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Langius-Wiffen E, de Jong PA, Mohamed Hoesein FA, Dekker L, van den Hoven AF, Nijholt IM, Boomsma MF, Veldhuis WB. Added value of an artificial intelligence algorithm in reducing the number of missed incidental acute pulmonary embolism in routine portal venous phase chest CT. Eur Radiol 2024; 34:367-373. [PMID: 37532902 DOI: 10.1007/s00330-023-10029-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 06/06/2023] [Accepted: 06/14/2023] [Indexed: 08/04/2023]
Abstract
OBJECTIVES The purpose of this study was to evaluate the incremental value of artificial intelligence (AI) compared to the diagnostic accuracy of radiologists alone in detecting incidental acute pulmonary embolism (PE) on routine portal venous contrast-enhanced chest computed tomography (CT). METHODS CTs of 3089 consecutive patients referred to the radiology department for a routine contrast-enhanced chest CT between 27-5-2020 and 31-12-2020, were retrospectively analysed by a CE-certified and FDA-approved AI algorithm. The diagnostic performance of the AI was compared to the initial report. To determine the reference standard, discordant findings were independently evaluated by two readers. In case of disagreement, another experienced cardiothoracic radiologist with knowledge of the initial report and the AI output adjudicated. RESULTS The prevalence of acute incidental PE in the reference standard was 2.2% (67 of 3089 patients). In 25 cases, AI detected initially unreported PE. This included three cases concerning central/lobar PE. Sensitivity of the AI algorithm was significantly higher than the outcome of the initial report (respectively 95.5% vs. 62.7%, p < 0.001), whereas specificity was very high for both (respectively 99.6% vs 99.9%, p = 0.012). The AI algorithm only showed a slightly higher amount of false-positive findings (11 vs. 2), resulting in a significantly lower PPV (85.3% vs. 95.5%, p = 0.047). CONCLUSION The AI algorithm showed high diagnostic accuracy in diagnosing incidental PE, detecting an additional 25 cases of initially unreported PE, accounting for 37.3% of all positive cases. CLINICAL RELEVANCE STATEMENT Radiologist support from AI algorithms in daily practice can prevent missed incidental acute PE on routine chest CT, without a high burden of false-positive cases. KEY POINTS • Incidental pulmonary embolism is often missed by radiologists in non-diagnostic scans with suboptimal contrast opacification within the pulmonary trunk. • An artificial intelligence algorithm showed higher sensitivity detecting incidental pulmonary embolism on routine portal venous chest CT compared to the initial report. • Implementation of artificial intelligence support in routine daily practice will reduce the number of missed incidental pulmonary embolism.
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Affiliation(s)
- Eline Langius-Wiffen
- Department of Radiology, Isala Hospital, Dr. Van Heesweg 2, 8025 AB, Zwolle, The Netherlands.
| | - Pim A de Jong
- Department of Radiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | | | - Lisette Dekker
- Department of Radiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Andor F van den Hoven
- Department of Radiology, University Medical Centre Utrecht, Utrecht, The Netherlands
- Department of Nuclear Medicine, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Ingrid M Nijholt
- Department of Radiology, Isala Hospital, Dr. Van Heesweg 2, 8025 AB, Zwolle, The Netherlands
| | - Martijn F Boomsma
- Department of Radiology, Isala Hospital, Dr. Van Heesweg 2, 8025 AB, Zwolle, The Netherlands
- Division of Imaging and Oncology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Wouter B Veldhuis
- Department of Radiology, University Medical Centre Utrecht, Utrecht, The Netherlands
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Langius-Wiffen E, de Jong PA, Hoesein FAM, Dekker L, van den Hoven AF, Nijholt IM, Boomsma MF, Veldhuis WB. Retrospective batch analysis to evaluate the diagnostic accuracy of a clinically deployed AI algorithm for the detection of acute pulmonary embolism on CTPA. Insights Imaging 2023; 14:102. [PMID: 37278961 PMCID: PMC10244304 DOI: 10.1186/s13244-023-01454-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 05/17/2023] [Indexed: 06/07/2023] Open
Abstract
PURPOSE To generate and extend the evidence on the clinical validity of an artificial intelligence (AI) algorithm to detect acute pulmonary embolism (PE) on CT pulmonary angiography (CTPA) of patients suspected of PE and to evaluate the possibility of reducing the risk of missed findings in clinical practice with AI-assisted reporting. METHODS Consecutive CTPA scan data of 3316 patients referred because of suspected PE between 24-2-2018 and 31-12-2020 were retrospectively analysed by a CE-certified and FDA-approved AI algorithm. The output of the AI was compared with the attending radiologists' report. To define the reference standard, discordant findings were independently evaluated by two readers. In case of disagreement, an experienced cardiothoracic radiologist adjudicated. RESULTS According to the reference standard, PE was present in 717 patients (21.6%). PE was missed by the AI in 23 patients, while the attending radiologist missed 60 PE. The AI detected 2 false positives and the attending radiologist 9. The sensitivity for the detection of PE by the AI algorithm was significantly higher compared to the radiology report (96.8% vs. 91.6%, p < 0.001). Specificity of the AI was also significantly higher (99.9% vs. 99.7%, p = 0.035). NPV and PPV of the AI were also significantly higher than the radiology report. CONCLUSION The AI algorithm showed a significantly higher diagnostic accuracy for the detection of PE on CTPA compared to the report of the attending radiologist. This finding indicates that missed positive findings could be prevented with the implementation of AI-assisted reporting in daily clinical practice. CRITICAL RELEVANCE STATEMENT Missed positive findings on CTPA of patients suspected of pulmonary embolism can be prevented with the implementation of AI-assisted care. KEY POINTS The AI algorithm showed excellent diagnostic accuracy detecting PE on CTPA. Accuracy of the AI was significantly higher compared to the attending radiologist. Highest diagnostic accuracy can likely be achieved by radiologists supported by AI. Our results indicate that implementation of AI-assisted reporting could reduce the number of missed positive findings.
