Hans Jürgen Biersack

Hepatic volume changes induced by radioembolization with 90Y resin microspheres. A single-centre study

PurposeLobar radioembolization (RE) of the liver can result in reduction in volume of the ipsilateral lobe as well as hypertrophy of the contralateral lobe. Theoretically, hypertrophy of the contralateral liver lobe after RE could increase the chance of a successful liver resection, especially in patients with limited liver function reserve. The aim of this preliminary study was to evaluate the early effects of RE with resin microspheres on the volumes of the liver lobes and spleen.MethodsWe retrospectively investigated 24 patients (12 women, 44–78xa0years old) with different types of cancer and liver-dominant metastatic disease who had undergone RE of the liver with resin microspheres. Changes in the volumes of the liver lobes and spleen were quantified by CT before and about 4 to 8xa0weeks after treatment.ResultsOf the 24 patients, 17 suffered from metastases in both liver lobes (group A) and 7 had metastases only in the right liver lobe (group B). The patients in the group A underwent sequential treatment starting with the right liver lobe. The median administered dose was 1.75xa0GBq. RE was associated with a median increase in volume of the left liver lobe of 34xa0% (Pu2009<u20090.001) and a median decrease in volume of the right liver lobe of 11xa0% (Pu2009=u20090.03). The volume of the spleen showed a median increase of 17xa0% (Pu2009=u20090.01). Separate analysis of the two groups showed a median increases in volume of the left liver lobe of 30xa0% (Pu2009=u20090.001) in group A and 70xa0% (Pu2009=u20090.01) in group B. There was no correlation between the injected dose and the volume alteration (ru2009=u20090.1–0.3).ConclusionRE of the right liver lobe with resin microspheres caused a significant increase in the volume of the left liver lobe. This may allow liver resection in patients with metastases in the right liver lobe and a small left liver lobe.

Is prophylactic embolization of the hepatic falciform artery needed before radioembolization in patients with 99mTc-MAA accumulation in the anterior abdominal wall?

PurposeWhile influx of chemoembolic agents into the hepatic falciform artery (HFA) from the hepatic artery can cause supraumbilical skin rash, epigastric pain and even skin necrosis, the significance of a patent HFA in patients undergoing radioembolization is not completely clear. Furthermore, the presence of tracer in the anterior abdominal wall seen in 99mTc-macroaggregated albumin (99mTc-MAA) images, which is generally performed prior to radioembolization, has been described as a sign of a patent HFA. The aim of this retrospective study was to evaluate the incidence and consequences of 99mTc-MAA accumulation in the anterior abdominal wall, indicating a patent HFA, in patients undergoing radioembolization of liver tumours.MethodsA total of 224 diagnostic hepatic angiograms combined with 99mTc-MAA SPECT/CT were acquired in 192 patients with different types of cancer, of whom 142 were treated with a total of 214 radioembolization procedures. All patients received a whole-body scan, and planar and SPECT/CT scans of the abdomen. Only patients with extrahepatic 99mTc-MAA accumulation in the anterior abdominal wall were included in this study. Posttreatment bremsstrahlung SPECT/CT and follow-up results for at least 3xa0months served as reference standards.ResultsTracer accumulation in the anterior abdominal wall was presentxa0in pretreatment 99mTc-MAA SPECT/CT images of 18 patients (9.3%). The HFA was found and embolized by radiologistsxa0before treatment inxa0onexa0patient. In the remaining patientsxa0radioembolization was performed without any modification in the treatment plan despite the previously mentioned extrahepatic accumulation. Only one patient experienced abdominal muscle pain above the navel, which started 24xa0h after treatment and lasted for 48xa0h without any skin changes. The remaining patients did not experience any relevant side effects during the follow-up period.ConclusionSide effects after radioembolization in patients with tracer accumulation in the anterior abdominal wall on 99mTc-MAA scans indicating a patent HFA are neither common nor severe. Thus, there is no absolute need for prophylactic embolization of the HFA or modification of the treatment plan if the HFA is not detectable on angiography.

Iodine-131-lipiodol therapy in hepatic tumours.

