Clinical Study
Yttrium-90 Radioembolization of the Right Inferior Phrenic Artery in 20 Patients with Hepatocellular Carcinoma

https://doi.org/10.1016/j.jvir.2017.10.010Get rights and content

Abstract

Purpose

To address the feasibility of infusion of yttrium-90 (90Y) glass microspheres directly through the right inferior phrenic artery (RIPA).

Materials and Methods

From November 2015 to May 2017, 20 patients underwent 90Y radioembolization through the RIPA. When the systemic-to-pulmonary shunt was demonstrated on C-arm computed tomography (CT) of the RIPA, prophylactic embolization by polyvinyl alcohol (PVA) particles was performed prior to infusion of 90Y glass microspheres. Follow-up CT scans were retrospectively reviewed for pulmonary complications. Tumor response was determined by the modified Response Evaluation Criteria in Solid Tumors.

Results

Nine (45%) patients had systemic-to-pulmonary shunts on C-arm CT images of the RIPA. The feeder of the systemic-to-pulmonary shunt was the azygoesophageal branch (n = 7) and the anterior branch (n = 2). The mean activity of 90Y glass microspheres infused into the RIPA was 0.49 GBq (range, 0.19–1.55 GBq). No patient had symptomatic radiation pneumonitis or cutaneous complications during follow-up. Seven patients had focal atelectasis (n = 5), focal ground-glass opacity (n = 2), and/or a small amount of pleural effusion (n = 2) on follow-up image. Best tumor response fed by the RIPA was complete response (n = 4), partial response (n = 9), stable disease (n = 2), progressive disease (n = 4), and unevaluable (n = 1).

Conclusion

The administration of 90Y glass microspheres through the RIPA may be safe after embolization of a systemic-to-pulmonary shunt identified on C-arm CT.

Introduction

Radioembolization with yttrium-90 (90Y) microspheres is commonly performed for patients with unresectable hepatocellular carcinoma (HCC) 1, 2, 3. To achieve favorable outcomes, adequate distribution of microspheres throughout the entire tumor is the important factor. Up to 30% of HCC patients may have blood supply from extrahepatic collateral arteries, and the right inferior phrenic artery (RIPA) is the most common collateral artery 4, 5, 6, 7.

Whereas some literature suggests that chemoembolization through the RIPA is safe 4, 5, 6, 7, there are little data on radioembolization through the RIPA. Burgmans et al reported that administration of radioactive microspheres via the RIPA is safe, but only 5 patients received delivery of radioactive microspheres into the RIPA of 21 patients with tumors supplied by the RIPA (8). Although Abdelmaksoud et al insisted that redistribution of arterial flow to the hepatic tumor by embolization of extrahepatic collateral arteries was safe and effective (9), it is possible that redistribution may not be established, or other collateral arteries may take over blood supply to the tumor.

In a study that employed C-arm computed tomography (CT), the RIPA accompanied systemic-to-pulmonary shunts in 69% of patients (10). We hypothesized that it may be safe to administer radioactive microspheres into the RIPA after embolization of systemic-to-pulmonary shunts. The aim of this retrospective study was to address the feasibility of infusion of 90Y glass microspheres directly through the RIPA.

Section snippets

Patients

The institutional review board approved this retrospective study and permitted the waiving of informed consent. Radioembolization rather than chemoembolization was commonly recommended by physicians for HCC patients with a large tumor or vascular invasion. All patients were informed that radioembolization has similar overall survival, longer progression-free survival, and results in better quality of life compared with chemoembolization and was not reimbursed by national health insurance. The

Results

Of 20 patients, 9 (45%) had systemic-to-pulmonary shunts on C-arm CT images of the RIPA. The feeder of the systemic-to-pulmonary shunt was the azygoesophageal branch (n = 7) (Fig 1) and the anterior branch (n = 2) (Fig 2). The azygoesophageal branch was embolized by 45–150 μm PVA particles in all 7 patients. The anterior branch was embolization by 45–150 μm PVA particles in 1 patient and was not embolized in the other patient because of a relative small shunt (Fig 3). In 4 (20%) patients, the

Discussion

Many interventional radiologists are reluctant to infuse 90Y microspheres into the extrahepatic collateral arteries because of the high risk of nontarget radiation. However, this study showed that administration of 90Y microspheres through the RIPA may be safe with the identification of a systemic-to-pulmonary shunt by using C-arm CT.

The common feeder of a systemic-to-pulmonary shunt was the azygoesophageal branch, which was mentioned in our previous study (10). It commonly originates from the

References (20)

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None of the authors have identified a conflict of interest.

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