Abstract
Radiation pneumonitis via arteriohepatovenous shunting is a theoretical complication after 90Y radioembolization of unresectable hepatic neoplasms. Hence, lung shunting fraction (LSF) is routinely assessed with intrahepatic arterial technetium-99m macroaggregated albumin (MAA) scanning prior to treatment to: 1) estimate and 2) limit the radiation dose to the lungs. Increased LSF is most frequently encountered in patients with large tumor burdens, but it is unclear if LSF has any other prognostic value. We hypothesize that patients with low LSF will have improved survival compared to patients with high LSF. 205 consecutive patients were treated with 90Y microspheres for hepatocellular carcinoma (HCC) at our institution. As per protocol, all patients underwent pre-treatment hepatic angiography and intrahepatic arterial 99mTc MAA scanning to assess LSF. Patients were stratified into low LSF (0-10%), medium LSF (11-20%), and high LSF (> 20%). Post 90Y radioembolization, we compared survival of these patients using chi-square analysis. Stratification of patients by LSF yielded significantly (p = 0.0006) different median survival times (low: 312 days [n = 142], medium: 219 days [n = 41], and high: 158 days [n = 22]). Patients were then sub-stratified by Child-Pugh score; of those classified as Child-Pugh A (n = 88), patients with medium LSF had significantly (p < 0.05) improved survival (548 days) when compared to patients with low LSF (446 days) and high LSF (220 days). Patients classified as Child-Pugh B/C had significant (p = 0.0114) decreases in survival in low LSF (204 days) and medium LSF (136 days) when compared with high LSF (96 days). LSF is an independent predictor of survival in patients undergoing 90Y radioembolization for HCC. Among patients classified as Child-Pugh A, those with medium LSF paradoxically survive longer than those with low LSF, while both low and medium LSF patients survive longer than patients with high LSF. Among patients classified as Child-Pugh B/C, survival decreases with increasing LSF. LSF appears to represent an independent prognosticator of survival.
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