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Affiliation(s)
- Eline Langius-Wiffen
- Department of Radiology, Isala Hospital, Dr. van Heesweg 2, 8025 AB, Zwolle, The Netherlands.
| | - Pim A de Jong
- Department of Radiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | | | - Lisette Dekker
- Department of Radiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Andor F van den Hoven
- Department of Radiology, University Medical Centre Utrecht, Utrecht, The Netherlands
- Department of Nuclear Medicine, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Ingrid M Nijholt
- Department of Radiology, Isala Hospital, Dr. van Heesweg 2, 8025 AB, Zwolle, The Netherlands
| | - Martijn F Boomsma
- Department of Radiology, Isala Hospital, Dr. van Heesweg 2, 8025 AB, Zwolle, The Netherlands
- Division of Imaging and Oncology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Wouter B Veldhuis
- Department of Radiology, University Medical Centre Utrecht, Utrecht, The Netherlands
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van den Hoven AF, Keijsers RGM, Lam MGEH, Glaudemans AWJM, Verburg FA, Vogel WV, Lavalaye J. Current research topics in FAPI theranostics: a bibliometric analysis. Eur J Nucl Med Mol Imaging 2023; 50:1014-1027. [PMID: 36437424 DOI: 10.1007/s00259-022-06052-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 11/18/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE The study aimed to provide a comprehensive bibliometric overview of the current scientific publications on fibroblast activation protein inhibitor (FAPI) positron emission tomography imaging and radionuclide therapy. METHODS A PubMed search was performed to identify all MEDLINE-indexed publications on FAPI imaging and radionuclide therapy. The last update was performed on 31 May 2022. An online database of this literature was created, and hierarchical topic-related tags were subsequently assigned to all relevant studies. Frequency analysis was used to evaluate the distribution of the following characteristics: first author's country of origin, journal of publication, study design, imaging techniques and radiopharmaceutical used, histopathological correlation, the type of cancer, and benign disease/uptake types evaluated. RESULTS A total of 294 relevant publications on original studies were identified, consisting of 209 (71%) case reports/series and 85 cohort studies (29%). The majority of studies focused on imaging topics, predominantly comparing uptake on FAPI-PET/CT with 2-[18F]FDG-PET/CT, anatomical imaging, and/or histopathology results. 68% of studies focused on malignancies, with gastro-intestinal cancer, hepato-pancreato-biliary cancer, mixed cancers/metastases, lung cancer, sarcoma, head and neck cancer, and breast cancer being the most frequently reported. 42% of studies focused on benign disease categories, with cardiovascular, musculoskeletal, HPB, head and neck, and IgG4-related disease as most common categories. 16/294 (5%) studies focused on radionuclide therapy, with preliminary reports of acceptable toxicity profiles, tumour activity retention, and suggestion of disease control. CONCLUSION FAPI research is rapidly expanding from diagnostic studies in malignancies and benign diseases to the first reports of salvage radionuclide therapy. The research activity needs to shift now from low-level-of-evidence case reports and series to prospectively designed studies in homogenous patient groups to provide evidence on how and in which clinical situations FAPI theranostics can be of added value to clinical care. We have provided an overview of current research topics to build upon.
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Affiliation(s)
- Andor F van den Hoven
- Department of Nuclear Medicine, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands.
| | - Ruth G M Keijsers
- Department of Nuclear Medicine, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands
| | - Marnix G E H Lam
- Department of Radiology and Nuclear Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Andor W J M Glaudemans
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Frederik A Verburg
- Department of Radiology and Nuclear Medicine, Erasmus Medical Centre, Rotterdam, Netherlands
| | - Wouter V Vogel
- Department of Nuclear Medicine, The Netherlands Cancer Institute, Amsterdam, The Netherlands.,Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Jules Lavalaye
- Department of Nuclear Medicine, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands
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van Roekel C, van den Hoven AF, Bastiaannet R, Bruijnen RCG, Braat AJAT, de Keizer B, Lam MGEH, Smits MLJ. Use of an anti-reflux catheter to improve tumor targeting for holmium-166 radioembolization-a prospective, within-patient randomized study. Eur J Nucl Med Mol Imaging 2020; 48:1658-1668. [PMID: 33128132 PMCID: PMC8113291 DOI: 10.1007/s00259-020-05079-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 10/15/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE The objective of this study was to investigate whether the use of an anti-reflux catheter improves tumor targeting for colorectal cancer patients with unresectable, chemorefractory liver metastases (mCRC) treated with holmium-166 (166Ho)-radioembolization. MATERIALS AND METHODS In this perspective, within-patient randomized study, left and right hepatic perfusion territories were randomized between infusion with a Surefire® anti-reflux catheter or a standard microcatheter. The primary outcome was the difference in tumor to non-tumor (T/N) activity distribution. Secondary outcomes included the difference in infusion efficiency, absorbed doses, predictive value of 166Ho-scout, dose-response relation, and survival. RESULTS Twenty-one patients were treated in this study (the intended number of patients was 25). The median T/N activity concentration ratio with the use of the anti-reflux catheter was 3.2 (range 0.9-8.7) versus 3.6 (range 0.8-13.3) with a standard microcatheter. There was no difference in infusion efficiency (0.04% vs. 0.03% residual activity for the standard microcatheter and anti-reflux catheter, respectively) (95%CI - 0.05-0.03). No influence of the anti-reflux catheter on the dose-response rate was found. Median overall survival was 7.8 months (95%CI 6-13). CONCLUSION Using a Surefire® anti-reflux catheter did not result in a higher T/N activity concentration ratio in mCRC patients treated with 166Ho-radioembolization, nor did it result in improved secondary outcomes measures. TRIAL REGISTRATION clinicaltrials.gov identifier: NCT02208804.
