Advertisement

Catheter-Directed Computed Tomography Hepatic Angiography for Yttrium-90 Selective Internal Radiotherapy of Hepatocellular Carcinoma Reduces Prophylactic Embolization of Extrahepatic Vessels

  • Winfred Xi Tai Goh
  • Sum LeongEmail author
  • Chow Wei Too
  • Lionel Tim-Ee Cheng
  • Seyed Ehsan Saffari
  • Rebekah Zhuyi Lee
  • Sean Tze Shen Ng
  • Richard Hoau Gong Lo
  • Kiang Hiong Tay
  • Shaun Xavier Ju Min Chan
  • Apoorva Gogna
  • Farah Gillan Irani
  • Nanda Venkatanarasimha
  • Kelvin Siu Hoong Loke
  • Pierce Kah Hoe Chow
  • David Chee Eng Ng
  • Thijs August Johan Urlings
  • Ankur Patel
  • Karthikeyan Damodharan
  • Luke Han Wei Toh
  • Bien Soo Tan
Clinical Investigation Imaging
Part of the following topical collections:
  1. Imaging

Abstract

Objectives

To determine the rate of prophylactic embolization of extrahepatic vessels in patients undergoing yttrium-90 selective internal radiotherapy (90Y SIRT) for hepatocellular carcinoma (HCC) with the use of catheter-directed computed tomography hepatic angiography (CD-CTHA).

Materials and Methods

This retrospective study included 186 HCC patients who received 90Y SIRT from May 2010 to June 2015 in a single institution. All procedures were performed in a hybrid angiography-CT suite equipped with digital subtraction angiography (DSA) and CD-CTHA capabilities. CD-CTHA was performed during pre-treatment hepatic angiography. 90Y SIRT was administered approximately 2 weeks later. Selective prophylactic embolization of extrahepatic vessels was performed if extrahepatic enhancement was seen on CD-CTHA or if an extrahepatic vessel opacified on DSA/CD-CTHA despite the final microcatheter position for 90Y microsphere delivery being beyond the origin of this vessel.

Results

Thirty-five patients (18.8%) required selective embolization of extrahepatic vessels. Technical success of 90Y SIRT was 99.5%. Two patients (1.1%) developed radiation-induced gastrointestinal ulceration, and one (0.54%) developed radiation-induced pneumonitis. Extrahepatic uptake of 90Y microspheres was seen in the gallbladder of one patient without significant complications.

Conclusion

The use of CD-CTHA in 90Y SIRT of HCC was associated with a low rate of prophylactic embolization of extrahepatic vessels while maintaining a high technical success rate of treatment and low rate of complications.

Level of Evidence

Level 4, case series.

Keywords

Hepatocellular carcinoma Selective internal radiotherapy Intra-arterial CT Prophylactive embolization 

Notes

Acknowledgements

WXT Goh would like to thank the AM-ETHOS Duke-NUS Medical Student Fellowship Award and the SingHealth Medical Student Talent Development Award for giving him the opportunity to work with faculty from the SingHealth Duke-NUS Radiological Sciences Academic Clinical Programme. The authors also thank Miss Hlaing Hlaing Win (clinical research coordinator) and Mr Cornelio Gutierrez Padre (principal radiographer) from Department of Vascular and Interventional Radiology SGH for their contributions to this publication.

Funding

This study was not supported by any funding.

Compliance with Ethical Standards

Conflict of interest

We would like to declare the following financial disclosures: CW Too—research and travel grants from Sirtex Medical, RHG Lo—proctor for Sirtex Medical, A Gogna—proctor for Sirtex Medical, grant support from Boston Scientific, FG Irani—proctor for Sirtex Medical, N Venkatanarasimha—travel grants from Sirtex Medical, PKH Chow—research grants and honorarium from Sirtex Medical, DCE Ng—research grants from Sirtex Medical, Merck, and Bayer, BS Tan—research grants from Boston Scientific.

Ethical Approval

For this type of study formal consent is not required. This study has obtained IRB approval from SingHealth Centralised Institutional Review Board.

Informed Consent

This study has obtained IRB approval from SingHealth Centralised Institutional Review Board and the need for informed consent was waived.

Consent for Publication

For this type of study, consent for publication is not required.

