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Same-day 90Y radioembolization: implementing a new treatment paradigm

  • Ahmed Gabr
  • Joseph Ralph Kallini
  • Vanessa L. Gates
  • Ryan Hickey
  • Laura Kulik
  • Kush Desai
  • Bartley Thornburg
  • Karen Marshall
  • Krystina Salzig
  • Melissa Williams
  • Carlene del Castillo
  • Daniel Ganger
  • Elias Hohlastos
  • Talia Baker
  • Robert J. Lewandowski
  • Riad SalemEmail author
Original Article

Abstract

Purpose

To assess the feasibility of conducting pretreatment mesenteric angiography, coil embolization, 99mTc macroaggregated albumin (99mTc-MAA) scintigraphy, and 90Y radioembolization treatment in a single, same-day, combined outpatient encounter.

Methods

This was a retrospective study of 78 patients treated during the period 2008 – 2015 who were managed in a single outpatient encounter under the guidance of the Interventional Radiology Department and The Nuclear Medicine Department. Pretreatment planning was performed by reviewing baseline imaging and estimated perfused liver volume bearing the tumor. The region of interest was estimated using 3-D software; this value was used for dosimetry planning. Maximum lung shunting fractions of 10 % for hepatocellular carcinoma and 5 % for liver metastases were assumed. Subsequently, hepatic angiography and 99mTc-MAA scintigraphy were performed followed by 90Y treatment in one outpatient encounter. Total in-room procedure time was recorded.

Results

All patients underwent same-day angiography, 99mTc-MAA scintigraphy and 90Y radioembolization. Of the 78 patients, 16 received multiple segmental treatments to both lobes, 44 received treatment to the right lobe, and 18 received treatment to the left lobe. The median dose was 106 Gy. The median number of 90Y vials needed was two (range one to six). The median in-room time was 160 min (75 – 250 min). The residential status of the patients was as follows, 18 % (14/78) were local residents, 55 % (43/78) traveled from outside the city limits, 18 % (14/78) were from out-of-state, and 9 % (7/78) were resident abroad. Of the 78 patients, 61 (77 %) had hepatocellular carcinoma, and 17 (22 %) had liver metastases. The median lung dose was 3.5 Gy.

Conclusion

This study demonstrated the feasibility of same-day 90Y evaluation and treatment while maintaining the principles of safe and effective 90Y infusion including tumoricidal dosimetry (lobar, segmentectomy), minimization of nontarget flow, and minimization of lung dose. This paradigm translates into expeditious cancer care and significant cost savings.

Keywords

Radioembolization Same-day Lung shunting fraction 

Notes

Compliance with ethical standards

Funding

None.

Conflicts of interest

R.J.L., L.K. and R.S. are advisors to BTG. The other authors declare no conflicts of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the principles of the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in this study.