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Affiliation(s)
- Caren van Roekel
- University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Andor F van den Hoven
- University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Remco Bastiaannet
- University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Rutger C G Bruijnen
- University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Arthur J A T Braat
- University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Bart de Keizer
- University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Marnix G E H Lam
- University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Maarten L J Smits
- University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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van Roekel C, Harlianto NI, Braat AJAT, Prince JF, van den Hoven AF, Bruijnen RCG, Lam MGEH, Smits MLJ. Evaluation of the Safety and Feasibility of Same-Day Holmium-166 -Radioembolization Simulation and Treatment of Hepatic Metastases. J Vasc Interv Radiol 2020; 31:1593-1599. [PMID: 32861571 DOI: 10.1016/j.jvir.2020.01.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 12/27/2019] [Accepted: 01/19/2020] [Indexed: 11/17/2022] Open
Abstract
PURPOSE To evaluate the safety and feasibility of same-day treatment, including the simulation procedure for assessment of intrahepatic and extrahepatic distribution of the microspheres, with holmium-166 (166Ho)-radioembolization. MATERIALS AND METHODS This was a secondary analysis of patients included in the 4 prospective studies (HEPAR I, HEPAR II, HEPAR PLuS, and SIM) on 166Ho-radioembolization. The technical success rate of the same-day treatment protocol, defined as the number of patients who completed the same-day treatment, was measured. Total in-room time, duration of the scout procedure, time to imaging, and duration of the treatment procedure were recorded. Reasons for discontinuation or adjustment of treatment were identified. Adverse events that occurred during the treatment day were recorded. RESULTS One hundred five of 120 scheduled patients completed the same-day treatment with 166Ho-radioembolization (success rate, 88%). After the simulation procedure, treatment was cancelled in 15 patients because of extrahepatic deposition (n = 8), suboptimal tumor targeting (n = 1), unanticipated vascular anatomy (n = 5), and dissection (n = 1). In another 14 patients, the treatment plan was adjusted. The median total procedure time (ie, simulation, imaging, and treatment) was 6:39 hours:minutes (range, 3:58-9:17 hours:minutes). Back pain was a major same-day treatment-related complaint (n = 28). CONCLUSION 166Ho-radioembolization as a same-day treatment procedure is feasible in most selected patients, although treatment was adjusted in 12% of patients and cancelled in 12% of patients. This approach might be beneficial for a select patient population, such as patients needing a radiation segmentectomy.
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Affiliation(s)
- Caren van Roekel
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, Netherlands.
| | - Netanja I Harlianto
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, Netherlands
| | - Arthur J A T Braat
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, Netherlands
| | - Jip F Prince
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, Netherlands
| | - Andor F van den Hoven
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, Netherlands
| | - Rutger C G Bruijnen
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, Netherlands
| | - Marnix G E H Lam
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, Netherlands
| | - Maarten L J Smits
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, Netherlands
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Suchá D, van Hamersvelt RW, van den Hoven AF, de Jong PA, Verkooijen HM. Suboptimal Quality and High Risk of Bias in Diagnostic Test Accuracy Studies at Chest Radiography and CT in the Acute Setting of the COVID-19 Pandemic: A Systematic Review. Radiol Cardiothorac Imaging 2020; 2:e200342. [PMID: 33778613 PMCID: PMC7393956 DOI: 10.1148/ryct.2020200342] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 07/07/2020] [Accepted: 07/20/2020] [Indexed: 12/28/2022]
Abstract
PURPOSE To synthesize the literature on diagnostic test accuracy of chest radiography, CT, and US for the diagnosis of coronavirus disease 2019 (COVID-19) in patients suspected of having COVID-19 in a hospital setting and evaluate the extent of suboptimal reporting and risk of bias. MATERIALS AND METHODS A systematic search was performed (April 26, 2020) in EMBASE, PubMed, and Cochrane to identify chest radiographic, CT, or US studies in adult patients suspected of having COVID-19, using reverse-transcription polymerase chain reaction test or clinical consensus as the standard of reference. Two × two contingency tables were reconstructed, and test sensitivity, specificity, positive predictive values, and negative predictive values were recalculated. Reporting quality was evaluated by adherence to the Standards for Reporting of Diagnostic Accuracy Studies (STARD), and risk of bias was evaluated by adherence to the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2). RESULTS Thirteen studies were eligible (CT = 12; chest radiography = 1; US = 0). Recalculated CT sensitivity and specificity ranged between 0.57 and 0.97, and 0.37 and 0.94, respectively, and positive predictive values and negative predictive values ranged between 0.59 and 0.92 and 0.57 and 0.96, respectively. On average, studies complied with only 35% of the STARD-guideline items. No study scored low risk of bias for all QUADAS-2 domains (patient selection, index test, reference test, and flow and timing). High risk of bias in more than one domain was scored in 10 of 13 studies (77%). CONCLUSION Reported CT test accuracy for COVID-19 diagnosis varies substantially. The validity and generalizability of these findings is complicated by poor adherence to reporting guidelines and high risk of bias, which are most likely due to the need for urgent publication of findings in the first months of the COVID-19 pandemic.Supplemental material is available for this article.© RSNA, 2020.
