Abstract
Purpose
The aim of this study was to establish an algorithm for the prescription of 90Y glass microsphere radioembolization (90Y-GMRE) of HCC in individual patients based on the relationship between tumour dose (TD) and response validated by 90Y PET/CT dosimetry and dual-tracer PET/CT metabolic parameters.
Methods
The study group comprised 62 HCC patients prospectively recruited for 90Y-GMRE who underwent pretreatment dual-tracer (11C-acetate and 18F-FDG) PET/CT as surrogate markers of HCC cellular differentiation. Pretreatment tumour-to-nontumour ratio on 99mTc-MAA SPECT/CT (T/NTMAA) was correlated with posttreatment 90Y PET/CT T/NT90Y after quantification validation. The TD–response relationship for HCC of different tracer groups was assessed on follow-up PET/CT 2 months after treatment.
Results
90Y PET/CT was accurate in the measurement of recovery of injected 90Y activity (81.9–99.9%, median 94.8%). Pretreatment SPECT/CT T/NTMAA was strongly correlated with posttreatment 90Y PET/CT T/NT90Y (5.6 ± 3.2 versus 5.9 ± 3.5, T/NT90Y 1.01 × T/NTMAA + 0.161, r = 0.918, P < 0.05). The response rates were 72.4% (21/29), 70.6% (12/17) and 25% (4/16) for well, moderately and poorly differentiated HCC, respectively. The cut-off TD for a good response was significantly different between poorly differentiated and well/moderately differentiated HCC (262 Gy versus 152/174 Gy) with 89.2% sensitivity and 88% specificity. At a limiting tolerated liver dose of 70 Gy, the T/NTMAA thresholds for predicting a good response in poorly differentiated and well/moderately differentiated HCC were 3.5 and 2.0/2.3. Disregarding HCC cellular differentiation, the cut-off TD became 170 Gy, with lower sensitivity (70.3%) and specificity (76%).
Conclusion
90Y PET/CT can provide accurate dosimetry for 90Y-GMRE. Pretreatment T/NTMAA predicts posttreatment T/NT90Y. The TD thresholds for a good response are tracer-dependent, with a strong correlation between HCC radiosensitivity and cellular differentiation and other PET-based parameters. These cytokinetic factors improve treatment efficacy while minimizing organ damage for the prescription of personalized 90Y-GMRE.
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References
Salem R, Thurston KG. Radioembolization with 90yttrium microspheres: a state-of-the-art brachytherapy treatment for primary and secondary liver malignancies. Part 1: technical and methodologic considerations. J Vasc Interv Radiol. 2006;17(8):1251–78.
Salem R, Thurston KG. Radioembolization with 90yttrium microspheres: a state-of-the-art brachytherapy treatment for primary and secondary liver malignancies. Part 2: special topics. J Vasc Interv Radiol. 2006;17(9):1425–39.
Salem R, Thurston KG. Radioembolization with yttrium-90 microspheres: a state-of-the-art brachytherapy treatment for primary and secondary liver malignancies: part 3: comprehensive literature review and future direction. J Vasc Interv Radiol. 2006;17(10):1571–93.
Pan CC, Kavanagh BD, Dawson LA, Li XA, Das SK, Miften M, et al. Radiation-associated liver injury. Int J Radiat Oncol Biol Phys. 2010;76(3 Suppl):S94–100.
Benson R, Madan R, Kilambi R, Chander S. Radiation induced liver disease: a clinical update. J Egypt Natl Canc Inst. 2016;28(1):7–11.
Cao X, He N, Sun J, Tan J, Zhang C, Yang J, et al. Hepatic radioembolization with yttrium-90 glass microspheres for treatment of primary liver cancer. Chin Med J. 1999;112(5):430–2.
Garin E. Radioembolization with (90)Y-loaded microspheres: high clinical impact of treatment simulation with MAA-based dosimetry. Eur J Nucl Med Mol Imaging. 2015;42(8):1189–91.
Kao YH, Steinberg JD, Tay YS, Lim GK, Yan J, Townsend DW, et al. Post-radioembolization yttrium-90 PET/CT - part 2: dose-response and tumor predictive dosimetry for resin microspheres. EJNMMI Res. 2013;3(1):57.
Kao YH, Steinberg JD, Tay YS, Lim GK, Yan J, Townsend DW, et al. Post-radioembolization yttrium-90 PET/CT - part 1: diagnostic reporting. EJNMMI Res. 2013;3(1):56.
Willowson KP, Tapner M, QUEST Investigator Team, Bailey DL. A multicentre comparison of quantitative (90)Y PET/CT for dosimetric purposes after radioembolization with resin microspheres: the QUEST Phantom Study. Eur J Nucl Med Mol Imaging. 2015;42(8):1202–22.
Ilhan H, Goritschan A, Paprottka P, Jakobs TF, Fendler WP, Bartenstein P, et al. Systematic evaluation of tumoral 99mTc-MAA uptake using SPECT and SPECT/CT in 502 patients before 90Y radioembolization. J Nucl Med. 2015;56(3):333–8.
