Research ArticleClinical Investigation

Comparison of 3 Different Therapeutic Particles in Radioembolization of Locally Advanced Intrahepatic Cholangiocarcinoma

Martijn E.H.M. Wagemans, Britt Kunnen, Martina Stella, Rob van Rooij, Maarten Smits, Rutger Bruijnen, Marnix G.E.H. Lam, Hugo W.A.M. de Jong and Arthur J.A.T. Braat
Journal of Nuclear Medicine February 2024, 65 (2) 272-278; DOI: https://doi.org/10.2967/jnumed.123.265597

Article Figures & Data

Figures

  • Figure
  • FIGURE 1.
    FIGURE 1.

    VOIs: tumor (red) segmented by [18F]FDG PET/CT thresholding, transferred to 90Y PET/CT (or 166Ho SPECT/CT). Lungs (blue) are segmented by thresholding of associated CT of [18F]FDG PET/CT for lung volume measurement and by associated CT of 90Y PET/CT (or 166Ho SPECT/CT) for dosimetry where lung portions within 2 cm of liver boundary are excluded (light blue). Liver (green) and treated liver (in this example same as liver) are manually delineated on associated CT. For response assessment, tumor (red) is segmented by [18F]FDG PET/CT thresholding (follow-up).

  • FIGURE 2.
    FIGURE 2.

    Microsphere posttreatment dosimetry. Numbers above box plots indicate number of included tumors or patients. *P < 0.05. G = 90Y-glass; H = 166Ho; R = 90Y-resin; T/N = tumor-to-nontumor activity concentration ratio.

  • FIGURE 3.
    FIGURE 3.

    Lung dosimetry. Individual patient data are connected by line. *P < 0.05. G = 90Y-glass; H = 166Ho; R = 90Y-resin.

  • FIGURE 4.
    FIGURE 4.

    Extensive intrahepatic edema and necrosis after left lobar treatment with 90Y-glass microspheres. Shown are multiphase contrast-enhanced CT at baseline (A and C) and 3 mo after treatment (B and D). At baseline, primary tumor invades left liver lobe on portal venous CT (C) and shows enhancement in arterial phase (A). Posttreatment images show intrahepatic edema and necrosis, masking tumor for RECIST 1.1 assessment. However, disappearance of arterial enhancement suggests complete response according to modified RECIST.

  • FIGURE 5.
    FIGURE 5.

    Response according to RECIST 1.1 and TLG change. CR = complete response; PD = progressive disease; PR = partial response; SD = stable disease.

  • FIGURE 6.
    FIGURE 6.

    Hepatotoxicity classification with respect to dose absorbed by whole normal liver (left) and treated normal liver (right).

Tables

  • TABLE 1.

    Microsphere Characteristics (7,31,32)

    Characteristic90Y-glass90Y-resin166Ho
    Mean diameter (μm)253030
    Range of diameter (μm)20–3020–6015–60
    Specific activity (Bq/sphere)4,354*40–70†200–400
    Mean β-energy (MeV)0.940.940.71
    Maximum β-energy (MeV)2.282.281.85 (50.0%), 1.77 (48.7%)
    Mean range of β-energy in tissue (mm)4.14.12.2
    Maximum range of β-energy in tissue (mm)11.311.38.7
    Half-life (h)64.264.226.8

    • ↵* At calibration, Pasciak et al. reported 4,354 Bq (24). Instructions for use indicate 2,500 Bq, but value can differ because of physical decay and administration timing.

    • ↵† Value may vary because FLEXdose (Sirtex) option allows injection up to 3 d before calibration, when vial activity is 10 GBq.

  • TABLE 2.

    Hepatotoxicity Classification (22)

    Hepatotoxicity gradeDescription
    0No liver toxicity
    1Minor liver toxicity, limited to increased aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, or γ-glutamyl transpeptidase levels (not exceeding grade 1 CTCAE toxicity)
    2Moderate liver toxicity, with self-limiting course; no medical intervention necessary
    3REILD manageable with noninvasive treatments such as diuretics, ursodeoxycholic acid, and steroids
    4REILD necessitating invasive medical treatment such as paracentesis, transfusions, hemodialysis, or TIPS
    5Fatal REILD

    • CTCAE = common terminology criteria for adverse events; TIPS = transjugular intrahepatic portosystemic shunt; REILD = radioembolization-induced liver disease.

  • TABLE 3.

    Patient Characteristics

    Characteristic90Y-glass90Y-resin166HoP*Significant pair
    Patients687
    Age (y)64.5 (32–80)61.5 (43–81)59 (45–83)0.87
    Sex0.94
     Male2432
     Female55
    Liver volume (cm3)2,077 (1,636–2,631)1,842 (1,231–2,182)2,261 (1,725–4,019)0.22
    Tumors724110.31
    Tumor volume (cm3)100 (10–470)156 (36–398)146 (16–2,655)0.73
    Total TLG (106)0.60 (0.09–5.8)1.2 (0.27–5.6)1.2 (0.11–24)0.77
    Type of radioembolization treatment0.0190Y-glass vs. 90Y-resin
     Whole liver084
     Lobar502
     Superselective101
     Previous treatments0.38
     Chemotherapy245
     Surgery100
     Chemotherapy + surgery130
     Chemotherapy + radioembolization100
     Surgery + radioembolization001
     None111
    ECOG performance status0.71
     0575
     1111
     2001
    Administered activity (MBq)2,273 (894–4,503)1,541 (729–1,943)6,568 (2,391–12,897)0.0190Y-glass vs. 166Ho; 90Y-resin vs. 166Ho
    Activity at posttreatment acquisition (MBq)1,818 (735–3,536)1,397 (596–1,697)324 (156–374)0.0190Y-glass vs. 166Ho; 90Y-resin vs. 166Ho
    LSF on planar [99mTc]MAA imaging3.5% (1.9%–11.7%)2.2% (0.8%–14.8%)4.4% (1.6%–13.4%)0.15

    • ↵* Numeric variables were assessed with Kruskal–Wallis H and Mann–Whitney U tests. For categoric variables, χ2 tests were used.

    • ECOG = Eastern Cooperative Oncology Group.

    • Qualitative data are number; continuous data are median and range.

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