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Affiliation(s)
- Dominika Suchá
- From the Department of Radiology (D.S., R.W.v.H., A.F.v.d.H., P.A.d.J., H.M.V.) and Imaging Division (H.M.V.), University Medical Center Utrecht, Heidelberglaan 100, 3508 GA, Utrecht, the Netherlands
| | - Robbert W. van Hamersvelt
- From the Department of Radiology (D.S., R.W.v.H., A.F.v.d.H., P.A.d.J., H.M.V.) and Imaging Division (H.M.V.), University Medical Center Utrecht, Heidelberglaan 100, 3508 GA, Utrecht, the Netherlands
| | - Andor F. van den Hoven
- From the Department of Radiology (D.S., R.W.v.H., A.F.v.d.H., P.A.d.J., H.M.V.) and Imaging Division (H.M.V.), University Medical Center Utrecht, Heidelberglaan 100, 3508 GA, Utrecht, the Netherlands
| | - Pim A. de Jong
- From the Department of Radiology (D.S., R.W.v.H., A.F.v.d.H., P.A.d.J., H.M.V.) and Imaging Division (H.M.V.), University Medical Center Utrecht, Heidelberglaan 100, 3508 GA, Utrecht, the Netherlands
| | - Helena M. Verkooijen
- From the Department of Radiology (D.S., R.W.v.H., A.F.v.d.H., P.A.d.J., H.M.V.) and Imaging Division (H.M.V.), University Medical Center Utrecht, Heidelberglaan 100, 3508 GA, Utrecht, the Netherlands
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Samim M, van Veenendaal LM, Braat MNGJA, van den Hoven AF, Van Hillegersberg R, Sangro B, Kao YH, Liu D, Louie JD, Sze DY, Rose SC, Brown DB, Ahmadzadehfar H, Kim E, van den Bosch MAAJ, Lam MGEH. Recommendations for radioembolisation after liver surgery using yttrium-90 resin microspheres based on a survey of an international expert panel. Eur Radiol 2017; 27:4923-4930. [PMID: 28674968 PMCID: PMC5674129 DOI: 10.1007/s00330-017-4889-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 03/15/2017] [Accepted: 05/11/2017] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Guidelines on how to adjust activity in patients with a history of liver surgery who are undergoing yttrium-90 radioembolisation (90Y-RE) are lacking. The aim was to study the variability in activity prescription in these patients, between centres with extensive experience using resin microspheres 90Y-RE, and to draw recommendations on activity prescription based on an expert consensus. METHODS The variability in activity prescription between centres was investigated by a survey of international experts in the field of 90Y-RE. Six representative post-surgical patients (i.e. comparable activity prescription, different outcome) were selected. Information on patients' disease characteristics and data needed for activity calculation was presented to the expert panel. Reported was the used method for activity prescription and whether, how and why activity reduction was found indicated. RESULTS Ten experts took part in the survey. Recommendations on activity reduction were highly variable between the expert panel. The median intra-patient range was 44 Gy (range 18-55 Gy). Reductions in prescribed activity were recommended in 68% of the cases. In consensus, a maximum DTarget of 50 Gy was recommended. CONCLUSION With a current lack of guidelines, large variability in activity prescription in post-surgical patients undergoing 90Y-RE exists. In consensus, DTarget ≤50 Gy is recommended. KEY POINTS • BSA method does not account for a decreased remnant liver volume after surgery. • In post-surgical patients, a volume-based activity determination method is recommended. • In post-surgical patients, a mean D Target of ≤ 50Gy should be aimed for.
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Affiliation(s)
- Morsal Samim
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Linde M van Veenendaal
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Manon N G J A Braat
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Andor F van den Hoven
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Bruno Sangro
- Liver Unit, Clinica Universidad de Navarra-IDISNA and CIBEREHD, Pamplona, Spain
| | - Yung Hsiang Kao
- Department of Nuclear Medicine, Cabrini Hospital, Melbourne, Australia
| | - Dave Liu
- Department of Radiology, Vancouver General Hospital. University of British Columbia, Vancouver, British Columbia, Canada
| | - John D Louie
- Division of Interventional Radiology, Stanford University Medical Center, Stanford, USA
| | - Daniel Y Sze
- Division of Interventional Radiology, Stanford University Medical Center, Stanford, USA
| | - Steven C Rose
- Department of Radiology, University of California, San Diego, USA
| | - Daniel B Brown
- Department of Radiology, Vanderbilt University, Medical Center North, Nashville, USA
| | | | - Edward Kim
- Division of Vascular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, USA
| | | | - Marnix G E H Lam
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
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Braat AJAT, Kappadath SC, Bruijnen RCG, van den Hoven AF, Mahvash A, de Jong HWAM, Lam MGEH. Adequate SIRT activity dose is as important as adequate chemotherapy dose. Lancet Oncol 2017; 18:e636. [PMID: 29208390 DOI: 10.1016/s1470-2045(17)30811-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 09/25/2017] [Accepted: 09/27/2017] [Indexed: 12/27/2022]
Affiliation(s)
- Arthur J A T Braat
- Department of Radiology and Nuclear Medicine, Imaging Division, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - S Cheenu Kappadath
- Department of Imaging Physics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rutger C G Bruijnen
- Department of Radiology and Nuclear Medicine, Imaging Division, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Andor F van den Hoven
- Department of Radiology and Nuclear Medicine, Imaging Division, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Armeen Mahvash
- Department of Interventional Radiology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hugo W A M de Jong
- Department of Radiology and Nuclear Medicine, Imaging Division, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marnix G E H Lam
- Department of Radiology and Nuclear Medicine, Imaging Division, University Medical Center Utrecht, Utrecht, The Netherlands
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Prince JF, van den Bosch MAAJ, Nijsen JFW, Smits MLJ, van den Hoven AF, Nikolakopoulos S, Wessels FJ, Bruijnen RCG, Braat MNGJA, Zonnenberg BA, Lam MGEH. Efficacy of Radioembolization with 166Ho-Microspheres in Salvage Patients with Liver Metastases: A Phase 2 Study. J Nucl Med 2017; 59:582-588. [PMID: 28916623 DOI: 10.2967/jnumed.117.197194] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 09/05/2017] [Indexed: 12/22/2022] Open
Abstract
Radioembolization of liver malignancies with 166Ho-microspheres has been shown to be safe in a phase 1 dose-escalation study. The purpose of this study was to investigate the efficacy of 166Ho radioembolization. Methods: In this prospective single-arm study, 56 patients were enrolled, all with liver metastases refractory to systemic therapy and ineligible for surgical resection. The primary outcome was a response by 2 target lesions on triphasic liver CT scans 3 mo after therapy, as assessed using RECIST, version 1.1. Secondary outcomes included overall tumor response, time to imaging progression, overall survival, toxicity, quality of life, and quantification of the microspheres on SPECT and MRI. Results: Between May 2012 and March 2015, 38 eligible patients were treated, one of whom was not evaluable. In 27 (73%) of 37 patients, the target lesions showed complete response, partial response, or stable disease (disease control) at 3 mo (95% confidence interval [CI], 57%-85%). The median overall survival was 14.5 mo (95% CI, 8.6-22.8 mo). For colorectal cancer patients (n = 23), the median overall survival was 13.4 mo (95% CI, 8.2-15.7 mo). Grade 3 or 4 toxic events after treatment (according to the Common Terminology Criteria for Adverse Events, version 4.03) included abdominal pain (in 18% of patients), nausea (8%), ascites (3%), fatigue (3%), gastric stenosis (3%), hepatic failure (3%), liver abscesses (3%), paroxysmal atrial tachycardia (3%), thoracic pain (3%), upper gastrointestinal hemorrhage (3%), and vomiting (3%). On SPECT, 166Ho could be quantified with high accuracy and precision, with a mean overestimation of 9.3% ± 7.1% in the liver. Conclusion: Radioembolization with 166Ho-microspheres induced a tumor response with an acceptable toxicity profile in salvage patients with liver metastases.