References

  1. 1.
    Bray F, Ferlay J, Soerjomataram I. Global Cancer Statistics 2018: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin. 2018;68:394–424.PubMedPubMedCentralGoogle Scholar
  2. 2.
    Llovet JM, Bru C, Bruix J. Prognosis of hepatocellular carcinoma: the BCLC staging classification. Semin Liver Dis. 1999;19(3):329–38.PubMedCrossRefPubMedCentralGoogle Scholar
  3. 3.
    Chow PKH, Choo SP, Ng DCE, Lo RHG, Wang MLC, Toh HC, et al. National cancer centre singapore consensus guidelines for hepatocellular carcinoma. Liver Cancer. 2016;5(2):97–106.PubMedPubMedCentralCrossRefGoogle Scholar
  4. 4.
    Salem R, Gordon AC, Mouli S, Hickey R, Kallini J, Gabr A, et al. Y90 radioembolization significantly prolongs time to progression compared with chemoembolization in patients with hepatocellular carcinoma. Gastroenterology. 2016;151(6):1155–63.PubMedPubMedCentralCrossRefGoogle Scholar
  5. 5.
    Gramenzi A, Golfieri R, Mosconi C, Cappelli A, Granito A, Cucchetti A, et al. Yttrium-90 radioembolization vs sorafenib for intermediate-locally advanced hepatocellular carcinoma: a cohort study with propensity score analysis. Liver Int. 2015;35(3):1036–47.PubMedCrossRefPubMedCentralGoogle Scholar
  6. 6.
    Saxena A, Meteling B, Kapoor J, Golani S, Danta M, Morris DL, et al. Yttrium-90 radioembolization is a safe and effective treatment for unresectable hepatocellular carcinoma: a single centre experience of 45 consecutive patients. Int J Surg. 2014;12(12):1403–8.PubMedCrossRefPubMedCentralGoogle Scholar
  7. 7.
    Kokabi N, Camacho JC, Xing M, El-Rayes BF, Spivey JR, Knechtle SJ, et al. Open-label prospective study of the safety and efficacy of glass-based yttrium 90 radioembolization for infiltrative hepatocellular carcinoma with portal vein thrombosis. Cancer. 2015;121(13):2164–74.PubMedCrossRefPubMedCentralGoogle Scholar
  8. 8.
    Sangro B, Carpanese L, Cianni R, Golfieri R, Gasparini D, Ezziddin S, et al. Survival after Yttrium-90 resin microsphere radioembolization of hepatocellular carcinoma across Barcelona clinic liver cancer stages: a European evaluation. Hepatology. 2011;54(3):868–78.PubMedCrossRefPubMedCentralGoogle Scholar
  9. 9.
    Tong AKT, Kao YH, Too CW, Chin KFW, Ng DCE, Chow PKH. Yttrium-90 hepatic radioembolization: clinical review and current techniques in interventional radiology and personalized dosimetry. Br J Radiol. 2016;89(1062):20150943.PubMedPubMedCentralCrossRefGoogle Scholar
  10. 10.
    Murthy R, Habbu A, Salem R. Trans-arterial hepatic radioembolisation of yttrium-90 microspheres. Biomed Imaging Interv J. 2006;2(3):e43.PubMedPubMedCentralCrossRefGoogle Scholar
  11. 11.
    Riaz A, Lewandowski RJ, Kulik LM, Mulcahy MF, Sato KT, Ryu RK, et al. Complications following Radioembolization with Yttrium-90 microspheres: a comprehensive literature review. J Vasc Interv Radiol. 2009;20(9):1121–30.PubMedCrossRefPubMedCentralGoogle Scholar
  12. 12.
    Riaz A, Awais R, Salem R. Side effects of yttrium-90 radioembolization. Front Oncol. 2014;4:198.PubMedPubMedCentralCrossRefGoogle Scholar
  13. 13.
    Leong QM, Lai HK, Lo RGH, Teo TKB, Goh A, Chow PKH. Radiation dermatitis following radioembolization for hepatocellular carcinoma: a case for prophylactic embolization of a patent falciform artery. J Vasc Interv Radiol. 2009;20(6):833–6.PubMedCrossRefPubMedCentralGoogle Scholar
  14. 14.
    Ward TJ, Louie JD, Sze DY. Yttrium-90 radioembolization with resin microspheres without routine embolization of the gastroduodenal artery. J Vasc Interv Radiol. 2017;28(2):246–53.PubMedCrossRefPubMedCentralGoogle Scholar
  15. 15.
    Ahmed O, Patel MV, Masrani A, Chong B, Osman M, Tasse J, et al. Assessing intra-arterial complications of planning and treatment angiograms for Y-90 radioembolization. Cardiovasc Intervent Radiol. 2017;40(5):704–11.PubMedCrossRefPubMedCentralGoogle Scholar
  16. 16.
    Paprottka PM, Paprottka KJ, Walter A, Haug AR, Trumm CG, Lehner S, et al. Safety of Radioembolization with 90Yttrium resin microspheres depending on coiling or no-coiling of aberrant/high-risk vessels. Cardiovasc Intervent Radiol. 2015;38(4):946–56.PubMedCrossRefPubMedCentralGoogle Scholar
  17. 17.
    Powerski M, Busse A, Seidensticker M, Fischbach F, Seidensticker R, Strach K, et al. Prophylactic embolization of the cystic artery prior to radioembolization of liver malignancies - an evaluation of necessity. Cardiovasc Intervent Radiol. 2015;38(3):678–84.PubMedCrossRefPubMedCentralGoogle Scholar
