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Effect of Gravity on Drug Distribution after Port-catheter Implantation for Hepatic Arterial Infusion Chemotherapy

Posted May 31, 2009 Updated Apr 7, 2023
By Yoshitaka Tamura MD , Osama Ikeda MD PhD , Yutaka Nakasone MD , Shinya Shiraishi MD PhD , Seiji Tomiguchi MD PhD , Yasuyuki Yamashita MD PhD , Hiroshi Takamori MD PhD , Hideo Baba MD PhD
8 min read

Rationale and Objectives

We evaluated the effect of gravity on intrahepatic perfusion (IHP) in patients with a port-catheter system (PCS) implanted for hepatic arterial infusion chemotherapy (HAIC). Using fused single photon-emission computed tomographic (SPECT)/computed tomographic (CT) images, we compared IHP after the injection of technetium-99m-labeled macroaggregated albumin (Tc-99m-MAA) via a PCS with the patient in the upright and decubitus positions.

Materials and Methods

We enrolled 27 patients with metastatic carcinoma of the liver who bore an implantable PCS for HAIC. SPECT/CT images were obtained on the third and seventh postimplantation day; 99mTc-MAA (185 MBq) was delivered with the patient in the upright and decubitus positions. We selected four regions of interest (ROIs) on SPECT images of the superior, inferior, anterior, and posterior regions. The anteroposterior and the superoinferior perfusion ratio (AP ratio, SI ratio) were derived from the mean counts in each ROI. Using an unpaired t -test, we compared these ratios after drug delivery in the upright and decubitus injection positions. We also visually compared IHP and classified the distribution of drugs delivered in the upright and decubitus positions on fused images. Moreover, using World Health Organization criteria, we evaluated the therapeutic response by comparing the tumor size on contrast-enhanced CT images obtained before and 3 months after treatment.

Results

The SI ratios in the upright and decubitus injection positions were 1.14 and 0.92, respectively; the corresponding AP ratios were 1.47 and 1.73, respectively, indicating that there was no significant difference in these parameters irrespective of the injection position (SI ratio: P = .27, AP ratio: P = .35). However, in 14 of the 27 patients (52%), the visual appearance of IHP was different in the upright and decubitus positions. A change in the location of the catheter side hole when the decubitus was changed to the upright position produced a difference in IHP. Of 13 patients with identical drug distribution in both injection positions, six (46%) manifested a partial response (PR), five (38%) experienced no change (NC), and two (15%) experienced progressive disease (PD). Among the 14 patients with different drug distribution in the two injection positions, four (28%) achieved PR, five (36%) manifested NC, and the other five (36%) had PD.

Conclusions

Although the patient posture affected IHP by changing the position of the infusion catheter side hole in the liver, gravity had no significant effect on IHP in patients bearing an implantable PCS for the delivery of HAIC.

Hepatic arterial infusion chemotherapy (HAIC) via an implantable port-catheter system (PCS) is now used as a regional treatment for malignant tumors of the liver . We previously reported that fusion imaging using the combined single photon-emission computed tomographic (SPECT)/computed tomographic (CT) system reflects the actual distribution of the infused anticancer agent and that a good response requires direct perfusion of the area of malignancy . All patients in the earlier studies underwent abdominal SPECT with technetium-99m-labeled macroaggregated albumin (Tc-99m-MAA) delivered via the implantable port. 5-Fluorouracil (5-FU) was delivered via the arterial port for 5 or more hours and the posture of the patients was changed during HAIC.

According to Lisbona and colleagues , gravity had an effect on pulmonary perfusion scintigraphy with Tc-99m-MAA. In normal erect subjects, the flow of blood to the lungs from the pulmonary artery is strikingly nonuniform and West and colleagues documented that gravity strongly influences regional resistance via its effects on the capillary caliber.

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Materials and methods

Patients

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Port System Implantation

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Fusion Images Using a Combined SPECT/CT System

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Drug Administration

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Evaluation

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Figure 1, Axial fused images of two regions of interest (ROI) in the liver including the anterior (ROI-A) and posterior (ROI-B) portion. Coronal fusion images of two ROI in the liver including the superior (ROI-C) and inferior (ROI-D) portion.

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Results

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Table 1

Comparison of SI and AP Ratios between Upright Injection and Decubitus Injection Perfusion Ratio (mean ± SD)

SI Ratio AP Ratio Upright injection 1.47 ± 0.21 ∗ 1.14 ± 0.17 ∗ † Decubitus injection 1.73 ± 0.19 ∗ 0.92 ± 0.08 ∗

AP, anteroposterior; SD, standard deviation; SI, superoinferior;

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Table 2

Difference in Intrahepatic Perfusion between Upright and Decubitus Injection in 2 Access Routes

Identical Distribution Different Distribution Subclavian artery 12 8 Femoral artery 1 6

P = .04.

Table 3

Difference in Intrahepatic Perfusion between Upright and Decubitus Injection in 3 Groups

Identical Distribution Different Distribution Group 1 8 5 Group 2 2 4 Group 3 3 5

P = .29.

Intrahepatic perfusion patterns on fusion imaging in upright and decubitus positions. Group 1: the catheter was fixed in the gastroduodenal artery; Group 2: the catheter was fixed in a branch of the hepatic artery; Group 3: the catheter was placed in the splenic artery.

Figure 2, A 73-year-old woman with liver metastasis from colorectal cancer. On coronal fused images, intrahepatic perfusion was identical in the upright and decubitus position. Common hepatic arteriogram through the port, obtained just after implantation of the port-catheter system, showing the left and right hepatic artery arising from the middle hepatic artery. Hemodynamic modification was by microcoil-embolization of the left gastric artery (arrow) , the replaced right hepatic artery (arrow) , and the right gastric artery (open arrow) . A catheter with a side hole at the proper hepatic artery was fixed to the gastroduodenal artery with microcoils (arrow head) . (Upright position) Note the homogeneous distribution of technetium-99m-macroaggregated albumin (Tc-99m-MAA) in the hepatic parenchyma. (Decubitus position) Note the homogeneous distribution of 99m-Tc-MAA in the hepatic parenchyma.

Figure 3, A 67-year-old man with liver metastasis from unresectable pancreatic cancer. Intrahepatic perfusion was different in the upright and decubitus position. Celiac angiogram through the port obtained just after implantation of the port-catheter system showing the left and right hepatic artery arising from the middle hepatic artery. Hemodynamic modulation was by microcoil embolization of the left gastric artery (arrow) , the replaced right hepatic artery (arrow) , the right gastric artery (open arrow) , and the gastroduodenal artery (open arrow) . A catheter with a side hole at the celiac trunk was placed in the splenic artery (arrow head) . Decubitus position , The axial fused image demonstrates homogeneous distribution in the whole hepatic parenchyma. Upright position , The axial fused image shows heterogeneous distribution in the whole hepatic parenchyma.

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Table 4

Relationship between Intrahepatic Perfusion Pattern on Fused Images and Initial Response of Liver Tumors

Initial Therapeutic Response Fused Image CR PR NC PD Identical drug distribution — 6 5 2 Different drug distribution — 4 5 5

CR, complete response; NC, no change; PD, progressive disease; PR, partial response.

P = .57.

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Discussion

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References

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Academic Radiology, Volume 16, Issue 6
Journals General Radiology
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