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      Post-radioembolization yttrium-90 PET/CT - part 1: diagnostic reporting

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          Abstract

          Background

          Yttrium-90 ( 90Y) positron emission tomography with integrated computed tomography (PET/CT) represents a technological leap from 90Y bremsstrahlung single-photon emission computed tomography with integrated computed tomography (SPECT/CT) by coincidence imaging of low abundance internal pair production. Encouraged by favorable early experiences, we implemented post-radioembolization 90Y PET/CT as an adjunct to 90Y bremsstrahlung SPECT/CT in diagnostic reporting.

          Methods

          This is a retrospective review of all paired 90Y PET/CT and 90Y bremsstrahlung SPECT/CT scans over a 1-year period. We compared image resolution, ability to confirm technical success, detection of non-target activity, and providing conclusive information about 90Y activity within targeted tumor vascular thrombosis. 90Y resin microspheres were used. 90Y PET/CT was performed on a conventional time-of-flight lutetium-yttrium-oxyorthosilicate scanner with minor modifications to acquisition and reconstruction parameters. Specific findings on 90Y PET/CT were corroborated by 90Y bremsstrahlung SPECT/CT, 99mTc macroaggregated albumin SPECT/CT, follow-up diagnostic imaging or review of clinical records.

          Results

          Diagnostic reporting recommendations were developed from our collective experience across 44 paired scans. Emphasis on the continuity of care improved overall diagnostic accuracy and reporting confidence of the operator. With proper technique, the presence of background noise did not pose a problem for diagnostic reporting. A counter-intuitive but effective technique of detecting non-target activity is proposed, based on the pattern of activity and its relation to underlying anatomy, instead of its visual intensity. In a sub-analysis of 23 patients with a median follow-up of 5.4 months, 90Y PET/CT consistently outperformed 90Y bremsstrahlung SPECT/CT in all aspects of qualitative analysis, including assessment for non-target activity and tumor vascular thrombosis. Parts of viscera closely adjacent to the liver remain challenging for non-target activity detection, compounded by a tendency for mis-registration.

          Conclusions

          Adherence to proper diagnostic reporting technique and emphasis on continuity of care are vital to the clinical utility of post-radioembolization 90Y PET/CT. 90Y PET/CT is superior to 90Y bremsstrahlung SPECT/CT for the assessment of target and non-target activity.

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          Radioembolization for hepatocellular carcinoma.

          I Bilbao, Mercedes Iñarrairaegui, Bruno Sangro (2012)
          Radioembolization is a form of brachytherapy in which intra-arterially injected (90)Y-loaded microspheres serve as sources for internal radiation purposes. It produces average disease control rates above 80% and is usually very well tolerated. Main complications do not result from the microembolic effect, even in patients with portal vein occlusion, but rather from an excessive irradiation of non-target tissues including the liver. All the evidence that support the use of radioembolization in HCC is based on retrospective series or non-controlled prospective studies. However, reliable data can be obtained from the literature, particularly since the recent publication of large series accounting for nearly 700 patients. When compared to the standard of care for the intermediate and advanced stages (transarterial embolization and sorafenib), radioembolization consistently provides similar survival rates. Two indications seem particularly appealing in the boundaries of these stages for first-line radioembolization. First, the treatment of patients straddling between the intermediate and advanced stages (intermediate patients with bulky or bilobar disease that are considered poor candidates for TACE, and advanced patients with solitary tumors invading a segmental or lobar branch of the portal vein). Second, the treatment of patients that are slightly above the criteria for resection, ablation or transplantation, for which downstaging could open the door for a radical approach. Radioembolization can also be used to treat patients progressing to TACE or sorafenib. With a number of clinical trials underway, the available evidence shows that it adds a significant value to the therapeutic weaponry against HCC of tertiary care centers dealing with this major cancer problem. Copyright © 2011 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.
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            Feasibility of 90Y TOF PET-based dosimetry in liver metastasis therapy using SIR-Spheres.

            Stephan Walrand, Stanislas Pauwels, Marc Van De Velde … (2010)
            (90)Y-labelled compounds used in targeted radiotherapy are usually imaged with SPECT by recording the bremsstrahlung X-rays of the beta decay. The continuous shape of the X-ray spectrum induces the presence of a significant fraction of scatter rays in the acquisition energy window, reducing the accuracy of biodistribution and of dosimetry assessments. The aim of this paper is to use instead the low branch of e(-) e(+) pair production in the (90)Y decay. After administration of (90)Y-labelled SIR-Spheres by catheterization of both liver lobes, the activity distribution is obtained by (90)Y time-of-flight (TOF) PET imaging. The activity distribution is convolved with a dose irradiation kernel in order to derive the regional dosimetry distribution. Evaluation on an anatomical phantom showed that the method provided an accurate dosimetry assessment. Preliminary results on a patient demonstrated a high-resolution absorbed dose distribution with a clear correlation with tumour response. This supports the implementation of (90)Y PET in selective internal radiation therapy of the liver.
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              Post-radioembolization yttrium-90 PET/CT - part 2: dose-response and tumor predictive dosimetry for resin microspheres

