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INTERESTING IMAGE
Year : 2020  |  Volume : 35  |  Issue : 3  |  Page : 267-268  

Complete pathological response noted in explanted liver after Y90-SIR-Spheres therapy for hepatocellular carcinoma


1 Department of Nuclear Medicine, MIOT International, Chennai, Tamil Nadu, India
2 Department of Pathology, MIOT International, Chennai, Tamil Nadu, India

Date of Submission06-Feb-2020
Date of Acceptance19-Feb-2020
Date of Web Publication01-Jul-2020

Correspondence Address:
Dr. Piyush Chandra
Department of Nuclear Medicine, MIOT International, Manapakkam, Chennai - 600 056, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijnm.IJNM_23_20

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   Abstract 


In the treatment of hepatocellular carcinoma, achieving complete pathological response (CPR) in explanted liver specimens following any locoregional treatments is associated with reduced recurrence rates and better posttransplant survival compared to the incomplete response. Here, we present the imaging findings of a patient who achieved CPR in the explanted liver following Y-90 SIR-Spheres® therapy.

Keywords: Carcinoma, complete, explant, hepatocellular, liver, response, SIR-Spheres®, Y90


How to cite this article:
Chandra P, Nath S, Jain D. Complete pathological response noted in explanted liver after Y90-SIR-Spheres therapy for hepatocellular carcinoma. Indian J Nucl Med 2020;35:267-8

How to cite this URL:
Chandra P, Nath S, Jain D. Complete pathological response noted in explanted liver after Y90-SIR-Spheres therapy for hepatocellular carcinoma. Indian J Nucl Med [serial online] 2020 [cited 2020 Aug 7];35:267-8. Available from: http://www.ijnm.in/text.asp?2020/35/3/267/288456



A 62-year-old male with a history of chronic liver disease (Child-Pugh score A) with 4.1 cm arterially enhancing lesion in the segment VI/VII of the liver [Figure 1]a and [Figure 1]b, bold black arrows] suggestive of hepatocellular carcinoma (HCC) was referred for selective internal radiation therapy (SIRT) using Y-90 SIR-Spheres® as a bridge to liver transplantation. Pre-SIRT planning angiography showed normal celiac axis anatomy and 4% hepatopulmonary shunt and tumor-to-normal liver uptake ratio (TNR) of 6 on Tc-99m macroaggregated (MAA) scintigraphy [Figure 1]c and [Figure 1]d, thin black arrows]. The therapeutic dose administered calculated using partition model, delivering a liver limiting dose (50 Gy), was 1.7 GBq, with an estimated tumor adsorbed dose (TAD) of about 350 Gy. After 10 days of angiography, SIRT was executed by administering Y90 SIR-spheres through selective cannulation of the distal right hepatic artery. Posttherapy, Y90 positron emission tomography/computed tomography (CT) showed selective concentration of Y-90 SIR-Spheres® in the tumor bed with high TNR [Figure 1]e and [Figure 1]f, white arrows], concordant with the MAA scan. The patient subsequently underwent successful deceased donor liver transplantation 1-month post-SIRT. Explant liver pathology study revealed no evidence of any viable tumor cells (absence of any mitotic activity) and extensive necrosis in the irradiated liver bed [Figure 2]a and [Figure 2]b, black arrows]. The patient continued to be asymptomatic and disease-free at 9 months follow-up (at the time of writing this report).
Figure 1: (a and b) Solitary arterially enhancing lesion in the right lobe involving segments VI/VII (bold black arrows). (c and d) Anterioposterior Tc-99m macroaggregated scinitigraphy showing focal increased perfusion in the right lobe (thin black arrows) with good tumor-to-normal liver uptake ratio and the absence of any significant hepatopulmonary shunting. (e and f) Post-therapy Y-90 SIR-Spheres positron emission tomography – computed tomography images showing selective intense uptake of the radio-pharmaceutical into the tumor bed (white arrows) polymerase chain reaction assay

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Figure 2: (a) Gross cut specimen of the explanted liver showing parenchymal necrosis in the tumor bed (thin black arrow) with background liver showing the cirrhotic change. (b) Tumor bed with in situ microspheres (bold black arrow) extensive tumor necrosis and no mitotic activity-suggestive of complete pathological response (H and E, ×400)

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Of all the locoregional therapies (LRT) available as a bridge therapy for liver transplantation, SIRT using Y90 has been reported to have a maximum incidence of complete pathological response (CPR) in the explanted liver with least liver toxicities.[1] Studies have shown that pathological downstaging of primary tumor or achieving CPR in explant liver pathology with LRT for HCC is a strong predictor of recurrence-free survival.[2],[3],[4] Response to Y-90 SIR-Spheres ® is a function of TAD, which critically depends on the method of therapeutic dose estimation used. The partition model should be preferred for over body surface/empirical methods for estimating the optimal Y90 therapeutic dose whenever feasible.[5] As per Chansanti et al., reported cutoff values for TAD (based on 99mTc-MAA single-photon emission CT/CT) was >190 Gy for responders (93% specificity) and that for nonresponders about <72 Gy (100% specificity).[6] For achieving the best long-term outcomes for bridge therapy for liver transplantation, proper patient selection and maximizing the TAD aiming for complete imaging/pathological response are imperative.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Mohamed M, Katz AW, Tejani MA, Sharma AK, Kashyap R, Noel MS, et al. Comparison of outcomes between SBRT, yttrium-90 radioembolization, transarterial chemoembolization, and radiofrequency ablation as bridge to transplant for hepatocellular carcinoma. Adv Radiat Oncol 2016;1:35-42.  Back to cited text no. 1
    
2.
Ho MH, Yu CY, Chung KP, Chen TW, Chu HC, Lin CK, et al. Locoregional therapy-induced tumor necrosis as a predictor of recurrence after liver transplant in patients with hepatocellular carcinoma. Ann Surg Oncol 2011;18:3632-9.  Back to cited text no. 2
    
3.
Chan KM, Yu MC, Chou HS, Wu TJ, Lee CF, Lee WC. Significance of tumor necrosis for outcome of patients with hepatocellular carcinoma receiving locoregional therapy prior to liver transplantation. Ann Surg Oncol 2011;18:2638-46.  Back to cited text no. 3
    
4.
Agopian VG, Morshedi MM, McWilliams J, Harlander-Locke MP, Markovic D, Zarrinpar A, et al. Complete pathologic response to pretransplant locoregional therapy for hepatocellular carcinoma defines cancer cure after liver transplantation: Analysis of 501 consecutively treated patients. Ann Surg 2015;262:536-45.  Back to cited text no. 4
    
5.
Kao YH, Tan EH, Ng CE, Goh SW. Clinical implications of the body surface area method versus partition model dosimetry for yttrium-90 radioembolization using resin microspheres: A technical review. Ann Nucl Med 2011;25:455-61.  Back to cited text no. 5
    
6.
Chansanti O, Jahangiri Y, Matsui Y, Adachi A, Geeratikun Y, Kaufman JA, et al. Tumor dose response in yttrium-90 resin microsphere embolization for neuroendocrine liver metastases: A tumor-specific analysis with dose estimation using SPECT-CT. J Vasc Interv Radiol 2017;28:1528-35.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2]



 

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