Rationale and Objectives
To prospectively analyze the correlation between parameters of liver perfusion from technetium 99m -macroaggregates of albumin ( 99m Tc-MAA) single photon emission computed tomography (SPECT) with those obtained from dynamic CT perfusion in patients with primary or metastatic liver malignancy.
Materials and Methods
Twenty-five consecutive patients (11 women, 14 men; mean age 60.9 ± 10.8; range: 32–78 years) with primary ( n = 5) or metastatic ( n = 20) liver malignancy planned to undergo selective internal radiotherapy underwent dynamic contrast-enhanced CT liver perfusion imaging (four-dimensional spiral mode, scan range 14.8 cm, 15 scans, cycle time 3 seconds) and 99m Tc-MAA SPECT after intraarterial injection of 180 MBq 99m Tc–MAA on the same day. Data were evaluated by two blinded and independent readers for the parameters arterial liver perfusion (ALP), portal venous perfusion (PVP), and total liver perfusion (TLP) from CT, and the 99m Tc-MAA uptake-ratio of tumors in relation to normal liver parenchyma from SPECT.
Results
Interreader agreements for quantitative perfusion parameters were high for dynamic CT ( r = 0.90–0.98, each P < .01) and 99m Tc -MAA SPECT ( r = 0.91, P < .01). Significant correlation was found between 99m Tc-MAA uptake ratio and ALP ( r = 0.7, P < .01) in liver tumors. No significant correlation was found between 99m Tc-MAA uptake ratio, PVP ( r = −0.381, P = .081), and TLP ( r = 0.039, P = .862).
Conclusion
This study indicates that in patients with primary and metastatic liver malignancy, ALP obtained by dynamic CT liver perfusion significantly correlates with the 99m Tc-MAA uptake ratio obtained by SPECT.
Selective internal radiotherapy (SIRT) with radioembolization of yttrium-90 ( 90 Y) microspheres is a catheter-based, liver-directed therapy that has gained recent acceptance for the treatment of primary and metastatic liver malignancies not qualifying for surgery . 90 Y microspheres are selectively injected via the hepatic artery and preferentially flow into tumor areas with a high arterial vascularization , whereas normal liver parenchyma, which is predominantly perfused over the portal venous system, is not affected . This allows administration of high radiation doses to tumors, whereas radiation exposure of normal liver parenchyma remains tolerably low.
To assess distribution of radiolabeled microspheres and to minimize side effects resulting from microsphere deposition in normal liver parenchyma, the lung, or the gastrointestinal tract, an angiography study is routinely performed before SIRT, and a tracer dose of technetium 99m -labeled macroaggregates of albumin ( 99m Tc-MAA) is injected via the hepatic artery with the catheter tip in treatment position to simulate the distribution of the therapeutic agent . Immediately after angiography, a single photon emission computed tomography (SPECT) is performed showing the distribution of 99m Tc-MAA particles, which demonstrates perfusion patterns of the normal and diseased liver parenchyma and indicates potential shunting to the lung and gastrointestinal tract .
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Material and methods
Patient Population
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Table 1
Patient Demographics
Characteristics No. of Patients (%) Mean age, mean ± SD (range, years) 60.9 ± 10.8 (32–78) Gender, M/F 11/14 Body mass index, mean ± SD (range, kg/m 2 ) 27.4 ± 5.3 (18.7–34.1) Primary liver malignancy 5 (20%) Hepatocellular carcinoma 3 Intrahepatic cholangiocarcinoma 1 Epithelioid hemangioendothelioma 1 Secondary liver malignancy 20 (80%) Colorectal cancer 9 Extrahepatic cholangiocarcinoma 2 Breast cancer 2 Pancreatic adenocarcinoma 1 Gastric adenocarcinoma 1 Melanoma 1 Sarcoma 1 Renal cell cancer 1 Non-small-cell lung cancer 1 Anal squamous cell carcinoma 1 Number of liver tumors 1–4 lesions 8 (32%) 7 or 8 lesions 2 (8%) >10 lesions 15 (60%) Previous therapy Surgery 7 (28%) Chemotherapy 15 (60%) Ongoing chemotherapy 2 (8%) VEGF-antibody treatment 2 (8%) Radiofrequency ablation 2 (8%) Transarterial chemoembolization 1 (4%) Portal vein ligation or embolization 3 (12%)
F, female; M, male; SD, standard deviation; VEGF, vascular endothelial growth factor.
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CT Data Acquisition
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Catheter Angiography
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99m Tc-MAA Scintigraphy
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Image Analysis
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99m Tc-MAA SPECT Images
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CT Perfusion Images
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Statistical Analysis
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Results
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99m Tc-MAA SPECT and CT Perfusion Measurements
Interreader agreement
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Table 2
Interreader Variability of Semiquantitative and Quantitative 99m Tc-MAA SPECT and Dynamic CT Perfusion Measurements
Mean Difference Range of Mean Difference Correlation 99m Tc-MAA SPECT 99m Tc-MAA uptake ratio 0.81 ± 1.64 −3.78, 3.76 0.91 ( P < .001) CT perfusion ALP T 0.28 ± 3.15 −7.09, 8.49 0.98 ( P < .001) PVP T −0.61 ± 12.58 −21.67, 34.04 0.91 ( P < .001) TLP T −0.26 ± 10.79 −18.71, 31.42 0.94 ( P < .001) ALP L 0.56 ± 2.23 −4.55, 5.19 0.95 ( P < .001) PVP L 3.63 ± 13.34 −9.29, 46.83 0.90 ( P < .001) TLP L 4.17 ± 12.37 −7.87, 42.71 0.95 ( P < .001)
99m Tc-MAA, technetium 99m -macroaggregates of albumin; ALP T and L , arterial liver perfusion in liver tumor and normal liver (in mL × min −1 × 100 mL −1 ); PVP T and L , portal-venous perfusion in liver tumor and normal liver (in mL × min −1 × 100 mL −1 ); SPECT, single photon emission computerized tomography; TLP T and L , total liver perfusion in liver tumor and normal liver (= ALP+PVP, in mL × min −1 × 100 mL −1 ).
Mean difference ± standard deviation.
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VOI sizes among modalities
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99m Tc-MAA SPECT parameters
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Table 3
Liver Perfusion Parameters from 99m Tc-MAA SPECT and from Dynamic CT Perfusion
Mean ± SD Range_P_ Values 99m Tc-MAA uptake ratio 6.00 ± 3.65 1.64–14.33 ALP Liver tumor 26.25 ± 15.88 3.34–73.96 <.001 Normal liver 11.60 ± 7.20 3.77–34.54 PVP Liver tumor 43.66 ± 27.97 0.02–107.55 <.001 Normal liver 73.79 ± 28.05 25.62–125.81 TLP Liver tumor 64.67 ± 30.05 18.96–142.14 <.05 Normal liver 86.06 ± 26.68 40.81–136.27
99m Tc-MAA uptake ratio, averaged technetium 99m -macroaggregates of albumin uptake tumor/averaged 99m Tc-MAA uptake liver; ALP, arterial liver perfusion (mL × min −1 × 100 mL −1 ); PVP, portal-venous perfusion (mL × min −1 × 100 mL −1 ); SD, standard deviation; TLP, total liver perfusion (mL × min −1 × 100 mL −1 ).
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CT perfusion parameters
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Correlation between 99m Tc-MAA SPECT and dynamic CT perfusion
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Discussion
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Acknowledgment
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