Abstract
During pre-therapy evaluation for yttrium-90 (Y-90) radioembolization, it is uncommon to find severe imaging discordance between hepatic angiography versus technetium-99m-macroaggregated albumin (Tc-99m-MAA) single photon emission computed tomography with integrated low-dose CT (SPECT/CT). The reasons for severe imaging discordance are unclear, and literature is scarce. We describe 3 patients with severe imaging discordance, whereby tumor angiographic contrast hypervascularity was markedly mismatched to the corresponding Tc-99m-MAA SPECT/CT, and its clinical impact. The incidence of severe imaging discordance at our institution was 4% (3 of 74 cases). We postulate that imaging discordance could be due to a combination of 3 factors: (1) different injection rates between soluble contrast molecules versus Tc-99m-MAA; (2) different arterial flow hemodynamics between soluble contrast molecules versus Tc-99m-MAA; (3) eccentric release position of Tc-99m-MAA due to microcatheter tip location, inadvertently selecting non-target microparticle trajectories. Tc-99m-MAA SPECT/CT more accurately represents hepatic microparticle biodistribution than soluble contrast hepatic angiography and should be a key criterion in patient selection for Y-90 radioembolization. Tc-99m-MAA SPECT/CT provides more information than planar scintigraphy to guide radiation planning and clinical decision making. Severe imaging discordance at pre-therapy evaluation is ominous and should be followed up by changes to the final vascular approach during Y-90 radioembolization.
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12149_2011_516_MOESM2_ESM.tif
SUPPLEMENTAL FIGURE 1: Patient 1. Triphasic liver CT shows the segment VII hepatocellular carcinoma (HCC) in transaxial view (Fig. 1A arterial phase; Fig. 1B delayed phase). Fig. 1C shows two HCC masses in segments V/VI and VII in coronal view (TIFF 3446 kb)
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SUPPLEMENTAL FIGURE 2: Patient 2. Digital subtraction angiogram (DSA) obtained with microcatheter tip (C) in the replaced right hepatic artery demonstrates good contrast hypervascularity in the segment V HCC (Figs. 2A and 2B, arrows: tumor). Corresponding catheter-directed CT hepatic angiogram (CTHA) showed good arterial contrast enhancement in the segment V tumor (Fig. 2C). Tc-99m-MAA was slowly injected at this location. Tc-99m-MAA SPECT/CT showed marked tumoral photopenia in the arterial territory of the replaced right hepatic artery (Fig. 2D, arrow: tumor). Fig. 2E: Tumoral photopenia (arrow) is accentuated by increasing the SPECT threshold of Fig. 2D. Mesenteric Tc-99m-MAA activity in Fig. 2E is due to extra-hepatic shunting of injected Tc-99m-MAA into a branch of the left gastric artery, not relevant to the current context. The patient underwent Y-90 radioembolization with no change to the vascular approach. Post-radioembolization Y-90 time-of-flight PET/CT showed poor tumoral Y-90 activity in the arterial territory of the replaced right hepatic artery, concordant with Tc-99m-MAA SPECT/CT (Fig. 2F Y-90 PET/CT; Fig. 2G Y-90 PET; Fig. 2H non-contrast-enhanced CT component of PET/CT; arrows: tumor) (TIFF 3824 kb)
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SUPPLEMENTAL FIGURE 3: Patient 3. Triphasic liver CT in the arterial phase shows a single large HCC in the right lobe (Fig. 3A). The tumor was supplied by the right hepatic artery, which trifurcates into 3 tumoral branches: superior (S), middle (M) and inferior (I). DSA obtained with the microcatheter tip (C) proximal to its trifurcation demonstrated good contrast perfusion in all 3 tumoral branches (Fig. 3B). Tc-99m-MAA was slowly injected at this location. Tc-99m-MAA SPECT/CT showed preferential Tc-99m-MAA implantation in the arterial territory of the superior branch (S), while territories supplied by the middle (M) and inferior (I) branches were markedly photopenic, suggesting severe imaging discordance (Fig. 3C). The vascular approach for Y-90 radioembolization was changed in response to the Tc-99m-MAA SPECT/CT findings, and Y-90 resin microspheres were injected super-selectively with the microcatheter tip positioned into each of the 3 branches (Fig. 3D; actual super-selective DSA images not shown). Super-selective catheter-directed CTHA obtained at each of the 3 branches delineate the perfused arterial territories (Fig. 3E superior branch; Fig. 3F middle branch; Fig. 3G inferior branch). Post-radioembolization Y-90 time-of-flight PET/CT showed satisfactory tumoral microsphere implantation in all 3 arterial territories (Fig. 3H Y-90 PET/CT; Fig. 3I Y-90 PET). (TIFF 4632 kb)
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Kao, Y.H., Tan, E.H., Teo, T.K.B. et al. Imaging discordance between hepatic angiography versus Tc-99m-MAA SPECT/CT: a case series, technical discussion and clinical implications. Ann Nucl Med 25, 669–676 (2011). https://doi.org/10.1007/s12149-011-0516-9
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DOI: https://doi.org/10.1007/s12149-011-0516-9