Splenomegaly-Associated Thrombocytopenia After Hepatic Yttrium-90 Radioembolization

Purpose

Thrombocytopenia is often observed after yttrium-90 radioembolization (RE). Possible mechanisms include radiation toxicity to the bone marrow, consumption in the liver due to local radiation effects, and sequestration in the spleen. We sought to identify the causative factors.

Materials and Methods

Patients with complete baseline and 3-month post-RE imaging and laboratory data were included in this retrospective analysis. Univariate and multivariate regression analyses were performed on clinical, procedural, and imaging data.

Results

A total of 116 patients were identified (65 male, 51 female; median age 64 years). Forty-six patients were treated for primary and 70 for metastatic liver malignancy. Of these, 86 were treated with resin and 30 with glass microspheres; median activity was 1.85 GBq. Eighty-three patients underwent whole-liver treatment. Maximum individual change in platelet count was ?20.2 % leading to new or increased grade of thrombocytopenia in 48 patients (41.4 %) by National Cancer Institute Common Toxicity Criteria for Adverse Events version 4.02 criteria. Independent risk factors for decreased platelet count included change in spleen volume (median change +17.5 %; p = 0.001) and whole-liver (rather than lobar or segmental) treatment (p = 0.025). Administered activity and absorbed dose were not associated with change in platelet count. The change in spleen volume itself was associated with previous epidermal growth factor receptor–inhibitor treatment (p = 0.002), whole-liver absorbed dose (p = 0.027), and multiple-line chemotherapy (0.012) for whole-liver treatments only.

Conclusion

Post-RE treatment increase of spleen volume is correlated with decreased peripheral platelet count suggesting a mechanism of increased portal hypertension and hypersplenism being responsible.     

Combination Ipsilateral Lobar and Segmental Radioembolization Using Glass Yttrium-90 Microspheres for Treatment of Multifocal Hepatic Malignancies

Eight patients with primary (n = 6) and metastatic (n = 2) disease of the liver underwent yttrium-90 radioembolization with glass microspheres using a combination of segmental and ipsilateral lobar approach to treat multifocal tumors containing a single dominant tumor. The superselective dose was administered to the dominant tumor, whereas lobar infusion was used for smaller tumors. Assuming uniform distribution, median dose to the segment with dominant tumor was 412.3 Gy and to the remaining lobe was 117.5 Gy. No instances of radiation-induced liver disease occurred. Combined segmental and ipsilateral lobar radioembolization is a well-tolerated procedure to treat unilateral multifocal hepatic tumors including a single dominant tumor.     

Hepatic Abscess After Yttrium-90 Radioembolization for Islet-Cell Tumor Hepatic Metastasis

Infectious complications after yttrium-90 (y-90) radioembolization of hepatic tumors are rare. Most reports describe hepatic abscesses as complications of other locoregional therapies, such as transcatheter arterial embolization or chemoembolization. These usually occur in patients with a history of biliary intervention and present several weeks after treatment. We report a case of hepatic abscess formed immediately after y-90 radioembolization of a hepatic metastasis in a patient who had no history of previous biliary instrumentation.     

Radiographic Response to Yttrium-90 Radioembolization in Anterior Versus Posterior Liver Segments

