Abstract
PurposeSelective Internal Radiation Therapy (SIRT) with 90yttrium (Y-90) is an increasingly used therapeutic option for unresectable liver malignancies. Nontarget embolization of extrahepatic tissue secondary to vascular shunting can lead to SIRT associated complications. Our aim was to assess whether extrahepatic shunts can reliably be diagnosed based on hepatic digital subtraction angiography (DSA) or whether subsequent SPECT/CT data can provide additional information.Materials and Methods825 patients with hepatocellular carcinoma (n = 636), hepatic metastases (n = 158) or cholangiocellular carcinoma (n = 31) were retrospectively analyzed. During hepatic DSA 128 arteries causing shunt flow to gastrointestinal tissue were coilembolized (right gastric artery n = 63, gastroduodenal artery n = 29; branches to duodenum / pancreas n = 36). Technectium-99m-labeled human serum albumin (HSA) was injected in all 825 patients. SPECT/CT data was used to identify additional or remaining shunts to extrahepatic tissue.ResultsAn unexpected uptake of HSA in extrahepatic tissue was found by SPECT/CT in 54/825 (6.5%) patients (located in stomach n = 13, duodenum n = 26, distal bowel segments n = 12, kidney n = 1, diaphragm n = 2). These patients underwent repeated DSA and newly identified shunt vessels were coilembolized in 22/54 patients, while in 12/54 patients a more distal catheter position for repeat injection of HSA was chosen. In 20/54 patients the repeated SPECT/CT data still revealed an extrahepatic HSA uptake. These patients did not receive SIRT.ConclusionMost extrahepatic shunts can be identified on DSA prior to Y-90 therapy. However, SPECT-CT data helps to identify additional shunts that were initially not seen on DSA.
Highlights
Selective Internal Radiation Therapy (SIRT), referred to as radioembolization (RE), is an increasingly used therapy for advanced primary and secondary liver malignancies [1,2,3]
An unexpected uptake of human serum albumin (HSA) in extrahepatic tissue was found by SPECT/CT in 54/825 (6.5%) patients
These patients underwent repeated digital subtraction angiography (DSA) and newly identified shunt vessels were coilembolized in 22/54 patients, while in 12/54 patients a more distal catheter position for repeat injection of HSA was chosen
Summary
Selective Internal Radiation Therapy (SIRT), referred to as radioembolization (RE), is an increasingly used therapy for advanced primary and secondary liver malignancies [1,2,3]. The incidence of side-effects associated with SIRT is relatively low [6] It may include vascular injuries during DSA, hepatobiliary toxicity / liver failure and postradioembolization syndrome (fatigue, nausea, vomiting) [7,8,9,10]. Complications can occur when microspheres are deposited in extrahepatic tissue The latter may lead to severe organ damage, of the gastrointestinal tract or the pancreas. It is mandatory to identify shunt vessels arising from the hepatic arterial tree supplying extrahepatic organs. These vessels should be either occluded by coil embolization prior to SIRT or a safe infusion side of the microspheres distal to the origin of the shunt vessel has to be chosen [11,12,13]
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