Hepatic Scintigraphy for Liver Function reserve pre-SIRT · Yttrium-90 radioembolization: third...

Hepatic Scintigraphy for Liver Function

reserve pre-SIRT

Marnix G.E.H. Lam, MD, PhD

Professor of Nuclear Medicine UMC Utrecht

Courtesy

Roel J. Bennink, MD, PhD

Professor of Nuclear Medicine AMC Amsterdam

Disclosure of speaker’s interests

Consultant for BTG, Sirtex and Terumo

The department of Radiology and Nuclear Medicine

of the UMC Utrecht receives royalties and research

support from Terumo / Quirem Medical

Regional liver function and SIRT

• Safety assessment, e.g. repeated treatment

• Patient selection

• Pre-surgical induction of hypertrophy of future liver remnant

Regional liver function and SIRT

• Safety assessment, e.g. repeated treatment

• Patient selection

• Pre-surgical induction of hypertrophy of future liver remnant

Baseline CT

Follow-up PET

Baseline PET Yttrium-90 resin

microspheres: 1196 MBq

RHA; 613 MBq LHA

Follow-up CT

Yttrium-90 radioembolization

1 year CT

Follow-up PET

1 year PET Yttrium-90 resin

microspheres: 613 MBq

LHA

Follow-up CT

Yttrium-90 radioembolization: second treatment

1.5 year CT

Follow-up PET

1.5 year PET Yttrium-90 resin

microspheres: 1122 MBq

RHA

Yttrium-90 radioembolization: third treatment

Follow-up PET

2.5 year PET Yttrium-90 glass

microspheres: 200 Gy

segment 8

Yttrium-90 radioembolization: fourth treatment

3.5 year PET

Hepatobiliary Scintigraphy

Imino-diacetic acid (IDA)

– Lidocaine analogue

– 99mTc-Mebrofenin

– Liver uptake, excretion, biliary kinetics

Krishnamurthy et al. Nuclear Hepatology

OATP1B1: IDA, bilirubin

OATP1B3: IDA, ICG

NTCP: ICG

HBS: Protocol

Dual head dynamic

scintigraphy

– 36 frames 10 sec/frame

– Liver, heart, geometric

mean dataset

– Liver uptake %/min

– Ekman algorithm*

* Ekman M. et al. Nucl Med Comm 1996; 17:235-242 150 350 sec

%/min

• Left (2-3) ± 4

• Right (5-8)

• Ext. Right (4-8)

R. Smitshuis, Radiology Assistant.nl

3.5 year PET

Follow-up PET August 2017, >4 years

after first radioembolization

3.5 year PET Yttrium-90 glass

microspheres: 200 Gy

segment 8

Yttrium-90 radioembolization: fifth treatment

Regional liver function and SIRT

• Safety assessment, e.g. repeated treatment

• Patient selection

• Pre-surgical induction of hypertrophy of future liver remnant

Child-Pugh: Case 1 A6 Case 2 B8 Case 3 B8

Regional liver function and SIRT

• Safety assessment, e.g. repeated treatment

• Patient selection

• Pre-surgical induction of hypertrophy of future liver remnant

Pre-surgical induction of hypertrophy of

future liver remnant

• Portal Vein Embolisation

– Polyvinyl alcohol particles and coils

– Atrophy embolised lobes

– Compensatory hypertrophy future remnant liver

• SIRT

Pre-operative screening with hepatobiliary scintigraphy

Multifocal HCC segment 5-8

Yttrium-90 radioembolization

PET/CT after 120 Gy yttrium-90 glass

radioembolization

Multifocal HCC segment 5-8

Yttrium-90 radioembolization

3 months post-radioembolization Multifocal HCC segment 5-8

Yttrium-90 radioembolization

Yttrium-90 radioembolization

Post-hemihepatectomy right, segment 5-8

3.5 year PET

Yttrium-90 radioembolization

ALPPS

Associating Liver Partition and Portal vein Ligation for Staged hepatectomy

ALPPS function

Preliminary conclusions

• Hepatobiliary scintigraphy may be used for safety assessment

in repeated treatment

• Hepatobiliary scintigraphy may be used for improved patient

selection

• Hepatobiliary scintigraphy may be used for assessment of

future remnant liver function after SIRT as an alternative for

PVE