Comparison of Tc-99m MAA Planar Versus SPECT/CT Imaging for Lung Shunt Fraction Evaluation Prior to Y-90 Radioembolization: Are We Overestimating Lung Shunt Fraction?

Abstract

Purpose

To compare lung shunt fraction (LSF) prior to Y-90 radioembolization calculated using planar imaging versus SPECT/CT in patients with hepatocellular carcinoma (HCC).

Methods

A single institution retrospective analysis of technetium-99m macroaggregated albumin (Tc-99m MAA) LSF studies for 293 consecutive patients with HCC between 2013 and 2018 was performed. LSF using planar imaging (PLSF) was compared to retrospectively calculated LSF using SPECT/CT (SLSF) via semiautomated segmentation using MIM v.6.9. Sub-analyses of patients were performed based on PLSF range, tumor size, BCLC stage, and Child–Pugh (C–P) score. Mean LSF absolute discrepancy between sub-groups was analyzed. Comparisons were performed using paired t tests and linear regression analysis.

Results

Mean PLSF, 8.27%, was greater than mean SLSF, 3.27% (p < 0.001). When categorizing patients by PLSF ranges of < 10%, 10–19.9%, and ≥ 20%, PLSF remained greater than SLSF in all subgroups (p’s < 0.001). Patients with PLSF ≥ 20% had a greater absolute discrepancy with SLSF (13.31%) compared to patients with PLSF < 20% (4.74%; p < 0.0001). LSF absolute discrepancy was greater for patients with a maximum liver tumor size ≥ 5.0 cm (5.59%) compared to a liver tumor size < 5.0 cm (4.40%; p = 0.0076). For all BCLC grades and C–P scores, PLSF was greater than SLSF. A greater LSF discrepancy existed for patients with a worse C–P score (C–P A: 4.78%, C–P B/C: 6.12%; p = 0.0081), but not BCLC stage (0/A/B: 4.87%, C: 4.56%; p = 0.5993).

Conclusion

In patients with HCC, SLSF is significantly lower compared to PLSF, with a greater discrepancy among patients with a PLSF ≥ 20%, tumor size ≥ 5 cm, and worse C–P score.

Level of Evidence

Level 3, Retrospective Study.

This is a preview of subscription content, access via your institution.

Fig. 1

References

  1. 1.

    Camacho JC, Moncayo V, Kokabi N, Reavey HE, Galt JR, Yamada K, et al. 90Y radioembolization: multimodality imaging pattern approach with angiographic correlation for optimized target therapy delivery. RadioGraphics. 2015;35(5):1602–18. https://doi.org/10.1148/rg.2015140314.

    Article  PubMed  Google Scholar 

  2. 2.

    Bhangoo MS, Karnani DR, Hein PN, Giap H, Knowles H, Issa C, et al. Radioembolization with Yttrium-90 microspheres for patients with unresectable hepatocellular carcinoma. J Gastrointest Oncol. 2015;6(5):469–78. https://doi.org/10.3978/j.issn.2078-6891.2015.056.

    Article  PubMed  PubMed Central  Google Scholar 

  3. 3.

    Gordon AC, Gabr A, Riaz A, Uddin OM, Abouchaleh N, Ali R, et al. Radioembolization super survivors: extended survival in non-operative hepatocellular carcinoma. Cardiovasc Intervent Radiol. 2018;41(10):1557–655. https://doi.org/10.1007/s00270-018-2008-y.

    Article  PubMed  PubMed Central  Google Scholar 

  4. 4.

    Wehrenberg-Klee E, Gandhi RT, Ganguli S. Patient selection and clinical outcomes of Y90 in hepatocellular carcinoma. Tech Vasc Intervent Radiol. 2019;22(2):70–3. https://doi.org/10.1053/j.tvir.2019.02.006.

    Article  Google Scholar 

  5. 5.

    Kooby DA, Egnatashvili V, Srinivasan S, Chamsuddin A, Delman KA, Kauh J, et al. Comparison of yttrium-90 radioembolization and transcatheter arterial chemoembolization for the treatment of unresectable hepatocellular carcinoma. JVIR. 2010;21(2):224–30. https://doi.org/10.1016/j.jvir.2009.10.013.

