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122 Radioembolization in segmentectomy, lobectomy, and future liver remnant hypertrophy
of patients with median time-to-disease response
1.2 months, and WHO response was reported
in 59% of patients with median time-to-disease
response of 7.2 months. e largest series published to date by Vouche et al. (2014) demonstrated
complete response in 47% of patients, partial
response in 39% of patients, and stable disease in
12% of patients according to modied Response
Evaluation Criteria for Solid Tumors (mRECIST).
Median time-to-disease progression in this series
was 33.1 months with new intrahepatic lesions
responsible for disease progression in a majority of cases (Vouche et al., 2014). For comparison,
median time-to-disease progression has been
reported between 7.9 and 33.3 months in prospective studies and large cohort retrospective studies (Lewandowski et al., 2009; Salem et al., 2010;
Sangro et al., 2011).
6.4.4.2 Radiation segmentectomy
survival outcomes
Median overall survival for patients undergoing radiation segmentectomy has been reported
at 13.6–53.4 months (Riaz et al., 2011; Vouche
et al., 2014). Censored for transplantation, the
overall survival in the 34.5 months in the Vouche
et al. (2014) study compared with the uncensored median overall survival of 53.4 months.
ese overall survival rates are comparable with
or exceed overall survival reported in other large
cohorts of patients undergoing radioembolization
(Sangro et al., 2011). e variability in the reported
segmentectomy median overall survival is likely
secondary to the duration of the largest studies of
radiation segmentectomy—5 and 8 years, respectively (Riaz et al., 2011; Vouche et al., 2014). In
addition, sorafenib was approved late in 2007 and
was therefore unavailable for approximately half
of the Riaz et al. (2011) study period, while it was
available for the majority of the Vouche et al. (2014)
study duration (Llovet et al., 2008).
Because radiation segmentectomy is ideally
suited as a complimentary therapy to ablation in
instances wherein ablation options are limited,
comparison to overall survival in ablation studies
is warranted. Vouche et al. (2014) argue that overall survival as well as local control of tumor lesions
in cases of radiation segmentectomy does not differ dramatically from overall survival achieved by
ablation when stratied by measure of baseline
liver dysfunction (e.g., Childs–Pugh score)—given
the inherent limitations in comparing locoregional
therapy survival with that of ablation (Lencioni etal.,
2005; Chen et al., 2006; Livraghi et al., 2008; Pompili
et al., 2013; Vouche et al., 2014). Further, Vouche et
al. (2014) postulate that radiation segmentectomy
might oer similar survival outcomes as those seen
in Barcelona Clinic Liver Cancer (BCLC) A patients.
While controversies exist regarding the limitations
of percutaneous ablation, radiation segmentectomy
remains a viable option for complex lesions with the
potential for complete pathological necrosis of the
target lesion (Salem et al., 2015; Seror et al., 2015).
6.4.4.3 Radiation segmentectomy
dose and response
relationship
As the goal of radiation segmentectomy is to
achieve complete pathological necrosis (CPN)
equivalent to that seen in analogous ablation procedures, several authors have focused on the radiation dose necessary to achieve such an outcome. By
utilizing
dosimetry calculations, Garin et al. (2012) established a threshold dose of 205 Gy as predictive of
EASL imaging response, progression-free survival,
and overall survival. Specic to radiation segmentectomy, in a study by Vouche et al. (2014), 33 of
the 102 patients studied went on to receive liver
transplantation; explant analysis revealed that a
dose >190 Gy was associated with CPN. eir nd-
ings suggest that a threshold radiation dose exists
to achieve CPN. In their study of highly selective radiation segmentectomy, Padia et al. (2014)
reported a median dose of 255 Gy (range 105–1055
Gy) with a complete EASL response noted in 19 of
20 patients in their cohort. A summary of dose,
imaging response, and survival outcomes for several radiation segmentectomy studies is included
in Table 6.2.
99m
Tc-MAA SPECT/CT as a surrogate in
6.5 RADIOEMBOLIZATION
TOXICITIES AND
COMPLICATIONS
e most commonly encountered clinical adverse
eect following radioembolization is fatigue
(Salem and urston, 2006a). In addition, patients
6.6 Posttreatment patient management / 6.6.1 Patient care 123
may experience fever and chills up to several days
following treatment—likely secondary to the
eects of radiation on normal hepatic parenchyma
and subsequent release of endogenous pyrogens
(Murthy et al., 2005; Salem et al., 2005; Salem and
urston, 2006c). Additional clinical toxicities
described include abdominal pain, nausea, vomiting, anorexia, diarrhea, and weight loss (Riaz et
al., 2011; Vouche et al., 2014);. While these adverse
eects are oen self-limited, endoscopic evaluation
should be considered if symptoms are persistent as
they may reect the development of gastrointestinal ulceration (Salem and urston, 2006c).
