Department of Nuclear Medicine and PET, Singapore General Hospital, Singapore.
J Nucl Med. 2012 Apr;53(4):559-66. doi: 10.2967/jnumed.111.097469. Epub 2012 Feb 17.
UNLABELLED: Compliance with radiobiologic principles of radionuclide internal dosimetry is fundamental to the success of (90)Y radioembolization. The artery-specific SPECT/CT partition model is an image-guided personalized predictive dosimetric technique developed by our institution, integrating catheter-directed CT hepatic angiography (CTHA), (99m)Tc-macroaggregated albumin SPECT/CT, and partition modeling for unified dosimetry. Catheter-directed CTHA accurately delineates planning target volumes. SPECT/CT tomographically evaluates (99m)Tc-macroaggregated albumin hepatic biodistribution. The partition model is validated for (90)Y resin microspheres based on MIRD macrodosimetry. METHODS: This was a retrospective analysis of our early clinical outcomes for inoperable hepatocellular carcinoma. Mapping hepatic angiography was performed according to standard technique with the addition of catheter-directed CTHA. (99m)Tc-MAA planar scintigraphy was used for liver-to-lung shunt estimation, and SPECT/CT was used for liver dosimetry. Artery-specific SPECT/CT partition modeling was planned by experienced nuclear medicine physicians. RESULTS: From January to May 2011, 20 arterial territories were treated in 10 hepatocellular carcinoma patients. Median follow-up was 21 wk (95% confidence interval [CI], 12-50 wk). When analyzed strictly as brachytherapy, (90)Y radioembolization planned by predictive dosimetry achieved index tumor regression in 8 of 8 patients, with a median size decrease of 58% (95% CI, 40%-72%). Tumor thrombosis regressed or remained stable in 3 of 4 patients with baseline involvement. The best α-fetoprotein reduction ranged from 32% to 95%. Clinical success was achieved in 7 of 8 patients, including 2 by sublesional dosimetry, in 1 of whom there was radioembolization lobectomy intent. Median predicted mean radiation absorbed doses were 106 Gy (95% CI, 105-146 Gy) to tumor, 27 Gy (95% CI, 22-33 Gy) to nontumorous liver, and 2 Gy (95% CI, 1.3-7.3 Gy) to lungs. Across all patients, tumor, nontumorous liver, and lungs received predicted ≥91 Gy, ≤51 Gy, and ≤16 Gy, respectively, via at least 1 target arterial territory. No patients developed significant toxicities within 3 mo after radioembolization. The median time to best imaging response was 76 d (95% CI, 55-114 d). Median time to progression and overall survival were not reached. SPECT/CT-derived mean tumor-to-normal liver ratios varied widely across all planning target volumes (median, 5.4; 95% CI, 4.1-6.7), even within the same patient. CONCLUSION: Image-guided personalized predictive dosimetry by artery-specific SPECT/CT partition modeling achieves high clinical success rates for safe and effective (90)Y radioembolization.
目的：介绍并评估一种新的、基于 SPECT/CT 动脉分区模型的预测性核素内照射剂量学方法，用于钇-90[90Y]放射性微球栓塞术。
方法：对 10 例不能手术的肝细胞癌患者进行回顾性分析。按照标准技术进行肝动脉造影，在此基础上增加导管定向 CT 肝血管造影术（CTHA）。采用 99mTc- 三聚氰胺白蛋白（MAA）平面闪烁扫描进行肝肺分流估计，采用 SPECT/CT 进行肝脏剂量学测定。由有经验的核医学医师进行 SPECT/CT 动脉特异性分区模型规划。
结果：2011 年 1 月至 5 月，10 例肝细胞癌患者的 20 个肝动脉区接受了治疗。中位随访时间为 21 周（95%置信区间，9-50 周）。严格按照近距离放射治疗分析，预测性剂量学计划的 90Y 放射性微球栓塞术在 8 例患者中的 8 例实现了肿瘤指数消退，肿瘤大小中位数下降 58%（95%置信区间，40%-72%）。基线受累的 4 例患者中，有 3 例肿瘤血栓消退或保持稳定。最佳甲胎蛋白下降范围为 32%-95%。8 例患者中有 7 例获得临床成功，包括 2 例接受亚病灶剂量学治疗，其中 1 例有放射性微球栓塞肝叶切除术意向。肿瘤的预测平均吸收剂量中位数为 106Gy（95%置信区间，105-146Gy），非肿瘤性肝脏为 27Gy（95%置信区间，22-33Gy），肺为 2Gy（95%置信区间，1.3-7.3Gy）。所有患者至少有 1 个靶动脉区接受预测的肿瘤≥91Gy、非肿瘤性肝脏≤51Gy 和肺≤16Gy。放射性微球栓塞术后 3 个月内无患者出现显著毒性。最佳影像学反应的中位时间为 76 天（95%置信区间，55-114 天）。中位无进展时间和总生存期未达到。SPECT/CT 衍生的肿瘤与正常肝脏比值在所有计划靶区差异很大（中位数，5.4；95%置信区间，4.1-6.7），即使在同一患者中也是如此。
结论：基于 SPECT/CT 动脉分区模型的个体化预测性核素内照射剂量学可实现安全有效的钇-90[90Y]放射性微球栓塞术的高临床成功率。
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