Radiation Pneumonitis Following Yttrium-90 Radioembolization: Case Report and Literature Review

doi:10.1016/j.jvir.2012.01.059

Journal of Vascular and Interventional Radiology

Volume 23, Issue 5, May 2012, Pages 669-674

https://doi.org/10.1016/j.jvir.2012.01.059 Get rights and content

Abstract

Radiation-induced pneumonitis (RP) is a rare complication of radioembolization with yttrium-90 (⁹⁰Y) microspheres. The present report describes a case of RP in a patient with liver metastases from a gastrointestinal stromal tumor after radioembolization with ⁹⁰Y glass microspheres. This patient developed clinical, functional, and radiographic findings consistent with RP, with near-complete pulmonary parenchymal recovery and no clinical evidence of relapse or progressive decline in pulmonary function over a 9-month period. As clinical use of radioembolization expands, rare adverse events such as RP may become more frequent. It is essential that interventional radiologists, radiation/medical oncologists, and nuclear medicine physicians recognize this potential complication.

Section snippets

Case Report

The information reported here complies with the Society of Interventional Radiology and American Association of Physicists in Medicine reporting standards (5, 6).

A 50-year-old white man was diagnosed in 2001 with a gastrointestinal stromal tumor (GIST) of the proximal jejunum. At resection, high-risk disease was found. Between 2003 and 2008, he was treated with imatinib, sunitinib, partial right hepatectomy, laparoscopic radiofrequency ablation, and chemoembolization. Chest computed tomography

Discussion

RP has been previously described (10). Patients present with nonproductive cough, dyspnea, fever, and bronchoalveolar lymphocytosis and eosinophilia (10, 11). Functionally, RP initially presents as a mild restrictive process on pulmonary testing (10, 11). Radiographically, RP presents 1–2 months after therapy with ill-defined patchy opacities and ground-glass nodularity in a symmetric (ie, “bat-wing”) pattern with relative peripheral/hilar sparing. Likewise, RP can also resemble an organizing

