title: Selective internal radiotherapy (SIRT) of hepatic tumors: how to deal with the cystic artery.
abstract: OBJECTIVE
  Selective internal radiotherapy (SIRT) with the beta emitter yttrium-90 (Y90) is a rapidly developing therapy option for unresectable liver malignancies. Nontarget irradiation of the gallbladder is a complication of SIRT. Thus, we aimed to assess different strategies to avoid infusion of Y90 into the cystic artery (CA).
  
  
  METHODS
  After hepatic digital subtraction angiography and administration of technetium-99m-labeled human serum albumin ((99)mTc-HSA), 295 patients with primary or secondary liver tumors underwent single-photon emission computed tomography/computed tomography (SPECT/CT). Different measures were taken before repeated Y90 mapping and SIRT to avoid unintended influx into the CA where necessary. Clinical symptoms, including pain, fever, or a positive Murphy sign, were assessed during patient follow-up.
  
  
  RESULTS
  A significant (99)mTc-HSA accumulation in the gallbladder wall (higher (99)mTc-HSA uptake than in normal liver tissue) was seen in 20 patients. The following measures were taken to avoid unintended influx into the CA: temporary/permanent occlusion of the CA with gelfoam (n = 5)/microcoil (n = 1), induction of vasospasm with a microwire (n = 4), or altering catheter position (n = 10). Clinical signs of cholecystitis were observed in only one patient after temporary CA occlusion with gelfoam and were successfully treated by antibiotics. Cholecystectomy was not required for any patient.
  
  
  CONCLUSIONS
  It is important to identify possible nontarget irradiation of the gallbladder. The risk for radiation-induced cholecystitis can be easily minimized by temporary or permanent CA embolization, vasospasm induction, or altering the catheter position.
authors.affiliation: Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Hufelandstrasse 55, 45122, Essen, Germany. jens.theysohn@uni-due.de
authors.forename: Jens M
authors.initials: JM
authors.lastname: Theysohn
authors.forename: Stefan
authors.initials: S
authors.lastname: Müller
authors.forename: Jörg F
authors.initials: JF
authors.lastname: Schlaak
authors.forename: Judith
authors.initials: J
authors.lastname: Ertle
authors.forename: Thomas W
authors.initials: TW
authors.lastname: Schlosser
authors.forename: Andreas
authors.initials: A
authors.lastname: Bockisch
authors.forename: Thomas C
authors.initials: TC
authors.lastname: Lauenstein
mesh_terms: D000328:Adult; D000368:Aged; D015901:Angiography, Digital Subtraction; D001918:Brachytherapy / Q000379:methods*; D006528:Carcinoma, Hepatocellular / Q000175:diagnosis / Q000401:mortality / Q000532:radiotherapy*; D015331:Cohort Studies; D018572:Disease-Free Survival; D005260:Female; D005500:Follow-Up Studies; D006499:Hepatic Artery / Q000000981:diagnostic imaging / Q000473:pathology; D006801:Humans; D008113:Liver Neoplasms / Q000175:diagnosis / Q000401:mortality / Q000532:radiotherapy*; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D018570:Risk Assessment; D015996:Survival Rate; D013668:Technetium Tc 99m Aggregated Albumin / Q000627:therapeutic use*; D015899:Tomography, Emission-Computed, Single-Photon / Q000379:methods; D016896:Treatment Outcome; D015021:Yttrium Radioisotopes
chemical_list: D013668:Technetium Tc 99m Aggregated Albumin; D015021:Yttrium Radioisotopes