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Hepatic Scintigraphy for Liver Function
reserve pre-SIRT
Marnix G.E.H. Lam, MD, PhD
Professor of Nuclear Medicine UMC Utrecht
Courtesy
Roel J. Bennink, MD, PhD
Professor of Nuclear Medicine AMC Amsterdam
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Disclosure of speaker’s interests
Consultant for BTG, Sirtex and Terumo
The department of Radiology and Nuclear Medicine
of the UMC Utrecht receives royalties and research
support from Terumo / Quirem Medical
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Regional liver function and SIRT
• Safety assessment, e.g. repeated treatment
• Patient selection
• Pre-surgical induction of hypertrophy of future liver remnant
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Regional liver function and SIRT
• Safety assessment, e.g. repeated treatment
• Patient selection
• Pre-surgical induction of hypertrophy of future liver remnant
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Baseline CT
Follow-up PET
Baseline PET Yttrium-90 resin
microspheres: 1196 MBq
RHA; 613 MBq LHA
Follow-up CT
Yttrium-90 radioembolization
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1 year CT
Follow-up PET
1 year PET Yttrium-90 resin
microspheres: 613 MBq
LHA
Follow-up CT
Yttrium-90 radioembolization: second treatment
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1.5 year CT
Follow-up PET
1.5 year PET Yttrium-90 resin
microspheres: 1122 MBq
RHA
Yttrium-90 radioembolization: third treatment
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Follow-up PET
2.5 year PET Yttrium-90 glass
microspheres: 200 Gy
segment 8
Yttrium-90 radioembolization: fourth treatment
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3.5 year PET
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Hepatobiliary Scintigraphy
Imino-diacetic acid (IDA)
– Lidocaine analogue
– 99mTc-Mebrofenin
– Liver uptake, excretion, biliary kinetics
Krishnamurthy et al. Nuclear Hepatology
OATP1B1: IDA, bilirubin
OATP1B3: IDA, ICG
NTCP: ICG
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HBS: Protocol
Dual head dynamic
scintigraphy
– 36 frames 10 sec/frame
– Liver, heart, geometric
mean dataset
– Liver uptake %/min
– Ekman algorithm*
* Ekman M. et al. Nucl Med Comm 1996; 17:235-242 150 350 sec
%/min
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• Left (2-3) ± 4
• Right (5-8)
• Ext. Right (4-8)
R. Smitshuis, Radiology Assistant.nl
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3.5 year PET
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Follow-up PET August 2017, >4 years
after first radioembolization
3.5 year PET Yttrium-90 glass
microspheres: 200 Gy
segment 8
Yttrium-90 radioembolization: fifth treatment
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Regional liver function and SIRT
• Safety assessment, e.g. repeated treatment
• Patient selection
• Pre-surgical induction of hypertrophy of future liver remnant
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Child-Pugh: Case 1 A6 Case 2 B8 Case 3 B8
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Regional liver function and SIRT
• Safety assessment, e.g. repeated treatment
• Patient selection
• Pre-surgical induction of hypertrophy of future liver remnant
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Pre-surgical induction of hypertrophy of
future liver remnant
• Portal Vein Embolisation
– Polyvinyl alcohol particles and coils
– Atrophy embolised lobes
– Compensatory hypertrophy future remnant liver
• SIRT
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Pre-operative screening with hepatobiliary scintigraphy
Multifocal HCC segment 5-8
Yttrium-90 radioembolization
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PET/CT after 120 Gy yttrium-90 glass
radioembolization
Multifocal HCC segment 5-8
Yttrium-90 radioembolization
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3 months post-radioembolization Multifocal HCC segment 5-8
Yttrium-90 radioembolization
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Yttrium-90 radioembolization
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Post-hemihepatectomy right, segment 5-8
3.5 year PET
Yttrium-90 radioembolization
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ALPPS
Associating Liver Partition and Portal vein Ligation for Staged hepatectomy
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ALPPS function
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Preliminary conclusions
• Hepatobiliary scintigraphy may be used for safety assessment
in repeated treatment
• Hepatobiliary scintigraphy may be used for improved patient
selection
• Hepatobiliary scintigraphy may be used for assessment of
future remnant liver function after SIRT as an alternative for
PVE