Characteristics of Primary and Secondary Hepatic Malignancies Associated with Hepatopulmonary Shunting

Gaba, Ron C.; Zivin, Sean P.; Dikopf, Mark S.; Parvinian, Ahmad; Casadaban, Leigh C.; Lü, Yang; Bui, James T.

doi:10.1148/radiol.14131969

Cited by 53 publications

(40 citation statements)

References 24 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…(dose reduction advocated), of which 6 were greater than 15% (further reduction) and of which 3 were greater than 20% (contraindication (22). A better estimator of the lung shunt would thus be relevant for clinical practice.…”

Section: Discussionmentioning

confidence: 99%

Safety of a Scout Dose Preceding Hepatic Radioembolization with ¹⁶⁶Ho Microspheres

et al. 2015

View full text Add to dashboard Cite

Before 166 Ho radioembolization, a small batch of the same type of microspheres is administered as a scout dose instead of the conventional 99m Tc-macroaggregated albumin ( 99m Tc-MAA). The 166 Ho scout dose provides a more accurate and precise lung shunt assessment. However, in contrast to 99m Tc-MAA, an unintended extrahepatic deposition of this β-emitting scout dose could inflict radiation damage, the extent of which we aimed to quantify in this study. Methods: All patients eligible for radioembolization in our institute between January 2011 and March 2014 were reviewed. Of the extrahepatic depositions of 99m Tc-MAA on SPECT, the amount and volume were measured. These were used to calculate the theoretic absorbed dose in the case a 166 Ho scout dose had been used. The extrahepatic activity was measured as the sum of all voxels of the deposition. Volumes were measured using a threshold technique including all voxels from the maximum voxel intensity up to a certain percentage. The threshold needed to obtain the true volume was studied in a phantom study. Results: In the phantom study, a threshold of 40% was found to overestimate the volume, with the consequence of underestimating the absorbed dose. Of 160 patients, 32 patients (34 cases) of extrahepatic deposition were identified. The depositions contained a median of 1.3% (range, 0.1%-19.5%) of the administered activity in a median volume of 6.8 mL (range, 1.1-42 mL). The use of a scout dose of 250 MBq of 166 Ho microspheres in these cases would theoretically have resulted in a median absorbed dose of 6.0 Gy (range, 0.9-374 Gy). The dose exceeded a limit of 49 Gy (reported in 2013) in 2 of 34 cases (5.9%; 95% confidence interval, 0.7%-20.1%) or 2 of 160 (1.3%; 95% confidence interval, 0.1%-4.7%) of all patients. In these 2 patients with a large absorbed dose (112 and 374 Gy), the culprit vessel was identified in 1 case. Conclusion: Extrahepatic deposition of a 166 Ho scout dose seems to be theoretically safe in most patients. Its safety in clinical practice is being evaluated in ongoing clinical trials. Radi oembolization is a minimally invasive treatment for hepatic malignancies. Millions of radioactive microspheres are injected in the hepatic artery to radiate and embolize malignancies (1). Deposition of microspheres in gastrointestinal organs can result in ulceration or inflammation of tissue by a combination of embolization and radiation damage (2-4). To prevent this, vessels leading to gastrointestinal organs may be coil-embolized in patients scheduled for radioembolization treatment, during a pretreatment session using contrastenhanced images (i.e., digital subtraction angiography complemented by C-arm CT) to identify the culprit vessel (5). 99m Tc-macroaggregated albumin ( 99m Tc-MAA) is administered in this pretreatment session to simulate intrahepatic treatment biodistribution and to assess lung shunting and the possibility of extrahepatic deposition of the microspheres (6). This procedure is safe because 99m Tc-MAA emits 140-keV g photons (detecta...

show abstract

Section: Discussionmentioning

confidence: 99%

Safety of a Scout Dose Preceding Hepatic Radioembolization with ¹⁶⁶Ho Microspheres

et al. 2015

View full text Add to dashboard Cite

show abstract

“…To ensure safety, the hepatopulmonary lung shunt fraction (LSF) is calculated in each 90 Y candidate prior to treatment by imaging the distribution of 99m Tc-MAA in the liver and lungs following its delivery within the targeted tissues. 8 Patients with excessive hepatopulmonary shunting may be ineligible for 90 Y or require dose reductions to offset the risk of lung damage. In addition to evaluating safety, current evidence shows that LSF may be associated with advanced disease.…”

mentioning

confidence: 99%

“…In addition to evaluating safety, current evidence shows that LSF may be associated with advanced disease. 8,9 In a study of 23 HCC patients treated with 90 Y, multivariate analysis demonstrated an association between prolonged progression-free survival and low LSF. 10 Considering the functional role of angiogenesis in metastasis, it is possible that LSF may be associated with the risk of metastatic spread of cancer cells from established primary and secondary liver tumors.…”

mentioning

confidence: 99%

90Y Radioembolization Lung Shunt Fraction in Primary and Metastatic Liver Cancer as a Biomarker for Survival

