Catheter-Directed Computed Tomography Hepatic Angiography for Yttrium-90 Selective Internal Radiotherapy of Hepatocellular Carcinoma Reduces Prophylactic Embolization of Extrahepatic Vessels
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.
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.
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.
KeywordsHepatocellular carcinoma Selective internal radiotherapy Intra-arterial CT Prophylactive embolization
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.
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.
For this type of study formal consent is not required. This study has obtained IRB approval from SingHealth Centralised Institutional Review Board.
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.
- 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.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.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
- 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
- 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
- 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.
- 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
- 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
- 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
- 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.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