title: Indicators of Lung Shunt Fraction Determined by Technetium-99 m Macroaggregated Albumin in Patients with Hepatocellular Carcinoma.
abstract: OBJECTIVE
  To determine the correlation of pre-procedural and imaging characteristics with lung shunt fraction (LSF) measured by technetium-99 m macroaggregated albumin (99mTc-MAA) scan in patients with hepatocellular carcinoma.
  
  
  METHODS
  A retrospective study was conducted of 428 subjects with hepatocellular carcinoma from 2004 to 2011 assessed for lung shunting by99mTc-MAA scan. Baseline characteristics included age, gender, ethnicity, tumor burden, maximum dimension, number of lesions, presence of extrahepatic metastases, macrovascular (hepatic and portal vein) invasion, ascites on imaging, laboratory values, and alpha-fetoprotein (AFP). Univariate and multivariate logistic regression analysis was performed. Receiver operating characteristic curves were used to obtain sensitivity (SN), specificity (SP), and positive likelihood ratios (LR+) of characteristics for low LSF (LSF <10%) and high LSF (LSF >20%).
  
  
  RESULTS
  Statistically significant (p < 0.05) independent indicators of low LSF included bilirubin <1.45 mg/dL (SN = 49.5%, SP = 69.1%, LR+= 1.60), maximum tumor size <7.15 cm (SN = 66.0%, SP = 75.9%, LR+= 2.74), AFP ≤200 ng/mL (SN = 64.6%, SP = 65.0%, LR+= 1.85), and absent macrovascular invasion (SN = 73.9%, SP = 64.9%, LR+= 2.11). Independent indicators of high LSF included albumin <2.65 g/dL (SN = 64.3%, SP = 64.1%, LR+= 1.79) and macrovascular invasion (SN = 74.4%, SP = 67.4%, LR+= 2.28). A combined risk factor model was constructed. If there is no macrovascular invasion: [Formula: see text]. With macrovascular invasion, [Formula: see text] (R2= 0.257). Since these factors all have LR+between 2 and 5, they only reflect slight increase in LSF predictivity.
  
  
  CONCLUSIONS
  Serum AFP, albumin, bilirubin, and portal/hepatic vein invasion on cross-sectional imaging are statistically significant but weak clinical indicators of LSF, as shown by low SN, SP, and LR+for clinically relevant cutoff LSF values. Thus, these factors cannot be relied upon in clinical practice.
authors.affiliation: Section of Interventional Radiology, Department of Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, 676 N. St. Clair Street, Suite 800, Chicago, IL, USA.
authors.forename: Joseph Ralph
authors.initials: JR
authors.lastname: Kallini
authors.affiliation: Section of Interventional Radiology, Department of Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, 676 N. St. Clair Street, Suite 800, Chicago, IL, USA.
authors.forename: Ahmed
authors.initials: A
authors.lastname: Gabr
authors.affiliation: Section of Interventional Radiology, Department of Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, 676 N. St. Clair Street, Suite 800, Chicago, IL, USA.
authors.forename: Ryan
authors.initials: R
authors.lastname: Hickey
authors.affiliation: Division of Hepatology, Department of Medicine, Northwestern University, Chicago, IL, 60611, USA.
authors.forename: Laura
authors.initials: L
authors.lastname: Kulik
authors.affiliation: Section of Interventional Radiology, Department of Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, 676 N. St. Clair Street, Suite 800, Chicago, IL, USA.
authors.forename: Kush
authors.initials: K
authors.lastname: Desai
authors.affiliation: Section of Interventional Radiology, Department of Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, 676 N. St. Clair Street, Suite 800, Chicago, IL, USA.
authors.forename: Yihe
authors.initials: Y
authors.lastname: Yang
authors.affiliation: Section of Interventional Radiology, Department of Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, 676 N. St. Clair Street, Suite 800, Chicago, IL, USA.
authors.forename: Vanessa L
authors.initials: VL
authors.lastname: Gates
authors.affiliation: Section of Interventional Radiology, Department of Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, 676 N. St. Clair Street, Suite 800, Chicago, IL, USA.
authors.forename: Ahsun
authors.initials: A
authors.lastname: Riaz
authors.affiliation: Section of Interventional Radiology, Department of Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, 676 N. St. Clair Street, Suite 800, Chicago, IL, USA.|Division of Hematology and Oncology, Department of Medicine, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL, USA.
authors.forename: Riad
authors.initials: R
authors.lastname: Salem
authors.affiliation: Section of Interventional Radiology, Department of Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, 676 N. St. Clair Street, Suite 800, Chicago, IL, USA. r-lewandowski@northwestern.edu.
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Lewandowski
mesh_terms: D000368:Aged; D001164:Arteriovenous Fistula / Q000000981:diagnostic imaging*; D006528:Carcinoma, Hepatocellular / Q000098:blood supply* / Q000000981:diagnostic imaging* / Q000532:radiotherapy; D004621:Embolization, Therapeutic; D005260:Female; D006801:Humans; D008113:Liver Neoplasms / Q000098:blood supply* / Q000000981:diagnostic imaging* / Q000532:radiotherapy; D008168:Lung / Q000098:blood supply* / Q000000981:diagnostic imaging*; D008297:Male; D008875:Middle Aged; D011169:Portal Vein / Q000473:pathology; D011879:Radiotherapy Dosage; D011880:Radiotherapy Planning, Computer-Assisted; D012189:Retrospective Studies; D013668:Technetium Tc 99m Aggregated Albumin; D047368:Tumor Burden; D015021:Yttrium Radioisotopes / Q000627:therapeutic use*
chemical_list: D013668:Technetium Tc 99m Aggregated Albumin; D015021:Yttrium Radioisotopes
keywords: Hepatocellular carcinoma (HCC); Hepatopulmonary shunt; Lung shunt fraction (LSF); Radioembolization; Risk factors; Technetium-99 m macroaggregated albumin (99mTc-MAA); Yttrium-90