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Year : 2016  |  Volume : 31  |  Issue : 4  |  Page : 311-312  

Hepatocellular carcinoma with intra-atrial tumor extension identified on 99mTc-labeled macroaggregated albumin single photon emission computed tomography/computed tomography


Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Hospital, Mumbai, Maharashtra, India

Date of Web Publication19-Sep-2016

Correspondence Address:
Venkatesh Rangarajan
Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Hospital, E. Borges Road, Parel, Mumbai - 400 012, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-3919.187449

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   Abstract 


99mTc macroaggregated albumin (MAA) scintigraphy is always performed before administration of 90Y--microspheres for the treatment of liver tumors for hepatopulmonary shunt calculation. Tumor thrombus visualization in the hepatic vasculature is an infrequent finding on the 99m Tc--MAA single photon emission computed tomography. We present a rare case of a hepatocellular carcinoma extending as a tumor thrombus through hepatic vein, inferior vena cava into the right atrium.

Keywords: 99mTc macroaggregated albumin, hepatocellular carcinoma, inferior vena cava, intra-atrial, right atrium, single photon emission computed tomography, thrombosis, tumor thrombus


How to cite this article:
Chandra P, Shah S, Purandare N, Agrawal A, Rangarajan V. Hepatocellular carcinoma with intra-atrial tumor extension identified on 99mTc-labeled macroaggregated albumin single photon emission computed tomography/computed tomography. Indian J Nucl Med 2016;31:311-2

How to cite this URL:
Chandra P, Shah S, Purandare N, Agrawal A, Rangarajan V. Hepatocellular carcinoma with intra-atrial tumor extension identified on 99mTc-labeled macroaggregated albumin single photon emission computed tomography/computed tomography. Indian J Nucl Med [serial online] 2016 [cited 2019 Jul 23];31:311-2. Available from: http://www.ijnm.in/text.asp?2016/31/4/311/187449



A 68-year-old male patient presented with loss of appetite and lower limbs swelling for 3 months. Routine biochemical evaluation revealed serum alpha-fetoprotein - 781 ng/ml and total bilirubin - 1.81 mg/dl. Contrast-enhanced computed tomography (CECT) abdomen showed cirrhotic liver and a 7.5 cm lesion in the right lobe of the liver with arterial enhancement and venous washout. There was also evidence of tumor thrombosis into hepatic vein, inferior vena cava (IVC), extending into the right atrium. The patient was planned for transarterial radioembolization (TARE) and underwent 99m Tc-macroaggregated albumin (MAA) scan for pretherapeutic evaluation. Coronal [Figure 1]a and sagittal [Figure 1]b MAA single photon emission computed tomography-computed tomography (SPECT) images showed increased tracer in the tumor in the right lobe and tumor thrombus in IVC extending into the right atrium (black and white arrowheads). Increased extrahepatic MAA uptake noted in bilateral lungs (thin white arrows). Correlative coronal [Figure 1]c and sagittal [Figure 1]d CECT images showed ill-defined hypodense lesion in the right hepatic vein, extending into IVC and right atrium (bold white and black arrowheads). Calculated hepatopulmonary shunt was 52%. Hence, TARE was deferred, and the patient was started on treatment with sorafenib.
Figure 1: Coronal (a) and sagittal (b) 99mTc macroaggregated albumin single photon emission computed tomography-computed tomography images show increased tracer in the tumor in the right lobe and tumor thrombus in inferior vena cava extending into the right atrium (black arrow and white arrowhead). Additionally, increased extra-hepatic 99mTc macroaggregated albumin uptake noted in bilateral lungs (thin white arrows). Correlative coronal (c) and sagittal (d) contrast enhanced computed tomography images shows ill-defined hypodense enhancing lesion in right hepatic vein, extending into inferior vena cava and right atrium (bold white arrow and black arrowhead)

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Pretherapeutic simulation using 99m Tc MAA scintigraphy (planar and/or SPECT) is considered mandatory before administration of 90 Y-microspheres for the treatment of liver tumors. Shunt calculation is the primary aim of this scan; however, MAA SPECT is also required for assessment of any gastrointestinal shunting and pretherapeutic dosimetric calculations using the differential uptake by normal liver and tumor component.[1]