  18. 18.
    Theysohn JM, Müller S, Schlaak JF, Ertle J, Schlosser TW, Bockisch A, et al. Selective internal radiotherapy (SIRT) of hepatic tumors: how to deal with the cystic artery. Cardiovasc Intervent Radiol. 2013;36(4):1015–22.PubMedCrossRefPubMedCentralGoogle Scholar
  19. 19.
    Daghir AA, Gungor H, Haydar AA, Wasan HS, Tait NP. Embolisation of the gastroduodenal artery is not necessary in the presence of reversed flow before yttrium-90 radioembolisation. Cardiovasc Intervent Radiol. 2012;35(4):839–44.PubMedCrossRefGoogle Scholar
  20. 20.
    Hamoui N, Minocha J, Memon K, Sato K, Ryu R, Salem R, et al. Prophylactic embolization of the gastroduodenal and right gastric arteries is not routinely necessary before radioembolization with glass microspheres. J Vasc Interv Radiol. 2013;24(11):1743–5.PubMedCrossRefPubMedCentralGoogle Scholar
  21. 21.
    Cosin O, Bilbao JI, Alvarez S, de Luis E, Alonso A, Martinez-Cuesta A. Right gastric artery embolization prior to treatment with yttrium-90 microspheres. Cardiovasc Intervent Radiol. 2007;30(1):98–103.PubMedCrossRefPubMedCentralGoogle Scholar
  22. 22.
    Louie JD, Kothary N, Kuo WT, Hwang GL, Hofmann LV, Goris ML, et al. Incorporating cone-beam CT into the treatment planning for Yttrium-90 radioembolization. J Vasc Interv Radiol. 2009;20(5):606–13.PubMedCrossRefPubMedCentralGoogle Scholar
  23. 23.
    Heusner TA, Hamami ME, Ertle J, Hahn S, Poeppel T, Hilgard P, et al. Angiography-based C-arm CT for the assessment of extrahepatic shunting before radioembolization. Rofo. 2010;182(7):603–8.PubMedCrossRefPubMedCentralGoogle Scholar
  24. 24.
    van den Hoven AF, Prince JF, de Keizer B, Vonken E-JPA, Bruijnen RCG, Verkooijen HM, et al. Use of C-arm cone beam CT during hepatic radioembolization: protocol optimization for extrahepatic shunting and parenchymal enhancement. Cardiovasc Intervent Radiol. 2016;39(1):64–73.PubMedCrossRefPubMedCentralGoogle Scholar
  25. 25.
    Roche G, Teo T, Tan A, Irani FG. Intra-arterial CT angiography visualization of arterial supply to inferior vena cava tumor thrombus prior to radioembolization of hepatocellular carcinoma. Saudi J Gastroenterol. 2012;18(6):384–7.PubMedPubMedCentralCrossRefGoogle Scholar
  26. 26.
    Burgmans MC, Kao YH, Irani FG, Dames EL, Teo TKB, Goh ASW, et al. Radioembolization with infusion of yttrium-90 microspheres into a right inferior phrenic artery with hepatic tumor supply is feasible and safe. J Vasc Interv Radiol. 2012;23(10):1294–301.PubMedCrossRefPubMedCentralGoogle Scholar
  27. 27.
    Burgmans MC, Too CW, Kao YH, Goh ASW, Chow PKH, Tan BS, et al. Computed tomography hepatic arteriography has a hepatic falciform artery detection rate that is much higher than that of digital subtraction angiography and 99mTc-MAA SPECT/CT: implications for planning 90Y radioembolization? Eur J Radiol. 2012;81(12):3979–84.PubMedCrossRefPubMedCentralGoogle Scholar
  28. 28.
    Miyayama S, Yamashiro M, Okuda M. Detection of corona enhancement of hypervascular hepatocellular carcinoma by C-arm dual-phase cone-beam CT during hepatic arteriography. Cardiovasc Intervent Radiol. 2011;34:81–6.CrossRefGoogle Scholar
  29. 29.
    Kao YH, Hock Tan AE, Burgmans MC, Irani FG, Khoo LS, Gong Lo RH, et al. Image-guided personalized predictive dosimetry by artery-specific SPECT/CT partition modeling for safe and effective 90Y radioembolization. J Nucl Med. 2012;53(4):559–66.PubMedCrossRefPubMedCentralGoogle Scholar
  30. 30.
    Kim YC, Kim YH, Um SH, Seo YS, Park EK, Oh SY, et al. Usefulness of bremsstrahlung images after intra-arterial Y-90 resin microphere radioembolization for hepatic tumors. Nucl Med Mol Imaging. 2010;45(1):59–67.PubMedPubMedCentralCrossRefGoogle Scholar
  31. 31.
    Pasciak AS, Bourgeois AC, McKinney JM, Chang TT, Osborne DR, Acuff SN, et al. Radioembolization and the dynamic role of (90)Y PET/CT. Front Oncol. 2014;4:38.PubMedPubMedCentralGoogle Scholar
  32. 32.
    Kao Y, Steinberg JD, Tay Y, Lim GKY, Yan J, Townsend DW, et al. Post-radioembolization yttrium-90 PET/CT - part 1: diagnostic reporting. EJNMMI Res. 2013;3(1):56.PubMedPubMedCentralCrossRefGoogle Scholar
  33. 33.
    National Institute of Cancer. Common Terminology Criteria for Adverse Events (CTCAE). NIH Publ [Internet]. 2010;2009:0–71. http://ctep.cancer.gov/protocolDevelopment/electronic_applications/docs/ctcaev3.pdf.
