Streamlining Y90 in UNOS T1/T2 by Eliminating the Lung Shunting - - PowerPoint PPT Presentation

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Jun 03, 2023 215 likes •391 views

Streamlining Y90 in UNOS T1/T2 by Eliminating the Lung Shunting Study: 403-patient Analysis Riad Salem MD MBA FSIR Professor of Radiology, Oncology, Surgery Director, Interventional Oncology Robert H Lurie Comprehensive Cancer Center

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Streamlining Y90 in UNOS T1/T2 by Eliminating the Lung Shunting Study: 403-patient Analysis

Riad Salem MD MBA FSIR Professor of Radiology, Oncology, Surgery Director, Interventional Oncology Robert H Lurie Comprehensive Cancer Center Northwestern Memorial Hospital Chicago, Illinois

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Disclosures

Consultant

BTG UK Ltd
Boston Scientific
BMS
Dova

Scientific Advisory Board

BTG UK Ltd
Cook
Eisai
Exelixis

Grant/Research Support

BTG UK Ltd

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Gaba et al. Radiology 2014

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Elsayed et al. Nuc Med Communicaitons 2019

RESULTS:

A total of 734 technetium-99 m macro aggregated albumin studies were identified

in 653 patients.

Among these cases, the liver tumor was hepatocellular carcinoma in 368 (50.1%),

colorectal cancer in 112 (15.3%), neuroendocrine tumor in 89 (12.1%), cholangiocarcinoma in 59 (8.0%), breast cancer in 27 (3.7%), and other metastatic malignancies in 79 (10.7%).

The mean lung shunt fraction for non-hepatocellular carcinoma cases was 7.4%,

which was significantly lower than the mean lung shunt fraction, 11.7%, for hepatocellular carcinoma cases (P = 0.0001).

In only one non-hepatocellular carcinoma case was yttrium-90 radioembolization

not pursued due to high lung shunt fraction (69.3%).

In comparison, the lung shunt fraction was too high to pursue radioembolization

in 37 hepatocellular carcinoma cases (mean lung shunt fraction 35.1%).

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CONCEPT

Subset of patients that current paradigm is challenging:
Travel challenges
Distance
Poor infrastructure
Procedural challenges
Difficult vascular access
Contrast allergy
Benefits:
Less travel
Cost savings
Fewer procedures à fewer potential risks
More competitive with other embolization procedures

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EJNMMI 2016

78 patients (2008-2015)

DEMOGRAPHICS:

9% (7/78) were international
18% (14/78) were from out-of-state
55% (43/78) traveled from outside city limits
18% (14/78) local residents
77% (61/78) with HCC
22% (17/78) with liver metastases

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EJNMMI 2016

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LI ET AL JVIR 2019

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WORK FLOW

Lobar Angiography/Call Nuclear Medicine Cone Beam CT Lobar MAA Administration/Transfer to Nuclear Medicine Selective Catheterization Radioembolization

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Methods: Ø Inclusion criteria:

early stage HCC (UNOS T1/T2/Milan criteria)solitary ≤5 cm, 3 nodules

≤3 cm). Ø LSF was estimated using MAA scanning in all patients. Ø Associations between LSF and baseline characteristics were investigated. Ø A “no-MAA” paradigm was then proposed based patients that expressed negligible LSF values and low risk of lung doses.

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Results: Ø Median LSF was 3.9% (IQR: 2.4%-6.2%). Ø Median administered activity was 0.96 GBq (IQR: 0.64-1.4), for a median segmental volume of 0.2 kg (IQR: 139.5-340.5) grams. Ø Median lung dose was 1.9 Gy (IQR: 1.0-3.4). Ø The presence of TIPS (N=35) was associated with LSF>10% (OR=10.79, CI:4.47-26.03, P<0.0001). Ø Median LSF was 3.9 (IQR: 2.4-5.9%) and 6.3 (IQR: 3.7-14.2%) in TIPS vs no-TIPS patients (P=0.0001).

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WORK FLOW

Lobar Angiography/Call Nuclear Medicine Cone Beam CT Lobar MAA Administration/Transfer to Nuclear Medicine Selective Catheterization Radioembolization

Cone Beam CT UNOS T1/T2 Radioembolization- Rad Seg

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66 Y/O MALE WITH HBV

5/27/14

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FOLLOW-UP

1 month post Y90

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CONCLUSIONS: PRINCIPLES OF NO-MAA Y90

Patient selection
Select segmental-never need to embolize UNOS T1/T2
Perform planar scan only
cone beam supersedes SPECT/CT findings
Assume 2 vessels perfusing the tumor
Complete elimination of MAA in UNOS T1/T2
“The 1 hour Y90”