Abstract
To prepare for yttrium-90 (90Y) radioembolization therapy, digital subtraction angiography (DSA) and technetium- 99m-labeled macroaggregated albumin (99mTc MAA) scintigraphy are used for treatment planning and detection of potential nontarget embolization. We investigated how c-arm computed tomography (CACT) affects treatment planning as an adjunct to these conventional imaging modalities. From March 2007 to October 2008, 50 consecutive patients (26 men, 24 women; mean age, 58 years; range, 21-75 y) undergoing radioembolization were evaluated by CACT in addition to DSA and 99mTc MAA scintigraphy during treatment planning, and their records were retrospectively reviewed. CACT was performed by selective injection of diluted contrast at the planned site of microsphere administration, and post-processing with soft-tissue multiplanar reconstructions. CACT images were analyzed real-time to determine completeness of perfusion of the targeted hepatic territory and to survey neighboring viscera for extrahepatic perfusion. Additional angiography, embolization, and/or catheter repositioning was performed accordingly. In 23 of 50 cases (46%), extrahepatic enhancement or incomplete tumor perfusion seen on CACT affected the treatment plan. In 14 patients (28%), the findings were evident exclusively on CACT and not detected by DSA. When comparing CACT versus 99mTc MAA scintigraphy, CACT showed eight cases of extrahepatic enhancement (16%) that were not evident on 99mTc MAA imaging. CACT findings directed the additional embolization of vessels or repositioning of the microcatheter for better contrast agent and presumed microsphere distribution. A case of gastric ulcer from nontarget embolization caused by reader error was observed. Due to its high three-dimensional spatial and contrast resolution, contrast-enhanced CACT provides additional information about tumor and tissue perfusion not currently detectable by standard DSA or 99mTc MAA imaging. As the availability of flat-panel systems becomes more widespread, optimization of microsphere delivery by incorporating CACT techniques may become standard of practice.
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