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


METHODS
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.


RESULTS
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.


CONCLUSIONS
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.
Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany.
Jens M
JM
Theysohn
Department of Nuclear Medicine, University Hospital Essen, Essen, Germany.
Marcus
M
Ruhlmann
Department of Nuclear Medicine, University Hospital Essen, Essen, Germany.
Stefan
S
Müller
Department of Gastroenterology and Hepatology, University Hospital Essen, Essen, Germany.
Alexander
A
Dechene
Department of Gastroenterology and Hepatology, University Hospital Essen, Essen, Germany.
Jan
J
Best
Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany.
Johannes
J
Haubold
Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany.
Lale
L
Umutlu
Department of Gastroenterology and Hepatology, University Hospital Essen, Essen, Germany.
Guido
G
Gerken
Department of Nuclear Medicine, University Hospital Essen, Essen, Germany.
Andreas
A
Bockisch
Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany.
Thomas C
TC
Lauenstein
D000368:Aged; D015901:Angiography, Digital Subtraction; D001918:Brachytherapy / Q000295:instrumentation*; D006528:Carcinoma, Hepatocellular / Q000000981:diagnostic imaging / Q000532:radiotherapy; D018281:Cholangiocarcinoma / Q000000981:diagnostic imaging / Q000532:radiotherapy; D002779:Cholestasis / Q000000981:diagnostic imaging / Q000532:radiotherapy*; D004621:Embolization, Therapeutic / Q000295:instrumentation*; D005260:Female; D006801:Humans; D008099:Liver / Q000000981:diagnostic imaging*; D008113:Liver Neoplasms / Q000000981:diagnostic imaging / Q000532:radiotherapy*; D008297:Male; D008863:Microspheres; D008875:Middle Aged; D012189:Retrospective Studies; D015899:Tomography, Emission-Computed, Single-Photon; D015021:Yttrium Radioisotopes / Q000627:therapeutic use
D015021:Yttrium Radioisotopes