⁹⁰Y Radioembolization After Radiation Exposure from Peptide Receptor Radionuclide Therapy

Abstract

Previous radiation therapy of the liver is a contraindication for performing ⁹⁰Y microsphere radioembolization, and its safety after internal radiation exposure through peptide receptor radionuclide therapy (PRRT) has not yet been investigated. Methods: We retrospectively assessed a consecutive cohort of 23 neuroendocrine tumor (NET) patients with liver-dominant metastatic disease undergoing radioembolization with ⁹⁰Y microspheres as a salvage therapy after failed PRRT. Toxicity was recorded throughout follow-up and reported according to Common Terminology Criteria for Adverse Events (version 3). Radiologic (response evaluation criteria in solid tumors), biochemical, and symptomatic responses were investigated at 3 mo after treatment, and survival analyses were performed with the Kaplan–Meier method (log-rank test, P < 0.05). Results: The median follow-up period after radioembolization was 38 mo (95% confidence interval, 18–58 mo). The mean previous cumulative activity of ¹⁷⁷Lu-DOTA-octreotate was 31.8 GBq. The mean cumulative treatment activity of ⁹⁰Y microspheres was 3.4 ± 2.1 GBq, administered to the whole liver in a single session (n = 8 patients), in a sequential lobar fashion (n = 10 patients), or to only 1 liver lobe (n = 5 patients). Only transient, mostly minor liver toxicity (no grade 4) was recorded. One patient (4.3%) developed a gastroduodenal ulcer (grade 2). The overall response rates for radiologic, biochemical, and symptomatic responses were 30.4%, 53.8%, and 80%, respectively. The median overall survival was 29 mo (95% confidence interval, 4–54 mo) from the first radioembolization session and 54 mo (95% confidence interval, 47–61 mo) from the first PRRT cycle. A tumor proliferation index Ki-67 greater than 5% predicted shorter survival (P = 0.007). Conclusion: Radioembolization is a safe and effective salvage treatment option in advanced NET patients with liver-dominant tumor burden who failed or reprogressed after PRRT. The lack of relevant liver toxicity despite high applied ⁹⁰Y activities and considerable previous cumulative activities of ¹⁷⁷Lu-octreotate is noteworthy and disputes internal radiation exposure by PRRT as a toxicity risk factor in subsequent radioembolization.