Laboratory toxicities following radioembolization most commonly include abnormalities in bilirubin, albumin, AST, ALT, alkaline phosphatase,
platelet levels, lymphocyte counts, and international normalized ratio (INR). Care must be taken
in the interpretation of laboratory toxicities as it is
oen dicult to separate progressive liver disease
secondary to underlying disease versus treatment
toxicity. In a majority of cases, laboratory abnormalities are of limited clinical signicance and
occasionally reect preexisting poor liver function and cirrhosis (Rhee et al., 2005; Vouche et al.,
2014).
Radioembolization-induced liver disease (REILD)
is analogous to the radiation-induced liver disease
(RILD) described in the external beam radiation
therapy literature and characterized by jaundice,
fatigue, and the development of ascites typically
1–2 months posttreatment in the absence of tumor
progression or bile duct obstruction (Lawrence
etal., 1995; Sangro et al., 2008). REILD represents
a form of VOD as does RILD; the two entities dier
in that RILD presentation is described as an “anicteric ascites” with a proportional elevation of liver
enzymes in contrast to REILD, which is characterized by markedly increased bilirubin (Sangro et al.,
2008). Risk factors for the development of REILD
have been identied as prior treatment with chemotherapy, relative young age, elevated baseline
bilirubin, cirrhosis at baseline, whole-liver treatment (versus lobar therapy), and the ratio of activity
administered relative to the volume of treated liver
(Sangro et al., 2008; Riaz et al., 2009a; FernandezRos et al., 2015). Additional discussion related to
the side eects of radioembolization can be found
in other chapters in this book. Chapter 14 focuses
on identifying and managing clinical sequelae using
posttreatment imaging.
6.5.1 RADIATION
SEGMENTECTOMY
TOXICITIES
Of particular interest to radiation segmentectomy
is bilirubin toxicity as the concentration of a lobar
dose within one or two segments imposes the theoretical risk of increased biliary complications (Riaz
et al., 2011). REILD is less of a concern in radiation segmentectomy compared with treatments
involving greater volumes of liver as the target
liver parenchyma volume is reduced without limiting tumor treatment ecacy (Sangro et al., 2008).
However, the increased radiation dose delivered to
a smaller volume of liver parenchyma raises concern for injury to the biliary system. Rhee et al.
(2015) reported a statistically signicant increase
in bilirubin following segmental infusion of a lobar
radiation dose but deemed this change clinically
insignicant as only one of the 14 patients included
in their study had a change in Childs–Pugh class
following radioembolization (Rhee et al., 2005).
Riaz et al. (2011) reported 5% of patients within
their cohort of 84 patients undergoing radiation
segmentectomy developed small bilomas postprocedure as well as 1% of patients developing biliary
stricture within the treated segment (Riaz et al.,
2011). Vouche et al. (2014) did not report biloma or
biliary stricture development in their multicenter
cohort of 102 patients. Padia et al. (2014) also did
not report biloma or biliary stricture in their 20
patient cohort. For comparison, in a study of 327
patients who underwent standard lobar treatment
protocols, Atassi et al. (2008) found 17 cases of
biliary necrosis, 8 cases of biliary strictures, and 3
cases of biloma.
6.6 POSTTREATMENT PATIENT
MANAGEMENT
6.6.1 PATIENT CARE IN THE
IMMEDIATE POSTPROCEDURE
SETTING
Radioembolization is generally performed on an
outpatient basis. Following treatment, patients
recover for 2–6 hours prior to discharge home.
Practice patterns vary between institutions, but
patients may be sent home with gastrointestinal
124 Radioembolization in segmentectomy, lobectomy, and future liver remnant hypertrophy
ulcer prophylaxis such as proton pump inhibitors
or with steroid tapers for treatment of fatigue. All
patients require instruction regarding radiation
safety precautions as their body surface readings
may reach 1 mrem/hour following radioembolization (Salem and urston, 2006c). Further,
patients treated with resin should be advised that
urinary excretion of radioactivity is possible at
trace levels (25–50 kBq per liter of urine per GBq
of dose), which may be safely disposed of with
standard precautionary methods. While the toxicity prole of radioembolization is limited, patients
should again be reminded of potential treatment
adverse eects that they may experience following
discharge.
