Truly dosimetric treatment planning with 99m-TC MAA SPECT prolonged overall survival in radioembolization of hepatocarcinoma with 90-y glass microspheres

Chiesa, Carlo; Mira, M.; Maccauro, Marco; Facciorusso, Antonio; Spreafico, Carlo; Romito, Raffaele; Sposito, Carlo; Brusa, A.; Padovano, Barbara; Migliorisi, M.; Marchianò, Alfonso; Crippa, Flavio; Mazzaferro, V.

doi:10.1016/j.ejmp.2016.01.351

Cited by 13 publications

(25 citation statements)

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“…For both resin and glass microspheres, the development of reliable dosimetric methods for activity prescription represent the holy grail . Dosimetric analysis indicates that better tumor responses are associated with higher mean absorbed doses.…”

Section: Liver Complicationsmentioning

confidence: 99%

“…(13) For both resin and glass microspheres, the development of reliable dosimetric methods for activity prescription represent the holy grail. (5,46,47) Dosimetric analysis indicates that better tumor responses are associated with higher mean absorbed doses. From the safety perspective, however, the use of dosimetric methods faces several problems including heterogeneous distribution of particles in the nontumoral liver, potential changes in particle distribution between MAA and 90 Y microsphere injections due to catheter position and local hemodynamic conditions, (48) and suboptimal measurement of the tumor to nontumor ratio for multinodular tumors.…”

Section: Prevention Of Reildmentioning

confidence: 99%

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Prevention and treatment of complications of selective internal radiation therapy: Expert guidance and systematic review

et al. 2017

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Selective internal radiation therapy (or radioembolization) by intra-arterial injection of radioactive yttrium-90-loaded microspheres is increasingly used for the treatment of patients with liver metastases or primary liver cancer. The high-dose beta-radiation penetrates an average of only 2.5 mm from the source, thus limiting its effects to the site of delivery. However, the off-target diversion of yttrium-90 microspheres to tissues other than the tumor may lead to complications. The most prominent of these complications include radiation gastritis and gastrointestinal ulcers, cholecystitis, radiation pneumonitis, and radioembolization-induced liver disease, which may occur despite careful pretreatment planning. Thus, selective internal radiation therapy demands an expert multidisciplinary team approach in order to provide comprehensive care for patients. This review provides recommendations to multidisciplinary teams on the optimal medical processes in order to ensure the safe delivery of selective internal radiation therapy. Based on the best available published evidence and expert opinion, we recommend the most appropriate strategies for the prevention, early diagnosis, and management of potential radiation injury to the liver and to other organs. (Hepatology 2017;66:969-982).

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Section: Liver Complicationsmentioning

confidence: 99%

Section: Prevention Of Reildmentioning

confidence: 99%

Prevention and treatment of complications of selective internal radiation therapy: Expert guidance and systematic review

et al. 2017

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“…A(voxel r ) is usually calculated multiplying the 99m Tc-MAA SPECT voxel counts by a calibration factor (CF) defined as the ratio between the 90 Y microsphere activity within the liver, and the sum of the 99m Tc-MAA SPECT counts over the entire liver. 9,18,19 The CF is therefore determined for each patient ("relative calibration method"). In this study, the CF was calculated for each reconstruction: the entire liver was delineated on the input activity map, by an isocount threshold yielding the same volume obtained with ITK-SNAP when generating the virtual patients (differences within 1%), and the region of interest (ROI) was superimposed on each SPECT dataset, summing the counts.…”

Section: C 3d Voxel Dosimetrymentioning

confidence: 99%

“…9,[17][18][19][20][21][22][23] Image-based 3D dosimetry can be performed in several ways: direct Monte Carlo (MC) simulation, which is considered the gold standard; 9,[24][25][26][27][28][29][30] convolution calculations by voxel S-values, reliable in nearly uniform density tissue; 19,[31][32][33][34][35][36] local energy deposition method. 18,20,[36][37][38][39] Activity distribution quantification by SPECT is the major concern, due to physical and clinical degrading factors of the images. Physical factors [i.e., attenuation, scatter, partial volume effects (PVEs), noise] require well known corrections for attenuation and scatter, whereas presently, corrections for PVE (on a voxel-by-voxel basis) are still under investigation.…”

