Hepatobiliary Cancer NM Flashcards by Vita Kan

Hypervascular lesion in cirrhotic liver

HCC - - washout in portal phase
Dysplastic nodule - - no washout in portal phase

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Hypervascular lesion in noncirrhotic liver
Benign

Hemangioma
Adenoma
FNH

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Hypervascular lesion in noncirrhotic liver
Malignant

MTS from breast, NET, melanoma
Fibrolamellar carcinoma

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Hypovascular lesion
Unknown primary

Liver cyst - - density similar to water (0-15 HU), no enhancement
Liver abscess - - hypervascular rim

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Hypovascular lesion
Known primary

Cystic - - MTS from mucinous colon, ovaries
Solid - - MTS from colon, pancreas, stomach, lung, renal, adrenal or liver involvement from lymphoma

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Liver cancer M

Lung
Bone
Adrenal
Peritoneum

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Fibrolamellar carcinoma

Rare
Better prognosis
No cirrhosis
Younger
Sharp margins
central scar with calcification

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Radiation induced liver disease

Dose >40 Gy
Max acceptable dose 35 Gy
Radiation dose to kill solid tumor >70 Gy

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Radioactive I131-Lipiodol

Lipidic particles injected into hepatic artery - - retain in tumor by pinocytosis
75% liver, 25% lung
Thyroid block
Fixed activity 65 mCi
Hospitalization for 1 week
Risk - interstitial pneumonitis

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Re188-Lipiodol

Inoperable large or multifocal HCC
Higher tumor killing efficacy
Lower toxicity

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Ho166-Microspheres = QuiremSpheres

Predict distribution before therapy
Predict radiation dose to tumor and normal liver
Highest paramagnetic properties - - MRI

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Y90-Microspheres

Inoperable primary or metastatic liver tumor
Embolization of precapillary vessels
T1/2 64.2h
Pure beta emitter 0.936 MeV
Pair production 511 keV - - PET
Mean tissue penetration 2.5mm, max 10 mm

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Y90-Microspheres type

Glass - TheraSphere - - 20-30 microm, carry 2500 Bq per particle, 1.2 mln are injected, high specific activity, total activity 81 mCi
Resin-Sirtex - - 20-60 microm, carry 50 Bq per particle, 40-80 mln injected, low specific activity, total activity 3 GBq

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SIRT patient selection

ECOG >2 - - not ideal candidate
Contra: total bilirubin >2.0 mg/dL, serum albumin <3 g/dL
Ascites - - poor hepatic reserve
Peritoneal MTS - - poor prognosis
Cross sectional imaging and arteriogram - - tumoral and non tumoral volume, portal vein potency, extent of extra hepatic disease, arteroportal shunt, liver to lung shunt
Prophylactic embolization of gastroduodenal artery and right gastric artery

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Pretreatment angiography

Tc-MAA inject into hepatic artery
SPECT within 1h
Later - - degradation of MAA, radioactivity in capillary, free pert in stomach - - overestimate liver to lung shunt
To avoid - Na-perchlorate PO 30 min before MAA injection
Tc-HAS - Microspheres - - within 4h

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LSF

Highest tolerable dose to lungs 30 Gy (50 Gy for cumulative)
Geometric mean of anterior and posterior views
LSF=lung counts/(lung counts+liver counts) *100
LSF <10% - - no restriction
LSF >20% - - contra
LSF 10-15% - - reduce activity by 20%
LSF 15-20% - - reduce activity by 40%

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Y90-Microspheres indication

Neoadjuvant before resection/transplant
Alternative in portal vein occlusion
Combi with bio therapy
Combi with chemo
Salvage treatment

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Y90-Microspheres administration

Under fluoroscopic guidance during transcutaneous arterial catheterization trying to copy the same positioning
One lobe - - selective procedure
Specific segment - - super selective
Manually - - to avoid early full embolization
Iodine contrast + sterile water/glucose solution for resin and saline for glass
Continuous fluoroscopy