6.6.2 FOLLOW-UP EVALUATION
Patients are typically seen in an outpatient setting
2 weeks following treatment with radioembolization. At the time of this assessment, providers
should focus their history and examination on
the preservation of the patient’s performance status in addition to monitoring for adverse eects,
tumor lysis syndrome, or toxicities of nontarget
organs such as the lungs and the gastrointestinal
tract. Laboratory testing may be obtained at this
point and is likely to show lymphopenia, transient
increases in aminotransferase levels, and transient
increases in tumor markers (Salem and urston,
2006c). Follow-up imaging is obtained as described
below.
6.6.3 IMAGING RESPONSE
Generally, follow-up imaging with contrastenhanced CT or MRI is obtained at 1–3 months
posttreatment and then at 3- to 6-month intervals
for lesion surveillance and future treatment planning regardless of whether radioembolization is
performed in segmental or lobar treatment. Optimal
imaging response is expected to be seen approximately 3–6 months following therapy with median
time to response 6.6 months for change in size and
1.2 months for evidence of necrosis (Sangro et al.,
2006; Riaz et al., 2009b; Salem et al., 2010, 2013).
6.7 CLINICAL CASE EXAMPLES
6.7.1 SAMPLE RADIATION
LOBECTOMY AND THE
FUTURE LIVER REMNANT
HYPERTROPHY CASE
A 68-year-old male with a past medical history signicant for hepatitis C cirrhosis was screened for
liver cancer using gadolinium contrast-enhanced
magnetic resonance imaging that revealed a right
hepatic lobe, segment 8 HCC (Figure 6.1). e
patient was scheduled for right radioembolization
lobectomy following a tumor board conference
attended by transplant surgeons, hepatologists,
medical oncologists, and interventional radiologists. Resin microspheres were utilized in this
(a)
Figure 6.1 Magnetic resonance T1-weighted gadolinium-enhanced arterial phase (a) and portal
venous phase (b) sequences demonstrating a right liver lobe mass measuring >3 cm with early arterial
enhancement and portal venous washout consistent with hepatocellular carcinoma.
(b)
6.7 Clinical case examples / 6.7.1 Sample radiation lobectomy and the future liver remnant hypertrophy case 125
20.725 0.425
()
20.725 0.425
()
2
()
BSA2.13m
2
=
tumornormal
A
V
VV
()
+
38.8mL
38.8mL 1381.2mL
A
+
GBq2.13 0.20.03
bsa
A
()
=−+
1.96GBq
bsa
A =
Gy(kg)
3.42GBq
gl
o
DM
A
()
⋅
(b)
patient’s radioembolization lobectomy procedure.
e activity calculations are provided following
the body surface area method presented in Chapter
5—specically Equations 5.6 and 5.7:
BSAm 0.2025 height (m)weight(kg)
BSAm 0.2025 1.88 (87.1)
BSAm 0.2025 1.58 6.68
=⋅ ⋅
=⋅ ⋅
=⋅⋅
GBqBSA 0.2
bsa
=−+
tumor
GBq2.13 0.2
=−+
()
bsa
(a)
If glass microspheres had been utilized in this
radiation lobectomy case, a sample of the hypothetical activity calculation is provided utilizing
Equation 5.9 following the conversion of the lobar
volume to mass (conversion factor of 1.05 kg/L):
GBq
A
()
o
A
GBq
()
o
av
=
=
49.98(Js)
120Gy1.42kg
49.98(Js)
=
iver
⋅
⋅
⋅
Following successful radioembolization of
the right lobe, subsequent right hepatic lobe
atrophy and compensatory le hepatic lobe
Figure 6.2 Magnetic resonance T1-weighted precontrast (a), T1-weighted gadolinium-enhanced arte-
rial phase (b), and subtracted arterial phase (c) sequences demonstrating a right liver lobe treatment
cavity with increased T1 signal intensity on the precontrast sequence and lack of arterial enhancement as evidenced by the subtracted sequence. Baseline increased T1 signal intensity is likely due to
hemorrhagic changes within the lesion following RE. Magnetic resonance T1-weighted gadoliniumenhanced 20-minute delayed sequence (d) demonstrates a right lobe treatment cavity, decreased
right lobar contrast retention suggesting decreased hepatocyte function and atrophy, and left lobar
contrast retention within normal limits.
