title: Management of High Hepatopulmonary Shunting in Patients Undergoing Hepatic Radioembolization.
abstract: OBJECTIVE
  To review the safety of hepatic radioembolization (RE) in patients with high (≥ 10%) hepatopulmonary shunt fraction (HPSF) using various prophylactic techniques.
  
  
  METHODS
  A review was conducted of 409 patients who underwent technetium 99m-labeled macroaggregated albumin scintigraphy before planned RE. Estimated pulmonary absorbed radiation doses based on scintigraphy and hepatic administered activity were calculated. Outcomes from dose reductions and adjunctive catheter-based prophylactic techniques used to reduce lung exposure were assessed.
  
  
  RESULTS
  There were 80 patients with HPSF ≥ 10% who received RE treatment (41 resin microspheres for metastases, 39 glass microspheres for hepatocellular carcinoma). Resin microspheres were used in 17 patients according to consensus guideline-recommended dose reduction; 38 patients received no dose reduction because the expected lung dose was < 30 Gy. Prophylactic techniques were used in 25 patients (with expected lung dose ≤ 74 Gy), including hepatic vein balloon occlusion, variceal embolization, or bland arterial embolization before, during, or after RE delivery. Repeated scintigraphy after prophylactic techniques to reduce HPSF in seven patients demonstrated a median change of -40% (range, +32 to -69%). Delayed pneumonitis developed in two patients, possibly related to radiation recall after chemoembolization. Response was lower in patients treated with resin spheres with dose reduction, with an objective response rate of 13% and disease control rate of 47% compared with 56% and 94%, respectively, without dose reduction (P = .023, P = .006).
  
  
  CONCLUSIONS
  Dose reduction recommendations for HPSF may compromise efficacy. Excessive shunting can be reduced by prophylactic catheter-based techniques, which may improve the safety of performing RE in patients with high HPSF.
authors.affiliation: Division of Interventional Radiology, Stanford University Medical Center, H-3646, 300 Pasteur Drive, Stanford, CA 94305-5642. Electronic address: Thomasjward@gmail.com.
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Ward
authors.affiliation: Division of Vascular and Interventional Radiology, Johns Hopkins University, Baltimore, Maryland.
authors.forename: Anobel
authors.initials: A
authors.lastname: Tamrazi
authors.affiliation: Division of Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: Marnix G E H
authors.initials: MG
authors.lastname: Lam
authors.affiliation: Division of Interventional Radiology, Stanford University Medical Center, H-3646, 300 Pasteur Drive, Stanford, CA 94305-5642.
authors.forename: John D
authors.initials: JD
authors.lastname: Louie
authors.affiliation: Division of Pulmonology and Critical Care, Stanford University Medical Center, H-3646, 300 Pasteur Drive, Stanford, CA 94305-5642.
authors.forename: Peter N
authors.initials: PN
authors.lastname: Kao
authors.affiliation: Division of Interventional Radiology, Stanford University Medical Center, H-3646, 300 Pasteur Drive, Stanford, CA 94305-5642.
authors.forename: Rajesh P
authors.initials: RP
authors.lastname: Shah
authors.affiliation: Division of Thoracic Imaging, Stanford University Medical Center, H-3646, 300 Pasteur Drive, Stanford, CA 94305-5642.
authors.forename: Michael A
authors.initials: MA
authors.lastname: Kadoch
authors.affiliation: Division of Interventional Radiology, Stanford University Medical Center, H-3646, 300 Pasteur Drive, Stanford, CA 94305-5642.
authors.forename: Daniel Y
authors.initials: DY
authors.lastname: Sze
mesh_terms: D002140:California / Q000453:epidemiology; D015897:Comorbidity; D005119:Extravasation of Diagnostic and Therapeutic Materials / Q000453:epidemiology / Q000517:prevention & control; D005260:Female; D020065:Hepatopulmonary Syndrome / Q000453:epidemiology* / Q000517:prevention & control*; D006801:Humans; D015994:Incidence; D008113:Liver Neoplasms / Q000453:epidemiology* / Q000517:prevention & control*; D008297:Male; D008875:Middle Aged; D011832:Radiation Injuries / Q000453:epidemiology* / Q000517:prevention & control*; D019275:Radiopharmaceuticals / Q000627:therapeutic use; D012189:Retrospective Studies; D012307:Risk Factors; D016896:Treatment Outcome; D015021:Yttrium Radioisotopes / Q000008:administration & dosage / Q000627:therapeutic use
chemical_list: D019275:Radiopharmaceuticals; D015021:Yttrium Radioisotopes