregated Albumin in Preparation for Radioembolization

Intraarterial Hepatic SPECT/CT Imaging Using 99mTc-Macroaggregated Albumin in Preparation for Radioembolization

Hepatic Structural Dosimetry in 90Y Microsphere Treatment: A Monte Carlo Modeling Approach Based on Lobular Microanatomy

Significance of Oral Administration of Sodium Perchlorate in Planning Liver-Directed Radioembolization

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Intraarterial Hepatic SPECT/CT Imaging Using ^99mTc-Macroaggregated Albumin in Preparation for Radioembolization

Intraarterial Hepatic SPECT/CT Imaging Using ^99mTc-Macroaggregated Albumin in Preparation for Radioembolization

Hepatic Structural Dosimetry in ⁹⁰Y Microsphere Treatment: A Monte Carlo Modeling Approach Based on Lobular Microanatomy