Hepatobiliary scintigraphy may improve radioembolization treatment planning in HCC patients

Abstract

BackgroundRoutine work-up for transarterial radioembolization, based on clinical and laboratory parameters, sometimes fails, resulting in severe hepatotoxicity in up to 5% of patients. Quantitative assessment of the pretreatment liver function and its segmental distribution, using hepatobiliary scintigraphy may improve patient selection and treatment planning. A case series will be presented to illustrate the potential of this technique.Hepatocellular carcinoma patients with cirrhosis (Child-Pugh A and B) underwent hepatobiliary scintigraphy pre- and 3 months post-radioembolization as part of a prospective study protocol, which was prematurely terminated because of limited accrual. Included patients were analysed together with their clinical, laboratory and treatment data.ResultsPretreatment-corrected 99mTc-mebrofenin liver uptake rates were marginal (1.8–3.0%/min/m2), despite acceptable clinical and laboratory parameters. Posttreatment liver functions seriously declined (corrected 99mTc-mebrofenin liver uptake rates: 0.6–2.4%/min/m2), resulting in lethal radioembolization-induced liver disease in two out of three patients.ConclusionsHepatobiliary scintigraphy may be of added value during work-up for radioembolization, to estimate liver function reserve and its segmental distribution, especially in patients with underlying cirrhosis, for whom analysis of clinical and laboratory parameters may not be sufficient.

A Pilot Study on Hepatobiliary Scintigraphy to Monitor Regional Liver Function in 90Y Radioembolization

“…One of these patients also had a decrease in liver function and died of radioembolizationinduced liver disease 4 mo after treatment, as described above. The other patient had a slight increase of function in the nontreated part (129.2%) but died 4 mo after treatment because of hepatic failure (probably radioembolization-induced liver disease, patient 2, Supplemental Table 1) (10).…”

“…In 2 patients, liver function declined in the nontreated part of the liver. One of these patients had limited liver function at baseline (patient 3, Supplemental Table 1) and died 4 mo after treatment as a result of definite radioembolization-induced liver disease (10). The other patient had massive tumor progression in both the treated and nontreated parts of the liver and died 5 mo after treatment.…”

“…Hence, the data of 13 patients (11 male, 2 female) were retrospectively analyzed. Three of these patients were earlier included in a case series by Braat et al (10). The medical ethics committee waived the need for informed consent.…”

“…This may improve the future work-up of patients who are candidates for radioembolization, reducing the risk of hepatotoxicity. In a small case-series of 3 patients, we previously showed that discrepancies between lab values and liver function assessment using HBS may lead to dismal outcomes that potentially could have been prevented if regional HBS results had been considered (10). The suggested cMUR cutoff of 2.69%/min/ m 2 for liver surgery (7) may be lower for lobar radioembolization, since radiation damage is a more gradual process than resection, and liver function may increase up to 12 mo after radioembolization, both in the treated and in the nontreated parts of the liver (18).…”

Dosimetric parameters predicting contralateral liver hypertrophy after unilobar radioembolization of hepatocellular carcinoma

“…Then, a simple volumetric analysis, in this situation of RE, more than likely underestimates the real percentage of the function of the FLR. In fact, an important reduction of the liver function of the treated lobe has been recently described using hepatobiliary scintigraphy in two patients out of three treated by RE [ 33 ]. In the future, the use of hepatobiliary scintigraphy should be used to evaluate more accurately the hypertrophy post RE with a more functional approach than a volumetric approach alone.…”