EANM procedure guideline for the treatment of liver cancer and liver metastases with intra-arterial radioactive compounds

Abstract

Primary liver cancers (i.e. hepatocellular carcinoma or cholangiocarcinoma) are worldwide some of the most frequent cancers, with rapidly fatal liver failure in a large majority of patients. Curative therapy consists of surgery (i.e. resection or liver transplantation), but only 10-20% of patients are candidates for this. In other patients, a variety of palliative treatments can be given, such as chemoembolization, radiofrequency ablation or recently introduced tyrosine kinase inhibitors, e.g. sorafenib. Colorectal cancer is the second most lethal cancer in Europe and liver metastases are prevalent either at diagnosis or in follow-up. These patients are usually treated by a sequence of surgery, chemotherapy and antibody therapy [Okuda et al. (Cancer 56:918-928, 1985); Schafer and Sorrell (Lancet 353:1253-1257, 1999); Leong et al. (Arnold, London, 1999)]. Radioembolization is an innovative therapeutic approach defined as the injection of micron-sized embolic particles loaded with a radioisotope by use of percutaneous intra-arterial techniques. Advantages of the use of these intra-arterial radioactive compounds are the ability to deliver high doses of radiation to small target volumes, the relatively low toxicity profile, the possibility to treat the whole liver including microscopic disease and the feasibility of combination with other therapy modalities. Disadvantages are mainly due to radioprotection constraints mainly for (131)I-labelled agents, logistics and the possibility of inadvertent delivery or shunting [Novell et al. (Br J Surg 78:901-906, 1991)]. The Therapy, Oncology and Dosimetry Committees have worked together in order to revise the European Association of Nuclear Medicine (EANM) guidelines on the use of the radiopharmaceutical (131)I-Lipiodol (Lipiocis®, IBA, Brussels, Belgium) and include the newer medical devices with (90)Y-microspheres. (90)Y is either bound to resin (SIR-Spheres®, Sirtex Medical, Lane Cove, Australia) or embedded in a glass matrix (TheraSphere®, MDS Nordion, Kanata, ON, Canada). Since (90)Y-microspheres are not metabolized, they are not registered as unsealed sources. However, the microspheres are delivered in aqueous solution: radioactive contamination is a concern and microspheres should be handled, like other radiopharmaceuticals, as open sources. The purpose of this guideline is to assist the nuclear medicine physician in treating and managing patients undergoing such treatment.

Therapy of Hepatocellular Carcinoma with Iodine-131-Lipidiol

“…The specific activity at calibration date is 1.1 GBq/ml and its shelf life from this time is 3 days 11,12 .…”

A review of 3D image-based dosimetry, technical considerations and emerging perspectives in 90Y microsphere therapy

“…Due to the lower number of GMS typically encountered (400,000/GBq), stasis and embolic effects have yet to be reported [28]. Therefore because of the mechanics of sphere deposition, a higher injected activity may not always lead to a higher D T .…”

“…Modifications to injected activity were proposed depending on the level of hepatopulmonary shunting of MS through arteriovenous vessels bypassing the capillary bed to the lungs, as an absorbed dose of 30 Gy to lungs (D LUNG ) has been suggested to cause RP [28]. The manufacturer of SIR-Spheres and recent guidelines recommend less than 25 Gy and preferably less than 20 Gy [29,30].…”

Multiagent imaging of liver tumors with reference to intra-arterial radioembolization

“…Several techniques have been developed to selectively target liver tumors; these include administration of cytostatic drugs or intra-arterial embolization techniques. Intra-arterial radioembolization (RE) using microspheres labeled with the high-energy beta-emitter yttrium-90 ( 90 Y) is an innovative local therapy for conditions in which, to date, systemic therapy was the only option [2]. This procedure allows the tumor to be irradiated with a dose higher than that allowed by whole-liver external beam radiation treatment, in which doses are limited to 30-40 Gray (Gy).…”