The incidence of hepatocellular carcinoma (HCC) is worldwide sharply on the rise and patients with advanced disease carry a poor prognosis. HCC is the sixth most common cancer and the third leading cause of cancer associated deaths in the world. Intra-arterially administered (131)I-Lipiodol is selectively retained by hepatocellular carcinomas, and has been used as a vehicle for delivery of therapeutic agents to these tumours. In this review we focus on the therapeutic indications, usefulness and methods of treatment with 131-Iodine Lipiodol. The effectiveness of (131)I-Lipiodol treatment is proven both in the treatment of HCC with portal thrombosis and also as an adjuvant to surgery after the resection of HCCs. It is at least as effective as chemoembolization and is tolerated much better. Severe liver dysfunction represents theoretic contraindication for radioembolization as well as for TACE. In such cases (131)I-Lipiodol is an alternative therapy option especially in tumours smaller than 6cm.

A Letter Regarding Diagnostic Accuracy of Ultrasound and 18-F-FDG PET or PET/CT for Patients With Suspected Recurrent Papillary Thyroid Carcinoma

were excluded from this study. AsDr.Ahmadzadehfar etal. stated,and asshown inour study, there can be no further debate on the sequential use of neck US, WBS and PET to detect recurrence in patients with elevated serum Tg after initial treatment. It is still unclear, however, whether WBS should be empirically performed at therapeutic dosein patients with negative neck US. Most studies addressing the benefits of therapeutic WBS in patients with negative diagnostic WBS were performed regardless of neck US findings (Lind 1999; Pacini et al. 2001; Koh et al. 2003). Therefore, it is unclear whether therapeutic WBS can benefit patients with negative results on neck US and/or PET. A recent study on the empirical use of therapeutic WBS in patients with elevated serum Tg, but negative neck US and PET after

Nuclear Medicine Training: Two Different Pathways?

TO THE EDITOR: I read with interest the editorial written by Segall et al. (1). The authors discuss a combined, multispecialty training ‘‘that maintains high standards for nuclear medicine education.’’ A 3-y residency in nuclear medicine that leads to American Board Nuclear Medicine certification alone may ‘‘not provide diplomates with adequate employment opportunities.’’ Instead, the proposed combined training would require 16 mo for nuclear medicine and 32 mo for radiology. We do not believe that it is possible to provide a solid nuclear medicine training program in only 16 mo; the same holds true for the proposed 32-mo radiology program. This becomes evident when the contents of the full training programs are considered. For example, radiology training must cover the topics of CT (thorax, abdomen, and angiography), neuro-CT, MRI (including of the brain), interventional radiology, ultrasound (vascular, pediatric, gynecologic, urologic, orthopedic, and trauma), and conventional radiology (thorax, abdomen, trauma, orthopedics, endocrinology, and surgery). Similarly, nuclear medicine training must include PET/CT, SPECT/CT, neuro nuclear medicine, endocrinology (thyroid and others), radiation biology, radiophysics, radiochemistry, and radiation safety. It must also cover ‘‘bread and butter’’ nuclear medicine, including bone, myocardium, lung, renal (genitourinary tract), liver (hepatobiliary), and radionuclide therapies (the latter of which has gained importance in the treatment of various malignancies). Additionally, the increasingly important topic of nuclear oncology could become a subspecialty of nuclear medicine, as has been suggested by Ahmadzadehfar and Essler (2). From this summary, it appears evident that it is not possible to provide comprehensive training in nuclear medicine and radiology within a short 4-y program. In Germany, a similar program leading up to the 2 board certifications requires a total 8.5 y of study. As this is a much longer period than the one proposed by Segall et al. (1), we believe that 2 independent training programs are necessary to adequately train nuclear medicine and radiology residents (3). Instead of seesawing between different specialties, we should accept nuclear medicine as a full specialty in its own right. Its need for CT to better anatomically localize its findings does not mean that this specialty should fall under the banner of radiology. Similarly, the presence of radionuclide therapies in nuclear medicine does not relegate it to the field of radiation oncology. The addition of sectional imaging training to nuclear medicine residency programs has the potential to solve all of these problems. This does not mean that a nuclear medicine physician will report CT or MRI, but SPECT/PET/CT and PET/MRI can be reported by nuclear medicine physicians.