Leung WT, Lau WY, Ho SK, Chan M, Leung NW, Lin J, et al. Measuring lung shunting in hepatocellular carcinoma with intrahepatic-arterial technetium-99m macroaggregated albumin. J Nucl Med. 1994;35(1):70–3.
Wahl RL, Jacene H, Kasamon Y, Lodge MA. From RECIST to PERCIST: evolving considerations for PET response criteria in solid tumors. J Nucl Med. 2009;50(Suppl 1):122S–50S.
Ho S, Lau WY, Leung TW, Chan M, Johnson PJ, Li AK. Clinical evaluation of the partition model for estimating radiation doses from yttrium-90 microspheres in the treatment of hepatic cancer. Eur J Nucl Med. 1997;24(3):293–8.
Chiesa C, Mira M, Maccauro M, Romito R, Spreafico C, Sposito C, et al. A dosimetric treatment planning strategy in radioembolization of hepatocarcinoma with 90Y glass microspheres. Q J Nucl Med Mol Imaging. 2012;56(6):503–8.
Lau WY, Leung WT, Ho S, Leung NW, Chan M, Lin J, et al. Treatment of inoperable hepatocellular carcinoma with intrahepatic arterial yttrium-90 microspheres: a phase I and II study. Br J Cancer. 1994;70(5):994–9.
Gulec SA, Sztejnberg ML, Siegel JA, Jevremovic T, Stabin M. Hepatic structural dosimetry in (90)Y microsphere treatment: a Monte Carlo modeling approach based on lobular microanatomy. J Nucl Med. 2010;51(2):301–10.
Haber AH, Rothstein BE. Radiosensitivity and rate of cell division: “law of Bergonie and Tribondeau”. Science. 1969;163(3873):1338–9.
Garin E, Lenoir L, Rolland Y, Edeline J, Mesbah H, Laffont S, et al. Dosimetry based on 99mTc-macroaggregated albumin SPECT/CT accurately predicts tumor response and survival in hepatocellular carcinoma patients treated with 90Y-loaded glass microspheres: preliminary results. J Nucl Med. 2012;53(2):255–63.
Garin E, Rolland Y, Edeline J, Icard N, Lenoir L, Laffont S, et al. Personalized dosimetry with intensification using 90Y-loaded glass microsphere radioembolization induces prolonged overall survival in hepatocellular carcinoma patients with portal vein thrombosis. J Nucl Med. 2015;56(3):339–46.
Ho S, Lau WY, Leung TW, Chan M, Ngar YK, Johnson PJ, et al. Partition model for estimating radiation doses from yttrium-90 microspheres in treating hepatic tumours. Eur J Nucl Med. 1996;23(8):947–52.
Ho S, Lau WY, Leung TW, Chan M, Chan KW, Lee WY, et al. Tumour-to-normal uptake ratio of 90Y microspheres in hepatic cancer assessed with 99Tcm macroaggregated albumin. Br J Radiol. 1997;70(836):823–8.
Lau WY, Sangro B, Chen PJ, Cheng SQ, Chow P, Lee RC, et al. Treatment for hepatocellular carcinoma with portal vein tumor thrombosis: the emerging role for radioembolization using yttrium-90. Oncology. 2013;84(5):311–8.
Srinivas SM, Natarajan N, Kuroiwa J, Gallagher S, Nasr E, Shah SN, et al. Determination of radiation absorbed dose to primary liver tumors and normal liver tissue using post-Radioembolization (90)Y PET. Front Oncol. 2014;4:255.
Lea WB, Tapp KN, Tann M, Hutchins GD, Fletcher JW, Johnson MS. Microsphere localization and dose quantification using positron emission tomography/CT following hepatic intraarterial radioembolization with yttrium-90 in patients with advanced hepatocellular carcinoma. J Vasc Interv Radiol. 2014;25(10):1595–603.
Pawlik TM, Keyomarsi K. Role of cell cycle in mediating sensitivity to radiotherapy. Int J Radiat Oncol Biol Phys. 2004;59(4):928–42.
Elschot M, Nijsen JF, Lam MG, Smits ML, Prince JF, Viergever MA, et al. (99m)Tc-MAA overestimates the absorbed dose to the lungs in radioembolization: a quantitative evaluation in patients treated with 166Ho-microspheres. Eur J Nucl Med Mol Imaging. 2014;41(10):1965–75.
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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the principles of the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.
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Ho, C.L., Chen, S., Cheung, S.K. et al. Radioembolization with 90Y glass microspheres for hepatocellular carcinoma: significance of pretreatment 11C-acetate and 18F-FDG PET/CT and posttreatment 90Y PET/CT in individualized dose prescription. Eur J Nucl Med Mol Imaging 45, 2110–2121 (2018). https://doi.org/10.1007/s00259-018-4064-6
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DOI: https://doi.org/10.1007/s00259-018-4064-6