Management of high hepatopulmonary shunting in patients undergoing hepatic radioembolization

Thomas J. Ward, Anobel Tamrazi, Marnix G E H Lam, John D. Louie, Peter N. Kao, Rajesh P. Shah, Michael A. Kadoch, Daniel Y. Sze

Research output: Contribution to journalArticle

Abstract

Purpose To review the safety of hepatic radioembolization (RE) in patients with high (≥ 10%) hepatopulmonary shunt fraction (HPSF) using various prophylactic techniques. Materials and Methods A review was conducted of 409 patients who underwent technetium 99m-labeled macroaggregated albumin scintigraphy before planned RE. Estimated pulmonary absorbed radiation doses based on scintigraphy and hepatic administered activity were calculated. Outcomes from dose reductions and adjunctive catheter-based prophylactic techniques used to reduce lung exposure were assessed. Results There were 80 patients with HPSF ≥ 10% who received RE treatment (41 resin microspheres for metastases, 39 glass microspheres for hepatocellular carcinoma). Resin microspheres were used in 17 patients according to consensus guideline-recommended dose reduction; 38 patients received no dose reduction because the expected lung dose was <30 Gy. Prophylactic techniques were used in 25 patients (with expected lung dose ≤ 74 Gy), including hepatic vein balloon occlusion, variceal embolization, or bland arterial embolization before, during, or after RE delivery. Repeated scintigraphy after prophylactic techniques to reduce HPSF in seven patients demonstrated a median change of -40% (range, +32 to -69%). Delayed pneumonitis developed in two patients, possibly related to radiation recall after chemoembolization. Response was lower in patients treated with resin spheres with dose reduction, with an objective response rate of 13% and disease control rate of 47% compared with 56% and 94%, respectively, without dose reduction (P =.023, P =.006). Conclusions Dose reduction recommendations for HPSF may compromise efficacy. Excessive shunting can be reduced by prophylactic catheter-based techniques, which may improve the safety of performing RE in patients with high HPSF.

Original languageEnglish (US)
Pages (from-to)1751-1760
Number of pages10
JournalJournal of Vascular and Interventional Radiology
Volume26
Issue number12
DOIs
StatePublished - Dec 1 2015

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Liver
Microspheres
Radionuclide Imaging
Lung
Catheters
Radiation
Safety
Balloon Occlusion
Hepatic Veins
Technetium
Glass
Albumins
Hepatocellular Carcinoma
Pneumonia
Guidelines
Neoplasm Metastasis

ASJC Scopus subject areas

  • Radiology Nuclear Medicine and imaging
  • Cardiology and Cardiovascular Medicine

Cite this

Ward, T. J., Tamrazi, A., Lam, M. G. E. H., Louie, J. D., Kao, P. N., Shah, R. P., ... Sze, D. Y. (2015). Management of high hepatopulmonary shunting in patients undergoing hepatic radioembolization. Journal of Vascular and Interventional Radiology, 26(12), 1751-1760. https://doi.org/10.1016/j.jvir.2015.08.027

Management of high hepatopulmonary shunting in patients undergoing hepatic radioembolization. / Ward, Thomas J.; Tamrazi, Anobel; Lam, Marnix G E H; Louie, John D.; Kao, Peter N.; Shah, Rajesh P.; Kadoch, Michael A.; Sze, Daniel Y.

In: Journal of Vascular and Interventional Radiology, Vol. 26, No. 12, 01.12.2015, p. 1751-1760.

Research output: Contribution to journalArticle

Ward, TJ, Tamrazi, A, Lam, MGEH, Louie, JD, Kao, PN, Shah, RP, Kadoch, MA & Sze, DY 2015, 'Management of high hepatopulmonary shunting in patients undergoing hepatic radioembolization', Journal of Vascular and Interventional Radiology, vol. 26, no. 12, pp. 1751-1760. https://doi.org/10.1016/j.jvir.2015.08.027
Ward, Thomas J. ; Tamrazi, Anobel ; Lam, Marnix G E H ; Louie, John D. ; Kao, Peter N. ; Shah, Rajesh P. ; Kadoch, Michael A. ; Sze, Daniel Y. / Management of high hepatopulmonary shunting in patients undergoing hepatic radioembolization. In: Journal of Vascular and Interventional Radiology. 2015 ; Vol. 26, No. 12. pp. 1751-1760.
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abstract = "Purpose To review the safety of hepatic radioembolization (RE) in patients with high (≥ 10{\%}) hepatopulmonary shunt fraction (HPSF) using various prophylactic techniques. Materials and Methods A review was conducted of 409 patients who underwent technetium 99m-labeled macroaggregated albumin scintigraphy before planned RE. Estimated pulmonary absorbed radiation doses based on scintigraphy and hepatic administered activity were calculated. Outcomes from dose reductions and adjunctive catheter-based prophylactic techniques used to reduce lung exposure were assessed. Results There were 80 patients with HPSF ≥ 10{\%} who received RE treatment (41 resin microspheres for metastases, 39 glass microspheres for hepatocellular carcinoma). Resin microspheres were used in 17 patients according to consensus guideline-recommended dose reduction; 38 patients received no dose reduction because the expected lung dose was <30 Gy. Prophylactic techniques were used in 25 patients (with expected lung dose ≤ 74 Gy), including hepatic vein balloon occlusion, variceal embolization, or bland arterial embolization before, during, or after RE delivery. Repeated scintigraphy after prophylactic techniques to reduce HPSF in seven patients demonstrated a median change of -40{\%} (range, +32 to -69{\%}). Delayed pneumonitis developed in two patients, possibly related to radiation recall after chemoembolization. Response was lower in patients treated with resin spheres with dose reduction, with an objective response rate of 13{\%} and disease control rate of 47{\%} compared with 56{\%} and 94{\%}, respectively, without dose reduction (P =.023, P =.006). Conclusions Dose reduction recommendations for HPSF may compromise efficacy. Excessive shunting can be reduced by prophylactic catheter-based techniques, which may improve the safety of performing RE in patients with high HPSF.",
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