SESSION TITLE: Medical Student/Resident Imaging Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Targeted radioembolization with 90Y (yttrium 90) has shown a survival advantage in advanced stage hepatocellular carcinoma1. Interventional radiologists perform this procedure, however nuclear, thoracic, and abdominal imagers play a key role in determining candidacy for this treatment via interpretation of 99mTc-MAA (macroaggregated albumin) hepatic perfusion imaging and accompanying CT scans2. It is critical for pulmonologists and thoracic radiologists to recognize normal and abnormal studies to avoid potential deadly complications in patients who are poor candidates for this therapy. CASE PRESENTATION: The patient is a 70-year-old male who presented with abdominal pain and was found to have multiple hepatic masses and bile duct dilation, which on biopsy was consistent with aggressive multifocal hepatocellular carcinoma. Additionally, he was found to have a partial portal vein thrombosis. Because of the extent of the disease he was deemed not to be a surgical candidate and therefore was referred for evaluation for potential 90Y chemoembolization. To evaluate candidacy, the patient underwent 99mTc-MAA hepatic perfusion imaging with chest and abdominopelvic CT scans. Results are shown in Figure 1. Scintigraphy demonstrated a pulmonary shunt fraction of 80%. DISCUSSION: It is essential to recognize that these results are highly abnormal and an absolute contraindication to 90Y chemoembolization. 90Y undergoes B-decay which can result in radiation pneumonitis when spheres containing the radiopharmaceutical lodge in the pulmonary capillaries. For 90Y sphere embolization, <10% lung shunting is considered acceptable for therapy. For patients with shunt fractions <10-20%, a reduction of spheres delivered is necessary, and shunts >20% are a contraindication to the procedure3. Notably, portal vein thrombosis is not a contraindication however should be considered in planning. CT and angiography are key tools for identifying the shunt. CONCLUSIONS: 90Y embolization may be a helpful tool to attenuate the progression of hepatocellular carcinoma, but carries the risk of dangerous radiation pneumonitis in patients with significant pulmonary shunts. It is essential for clinicians to be aware of the potential danger and able to recognize abnormalities on preprocedural imaging studies to prevent harming the patient. Reference #1: Jordi Bruix, Margarita Sala, Josep M. Llovet. Chemoembolization for hepatocellular carcinoma. Gastroenterology; Volume 127, Issue 5, Supplement 1, 2004, S179-S188, https://doi.org/10.1053/j.gastro.2004.09.032. Reference #2: Kao, Y., Steinberg, J.D., Tay, Y. et al. Post-radioembolization yttrium-90 PET/CT - part 1: diagnostic reporting. EJNMMI Res 3, 56 (2013). https://doi.org/10.1186/2191-219X-3-56. Reference #3: Livnat Uliel, Henry D. Royal, Michael D. Darcy, Darryl A. Zuckerman, Akash Sharma and Nael E. Saad. From the Angio Suite to the γ-Camera: Vascular Mapping and 99mTc-MAA Hepatic Perfusion Imaging Before Liver Radioembolization—A Comprehensive Pictorial Review. J Nucl Med November 1, 2012 vol. 53 no. 11 1736-1747. doi: 10.2967/jnumed.112.105361. DISCLOSURES: No relevant relationships by Kathleen Capaccione, source=Web Response Speaker/Speaker's Bureau relationship with Genentech Please note: $20001 - $100000 Added 06/11/2020 by Mary Salvatore, source=Web Response, value=Honoraria research grant relationship with Boehringer Ingelheim Please note: >$100000 Added 06/11/2020 by Mary Salvatore, source=Web Response, value=Grant/Research Support