  34. 34.
    Padia SA, Lewandowski RJ, Johnson GE, Sze DY, Ward TJ, Gaba RC, et al. Radioembolization of hepatic malignancies: background, quality improvement guidelines, and future directions. J Vasc Interv Radiol. 2017;28(1):1–15.PubMedCrossRefPubMedCentralGoogle Scholar
  35. 35.
    Raj S, Irani FG, Tay KH, Tan BS. C-arm cone beam computed tomography: a new tool in the interventional suite. Ann Acad Med Singap. 2013;42(11):585–92.PubMedPubMedCentralGoogle Scholar
  36. 36.
    Wong KM, Tan BS, Taneja M, Wong SY, Loke JS, Lin SE, et al. Cone beam computed tomography for vascular interventional radiology procedures: early experience. Ann Acad Med Singap. 2011;40(7):308–14.PubMedPubMedCentralGoogle Scholar
  37. 37.
    Loffroy R, Lin M, Rao P. Comparing the detectability of hepatocellular carcinoma by C-arm dual-phase cone-beam computed tomography during hepatic arteriography with conventional contrast- enhanced magnetic resonance imaging. Cardiovasc Intervent Radiol.2012;35:97–104.Google Scholar
  38. 38.
    Miyayama S, Matsui O. Superselective Conventional transarterial chemoembolization for hepatocellular carcinoma: rationale, technique, and outcome. J Vasc Interv Radiol. 2016;27(9):1269–78.PubMedCrossRefPubMedCentralGoogle Scholar
  39. 39.
    Tsurusaki M, Murakami T. Surgical and locoregional therapy of HCC: TACE. Liver Cancer. 2015;4(3):165–75.PubMedPubMedCentralCrossRefGoogle Scholar
  40. 40.
    Toyoda H, Kumada T, Sone Y. Impact of a unified CT angiography system on outcome of patients with hepatocellular carcinoma. Am J Roentgenol. 2009;192(3):766–74.PubMedCrossRefPubMedCentralGoogle Scholar
  41. 41.
    Takayasu K, Muramatsu Y, Maeda T, Iwata R, Furukawa H, Muramatsu Y, et al. Targeted transarterial oily chemoembolization for small foci of hepatocellular carcinoma using a unified helical CT and angiography system: analysis of factors affecting local recurrence and survival rates. Am J Roentgenol. 2001;176(3):681–8.CrossRefGoogle Scholar
  42. 42.
    Morshedi MM, Bauman M, Rose SC, Kikolski SG. Yttrium-90 resin microsphere radioembolization using an antireflux catheter: an alternative to traditional coil embolization for nontarget protection. Cardiovasc Intervent Radiol. 2015;38(2):381–8.PubMedCrossRefPubMedCentralGoogle Scholar
  43. 43.
    Pasciak AS, Mcelmurray JH, Bourgeois AC, Heidel RE, Bradley YC. The impact of an antireflux catheter on target volume particulate distribution in liver-directed embolotherapy: a pilot study. J Vasc Interv Radiol. 2015;26(5):660–9.PubMedCrossRefPubMedCentralGoogle Scholar
  44. 44.
    Sacco R, Conte C, Tumino E, Parisi G, Marceglia S, Metrangolo S, et al. Transarterial radioembolization for hepatocellular carcinoma: a review. J Hepatocell Carcinoma. 2016;3:25–9.CrossRefGoogle Scholar
  45. 45.
    Rohr A, Haverkamp B, Pedersen W, Vavricek J, Iqbal S, Jones J, et al. Retrospective review of tumor response to glass and resin Y-90 microsphere treatments in patients with hepatocellular carcinoma. Res J Oncol. 2017;1(1):1–7.Google Scholar
  46. 46.
    Borggreve AS, Landman AJEMC, Vissers CMJ, De Jong CD, Lam MGEH, Monninkhof EM, et al. Radioembolization: is prophylactic embolization of hepaticoenteric arteries necessary? A systematic review. Cardiovasc Intervent Radiol. 2016;39(5):696–704.PubMedPubMedCentralCrossRefGoogle Scholar
  47. 47.
    Schelhorn J, Ertle J, Schlaak JF, Mueller S, Bockisch A, Schlosser T, et al. Selective internal radiation therapy of hepatic tumors: procedural implications of a patent hepatic falciform artery. Springerplus. 2014;3:595.PubMedPubMedCentralCrossRefGoogle Scholar
  48. 48.
    Ahmadzadehfar H, Möhlenbruch M, Sabet A, Meyer C, Biersack HJ, Ezziddin S. Is prophylactic embolization of the hepatic falciform artery needed before radioembolization in patients with 99m Tc-MAA accumulation in the anterior abdominal wall? Eur J Nucl Med Mol Imaging. 2011;38:1477–84.PubMedCrossRefPubMedCentralGoogle Scholar
  49. 49.
    Karunanithy N, Gordon F, Hodolic M, Al-Nahhas A, Wasan HS, Habib N, et al. Embolization of hepatic arterial branches to simplify hepatic blood flow before yttrium 90 radioembolization: a useful technique in the presence of challenging anatomy. Cardiovasc Intervent Radiol. 2011;34(2):287–94.PubMedCrossRefPubMedCentralGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2019

