Clinical StudyYttrium-90 Radioembolization of the Right Inferior Phrenic Artery in 20 Patients with Hepatocellular Carcinoma
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.
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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
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None of the authors have identified a conflict of interest.