Selection:

• Liver dominant disease/Minor EHD
• Extensive angiogram work up/ some arterial embolization (GDA)
• Adequate hepatic function: Bilirubin should be no higher than 1.8-2.0
• Lung shunting less than 20% as determined by a MAA scan
• Patients shold be taken off SYS chemotherapy 2-4 weeks prior to SIRT. SYS chemotherapy can resume 4 weeks after RX
• Not eligible for resection or transplant
• No other hepatic disease
• Adequate renal function
  • creatinine < 150 µmol/L
• Adequate hematological function
  • Granulocytes >1.5 x 10⁹/L
  • Platelets >100 x 10⁹/L

Patient Work-Up

• CT scan showing unresectable liver malignancies within 28 days of SIRT

• Angiography

• CTHA

• MAA – lung shunting

• Patient workup procedure results in 5-10 % of patients not being eligible for SIRT

• Diagnostic Angiography prior to placement of SIR Spheres

  • Technical issues: Groin /Arm / Type of Cath
  • Anatomy: Replaced /Anomalous /Variants
  • Selective / super-selective
  • Portal vein patency
  • Porto-venous shunts
  • Coil embolization of GDA and RGA to prevent inadvertent spilling

PRE-TESTING- 1st Patient Outpatient Admission

• Chest x-ray
• Triple Phase CT Scan of abdomen, chest and pelvis
• Abdominal/pelvic ultrasound and bone scan?
• PET Scan/PET CT
• Baseline liver function testing to determine the extent of liver damage/dysfunction
• Diagnostic mesenteric angiography for vascular mapping
  • Determines hepatic arterial anatomy
    • Assessment of variants in vascular anatomy
  • Assesses risks of complications
    • Shunt through tumor vascular bed to lungs
    • Non-target embolization to adjacent organs
  • Can convert a "non-candidate" 
    • Prophylactic embolization of branches to GB, GI tract, pancreas
  • Assessment of Anomalous Arteries
    • 50% of patients have aberrant arteries supplying the liver
    • 15% of patients have aberrant arteries from liver supplying the gut
    • Variant hepatic anatomy: Covey et al, Radiology, 2002; 224; 542-547
• MAA Shunt study

  • Tc-99m MAA STUDY: to determine pulmonary shunting that could result in non-targeted delivery to gastrointestinal tract

  • Maximum 20% shunting as this will deliver a total cumulative dose to the lung of 30 Gray - maximum tolerable dose of lungs

    
    MAA Spect

Treatment Algorithm:

• Initiate insurance certification process
• Consider pre-SIRT PET-CT (volumetric)
• Diagnostic mesenteric angiography
• MAA Shunting Study
• Joint treatment plan & calculation of dose (IR, Nuclear Med, Radiation Oncology)
  • Lobar vs whole liver ?