Authors and Affiliations

  • Winfred Xi Tai Goh
    • 1
  • Sum Leong
    • 2
    • 3
    Email author
  • Chow Wei Too
    • 2
    • 3
  • Lionel Tim-Ee Cheng
    • 2
    • 4
  • Seyed Ehsan Saffari
    • 5
  • Rebekah Zhuyi Lee
    • 1
  • Sean Tze Shen Ng
    • 1
  • Richard Hoau Gong Lo
    • 2
    • 3
  • Kiang Hiong Tay
    • 2
    • 3
  • Shaun Xavier Ju Min Chan
    • 2
    • 3
  • Apoorva Gogna
    • 2
    • 3
  • Farah Gillan Irani
    • 2
    • 3
  • Nanda Venkatanarasimha
    • 2
    • 3
  • Kelvin Siu Hoong Loke
    • 2
    • 6
  • Pierce Kah Hoe Chow
    • 7
    • 8
    • 9
  • David Chee Eng Ng
    • 2
    • 6
  • Thijs August Johan Urlings
    • 10
  • Ankur Patel
    • 2
    • 3
  • Karthikeyan Damodharan
    • 2
    • 3
  • Luke Han Wei Toh
    • 2
    • 3
  • Bien Soo Tan
    • 2
    • 3
  1. 1.MOH Holdings Pte LtdSingaporeSingapore
  2. 2.Office of Academic and Clinical DevelopmentDuke-NUS Medical SchoolSingaporeSingapore
  3. 3.Department of Vascular and Interventional RadiologySingapore General HospitalSingaporeSingapore
  4. 4.Department of Diagnostic RadiologySingapore General HospitalSingaporeSingapore
  5. 5.Centre for Quantitative MedicineDuke-NUS Medical SchoolSingaporeSingapore
  6. 6.Department of Nuclear Medicine and Molecular ImagingSingapore General HospitalSingaporeSingapore
  7. 7.Division of Surgical OncologyNational Cancer Centre SingaporeSingaporeSingapore
  8. 8.Department of Hepato-Pancreato-Biliary and Transplant SurgerySingapore General HospitalSingaporeSingapore
  9. 9.Office of Clinical Sciences, Academic and Faculty AffairsDuke-NUS Medical SchoolSingaporeSingapore
  10. 10.Haaglanden Medical CentreThe HagueThe Netherlands

Personalised recommendations