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Affiliation(s)
- Jip F Prince
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands; and
| | - Maurice A A J van den Bosch
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands; and
| | - Johannes F W Nijsen
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands; and
| | - Maarten L J Smits
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands; and
| | - Andor F van den Hoven
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands; and
| | - Stavros Nikolakopoulos
- Department of Biostatistics, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frank J Wessels
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands; and
| | - Rutger C G Bruijnen
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands; and
| | - Manon N G J A Braat
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands; and
| | - Bernard A Zonnenberg
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands; and
| | - Marnix G E H Lam
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands; and
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Dankbaar JW, Horsch AD, van den Hoven AF, Kappelle LJ, van der Schaaf IC, van Seeters T, Velthuis BK. Prediction of Clinical Outcome After Acute Ischemic Stroke. Stroke 2017; 48:2593-2596. [DOI: 10.1161/strokeaha.117.017835] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 06/23/2017] [Accepted: 06/27/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Jan W. Dankbaar
- From the Departments of Radiology (J.W.D., A.D.H., A.F.v.d.H., I.C.v.d.S., T.v.S., B.K.V.) and Neurology and Neurosurgery (L.J.K.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands
| | - Alexander D. Horsch
- From the Departments of Radiology (J.W.D., A.D.H., A.F.v.d.H., I.C.v.d.S., T.v.S., B.K.V.) and Neurology and Neurosurgery (L.J.K.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands
| | - Andor F. van den Hoven
- From the Departments of Radiology (J.W.D., A.D.H., A.F.v.d.H., I.C.v.d.S., T.v.S., B.K.V.) and Neurology and Neurosurgery (L.J.K.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands
| | - L. Jaap Kappelle
- From the Departments of Radiology (J.W.D., A.D.H., A.F.v.d.H., I.C.v.d.S., T.v.S., B.K.V.) and Neurology and Neurosurgery (L.J.K.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands
| | - Irene C. van der Schaaf
- From the Departments of Radiology (J.W.D., A.D.H., A.F.v.d.H., I.C.v.d.S., T.v.S., B.K.V.) and Neurology and Neurosurgery (L.J.K.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands
| | - Tom van Seeters
- From the Departments of Radiology (J.W.D., A.D.H., A.F.v.d.H., I.C.v.d.S., T.v.S., B.K.V.) and Neurology and Neurosurgery (L.J.K.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands
| | - Birgitta K. Velthuis
- From the Departments of Radiology (J.W.D., A.D.H., A.F.v.d.H., I.C.v.d.S., T.v.S., B.K.V.) and Neurology and Neurosurgery (L.J.K.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands
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van den Hoven AF, Prince JF, Bruijnen RCG, Verkooijen HM, Krijger GC, Lam MGEH, van den Bosch MAAJ. Surefire infusion system versus standard microcatheter use during holmium-166 radioembolization: study protocol for a randomized controlled trial. Trials 2016; 17:520. [PMID: 27782851 PMCID: PMC5080784 DOI: 10.1186/s13063-016-1643-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 10/05/2016] [Indexed: 12/31/2022] Open
Abstract
Background An anti-reflux catheter (ARC) may increase the tumor absorbed dose during radioembolization (RE) by elimination of particle reflux and its effects on hemodynamics. Since the catheter is fixed in a centro-luminal position, it may also increase the predictive accuracy of a scout dose administration before treatment. The purpose of the SIM trial is to compare the effects of ARC use during RE with holmium-166 (166Ho) microspheres in patients with colorectal liver metastases (CRLM), with the use of a standard end-hole microcatheter. Methods/Design A within-patient randomized controlled trial (RCT) will be conducted in 25 patients with unresectable chemorefractory liver-dominant CRLM. Study participants will undergo a 166Ho scout dose procedure in the morning and a therapeutic procedure in the afternoon. The ARC will be randomly allocated to the left/right hepatic artery, and a standard microcatheter will be used in the contralateral artery. SPECT/CT imaging will be performed for quantitative analyses of the microsphere distribution directly after the scout and treatment procedure. Baseline and follow-up investigations include 18F-FDG-PET + liver CT, clinical and laboratory examinations. The primary endpoint is the comparison of tumor to non-tumor (T/N) activity ratio in both groups. Secondary endpoints include comparisons of mean absorbed dose in tumors and healthy liver tissue, infusion efficiency, the predictive value of 166Ho scout dose for tumor response. In the entire cohort, a dose-response relationship, clinical toxicity, and overall survival will be assessed. The sample was determined for the expectation that the ARC will increase the T/N ratio by 25 % (mean T/N ratio 2.0 vs. 1.6). Discussion The SIM trial is a within-patient RCT that will assess whether 166Ho RE treatment can be optimized by using an ARC. Trial registration The SIM trial is registered at clinicaltrials.gov (NCT02208804). Registered on 31 July 2014. Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1643-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Andor F van den Hoven
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Jip F Prince
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Rutger C G Bruijnen
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Helena M Verkooijen
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Gerard C Krijger
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Marnix G E H Lam
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Maurice A A J van den Bosch
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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van den Hoven AF, Braat MNGJA, Prince JF, van Doormaal PJ, van Leeuwen MS, Lam MGEH, van den Bosch MAAJ. Liver CT for vascular mapping during radioembolisation workup: comparison of an early and late arterial phase protocol. Eur Radiol 2016; 27:61-69. [PMID: 27108297 PMCID: PMC5127855 DOI: 10.1007/s00330-016-4343-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 03/20/2016] [Accepted: 03/21/2016] [Indexed: 11/25/2022]
Abstract
Objectives To compare right gastric (RGA) and segment 4 artery (A4) origin detection rates during radioembolisation workup between early and late arterial phase liver CT protocols. Methods 100 consecutive patients who underwent liver CT between May 2012–January 2015 with early or late arterial phase protocol (n = 50 each, 10- vs. 20-s post-threshold delay) were included. RGA/A4 origin detection rates, assessed by two raters, and contrast-to-noise ratio (CNR) of the hepatic artery relative to the portal vein were compared between the protocols. Results The first–second rater scored the RGA origin as visible in 58–65 % (specific proportion of agreement 82 %, κ = 0.62); A4 origin in 96–89 % (94 %, κ = 0.54). Thirty-six percent of RGA origins not detectable by DSA were identified on CT. Origin detection rates were not significantly different for early/late arterial phases. Mean CNR was higher in the early arterial phase protocol (1.7 vs. 1.2, p < 0.001). Conclusion A 10-s delay arterial phase CT protocol does not significantly improve detection of small intra- and extrahepatic branches. RGA origin detection requires further optimization, whereas A4/MHA origin detection is adequate, with good inter-rater reproducibility. CT remains important for preprocedural planning, because it may reveal arterial anatomy not discernible on DSA. Key Points • An early arterial phase does not significantly improve RGA and A4/MHA origin detection. • RGA origin detection (58–65 %) on CT is still suboptimal. • 36 % of RGA origins undetectable on DSA can be identified on CT. • A4/MHA origin detection (89–96 %) on CT is excellent. • Inter-rater reproducibility is good for RGA and A4/MHA origin detection on CT.