Xing

Lahti

Kokabi

et al. 2016

Clinical Nuclear Medicine

View full text Add to dashboard Cite

show abstract

“…Planning angiography provides the opportunity for vascular mapping, embolization of variant vascularity to ensure safe treatment, as well as evaluation of tumor shunting which would result in inadvertent radioactivity delivery to the lungs. In order to evaluate tumor shunting, technetium-99 m labeled macroaggregated albumin (MAA) is injected into the desired hepatic lobar or segmental artery followed by planar/SPECT gamma imaging to determine the fraction of shunting from the liver to the lungs (41).…”

Section: Technical Considerationsmentioning

confidence: 99%

Locoregional and systemic therapy for hepatocellular carcinoma

Gbolahan

Schacht

Beckley

et al. 2017

J. Gastrointest. Oncol.

View full text Add to dashboard Cite

The management of hepatocellular carcinoma (HCC) remains challenging due to late presentation and the presence of accompanying liver dysfunction. As such, most patients are not eligible for curative resection and liver transplant. Management in this scenario depends on a number of factors including hepatic function, tumor burden, patency of hepatic vasculature and patients' functional status. Based on these, patients can be offered catheter based intra-arterial therapy for intermediate stage disease and in more advanced disease, sorafenib. Given recent data, regorafenib is now an option following failure of sorafenib.Catheter directed intra-arterial therapy takes advantage of tumor hypervascularity and the unique dual blood supply of the liver, as hepatic tumors receive arterial perfusion via the hepatic artery while the rest of the liver is supplied by the portal vein. This allows selective embolization and delivery of chemotherapeutic agents to the tumor. Compared to best supportive care, intra-arterial therapy offers a survival benefit in intermediate stage HCC and is the recommended approach for treatment. None of the catheter based approaches; including bland embolization, conventional trans-arterial chemoembolization (cTACE), drug eluting bead trans-arterial chemoembolization (DEB-TACE) or trans-arterial radioembolization (TARE) offers a clear advantage over the other, although DEB-TACE may be characterized by less systemic toxicity. All of these approaches are contraindicated in patients with portal vein thrombosis (PVT). On the other hand, intraarterial, radio embolization, with Yttrium-90 (Y90) can be offered to patients with PVT. The place of this modality in management of HCC is still being investigated. The role of sorafenib in advanced HCC is not in doubt, as until recently, it was the only systemic therapy approved for the management in this setting. This is despite multiple trials evaluating other agents. The addition of sorafenib to catheter-based therapy in intermediate stage disease has also failed to show any benefit. The modest survival benefit with sorafenib and the failure of other targeted agents suggest that it is important to look beyond inhibition of angiogenesis in advanced HCC. Identification of key drivers and mediators of HCC remains paramount for successful drug development. In line with this, it is refreshing that the excitement that has followed developments in cancer immunotherapy is finding its way to HCC with early trials of anti-PD1 monoclonal antibodies showing sufficient activity that phase III trials are now ongoing for Pembrolizumab and Nivolumab in advanced HCC. Future drug development efforts will focus on defining the feasibility of combining different treatment approaches targeting multiple important modulators of HCC.

show abstract

Characteristics of Primary and Secondary Hepatic Malignancies Associated with Hepatopulmonary Shunting

Abstract: LSF greater than 20% periodically occurs in HCC but is uncommon in other liver tumors. Specific tumor characteristics are associated with LSF greater than 20% and may indicate need for interventions to reduce LSF.

Cited by 53 publications

References 24 publications

Safety of a Scout Dose Preceding Hepatic Radioembolization with ¹⁶⁶Ho Microspheres

Safety of a Scout Dose Preceding Hepatic Radioembolization with ¹⁶⁶Ho Microspheres

90Y Radioembolization Lung Shunt Fraction in Primary and Metastatic Liver Cancer as a Biomarker for Survival

Locoregional and systemic therapy for hepatocellular carcinoma

Contact Info

Product

Resources

About

Characteristics of Primary and Secondary Hepatic Malignancies Associated with Hepatopulmonary Shunting

Abstract: LSF greater than 20% periodically occurs in HCC but is uncommon in other liver tumors. Specific tumor characteristics are associated with LSF greater than 20% and may indicate need for interventions to reduce LSF.

Cited by 53 publications

References 24 publications

Safety of a Scout Dose Preceding Hepatic Radioembolization with 166Ho Microspheres

Safety of a Scout Dose Preceding Hepatic Radioembolization with 166Ho Microspheres

90Y Radioembolization Lung Shunt Fraction in Primary and Metastatic Liver Cancer as a Biomarker for Survival

Locoregional and systemic therapy for hepatocellular carcinoma

Contact Info

Product

Resources

About

Safety of a Scout Dose Preceding Hepatic Radioembolization with ¹⁶⁶Ho Microspheres

Safety of a Scout Dose Preceding Hepatic Radioembolization with ¹⁶⁶Ho Microspheres