              Yung Kao, Jeffrey D Steinberg, Young-Soon Tay … (2013)
              Background Coincidence imaging of low-abundance yttrium-90 (90Y) internal pair production by positron emission tomography with integrated computed tomography (PET/CT) achieves high-resolution imaging of post-radioembolization microsphere biodistribution. Part 2 analyzes tumor and non-target tissue dose-response by 90Y PET quantification and evaluates the accuracy of tumor 99mTc macroaggregated albumin (MAA) single-photon emission computed tomography with integrated CT (SPECT/CT) predictive dosimetry. Methods Retrospective dose quantification of 90Y resin microspheres was performed on the same 23-patient data set in part 1. Phantom studies were performed to assure quantitative accuracy of our time-of-flight lutetium-yttrium-oxyorthosilicate system. Dose-responses were analyzed using 90Y dose-volume histograms (DVHs) by PET voxel dosimetry or mean absorbed doses by Medical Internal Radiation Dose macrodosimetry, correlated to follow-up imaging or clinical findings. Intended tumor mean doses by predictive dosimetry were compared to doses by 90Y PET. Results Phantom studies demonstrated near-perfect detector linearity and high tumor quantitative accuracy. For hepatocellular carcinomas, complete responses were generally achieved at D 70 > 100 Gy (D 70, minimum dose to 70% tumor volume), whereas incomplete responses were generally at D 70 100 Gy more easily than larger tumors. There was complete response in a cholangiocarcinoma at D 70 90 Gy and partial response in an adrenal gastrointestinal stromal tumor metastasis at D 70 53 Gy. In two patients, a mean dose of 18 Gy to the stomach was asymptomatic, 49 Gy caused gastritis, 65 Gy caused ulceration, and 53 Gy caused duodenitis. In one patient, a bilateral kidney mean dose of 9 Gy (V 20 8%) did not cause clinically relevant nephrotoxicity. Under near-ideal dosimetric conditions, there was excellent correlation between intended tumor mean doses by predictive dosimetry and those by 90Y PET, with a low median relative error of +3.8% (95% confidence interval, -1.2% to +13.2%). Conclusions Tumor and non-target tissue absorbed dose quantification by 90Y PET is accurate and yields radiobiologically meaningful dose-response information to guide adjuvant or mitigative action. Tumor 99mTc MAA SPECT/CT predictive dosimetry is feasible. 90Y DVHs may guide future techniques in predictive dosimetry.
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                Author and article information

                Journal
                Journal ID (nlm-ta): EJNMMI Res
                Journal ID (iso-abbrev): EJNMMI Res
                Title: EJNMMI Research
                Publisher: Springer
                ISSN (Electronic): 2191-219X
                Publication date Collection: 2013
                Publication date (Electronic): 25 July 2013
                Volume: 3
                Page: 56
                Affiliations
                [1 ]Department of Nuclear Medicine and PET, Singapore General Hospital, Outram Road, Singapore 169608, Singapore
                [2 ]Department of Nuclear Medicine, Sir Charles Gairdner Hospital, Hospital Ave, Perth, Western Australia 6009, Australia
                [3 ]Department of Nuclear Medicine, Austin Hospital, 145 Studley Rd, Melbourne, VIC 3084, Australia
                [4 ]Singapore Bioimaging Consortium, Agency for Science Technology and Research (A*STAR), 11 Biopolis Way, Helios Building, Singapore 138667, Singapore
                [5 ]Agency for Science Technology and Research (A*STAR) - National University of Singapore (NUS) Clinical Imaging Research Centre, 14 Medical Drive, Singapore 117599, Singapore
                [6 ]Department of Pathology, Singapore General Hospital, Outram Road, Singapore 169608, Singapore
                [7 ]Department of Diagnostic Radiology, Singapore General Hospital, Outram Road, Singapore 169608, Singapore
                [8 ]Department of General Surgery, Singapore General Hospital, Outram Road, Singapore 169608, Singapore
                [9 ]Department of Surgical Oncology, National Cancer Centre Singapore, 11 Hospital Drive, Singapore 169610, Singapore
                [10 ]Office of Clinical Sciences, Duke-National University of Singapore Graduate Medical School, 8 College Rd, Singapore 169857, Singapore
                [11 ]Department of Radiology, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
                Article
                Publisher ID: 2191-219X-3-56
                DOI: 10.1186/2191-219X-3-56
                PMC ID: 3726297
                PubMed ID: 23883566
                SO-VID: ba7d29ba-2399-4989-82ab-169028c00349
                Copyright © Copyright ©2013 Kao et al.; licensee Springer.
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 10 June 2013
                Date accepted : 16 July 2013
                Categories
                Subject: Original Research

                ScienceOpen disciplines: Radiology & Imaging
                Keywords: yttrium-90 radioembolization,selective internal radiation therapy,yttrium-90 pet/ct,bremsstrahlung spect/ct,diagnostic reporting,non-target activity
                Data availability:
                ScienceOpen disciplines: Radiology & Imaging
                Keywords: yttrium-90 radioembolization, selective internal radiation therapy, yttrium-90 pet/ct, bremsstrahlung spect/ct, diagnostic reporting, non-target activity

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