Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL.
Department of Medicine, Division of Hepatology, Northwestern University, Chicago, IL.
J Hepatol. 2020 Jun;72(6):1151-1158. doi: 10.1016/j.jhep.2020.02.024. Epub 2020 Mar 5.
BACKGROUND & AIMS: Pre-treatment Tc-99m macroaggregated albumin (MAA) scans are routinely performed prior to transarterial radioembolization (TARE) to estimate lung shunt fraction (LSF) and lung dose. In this study, we investigate LSF observed in early hepatocellular carcinoma (HCC) and provide the scientific rationale for eliminating this step from routine practice.
Patients with HCC who underwent Y90 from 2004 to 2018 were reviewed. Inclusion criteria were early stage HCC (UNOS T1/T2/Milan criteria: solitary ≤5 cm, 3 nodules ≤3 cm). LSF was determined using MAA in all patients. Associations between LSF and baseline characteristics were investigated. A "no-MAA" paradigm was then proposed based on a homogenous group that expressed very low LSF.
Of 1,175 patients with HCC treated with TARE, 448 patients met inclusion criteria. Mean age was 65.6 years and 303 (68%) were males. A total of 352 (79%) had solitary lesions and 406 (91%) unilobar disease. Two-hundred and forty-three (54%), 178 (40%) and 27 (6%) patients were Child-Pugh class A, B and C, respectively. Median LSF was 3.9% (IQR 2.4-6%). Median administered activity was 0.9 GBq (IQR 0.6-1.4), for a median segmental volume of 170 cm (range: 60-530). Median lung dose was 1.9 Gy (IQR: 1.0-3.3). The presence of a transjugular intrahepatic portosystemic shunt (TIPS; n = 38) was associated with LSF >10% (odds ratio 12.2; 95% CI 5.2-28.6; p <0.001). Median LSF was 3.8% (IQR: 2.4-5.7%) and 6% (IQR: 3.8-15.3%) in no-TIPS vs. TIPS patients (p <0.001).
LSF is clinically negligible in patients with UNOS T1/T2 HCC without TIPS. When segmental injections are planned, this step can be eliminated, thereby reducing time-to-treatment, number of procedures, and improving convenience for patients traveling from faraway.
Transarterial radioembolization is a microembolic transarterial treatment for hepatocellular carcinoma. In our study, we found that early stage patients, where segmental injections are planned, exhibited low lung shunting, effectively eliminating the risk of radiation pneumonitis. We propose that the lung shunt study be eliminated in this subgroup, thus leading to fewer procedures, a cost reduction and improved convenience for patients.
在经肝动脉放射性栓塞术（TARE）之前，通常会进行预处理的 Tc-99m 聚合白蛋白（MAA）扫描，以估计肺分流分数（LSF）和肺剂量。本研究旨在观察早期肝细胞癌（HCC）中观察到的 LSF，并为从常规实践中消除这一步骤提供科学依据。
回顾了 2004 年至 2018 年间接受 Y90 治疗的 HCC 患者。纳入标准为早期 HCC（UNOS T1/T2/Milan 标准：单发肿瘤≤5cm，3 个肿瘤结节≤3cm）。所有患者均使用 MAA 确定 LSF。研究了 LSF 与基线特征之间的关系。然后根据表达非常低 LSF 的同质组提出了“无 MAA”范式。
在 1175 例接受 TARE 治疗的 HCC 患者中，448 例符合纳入标准。平均年龄为 65.6 岁，303 例（68%）为男性。共有 352 例（79%）为单发肿瘤，406 例（91%）为单叶疾病。243 例（54%）、178 例（40%）和 27 例（6%）患者分别为 Child-Pugh 分级 A、B 和 C。LSF 的中位数为 3.9%（IQR 2.4-6%）。中位给药活度为 0.9GBq（IQR 0.6-1.4），中位节段体积为 170cm（范围：60-530）。中位肺剂量为 1.9Gy（IQR：1.0-3.3）。存在经颈静脉肝内门体分流术（TIPS；n=38）与 LSF>10%相关（比值比 12.2；95%CI 5.2-28.6；p<0.001）。无 TIPS 组的 LSF 中位数为 3.8%（IQR：2.4-5.7%），TIPS 组为 6%（IQR：3.8-15.3%）（p<0.001）。
无 TIPS 的 UNOS T1/T2 HCC 患者的 LSF 临床意义不大。当计划进行节段性注射时，可以消除这一步骤，从而缩短治疗时间、手术次数，并提高长途旅行患者的便利性。
经肝动脉放射性栓塞术是治疗肝细胞癌的一种微栓塞经肝动脉治疗方法。在我们的研究中，我们发现计划进行节段性注射的早期患者，其肺分流作用较低，有效地消除了放射性肺炎的风险。我们建议在这一亚组中消除肺分流研究，从而减少手术次数，降低成本，并提高患者的便利性。