    Article  PubMed  Google Scholar 

  6. 6.

    Allred JD, Niedbala J, Mikell JK, Owen D, Frey KA, Dewaraja YK. The value of (99m)Tc-MAA SPECT/CT for lung shunt estimation in (90)Y radioembolization: a phantom and patient study. EJNMMI Res. 2018;8(1):50. https://doi.org/10.1186/s13550-018-0402-8.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  7. 7.

    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 Nuclear Med. 1994;35(1):70–3.

    CAS  Google Scholar 

  8. 8.

    Dittmann H, Kopp D, Kupferschlaeger J, Feil D, Groezinger G, Syha R, et al. A prospective study of quantitative SPECT/CT for evaluation of lung shunt fraction before SIRT of liver tumors. J Nuclear Med. 2018;59(9):1366–72. https://doi.org/10.2967/jnumed.117.205203.

    CAS  Article  Google Scholar 

  9. 9.

    Kao YH, Magsombol BM, Toh Y, Tay KH, Chow PK, Goh AS, et al. Personalized predictive lung dosimetry by technetium-99m macroaggregated albumin SPECT/CT for yttrium-90 radioembolization. EJNMMI Res. 2014;4:33. https://doi.org/10.1186/s13550-014-0033-7.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  10. 10.

    Vouche M, Habib A, Ward TJ, Kim E, Kulik L, Ganger D, et al. Unresectable solitary hepatocellular carcinoma not amenable to radiofrequency ablation: multicenter radiology-pathology correlation and survival of radiation segmentectomy. Hepatology (Baltimore, MD). 2014;60(1):192–201. https://doi.org/10.1002/hep.27057.

    Article  Google Scholar 

  11. 11.

    Strigari L, Sciuto R, Rea S, Carpanese L, Pizzi G, Soriani A, et al. Efficacy and toxicity related to treatment of hepatocellular carcinoma with 90Y-SIR spheres: radiobiologic considerations. J Nuclear Med. 2010;51(9):1377–85. https://doi.org/10.2967/jnumed.110.075861.

    CAS  Article  Google Scholar 

  12. 12.

    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. https://doi.org/10.3389/fonc.2014.00255.

    Article  PubMed  PubMed Central  Google Scholar 

  13. 13.

    Demirelli S, Erkilic M, Oner AO, Budak ES, Gunduz S, Ozgur O, et al. Evaluation of factors affecting tumor response and survival in patients with primary and metastatic liver cancer treated with microspheres. Nucl Med Commun. 2015;36(4):340–9. https://doi.org/10.1097/mnm.0000000000000257.

    CAS  Article  PubMed  Google Scholar 

  14. 14.

    Kennedy A, Nag S, Salem R, Murthy R, McEwan AJ, Nutting C, et al. Recommendations for radioembolization of hepatic malignancies using yttrium-90 microsphere brachytherapy: a consensus panel report from the radioembolization brachytherapy oncology consortium. Int J Radiat Oncol Biol Phys. 2007;68(1):13–23. https://doi.org/10.1016/j.ijrobp.2006.11.060.

    Article  PubMed  Google Scholar 

  15. 15.

    Sarfaraz M, Kennedy AS, Lodge MA, Li XA, Wu X, Yu CX. Radiation absorbed dose distribution in a patient treated with yttrium-90 microspheres for hepatocellular carcinoma. Med Phys. 2004;31(9):2449–533. https://doi.org/10.1118/1.1781332.

    Article  PubMed  Google Scholar 

  16. 16.

    Yu N, Srinivas SM, Difilippo FP, Shrikanthan S, Levitin A, McLennan G, et al. Lung dose calculation with SPECT/CT for (9)(0)Yittrium radioembolization of liver cancer. Int J Radiat Oncol Biol Phys. 2013;85(3):834–9. https://doi.org/10.1016/j.ijrobp.2012.06.051.

    Article  PubMed  Google Scholar 

  17. 17.

    Gill H, Bian J, Gabriel M, Molvar C, Wagner R, Halama J. 99mTc-MAA SPECT/CT imaging for quantitative assessment of lung shunt fraction prior to 90Y transarterial radioembolization. J Nuclear Med. 2019;60(supplement 1):265.