Careful assessment of the tracer uptake is required for better delineation of tumor and to avoid any gastrointestinal complications secondary to 90 Y-micropsheres. Extra-hepatic uptake is better seen on SPECT than planar images and could either be due to uptake in digestive tract, gall bladder, coil embolization site, or hepatic vasculature. Uptake in the vasculature most commonly is seen in the portal vein, hepatic artery, hepatic vein, or falciform artery.[2] Uptake in the portal vein, hepatic vein, or IVC is usually secondary to intravascular tumor thrombus. Vascular invasion is recognized as an adverse prognostic factor in hepatocellular carcinoma (HCC) with limited treatment options.[3] TARE, unlike transarterial chemoembolization (TACE), is not an absolute contraindication for HCC with major vessel invasion and has shown modest benefits in selected patients.[4] The patient with tumor thrombosis in hepatic vein extending into IVC has a worse prognosis compared to the tumor thrombus in hepatic vein or portal vein alone.[5] Studies have shown that IVC invasion by tumor is associated with higher lung shunting compared to patients with HCC and no identifiable thrombus.[6]

HCC extending through hepatic vein and IVC into the right atrium is very rare with an incidence of 0.6–4%.[6] These patients have an extremely dismal prognosis with median survival up to 4 months from diagnosis.[7] Surgery whenever possible is the modality of choice and shown survival benefit compared to TACE which has not shown any improvement in prognosis.[8] Experiences with TARE in these subsets of patients have not been reported in literature, probably due to lower median survival or even higher lung shunting, as seen in our case.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Garin E, Lenoir L, Rolland Y, Edeline J, Mesbah H, Laffont S, et al. Dosimetry based on 99mTc-macroaggregated albumin SPECT/CT accurately predicts tumor response and survival in hepatocellular carcinoma patients treated with 90Y-loaded glass microspheres: Preliminary results. J Nucl Med 2012;53:255-63.  Back to cited text no. 1
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2.
Lenoir L, Edeline J, Rolland Y, Pracht M, Raoul JL, Ardisson V, et al. Usefulness and pitfalls of MAA SPECT/CT in identifying digestive extrahepatic uptake when planning liver radioembolization. Eur J Nucl Med Mol Imaging 2012;39:872-80.  Back to cited text no. 2
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3.
Forner A, Llovet JM, Bruix J. Hepatocellular carcinoma. Lancet 2012;379:1245-55.  Back to cited text no. 3
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4.
Iñarrairaegui M, Thurston KG, Bilbao JI, D'Avola D, Rodriguez M, Arbizu J, et al. Radioembolization with use of yttrium-90 resin microspheres in patients with hepatocellular carcinoma and portal vein thrombosis. J Vasc Interv Radiol 2010;21:1205-12.  Back to cited text no. 4
    
5.
Gao HJ, Xu L, Zhang YJ, Chen MS. Long-term survival of patients with hepatocellular carcinoma with inferior vena cava tumor thrombus treated with sorafenib combined with transarterial chemoembolization: Report of two cases and literature review. Chin J Cancer 2014;33:259-64.  Back to cited text no. 5
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6.
Fleming CJ, Andrews JC, Wiseman GA, Gansen DN, Roberts LR. Hepatic vein tumor thrombus as a risk factor for excessive pulmonary deposition of microspheres during TheraSphere therapy for unresectable hepatocellular carcinoma. J Vasc Interv Radiol 2009;20:1460-3.  Back to cited text no. 6
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7.
Kojiro M, Nakahara H, Sugihara S, Murakami T, Nakashima T, Kawasaki H. Hepatocellular carcinoma with intra-atrial tumor growth. A clinicopathologic study of 18 autopsy cases. Arch Pathol Lab Med 1984;108:989-92.  Back to cited text no. 7
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8.
Wang Y, Yuan L, Ge RL, Sun Y, Wei G. Survival benefit of surgical treatment for hepatocellular carcinoma with inferior vena cava/right atrium tumor thrombus: Results of a retrospective cohort study. Ann Surg Oncol 2013;20:914-22.  Back to cited text no. 8
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