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Repeat Evaluation of Lung Shunt Fraction is Unnecessary: A Retrospective Observational Study of Successive Lung Shunt Fractions from Variable Arterial Distributions in Patients Undergoing Radioembolization of Primary and Secondary Liver Tumors
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Citation Excerpt :
This provides further evidence that the risk of clinically apparent RP is low after radioembolization and perhaps the current highly vigilant practice of repeating LSFs is unnecessary in most patients. However, some patients nearing a high CLD from prior treatment in the setting of a high LSF may require repeat LSF calculation to ensure the safety of radioembolization, especially as some cases of RP have been reported at lung doses of 23 Gy (less than the accepted dose of 30 Gy) (25–27). There were 2 outliers in the dataset that are worth considering when deciding on future treatments.
To evaluate whether the recalculation of lung shunt fraction (LSF) is necessary prior to next-stage or same lobe repeat radioembolization.
Retrospective chart review was performed for patients who underwent radioembolization between February 2008 and December 2018. Eighty of 312 patients had repeat mapping angiograms and LSF calculations. A total of 160 LSF calculations were made using planar imaging (155, [97%]) and single-photon emission computed tomography (5 [3%]) technetium-99m macroaggregated albumin hepatic arterial injection imaging. The mean patient age was 61.8 years ± 12.7; 69 (86%) patients had metastatic disease and 11 (14%) had hepatocellular carcinoma.
Patients had a median LSF of 5% (interquartile range [IQR] 3%–9%) with a median absolute difference of 1.25 (IQR 0.65–3.4) and a median of 76 days (IQR 42.5–120 days) between repeat LSF calculations. There was a median change in LSF of 0.2% between mapping studies (P = .11). There was no statistical significance between the repeat LSFs regardless of the arterial distribution (P = .79) or between tumor types (P = .75). No patients exceeded lung dose limits using actual or predicted prescribed dose amounts. The actual median lung dose was 2.6 Gy (IQR 1.8–4.4 Gy, maximum = 20.5) for the first radioembolization and 2.0 Gy (IQR 1.3–3.7 Gy, maximum = 10.1) for the second radioembolization.
No significant difference in LSF was identified between different time points and arterial distributions within the same patient undergoing repeat radioembolization. In patients who receive well under 30-Gy lung dose for the initial treatment and a 50-Gy cumulative lung dose, repeat radioembolization treatments in the same patient may not require a repeat LSF calculation.
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Another method, known as ‘skeletonisation’ (i.e. coil embolisation of all side branches of the hepatic artery), which used to be common practice, is no longer considered necessary, partly due to the use of injection positions that are located distally in the right and/or left hepatic arteries instead of a single proximal location in the proper hepatic artery [10]. Arteriovenous anastomoses, present in the hepatic tumours or parenchyma, allow microspheres to shunt towards the lungs through the venous circulation, which may lead to radiation pneumonitis [25]. Thus, excessive lung shunting is considered a contraindication.
Radioembolisation is a locoregional treatment modality for hepatic malignancies. It consists of several stages that are vital to its success, which include a pre-treatment angiographic simulation followed by nuclear medicine imaging, treatment activity choice, treatment procedure and post-treatment imaging. All these stages have seen much advancement over the past decade. Here we aim to provide an overview of the practice of radioembolisation, discuss the limitations of currently applied methods and explore promising developments.
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This unintended irradiation is uncommon but may potentially result in radiation induced damage to the organs with significant morbidity and rarely mortality. Radiation pneumonitis is a rare but dangerous complication with increased risk related to high liver-lung shunting above 10%98 and particularly more so if the liver-lung shunt is above 20%. This can be prevented either by excluding ineligible patients with high liver-lung shunt or by following dosimetry models and giving lung limiting Y-90 dose activities.78,99
Liver cancer is one of the top leading causes of mortality worldwide. Conventional imaging using contrast enhanced CT and MRI are currently the mainstay of oncologic imaging of the liver for the diagnosis and management of cancer. In the past two decades, especially since the advent of hybrid imaging in the form of PET/CT and SPECT/CT, molecular imaging has been increasingly utilized for oncologic imaging and the variety of radionuclide probes for imaging liver cancers have been expanding. Beyond the usual workhorse of FDG as an oncologic tracer, there is a growing body of evidence showing that radiolabeled choline tracers, C-11 acetate and other new novel tracers may have increasing roles to play for the imaging of liver tumors. On the therapy front, there have also been advances in recent times in terms of targeted therapies for both primary and secondary liver malignancies, particularly with transarterial radioembolization. The concept of theranostics can be applied to transarterial radioembolization by utilizing a pretreatment planning scan, such as Tc-99m macroaggregated albumin scintigraphy, coupled with post treatment imaging. Radiation dose planning by personalized dosimetric calculations to the liver tumors is also being advocated. This article explores the general trends in the field of nuclear medicine for the imaging and treatment of liver cancer above and beyond routine diagnosis and management.
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Liver metastases are an important cause of cancer-related death. Whereas treatment options previously consisted mainly of systemic chemotherapy and in some cases surgical resection, interventional radiological techniques offer alternatives for effecting disease control or even cure. In this chapter, the techniques of radioembolization and chemoembolization are reviewed. In addition, the role of chemoembolization and radioembolization is discussed in the management of liver metastases, focusing on the strongest evidence base in the areas of colorectal cancer and neuroendocrine tumors. Transcatheter embolization of liver metastases in other diseases such as uveal melanoma and breast cancer is also outlined.
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Y90 radioembolization is an alternative to transarterial chemoembolization for the intra-arterial treatment of hepatocellular carcinoma (HCC). However, the optimal treatment of HCC varies by tumor stage, underlying liver function and functional status, and local expertise. Therefore, the appropriate selection of patients for Y90 radioembolization is of paramount importance for optimal outcomes. Data on the role of Y90 radioembolization for HCC are most robust in the palliative treatment of inoperable, liver-confined disease. However, data are also present on the role of Y90 radioembolization as a bridge to or to downstage patients for transplant. Outcomes for radiation segmentectomy (ablative radiation doses) with curative intent or prior to resection are also discussed.

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: R.S. is a consultant for Nordion (Ottawa, Ontario, Canada). None of the other authors have identified a conflict of interest.

: C.L.W. and J.D.W. are cofirst authors of this article.

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Brief reportRadiation Pneumonitis Following Yttrium-90 Radioembolization: Case Report and Literature Review

Abstract

Section snippets

Case Report

Discussion

J Vasc Interv Radiol

J Vasc Interv Radiol

J Vasc Interv Radiol

J Vasc Interv Radiol

J Vasc Interv Radiol

J Vasc Interv Radiol

Int J Radiat Oncol Biol Phys

J Vasc Interv Radiol

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Semin Radiat Oncol

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Radiother Oncol

Radiother Oncol

Brief report
Radiation Pneumonitis Following Yttrium-90 Radioembolization: Case Report and Literature Review