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Affiliation(s)
- Andor F van den Hoven
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Manon N G J A Braat
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Jip F Prince
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Pieter J van Doormaal
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Maarten S van Leeuwen
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Marnix G E H Lam
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Maurice A A J van den Bosch
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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Braat MNGJA, van den Hoven AF, van Doormaal PJ, Bruijnen RC, Lam MGEH, van den Bosch MAAJ. The Caudate Lobe: The Blind Spot in Radioembolization or an Overlooked Opportunity? Cardiovasc Intervent Radiol 2016; 39:847-54. [DOI: 10.1007/s00270-016-1321-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 02/22/2016] [Indexed: 12/14/2022]
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van den Hoven AF, Rosenbaum CE, Elias SG, de Jong HW, Koopman M, Verkooijen HM, Alavi A, van den Bosch MA, Lam MG. Insights into the Dose–Response Relationship of Radioembolization with Resin 90Y-Microspheres: A Prospective Cohort Study in Patients with Colorectal Cancer Liver Metastases. J Nucl Med 2016; 57:1014-9. [DOI: 10.2967/jnumed.115.166942] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 02/01/2016] [Indexed: 12/15/2022] Open
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van den Hoven AF, Lam MGEH, Jernigan S, van den Bosch MAAJ, Buckner GD. Innovation in catheter design for intra-arterial liver cancer treatments results in favorable particle-fluid dynamics. J Exp Clin Cancer Res 2015; 34:74. [PMID: 26231929 PMCID: PMC4522078 DOI: 10.1186/s13046-015-0188-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 07/06/2015] [Indexed: 12/30/2022]
Abstract
Background Liver tumors are increasingly treated with radioembolization. Here, we present first evidence of catheter design effect on particle-fluid dynamics and downstream branch targeting during microsphere administrations. Materials and methods A total of 7 experiments were performed in a bench-top model of the hepatic arterial vasculature with recreated hemodynamics. Fluorescent microspheres and clinically used holmium microspheres were administered with a standard microcatheter (SMC) and an anti-reflux catheter (ARC) positioned at the same level along the longitudinal vessel axis. Catheter-related particle flow dynamics were analyzed by reviewing video recordings of UV-light illuminated fluorescent microsphere administrations. Downstream branch distribution was analyzed by quantification of collected microspheres in separate filters for two first-order branches. Mean deviation from a perfectly homogenous distribution (DHD) was used to compare the distribution homogeneity between catheter types. Results The SMC administrations demonstrated a random off-centered catheter position (in 71 % of experiments), and a laminar particle flow pattern with an inhomogeneous downstream branch distribution, dependent on catheter position and injection force. The ARC administrations demonstrated a fixed centro-luminal catheter position, and a turbulent particle flow pattern with a more consistent and homogenous downstream branch distribution. Quantitative analyses confirmed a significantly more homogeneous distribution with the ARC; the mean DHD was 40.85 % (IQR 22.76 %) for the SMC and 15.54 % (IQR 6.46 %) for the ARC (p = 0.047). Conclusion Catheter type has a significant impact on microsphere administrations in an in-vitro hepatic arterial model. A within-patient randomized controlled trial has been initiated to investigate clinical catheter-related effects during radioembolization treatment. Electronic supplementary material The online version of this article (doi:10.1186/s13046-015-0188-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Andor F van den Hoven
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Room E.01.132, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Marnix G E H Lam
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Room E.01.132, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Shaphan Jernigan
- Department of Mechanical and Aerospace Engineering, North Carolina State University, 911 Oval Drive, Raleigh, North Carolina, 27695, USA.
| | - Maurice A A J van den Bosch
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Room E.01.132, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Gregory D Buckner
- Department of Mechanical and Aerospace Engineering, North Carolina State University, 911 Oval Drive, Raleigh, North Carolina, 27695, USA.
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van den Hoven AF, Prince JF, de Keizer B, Vonken EJPA, Bruijnen RCG, Verkooijen HM, Lam MGEH, van den Bosch MAAJ. Use of C-Arm Cone Beam CT During Hepatic Radioembolization: Protocol Optimization for Extrahepatic Shunting and Parenchymal Enhancement. Cardiovasc Intervent Radiol 2015; 39:64-73. [PMID: 26067803 PMCID: PMC4689758 DOI: 10.1007/s00270-015-1146-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Accepted: 05/02/2015] [Indexed: 12/17/2022]
Abstract
Purpose To optimize a C-arm computed tomography (CT) protocol for radioembolization (RE), specifically for extrahepatic shunting and parenchymal enhancement. Materials and Methods A prospective development study was performed per IDEAL recommendations. A literature-based protocol was applied in patients with unresectable and chemorefractory liver malignancies undergoing an angiography before radioembolization. Contrast and scan settings were adjusted stepwise and repeatedly reviewed in a consensus meeting. Afterwards, two independent raters analyzed all scans. A third rater evaluated the SPECT/CT scans as a reference standard for extrahepatic shunting and lack of target segment perfusion. Results Fifty scans were obtained in 29 procedures. The first protocol, using a 6 s delay and 10 s scan, showed insufficient parenchymal enhancement. In the second protocol, the delay was determined by timing parenchymal enhancement on DSA power injection (median 8 s, range 4–10 s): enhancement improved, but breathing artifacts increased (from 0 to 27 %). Since the third protocol with a 5 s scan decremented subjective image quality, the second protocol was deemed optimal. Median CNR (range) was 1.7 (0.6–3.2), 2.2 (−1.4–4.0), and 2.1 (−0.3–3.0) for protocol 1, 2, and 3 (p = 0.80). Delineation of perfused segments was possible in 57, 73, and 44 % of scans (p = 0.13). In all C-arm CTs combined, the negative predictive value was 95 % for extrahepatic shunting and 83 % for lack of target segment perfusion. Conclusion An optimized C-arm CT protocol was developed that can be used to detect extrahepatic shunts and non-perfusion of target segments during RE.