(c)
(d)
126 Radioembolization in segmentectomy, lobectomy, and future liver remnant hypertrophy
(a)
(b)
Figure 6.3 Volumetric rendering using Vitrea software (Vital Imaging, Inc., Minnetonka, Minnesota) of
the left lobe at the time of diagnosis (a) and 3 months following 90Y radioembolization lobectomy (b)
demonstrating interval hypertrophy of the future liver remnant.
hypertrophy were noted. At 3-month followup, complete mRECIST response was noted in
right lobe hepatectomy, the patient remains free
of recurrence.
the right lobe HCC (Figure 6.2). Le liver lobe
volumes prior to and 3 months following radioembolization lobectomy are provided (Figure
6.7.2 SAMPLE RADIATION
SEGMENTECTOMY CASE
6.3). e patient underwent surgical right lobe
hepatectomy 5 months following radioembolization lobectomy. As such, this case represents
successful treatment of the right hepatic tumor
along with le lobe hypertrophy in preparation
for surgical right lobectomy. Aer three years of
A 75-year-old male with a past medical history
signicant for nonalcoholic hepatic steatosis
was screened for liver cancer using contrastenhanced magnetic resonance imaging revealing
a right hepatic dome HCC (Figure 6.4). While
6.7 Clinical case examples / 6.7.2 Sample radiation segmentectomy case 127
Gy(kg)
gl
DM
()
⋅
GBq1SF 1 49.98(J s)
AR
()
()()
−−⋅⋅
2GBq10.05 10.01 49.98(Js)
0.09Kg
()()
⋅− ⋅− ⋅⋅
2GBq0.950.99 49.98(Js)
0.09Kg
⋅⋅⋅ ⋅
1042Gy
delivered
D =
(a)
Figure 6.4 Magnetic resonance T1-weighted gadolinium-enhanced arterial phase (a) and portal
venous phase (b) sequences demonstrating a hepatic dome mass measuring 2.5 cm with early arterial enhancement and portal venous washout consistent with hepatocellular carcinoma. Note the
location of the lesion, which is adjacent to the inferior vena cava, the right hepatic vein, and the
diaphragm.
the size of the lesion (2.5 cm in greatest axial
diameter) is amenable to percutaneous ablation,
the location of the lesion adjacent to the inferior
vena cava, the right hepatic vein, and the diaphragm limit the role of percutaneous ablation.
e patient was listed for liver transplantation,
received sorafenib therapy, and scheduled for
(b)
Given the segmental administration of the dose
calculated for lobar infusion, we can calculate the
dose delivered using Equation 6.1 with a 5% lung
shunt fraction, minimal dose remaining within
the vial (1%) at completion of radioembolization,
and a segmental volume of 89.1 mL (0.09 kg utilizing the 1.05 kg/L conversion):
radioembolization segmentectomy following a
tumor board conference consisting of transplant
surgeons, hepatologists, medical oncologists,
D
delivered
Gy
()
o
=
M
liver
(kg)
and interventional radiologists. e volume
of the right hepatic lobe was found to be 789.9
mL; utilizing the conversion factor of 1.05 kg/L,
D
delivered
Gy
=
()
the mass of the right lobe was calculated at 0.83
kg. e activity calculations utilizing the MIRD
model described in Chapter 5 are provided—specically utilizing Equation 5.9:
D
delivered
Gy
=
()
GBq
A
()
o
A
GBq
()
o
av
=
49.98(J s)
120Gy0.83kg
=
A
2.00GBq
=
o
⋅
49.98(J s)
At follow-up imaging, the patient demon-
iver
⋅
strated mRECIST complete response with progressive decrease in size of both the treatment
cavity and the treated segment (Figure 6.5).
e patient has remained tumor free with con-
⋅
tinued HCC surveillance 3 years aer radiation
segmentectomy.
128 Radioembolization in segmentectomy, lobectomy, and future liver remnant hypertrophy
(a)
(b)
(c)
Figure 6.5 Magnetic resonance T1-weighted gadolinium-enhanced arterial phase (a) at the time of
diagnosis. Magnetic resonance T1-weighted gadolinium-enhanced 20-minute delayed sequences
3 months after radioembolization (b) and 2 years after radioembolization (c) demonstrate progressive decrease in size of both the treatment cavity and the treated segment, which demonstrates
decreased contrast retention suggesting decreased hepatocyte function and atrophy.
6.8 CONCLUSIONS
e preceding discussion and sample cases
highlight the range of radioembolization applications available to physicians for patients with
varying disease severity. From BCLC A patients
with anatomically challenging lesions otherwise
amenable to ablation to patients with metastatic disease deemed unresectable at the time
of diagnosis, radioembolization oers solutions
in a variety of challenging clinical situations.
Understanding the underlying radiation and
tumor biology, dosimetry considerations, and
patient selection criteria are integral to proper
application of the breadth of radioembolization
techniques.
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