    Google Scholar 

  18. 18.

    Zaharakis A, Leveque F, Backiel J, Tursi G, Palestro C, Nichols K. SPECT/CT for estimating hepatopulmonary shunting in selective internal radiotherapy: a phantom study. J Nucl Med. 2014;55(supplement 1):1496.

    Google Scholar 

  19. 19.

    Elschot M, Nijsen JF, Lam MG, Smits ML, Prince JF, Viergever MA, et al. ((9)(9)m)Tc-MAA overestimates the absorbed dose to the lungs in radioembolization: a quantitative evaluation in patients treated with (1)(6)(6)Ho-microspheres. Eur J Nuclear Med Mol Imaging. 2014;41(10):1965–75. https://doi.org/10.1007/s00259-014-2784-9.

    CAS  Article  Google Scholar 

  20. 20.

    Deipolyi AR, Iafrate AJ, Zhu AX, Ergul EA, Ganguli S, Oklu R. High lung shunt fraction in colorectal liver tumors is associated with distant metastasis and decreased survival. JVIR. 2014;25(10):1604–8. https://doi.org/10.1016/j.jvir.2014.06.019.

    Article  PubMed  Google Scholar 

  21. 21.

    Ludwig JM, Ambinder EM, Ghodadra A, Xing M, Prajapati HJ, Kim HS. Lung shunt fraction prior to yttrium-90 radioembolization predicts survival in patients with neuroendocrine liver metastases: single-center prospective analysis. Cardiovasc Intervent Radiol. 2016;39(7):1007–144. https://doi.org/10.1007/s00270-016-1323-4.

    Article  PubMed  Google Scholar 

  22. 22.

    Dendy MS, Ludwig JM, Kim HS. Predictors and prognosticators for survival with Yttrium-90 radioembolization therapy for unresectable colorectal cancer liver metastasis. Oncotarget. 2017;8(23):37912–22. https://doi.org/10.18632/oncotarget.16007.

    Article  PubMed  PubMed Central  Google Scholar 

  23. 23.

    Antkowiak M, Gabr A, Das A, Ali R, Kulik L, Ganger D, et al. Prognostic role of albumin, bilirubin, and ALBI scores: analysis of 1000 patients with hepatocellular carcinoma undergoing radioembolization. Cancers (Basel). 2019;11(6):879. https://doi.org/10.3390/cancers11060879.

    CAS  Article  Google Scholar 

  24. 24.

    Elsayed M, Martin JG, Dabrowiecki A, Goldman DT, Faraj R, McMahon JT, et al. Tc-99m-MAA lung shunt fraction before Y-90 radioembolization is low among patients with non-hepatocellular carcinoma malignancies. Nucl Med Commun. 2019;40(11):1154–7. https://doi.org/10.1097/mnm.0000000000001089.

    CAS  Article  PubMed  Google Scholar 

  25. 25.

    Gaba RC, Zivin SP, Dikopf MS, Parvinian A, Casadaban LC, Lu Y, et al. Characteristics of primary and secondary hepatic malignancies associated with hepatopulmonary shunting. Radiology. 2014;271(2):602–12. https://doi.org/10.1148/radiol.14131969.

    Article  PubMed  Google Scholar 

Download references

Funding

This study was not supported by any funding.

Author information

Affiliations

Authors

Corresponding author

Correspondence to Mohammad Elsayed.

Ethics declarations

Conflict of interest

Nima Kokabi receives research support from SIRTEX Medical Ltd. The remaining authors have no financial disclosures.

Ethical Approval

For this type of study, formal consent is not required.

Informed Consent

Informed consent was obtained from all individual participants included in the study.

Consent for Publication

Consent for publication was obtained for every individual person’s data included in the study.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Elsayed, M., Cheng, B., Xing, M. et al. Comparison of Tc-99m MAA Planar Versus SPECT/CT Imaging for Lung Shunt Fraction Evaluation Prior to Y-90 Radioembolization: Are We Overestimating Lung Shunt Fraction?. Cardiovasc Intervent Radiol 44, 254–260 (2021). https://doi.org/10.1007/s00270-020-02638-8

Download citation