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Affiliation(s)
- Andor F van den Hoven
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Room E.01.132, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Jip F Prince
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Room E.01.132, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Bart de Keizer
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Room E.01.132, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Evert-Jan P A Vonken
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Room E.01.132, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Rutger C G Bruijnen
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Room E.01.132, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Helena M Verkooijen
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Room E.01.132, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Marnix G E H Lam
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Room E.01.132, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Maurice A A J van den Bosch
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Room E.01.132, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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Braat AJAT, Smits MLJ, Braat MNGJA, van den Hoven AF, Prince JF, de Jong HWAM, van den Bosch MAAJ, Lam MGEH. ⁹⁰Y Hepatic Radioembolization: An Update on Current Practice and Recent Developments. J Nucl Med 2015; 56:1079-87. [PMID: 25952741 DOI: 10.2967/jnumed.115.157446] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Accepted: 04/25/2015] [Indexed: 12/14/2022] Open
Abstract
Radioembolization is an established treatment modality that has been subjected to many improvements over the last decade. Developments are occurring at a high pace, affecting patient selection and treatment. The aim of this review is therefore to provide an overview of current practice, with a focus on recent developments in the field of radioembolization. Several practical issues and recommendations in the application of radioembolization will be discussed, ranging from patient selection to treatment response and future applications.
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Affiliation(s)
- Arthur J A T Braat
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan, Utrecht, The Netherlands
| | - Maarten L J Smits
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan, Utrecht, The Netherlands
| | - Manon N G J A Braat
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan, Utrecht, The Netherlands
| | - Andor F van den Hoven
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan, Utrecht, The Netherlands
| | - Jip F Prince
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan, Utrecht, The Netherlands
| | - Hugo W A M de Jong
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan, Utrecht, The Netherlands
| | - Maurice A A J van den Bosch
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan, Utrecht, The Netherlands
| | - Marnix G E H Lam
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan, Utrecht, The Netherlands
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van den Hoven AF, Prince JF, van den Bosch MA, Lam MG. Hepatic Radioembolization as a True Single-Session Treatment. J Vasc Interv Radiol 2014; 25:1143-4. [DOI: 10.1016/j.jvir.2014.01.037] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Revised: 01/27/2014] [Accepted: 01/27/2014] [Indexed: 10/25/2022] Open
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van den Hoven AF, Smits MLJ, de Keizer B, van Leeuwen MS, van den Bosch MAAJ, Lam MGEH. Identifying aberrant hepatic arteries prior to intra-arterial radioembolization. Cardiovasc Intervent Radiol 2014; 37:1482-93. [PMID: 24469409 DOI: 10.1007/s00270-014-0845-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Accepted: 12/21/2013] [Indexed: 10/25/2022]
Abstract
PURPOSE Failing to identify aberrant hepatic arteries before radioembolization (RE) may compromise its treatment efficacy due to inadequate biodistribution of radioactive microspheres. The purpose of this study was to evaluate how often aberrant hepatic arteries were identified correctly in clinical practice, with computed tomography (CT), and during angiography in patients with liver tumors who received a workup for RE. METHODS The presence and vascularization pattern of aberrant (i.e., accessory and replaced) hepatic arteries was assessed on triphasic liver CT in 110 patients. Subsequently, radiological reports on CT and angiographic procedures were reviewed to determine whether aberrant hepatic arteries were identified correctly in clinical practice. The intrahepatic biodistribution of (99m)Tc-MAA and radioactive microspheres was assessed on SPECT/CT and PET/CT in all patients with unidentified aberrant hepatic arteries. RESULTS Thirty-seven of 110 patients (34%) had aberrant hepatic arteries. In 18 of 37 (49%) patients, the aberrant hepatic arteries were correctly identified on CT and in 32 of 37 (86%) during angiography. Aberrant right hepatic arteries were identified more frequently than aberrant left hepatic arteries on CT (54 vs. 44%) and during angiography (100 vs. 69%, p = 0.007). In five patients (14%), an aberrant left hepatic artery remained unidentified, resulting in a lack of (99m)Tc-MAA and (90)Y activity in the segmental territory of the unidentified aberrant hepatic arteries. CONCLUSIONS Aberrant left hepatic arteries were the most common unidentified aberrant hepatic arteries, resulting in incomplete radiation coverage. We formulated a practical approach to identify aberrant hepatic arteries correctly before RE.