References

  1. 1.
    Ahmadzadehfar H, Meyer C, Ezziddin S, Sabet A, Hoff-Meyer A, Muckle M, et al. Hepatic volume changes induced by radioembolization with 90Y resin microspheres. A single-centre study. Eur J Nucl Med Mol Imaging. 2013;40:80–90. doi: 10.1007/s00259-012-2253-2.CrossRefPubMedGoogle Scholar
  2. 2.
    Habib A, Desai K, Hickey R, Thornburg B, Lewandowski R, Salem R. Locoregional therapy of hepatocellular carcinoma. Clin Liver Dis. 2015;19:401–20. doi: 10.1016/j.cld.2015.01.008.CrossRefPubMedGoogle Scholar
  3. 3.
    Dezarn WA, Cessna JT, DeWerd LA, Feng W, Gates VL, Halama J, et al. Recommendations of the American Association of Physicists in Medicine on dosimetry, imaging, and quality assurance procedures for 90Y microsphere brachytherapy in the treatment of hepatic malignancies. Med Phys. 2011;38:4824–45.CrossRefPubMedGoogle Scholar
  4. 4.
    Mazzaferro V, Sposito C, Bhoori S, Romito R, Chiesa C, Morosi C, et al. Yttrium-90 radioembolization for intermediate-advanced hepatocellular carcinoma: a phase 2 study. Hepatology. 2013;57:1826–37. doi: 10.1002/hep.26014.CrossRefPubMedGoogle Scholar
  5. 5.
    Gates VL, Marshall KG, Salzig K, Williams M, Lewandowski RJ, Salem R. Outpatient single-session yttrium-90 glass microsphere radioembolization. J Vasc Interv Radiol. 2014;25:266–70. doi: 10.1016/j.jvir.2013.11.005.CrossRefPubMedGoogle Scholar
  6. 6.
    Hamami ME, Poeppel TD, Muller S, Heusner T, Bockisch A, Hilgard P, et al. SPECT/CT with 99mTc-MAA in radioembolization with 90Y microspheres in patients with hepatocellular cancer. Eur J Nucl Med. 2009;50:688–92. doi: 10.2967/jnumed.108.058347.CrossRefGoogle Scholar
  7. 7.
    Louie JD, Kothary N, Kuo WT, Hwang GL, Hofmann LV, Goris ML, et al. Incorporating cone-beam CT into the treatment planning for yttrium-90 radioembolization. J Vasc Interv Radiol. 2009;20:606–13. doi: 10.1016/j.jvir.2009.01.021.CrossRefPubMedGoogle Scholar
  8. 8.
    Gates VL, Hickey R, Marshall K, Williams M, Salzig K, Lewandowski RJ, et al. Gastric injury from 90Y to left hepatic lobe tumors adjacent to the stomach: fact or fiction? Eur J Nucl Med Mol Imaging. 2015;42:2038–44. doi: 10.1007/s00259-015-3122-6.CrossRefPubMedGoogle Scholar
  9. 9.
    Leung TW, Lau WY, Ho SK, Ward SC, Chow JH, Chan MS, et al. Radiation pneumonitis after selective internal radiation treatment with intraarterial 90yttrium-microspheres for inoperable hepatic tumors. Int J Radiat Oncol Biol Phys. 1995;33:919–24. doi: 10.1016/0360-3016(95)00039-3.CrossRefPubMedGoogle Scholar
  10. 10.
    Atassi B, Bangash AK, Lewandowski RJ, Ibrahim S, Kulik L, Mulcahy MF, et al. Biliary sequelae following radioembolization with yttrium-90 microspheres. J Vasc Interv Radiol. 2008;19:691–7. doi: 10.1016/j.jvir.2008.01.003.CrossRefPubMedGoogle Scholar
  11. 11.
    European Association for Study of Liver; European Organisation for Research and Treatment of Cancer. EASL-EORTC clinical practice guidelines: management of hepatocellular carcinoma. Eur J Cancer. 2012;48:599–641. doi: 10.1016/j.ejca.2011.12.021.CrossRefGoogle Scholar
  12. 12.
    Leung DA, Goin JE, Sickles C, Raskay BJ, Soulen MC. Determinants of postembolization syndrome after hepatic chemoembolization. J Vasc Interv Radiol. 2001;12:321–6.CrossRefPubMedGoogle Scholar
  13. 13.
    Abando A, Hood D, Weaver F, Katz S. The use of the Angioseal device for femoral artery closure. J Vasc Surg. 2004;40:287–90. doi: 10.1016/j.jvs.2004.05.007.CrossRefPubMedGoogle Scholar
  14. 14.
    Vouche M, Lewandowski RJ, Atassi R, Memon K, Gates VL, Ryu RK, et al. Radiation lobectomy: time-dependent analysis of future liver remnant volume in unresectable liver cancer as a bridge to resection. J Hepatol. 2013;59:1029–36. doi: 10.1016/j.jhep.2013.06.015.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Lewandowski RJ, Donahue L, Chokechanachaisakul A, Kulik L, Mouli S, Caicedo J, et al. 90Y radiation lobectomy: outcomes following surgical resection in patients with hepatic tumors and small future liver remnant volumes. J Surg Oncol. 2016. doi: 10.1002/jso.24269.PubMedGoogle Scholar
  16. 16.
    Vouche M, Habib A, Ward TJ, Kim E, Kulik L, Ganger D, et al. Unresectable solitary hepatocellular carcinoma not amenable to radiofrequency ablation: multicenter radiology-pathology correlation and survival of radiation segmentectomy. Hepatology. 2014;60:192–201. doi: 10.1002/hep.27057.CrossRefPubMedGoogle Scholar
  17. 17.
    Heusner TA, Hamami ME, Ertle J, Hahn S, Poeppel T, Hilgard P, et al. Angiography-based C-arm CT for the assessment of extrahepatic shunting before radioembolization. Rofo. 2010;182:603–8. doi: 10.1055/s-0029-1245192.CrossRefPubMedGoogle Scholar
  18. 18.
    Lewandowski RJ, Sato KT, Atassi B, Ryu RK, Nemcek Jr AA, Kulik L, et al. Radioembolization with 90Y microspheres: angiographic and technical considerations. Cardiovasc Intervent Radiol. 2007;30:571–92. doi: 10.1007/s00270-007-9064-z.CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2016

Authors and Affiliations

  • Ahmed Gabr
    • 1
  • Joseph Ralph Kallini
    • 1
  • Vanessa L. Gates
    • 1
  • Ryan Hickey
    • 1
  • Laura Kulik
    • 2
  • Kush Desai
    • 1
  • Bartley Thornburg
    • 1
  • Karen Marshall
    • 1
  • Krystina Salzig
    • 1
  • Melissa Williams
    • 1
  • Carlene del Castillo
    • 1
  • Daniel Ganger
    • 2
  • Elias Hohlastos
    • 1
  • Talia Baker
    • 3
  • Robert J. Lewandowski
    • 1
  • Riad Salem
    • 1
    • 3
    • 4
    Email author
  1. 1.Department of Radiology, Section of Interventional RadiologyNorthwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer CenterChicagoUSA
  2. 2.Department of Medicine, Division of HepatologyNorthwestern UniversityChicagoUSA
  3. 3.Department of Surgery, Division of Transplantation, Comprehensive Transplant CenterNorthwestern UniversityChicagoUSA
  4. 4.Department of Medicine, Division of Hematology and OncologyRobert H. Lurie Comprehensive Cancer Center, Northwestern UniversityChicagoUSA

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