Section: Introductionmentioning

confidence: 99%

Impact of SPECT corrections on 3D‐dosimetry for liver transarterial radioembolization using the patient relative calibration methodology

et al. 2016

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Purpose: Many centers aim to plan liver transarterial radioembolization (TARE) with dosimetry, even without CT-based attenuation correction (AC), or with unoptimized scatter correction (SC) methods. This work investigates the impact of presence vs absence of such corrections, and limited spatial resolution, on 3D dosimetry for TARE. Methods: Three voxelized phantoms were derived from CT images of real patients with different body sizes. Simulations of 99m Tc-SPECT projections were performed with the SIMIND code, assuming three activity distributions in the liver: uniform, inside a "liver's segment," or distributing multiple uptaking nodules ("nonuniform liver"), with a tumoral liver/healthy parenchyma ratio of 5:1. Projection data were reconstructed by a commercial workstation, with OSEM protocol not specifically optimized for dosimetry (spatial resolution of 12.6 mm), with/without SC (optimized, or with parameters predefined by the manufacturer; dual energy window), and with/without AC. Activity in voxels was calculated by a relative calibration, assuming identical microspheres and 99m Tc-SPECT counts spatial distribution. 3D dose distributions were calculated by convolution with lesions and healthy parenchyma from different reconstructions were compared with those obtained from the reference biodistribution (the "gold standard," GS), assessing differences for D95%, D70%, and D50% (i.e., minimum value of the absorbed dose to a percentage of the irradiated volume). γ tool analysis with tolerance of 3%/13 mm was used to evaluate the agreement between GS and simulated cases. The influence of deep-breathing was studied, blurring the reference biodistributions with a 3D anisotropic gaussian kernel, and performing the simulations once again. Results: Differences of the dosimetric indicators were noticeable in some cases, always negative for lesions and distributed around zero for parenchyma. Application of AC and SC reduced systematically the differences for lesions by 5%-14% for a liver segment, and by 7%-12% for a nonuniform liver. For parenchyma, the data trend was less clear, but the overall range of variability passed from −10%/40% for a liver segment, and −10%/20% for a nonuniform liver, to −13%/6% in both cases. Applying AC, SC with preset parameters gave similar results to optimized SC, as confirmed by γ tool analysis. Moreover, γ analysis confirmed that solely AC and SC are not sufficient to obtain accurate 3D dose distribution. With breathing, the accuracy worsened severely for all dosimetric indicators, above all for lesions: with AC and optimized SC, −38%/−13% in liver's segment, −61%/−40% in the nonuniform liver. For parenchyma, D50% resulted always less sensitive to breathing and sub-optimal correction methods (difference overall range: −7%/13%). Conclusions: Reconstruction protocol optimization, AC, SC, PVE and respiratory motion corrections should be implemented to obtain the best possible dosimetric accuracy. On the other side, thanks to the relative calibration, D50% inaccuracy for the healthy paren...

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“…For glass microspheres, Garin et al reported that a tumor dose exceeding 205 Gy and Chiesa et al reported that a tumor dose of 257 Gy were required to induce tumor response (21,22). Similarly, Riaz et al reported that when segmental dosimetry (segment receives 100% of radiation dose) was used, a dose greater than 190 Gy was required to perform a segmentectomy (Supplemental Fig.…”

Section: Figurementioning

confidence: 99%

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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Truly dosimetric treatment planning with 99m-TC MAA SPECT prolonged overall survival in radioembolization of hepatocarcinoma with 90-y glass microspheres

Cited by 13 publications

References 0 publications

Prevention and treatment of complications of selective internal radiation therapy: Expert guidance and systematic review

Prevention and treatment of complications of selective internal radiation therapy: Expert guidance and systematic review

Impact of SPECT corrections on 3D‐dosimetry for liver transarterial radioembolization using the patient relative calibration methodology

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

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Truly dosimetric treatment planning with 99m-TC MAA SPECT prolonged overall survival in radioembolization of hepatocarcinoma with 90-y glass microspheres

Cited by 13 publications

References 0 publications

Prevention and treatment of complications of selective internal radiation therapy: Expert guidance and systematic review

Prevention and treatment of complications of selective internal radiation therapy: Expert guidance and systematic review

Impact of SPECT corrections on 3D‐dosimetry for liver transarterial radioembolization using the patient relative calibration methodology

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

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