Ahmed Gabr1, Srirajkumar Ranganathan1, Samdeep K Mouli1, Ahsun Riaz1, Vanessa L Gates1, Laura Kulik2, Daniel Ganger2, Haripriya Maddur2, Christopher Moore2, Elias Hohlastos1, Nitin Katariya3, Juan Carlos Caicedo3, Aparna Kalyan4, Robert J Lewandowski5, Riad Salem6. 1. Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL. 2. Department of Medicine, Division of Hepatology, Northwestern University, Chicago, IL. 3. Department of Surgery, Division of Transplantation, Comprehensive Transplant Center, Northwestern University, Chicago, IL. 4. Department of Medicine, Division of Medical Oncology, Northwestern University, Chicago, IL. 5. Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL; Department of Surgery, Division of Transplantation, Comprehensive Transplant Center, Northwestern University, Chicago, IL. 6. Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL; Department of Surgery, Division of Transplantation, Comprehensive Transplant Center, Northwestern University, Chicago, IL; Department of Medicine, Division of Medical Oncology, Northwestern University, Chicago, IL. Electronic address: r-salem@northwestern.edu.
Abstract
BACKGROUND & AIMS: Pre-treatment Tc-99m macroaggregated albumin (MAA) scans are routinely performed prior to transarterial radioembolization (TARE) to estimate lung shunt fraction (LSF) and lung dose. In this study, we investigate LSF observed in early hepatocellular carcinoma (HCC) and provide the scientific rationale for eliminating this step from routine practice. METHODS: Patients with HCC who underwent Y90 from 2004 to 2018 were reviewed. Inclusion criteria were early stage HCC (UNOS T1/T2/Milan criteria: solitary ≤5 cm, 3 nodules ≤3 cm). LSF was determined using MAA in all patients. Associations between LSF and baseline characteristics were investigated. A "no-MAA" paradigm was then proposed based on a homogenous group that expressed very low LSF. RESULTS: Of 1,175 patients with HCC treated with TARE, 448 patients met inclusion criteria. Mean age was 65.6 years and 303 (68%) were males. A total of 352 (79%) had solitary lesions and 406 (91%) unilobar disease. Two-hundred and forty-three (54%), 178 (40%) and 27 (6%) patients were Child-Pugh class A, B and C, respectively. Median LSF was 3.9% (IQR 2.4-6%). Median administered activity was 0.9 GBq (IQR 0.6-1.4), for a median segmental volume of 170 cm3 (range: 60-530). Median lung dose was 1.9 Gy (IQR: 1.0-3.3). The presence of a transjugular intrahepatic portosystemic shunt (TIPS; n = 38) was associated with LSF >10% (odds ratio 12.2; 95% CI 5.2-28.6; p <0.001). Median LSF was 3.8% (IQR: 2.4-5.7%) and 6% (IQR: 3.8-15.3%) in no-TIPS vs. TIPS patients (p <0.001). CONCLUSION: LSF is clinically negligible in patients with UNOS T1/T2 HCC without TIPS. When segmental injections are planned, this step can be eliminated, thereby reducing time-to-treatment, number of procedures, and improving convenience for patients traveling from faraway. LAY SUMMARY: Transarterial radioembolization is a microembolic transarterial treatment for hepatocellular carcinoma. In our study, we found that early stage patients, where segmental injections are planned, exhibited low lung shunting, effectively eliminating the risk of radiation pneumonitis. We propose that the lung shunt study be eliminated in this subgroup, thus leading to fewer procedures, a cost reduction and improved convenience for patients.
BACKGROUND & AIMS: Pre-treatment Tc-99m macroaggregated albumin (MAA) scans are routinely performed prior to transarterial radioembolization (TARE) to estimate lung shunt fraction (LSF) and lung dose. In this study, we investigate LSF observed in early hepatocellular carcinoma (HCC) and provide the scientific rationale for eliminating this step from routine practice. METHODS:Patients with HCC who underwent Y90 from 2004 to 2018 were reviewed. Inclusion criteria were early stage HCC (UNOS T1/T2/Milan criteria: solitary ≤5 cm, 3 nodules ≤3 cm). LSF was determined using MAA in all patients. Associations between LSF and baseline characteristics were investigated. A "no-MAA" paradigm was then proposed based on a homogenous group that expressed very low LSF. RESULTS: Of 1,175 patients with HCC treated with TARE, 448 patients met inclusion criteria. Mean age was 65.6 years and 303 (68%) were males. A total of 352 (79%) had solitary lesions and 406 (91%) unilobar disease. Two-hundred and forty-three (54%), 178 (40%) and 27 (6%) patients were Child-Pugh class A, B and C, respectively. Median LSF was 3.9% (IQR 2.4-6%). Median administered activity was 0.9 GBq (IQR 0.6-1.4), for a median segmental volume of 170 cm3 (range: 60-530). Median lung dose was 1.9 Gy (IQR: 1.0-3.3). The presence of a transjugular intrahepatic portosystemic shunt (TIPS; n = 38) was associated with LSF >10% (odds ratio 12.2; 95% CI 5.2-28.6; p <0.001). Median LSF was 3.8% (IQR: 2.4-5.7%) and 6% (IQR: 3.8-15.3%) in no-TIPS vs. TIPS patients (p <0.001). CONCLUSION:LSF is clinically negligible in patients with UNOS T1/T2 HCC without TIPS. When segmental injections are planned, this step can be eliminated, thereby reducing time-to-treatment, number of procedures, and improving convenience for patients traveling from faraway. LAY SUMMARY: Transarterial radioembolization is a microembolic transarterial treatment for hepatocellular carcinoma. In our study, we found that early stage patients, where segmental injections are planned, exhibited low lung shunting, effectively eliminating the risk of radiation pneumonitis. We propose that the lung shunt study be eliminated in this subgroup, thus leading to fewer procedures, a cost reduction and improved convenience for patients.
Authors: Riad Salem; Siddharth A Padia; Marnix Lam; Carlo Chiesa; Paul Haste; Bruno Sangro; Beau Toskich; Kirk Fowers; Joseph M Herman; S Cheenu Kappadath; Thomas Leung; Daniel Y Sze; Edward Kim; Etienne Garin Journal: Eur J Nucl Med Mol Imaging Date: 2022-09-17 Impact factor: 10.057
Authors: Adam Swersky; Laura Kulik; Aparna Kalyan; Karen Grace; Juan Carlos Caicedo; Robert J Lewandowski; Riad Salem Journal: Semin Intervent Radiol Date: 2021-10-07 Impact factor: 1.780
Authors: Ahmed Gabr; Ahsun Riaz; Guy E Johnson; Edward Kim; Siddharth Padia; Robert J Lewandowski; Riad Salem Journal: Eur J Nucl Med Mol Imaging Date: 2020-08-04 Impact factor: 9.236
Authors: Mohammad Elsayed; Mohammad Loya; James Galt; David M Schuster; Zachary L Bercu; Janice Newsome; David Brandon; Sonia Benenati; Keywan Behbahani; Richard Duszak; Ila Sethi; Nima Kokabi Journal: World J Gastrointest Oncol Date: 2021-05-15