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Post SIRT image

SPECT based on Bremsstrahlung emission - - very poor quality
PET based on beta+ - - detection of extrahepatic distribution and estimation of absorbed dose

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Tumor response assess

AFP
CECT in 1m
NECT every 3 m
PET in 6 weeks

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HCC SIRT

Response after TARE/SIRT - 6 m for reduction in tumor size
Changes in vascular enhancement in 2m
Too advanced to meet transplant criteria without malignant portal vein thrombosis or MTS - - TARE downstages - - transplantation
Portal vein thrombosis - - better survival

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Intrahepatic Cholangiocarcinoma TARE

Improve survival, downstage
Combi with chemo - - downstage - - resectable

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Metastatic colorectal cancer TARE

Unresectable liver MTS on chemo
FDG

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Metastatic NET TARE

Study These Flashcards

Carcinoid, VIPoma, gastrinoma, somatostatinoma - - liver MTS well arterialized - - ideal candidate

TARE/SIRT Contra

Absolute Lung to liver shunt Inability to prevent deposition of radiolabeled microspheres in GIT HCC - distant MTS Relative Reduced pulmonary function Poor functional liver reserve Creatinine >2 PLT <75 - - Consider Lipiodol

TARE/SIRT toxicities

Immediate - lymphopenia Post-embolic sy - most common - fatigue, abd discomfort, pain, fever Cholecystitis Gastric Ulceration Gastroduodenitis Pancreatitis Pneumonitis RILD = radiation induced liver disease

Intrahepatic Cholangiocarcinoma M

LN (celiac, paraaortic, paracaval) Peritoneum Lung Bone Brain

Intrahepatic Cholangiocarcinoma risk

Age Primary sclerosing Cholangitis Smoke Chronic ulcerative colitis

Intrahepatic Cholangiocarcinoma

90% adenocarcinoma Obstructive jaundice without malignancy - - elevated CA19-9 - - not persist after decompression CA125--peritoneal involvement CEA non specific FNA of perihilar mass - - peritoneal seeding

Pancreas Carcinoma M

Liver Peritoneum

Pancreas Carcinoma

No capsule - - early local spread Perineural spread 80% Majority from ductal structure Head 60-70% Body 20% Tail 5% Diffuse 10-20%

Pancreas Carcinoma high risk

Borderline resectable Elevated CA19-9 Large tumor Large LN Very symptomatic

Pancreas Carcinoma resectable

No arterial contact No contact with SMV or PV or <180° contact without vein contour irregularity M0

Pancreas Carcinoma unresectable

M1 Solid tumor contact with SMA or CA >180° Unreconstructible SMV/PV due to tumor involvement or occlusion

Post-op perivascular soft tissue thickening and induration

Local recurrence vs post op changes Time for recurrence 20 m Progressive thickening - - suspicious

Liver abscess after surgery

Mimic MTS Liver function abnormality Double target sign

Head and ulcinate tumor

Whipple = pancreatoduadenectomy

Body and tail

Distal pancreatectomy + splenectomy

HCC staging

CT preferred for MTS MRI - local staging, most sensitive, gold standard in cirrhosis Tc sulfur colloid - focal defect in cirrhosis Hepatobiliary scan Gallium scan FDG - not recommended due to limited sensitivity

Intrahepatic Cholangiocarcinoma FDG

Not for primary lesion Limited if large fibrosis Focal uptake + elevated CA19-9

Pancreas imaging

CeCT - best for diagnosis and initial management FDG - local extent and distant MTS esp high risk, recurrence vs fibrosis Increased sensitivity for MTS if PET after CT Generally increased uptake, unless mucinous 11% change management False-negative: <8 mm, sugar >150

Intrahepatic Cholangiocarcinoma resectable

Resectable - - LN at porta Unresectable - - Celiac, retropancreatic, paraaortic LN

HCC Solitary large mass well-defined margins peripheral pseudocapsule

Intrahepatic Cholangiocarcinoma Arterial - peripheral contrast enhancement with progressive fill, early thick rim with patchy central enhancement Portal - persistent enhancement, without nodular or globular pattern, > liver parenchyma