Radioembolization with Y-90 Glass Microspheres: Do We Really Need SPECT-CT to Identify Extrahepatic Shunts?

• Published in: PloS one Vol. 10; no. 9; p. e0137587
• Main Authors: Theysohn, Jens M, Ruhlmann, Marcus, Müller, Stefan, Dechene, Alexander, Best, Jan, Haubold, Johannes, Umutlu, Lale, Gerken, Guido, Bockisch, Andreas, Lauenstein, Thomas C
• Format: Journal Article
• Language: English
• Published: United States Public Library of Science 03-09-2015; Public Library of Science (PLoS)
• Subjects: Aged; Analysis; Angiography; Angiography, Digital Subtraction; Arteries; Blood vessels; Brachytherapy - instrumentation; Bypasses; Carcinoma, Hepatocellular - diagnostic imaging; Carcinoma, Hepatocellular - radiotherapy; Cholangiocarcinoma - diagnostic imaging; Cholangiocarcinoma - radiotherapy; Cholestasis - diagnostic imaging; Cholestasis - radiotherapy; Complications; Crotalus cerastes; Diaphragm; Diaphragm (anatomy); Digital subtraction angiography; Drug dosages; Duodenum; Embolization; Embolization, Therapeutic - instrumentation; Female; Gastroenterology; Hepatocellular carcinoma; Hepatology; Hospitals; Human serum albumin; Humans; Intestine; Kidneys; Liver; Liver - diagnostic imaging; Liver cancer; Liver Neoplasms - diagnostic imaging; Liver Neoplasms - radiotherapy; Male; Medical imaging; Medical instruments; Metastases; Microspheres; Middle Aged; Nuclear medicine; Pancreas; Patients; Radiation; Radiation therapy; Radiotherapy; Retrospective Studies; Serum albumin; Shunts; Single photon emission computed tomography; Stomach; Tomography, Emission-Computed, Single-Photon; Tumors; Veins & arteries; Yttrium Radioisotopes - therapeutic use
• ISSN: 1932-6203; 1932-6203
• DOI: 10.1371/journal.pone.0137587

Selective Internal Radiation Therapy (SIRT) with 90yttrium (Y-90) is an increasingly used therapeutic option for unresectable liver malignancies. Nontarget embolization of extrahepatic tissue secondary to vascular shunting can lead to SIRT associated complications. Our aim was to assess whether extrahepatic shunts can reliably be diagnosed based on hepatic digital subtraction angiography (DSA) or whether subsequent SPECT/CT data can provide additional information.
825 patients with hepatocellular carcinoma (n = 636), hepatic metastases (n = 158) or cholangiocellular carcinoma (n = 31) were retrospectively analyzed. During hepatic DSA 128 arteries causing shunt flow to gastrointestinal tissue were coilembolized (right gastric artery n = 63, gastroduodenal artery n = 29; branches to duodenum / pancreas n = 36). Technectium-99m-labeled human serum albumin (HSA) was injected in all 825 patients. SPECT/CT data was used to identify additional or remaining shunts to extrahepatic tissue.
An unexpected uptake of HSA in extrahepatic tissue was found by SPECT/CT in 54/825 (6.5%) patients (located in stomach n = 13, duodenum n = 26, distal bowel segments n = 12, kidney n = 1, diaphragm n = 2). These patients underwent repeated DSA and newly identified shunt vessels were coilembolized in 22/54 patients, while in 12/54 patients a more distal catheter position for repeat injection of HSA was chosen. In 20/54 patients the repeated SPECT/CT data still revealed an extrahepatic HSA uptake. These patients did not receive SIRT.
Most extrahepatic shunts can be identified on DSA prior to Y-90 therapy. However, SPECT-CT data helps to identify additional shunts that were initially not seen on DSA.