The purpose of our study was to determine if preferential radiographic tumor response occurs in tumors located in posterior versus anterior liver segments following radioembolization with yttrium-90 glass microspheres. One hundred thirty-seven patients with chemorefractory liver metastases of various primaries were treated with yttrium-90 glass microspheres. Of these, a subset analysis was performed on 89 patients who underwent 101 whole-right-lobe infusions to liver segments V, VI, VII, and VIII. Pre- and posttreatment imaging included either triphasic contrast material-enhanced CT or gadolinium-enhanced MRI. Responses to treatment were compared in anterior versus posterior right lobe lesions using both RECIST and WHO criteria. Statistical comparative studies were conducted in 42 patients with both anterior and posterior segment lesions using the paired-sample t-test. Pearson correlation was used to determine the relationship between pretreatment tumor size and posttreatment tumor response. Median administered activity, delivered radiation dose, and treatment volume were 2.3 GBq, 118.2 Gy, and 1,072 cm³, respectively. Differences between the pretreatment tumor size of anterior and posterior liver segments were not statistically significant (p = 0.7981). Differences in tumor response between anterior and posterior liver segments were not statistically significant using WHO criteria (p = 0.8557). A statistically significant correlation did not exist between pretreatment tumor size and posttreatment tumor response (r = 0.0554, p = 0.4434). On imaging follow-up using WHO criteria, for anterior and posterior regions of the liver, (1) response rates were 50% (PR = 50%) and 45% (CR = 9%, PR = 36%), and (2) mean changes in tumor size were −41% and −40%. In conclusion, this study did not find evidence of preferential radiographic tumor response in posterior versus anterior liver segments treated with yttrium-90 glass microspheres. Disclosure: R.S. is a consultant for MDS Nordion and has disclosed a potential conflict of interest. None of the other authors have disclosed a conflict. The data were controlled by all authors. No industry support for this study was provided.     

Long-Term Toxicity after Transarterial Radioembolization with Yttrium-90 Using Resin Microspheres for Neuroendocrine Tumor Liver Metastases

Purpose

To evaluate long-term effects of yttrium-90 (⁹⁰Y) transarterial radioembolization (TARE) for unresectable hepatic metastases of neuroendocrine tumors (NETs).

Safety and Efficacy of Y-90 Radioembolization After Prior Major Hepatic Resection

CardioVascular and Interventional Radiology - To evaluate the safety and efficacy of yttrium-90 radioembolization (RE) following left or right hepatic lobectomy. Between 2011 and 2016, 15 patients...     

90钇玻璃微球治疗肝癌的临床研究

探讨＾９０钇玻璃微球治疗肝癌的临床效果。材料与方法,１９９６年８月至１９９８年５月,应用＾９０钇治疗肝癌１７例,采用含有＾９０钇的三明治疗法：首先注入＾９０钇和超注化碘油悬浮液,然后注入三联合化疗药,最后用明胶海绵颗粒栓塞。对其中１２例施行了经皮股动脉药盒导管系统植入,并对操作技术进行了改进。     

Safety and Efficacy of Y-90 Radioembolization After Prior Major Hepatic Resection: Dosimetric Consideration

CardioVascular and Interventional Radiology -     

Radioembolization of Symptomatic,Unresectable Neuroendocrine Hepatic Metastases Using Yttrium-90 Microspheres

Purpose  

To evaluate safety, efficacy, and symptom-control of radioembolization in patients with unresectable liver metastases from neuroendocrine tumors (NETLMs).     

Reply To: Safety and Efficacy of Y-90 Radioembolization After Prior Major Hepatic Resection: Dosimetric Consideration

CardioVascular and Interventional Radiology -     

Radioembolization with 90Y Resin Microspheres of Neuroendocrine Liver Metastases: International Multicenter Study on Efficacy and Toxicity

CardioVascular and Interventional Radiology - Radioembolization of liver metastases of neuroendocrine neoplasms (NEN) has shown promising results; however, the current literature is of limited...     

Root Cause Analysis of Gastroduodenal Ulceration After Yttrium-90 Radioembolization

Introduction

A root cause analysis was performed on the occurrence of gastroduodenal ulceration after hepatic radioembolization (RE). We aimed to identify the risk factors in the treated population and to determine the specific mechanism of nontarget RE in individual cases.

Methods

The records of 247 consecutive patients treated with yttrium-90 RE for primary (n = 90) or metastatic (n = 157) liver cancer using either resin (n = 181) or glass (n = 66) microspheres were reviewed. All patients who developed a biopsy-proven microsphere-induced gastroduodenal ulcer were identified. Univariate and multivariate analyses were performed on baseline parameters and procedural data to determine possible risk factors in the total population. Individual cases were analyzed to ascertain the specific cause, including identification of the culprit vessel(s) leading to extrahepatic deposition of the microspheres.