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Affiliation(s)
- Andor F van den Hoven
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Room E.01.132, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands,
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van den Hoven AF, Smits MLJ, Rosenbaum CENM, Verkooijen HM, van den Bosch MAAJ, Lam MGEH. The effect of intra-arterial angiotensin II on the hepatic tumor to non-tumor blood flow ratio for radioembolization: a systematic review. PLoS One 2014; 9:e86394. [PMID: 24466071 PMCID: PMC3895031 DOI: 10.1371/journal.pone.0086394] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Accepted: 12/06/2013] [Indexed: 12/23/2022] Open
Abstract
PURPOSE Treatment efficacy of intra-arterial radioembolization for liver tumors depends on the selective targeting of tumorous tissue. Recent investigations have demonstrated that tumors may receive inadequate doses of radioactivity after radioembolization, due to unfavorable tumor to non-tumor (T/N) uptake ratios of radioactive microspheres. Hepatic arterial infusion of the vasoconstrictor angiotensin II (AT-II) is reported to increase the T/N blood flow ratio. The purpose of this systematic review was to provide a comprehensive overview of the effect of hepatic arterial AT-II on T/N blood flow ratio in patients with hepatic malignancies, and determine its clinical value for radioembolization. METHODS This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A structured search was performed in the PubMed, EMBASE and Cochrane databases. Only studies that presented data on T/N ratios before and after infusion of AT-II into the hepatic artery, in human patients with hepatic malignancies, were selected. Median T/N ratios before, during and after AT-II infusion, and the median T/N ratio improvement factor were extracted from the selected articles. All data on systemic blood pressure measurements and clinical symptoms were also extracted. RESULTS The search identified 524 titles of which 5 studies, including a total of 71 patients were considered relevant. Median T/N ratios before infusion of AT-II ranged from 0.4 to 3.4. All studies observed a substantial improvement of the T/N ratio after AT-II infusion, with median improvement factors ranging from 1.8 to 3.1. A transitory increase of systemic blood pressure was observed during AT-II infusion. CONCLUSIONS Infusion of AT-II into the hepatic artery leads to an increase of the tumor to non-tumor blood flow ratio, as measured by T/N uptake ratios. Clinical trials are warranted to assess safety aspects, optimal administration strategy and impact on treatment efficacy during radioembolization.
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Affiliation(s)
- Andor F. van den Hoven
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Maarten L. J. Smits
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Helena M. Verkooijen
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Marnix G. E. H. Lam
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
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Smits MLJ, van den Hoven AF, Rosenbaum CENM, Zonnenberg BA, Lam MGEH, Nijsen JFW, Koopman M, van den Bosch MAAJ. Clinical and laboratory toxicity after intra-arterial radioembolization with (90)y-microspheres for unresectable liver metastases. PLoS One 2013; 8:e69448. [PMID: 23894481 PMCID: PMC3722288 DOI: 10.1371/journal.pone.0069448] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2012] [Accepted: 06/07/2013] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To investigate clinical and laboratory toxicity in patients with unresectable liver metastases, treated with yttrium-90 radioembolization ((90)Y-RE). METHODS Patients with liver metastases treated with (90)Y-RE, between February 1(st) 2009 and March 31(st) 2012, were included in this study. Clinical toxicity assessment was based on the reporting in patient's charts. Laboratory investigations at baseline and during a four-month follow-up were used to assess laboratory toxicity according to the Common Terminology Criteria for Adverse Events version 4.02. The occurrence of grade 3-4 laboratory toxicity was stratified according to treatment strategy (whole liver treatment in one session versus sequential sessions). Response assessment was performed at the level of target lesions, whole liver and overall response in accordance with RECIST 1.1 at 3- and 6 months post-treatment. Median time to progression (TTP) and overall survival were calculated by Kaplan-Meier analysis. RESULTS A total of 59 patients, with liver metastases from colorectal cancer (n = 30), neuroendocrine tumors (NET) (n = 6) and other primary tumors (n = 23) were included. Clinical toxicity after (90)Y-RE treatment was confined to grade 1-2 events, predominantly post-embolization symptoms. No grade 3-4 clinical toxicity was observed, whereas laboratory toxicity grade 3-4 was observed in 38% of patients. Whole liver treatment in one session was not associated with increased laboratory toxicity. Three-months disease control rates for target lesions, whole liver and overall response were 35%, 21% and 19% respectively. Median TTP was 6.2 months for target lesions, 3.3 months for the whole liver and 3.0 months for overall response. Median overall survival was 8.9 months. CONCLUSION The risk of severe complications or grade 3-4 clinical toxicity in patients with liver metastases of various primary tumors undergoing (90)Y-RE is low. In contrast, laboratory toxicity grade 3-4 can be expected to occur in more than one-third of patients without any clinical signs of radiation induced liver disease.
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Affiliation(s)
- Maarten L. J. Smits
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Andor F. van den Hoven
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Charlotte E. N. M. Rosenbaum
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Bernard A. Zonnenberg
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marnix G. E. H. Lam
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Johannes F. W. Nijsen
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Miriam Koopman
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Maurice A. A. J. van den Bosch
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
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Smits MLJ, Prince JF, Rosenbaum CENM, van den Hoven AF, Nijsen JFW, Zonnenberg BA, Seinstra BA, Lam MGEH, van den Bosch MAAJ. Intra-arterial radioembolization of breast cancer liver metastases: a structured review. Eur J Pharmacol 2013; 709:37-42. [PMID: 23545356 DOI: 10.1016/j.ejphar.2012.11.067] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2012] [Revised: 11/19/2012] [Accepted: 11/23/2012] [Indexed: 12/11/2022]
Abstract
Radioembolization using yttrium-90 microspheres (⁹⁰Y-RE) is an emerging treatment option for breast cancer liver metastases (BCLM) patients if other locoregional and systemic treatment options fail. The purpose of this study was to provide a systematic overview of the current literature concerning ⁹⁰Y-RE for BCLM patients. A systematic search for relevant articles was performed in MEDLINE, EMBASE, and The Cochrane Library (January 2012) by combining an extensive list of synonyms for the determinants 'radioembolization', 'yttrium-90' and 'microsphere' with synonyms for the domain 'liver'. Data on tumor response, survival and toxicity were extracted and collected from all relevant articles. The search yielded 4078 studies, of which six were finally included for analysis, concerning a total of 198 patients. Tumor response was scored in five studies using either RECIST (n=3) or WHO criteria (n=2). Overall disease control rates (complete response, partial response and stable disease) at 2-4 months post treatment ranged from 78% to 96%. Median survival, available in four studies, ranged from 10.8 to 20.9 months. In total, gastric ulceration was reported in ten patients (5%) and treatment related mortality in three patients (2%). The results from the analyzed studies consistently show that ⁹⁰Y-RE is a safe and effective treatment option for BCLM patients. Comparative studies, especially combining ⁹⁰Y-RE with systemic therapy are strongly encouraged.
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Affiliation(s)
- Maarten L J Smits
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
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