Results

Eight patients (3.2 %) developed a gastroduodenal ulcer. Stasis during injection was the strongest independent risk factor (p = 0.004), followed by distal origin of the gastroduodenal artery (p = 0.004), young age (p = 0.040), and proximal injection of the microspheres (p = 0.043). Prolonged administrations, pain during administration, whole liver treatment, and use of resin microspheres also showed interrelated trends in multivariate analysis. Retrospective review of intraprocedural and postprocedural imaging showed a probable or possible culprit vessel, each a tiny complex collateral vessel, in seven patients.

Conclusion

Proximal administrations and those resulting in stasis of flow presented increased risk for gastroduodenal ulceration. Patients who had undergone bevacizumab therapy were at high risk for developing stasis.     

FDG PET/CT as a Prognostic Test After 90Y Radioembolization in Patients With Metastatic Hepatic Disease

ABSTRACT: The purpose of this study was to determine FDG PET/CT utility in predicting patient outcome undergoing Y RE for metastatic liver tumors.Thirty-one patients with metastatic tumors to the liver underwent Y RE between March 15, 2007, and May 5, 2011, at our institution. FDG PET/CT imaging was performed on each patient within 3 months before and after undergoing Y RE. Pretreatment and posttreatment FDG PET/CT were evaluated for SUV, number of liver lesions, and presence of disease outside the liver. The Kaplan-Meier method and Cox proportional hazard modeling was used to evaluate if SUV was a predictor of overall survival.Of the 31 patients, 12 were alive at the end of the study; median survival was 9 months (95% confidence interval, 7-18 months). The 24-month survival rate was 0.28 (95% confidence interval, 0.12-0.48). Kaplan-Meier analysis of preprocedure FDG PET/CT imaging showed no difference in rates of survival by number of lesions observed in the liver (P = 0.114) or presence of disease observed outside the liver (P = 0.719). Cases with new lesions outside the liver after treatment had significantly shorter survival times than cases without new lesions outside the liver (P = 0.002). Cox proportional hazard model showed that SUV levels before and after treatment were not significant predictors of overall survival.The appearance of new lesions outside the liver on FDG PET/CT within 3 months after Y RE was the only statistically significant variable in predicting poor outcome. Absence of new lesions outside the liver on postprocedure FDG PET/CT imaging helps identify patients achieving long-term survival.     

Prospective Study of Systemic Yttrium-90 Elution during Radioembolization of Hepatic Metastases

PurposeTo evaluate total blood radioactivity (BR) after SIR-Spheres yttrium-90 (⁹⁰Y) radioembolization and differences in BR based on delivery method.Materials and MethodsTwenty participants with hepatic metastases undergoing first radioembolization were prospectively enrolled from December 2017 to June 2018. Blood samples were drawn at baseline and 0, 10, 20, 60, and 120 minutes after ⁹⁰Y administration. BR was measured with a γ-counter and scaled by estimated blood volume. Percentage of instilled radioactivity in the bloodstream was calculated as area under the fitted curve, and differences between delivery methods were examined with nonparametric statistical tests.ResultsIn 10 participants, resin microspheres were instilled with 50% Isovue 300 diluted in saline solution in the D line, and 10 others were treated with dextrose 5% in water (D5W) in the D line. Median administered activities were 944 MBq (range, 746–1,993 MBq) and 1,213 MBq (range, 519–2,066 MBq), respectively. Fraction of ⁹⁰Y in blood was significantly higher with dilute contrast agent than with D5W (median, 0.5% of injected activity vs 0.2%; P = .001). Among all participants, the maximum activity delivered was 2,066 MBq, and a maximum of 1% of administered radioactivity was measured as free ⁹⁰Y in blood. Assuming these highest-case values and complete decay of all free ⁹⁰Y in bone, a dose to red marrow of 132.3 mGy was calculated by Organ Level INternal Dose Assessment/EXponential Modeling.ConclusionsBlood sampling after radioembolization allowed for estimation of the time–activity curve and BR. Delivery with 50% contrast agent in saline solution resulted in a significant increase in BR vs D5W, even though the total BR for both groups was nominal.