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Liver mets and Y90 radioembolisation Tips and Tricks 1 Jens Ricke Radiology and Nuclear medicine, University of Magdeburg

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Page 1: Rild tips tricks

Liver mets and Y90 radioembolisationTips and Tricks

1

Jens Ricke

Radiology and Nuclear medicine, University of Magdeburg

Page 2: Rild tips tricks

Potential Serious Adverse Events

CTCAE v3: Common Terminology Criteria for Adverse Events version 3.0

ENRY, Hepatology 2011

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Pathophysiology of RILD

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• Weight gain in 90 – 95 % • Ascites in 50 – 85%• Bilirubin in 98 % with

– Moderate increase: AST & ALT, intense: AP– Right upper quadrant pain in 50-75%

• Biopsy, hepatic porto-venous pressure

• Incidence 20% in total liver RE*

Clinical criteria of REILD

*Sangro 2008

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Risk factors for REILD

Sangro 2008

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Recommended Medication

Premedication:20 mg dexamethasone iv (e.g., Fortecortin®)*8 mg ondansetrone iv (e.g., Zofran®)

*Gil-Alzugaray, Sangro et al. Hepatology 2013

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Sequential lobar vs. bilobar radioembolisation

Primary endpoint•Hepatotoxicity

Secondary endpoint•Overall survival

REILD: prevention by split dose?

Seidensticker CVIR 2011

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12,0%

0,0%

35,0%

18,0%

0%

5%

10%

15%

20%

25%

30%

35%

40%

Ant

eil P

atie

nten

mit

Gra

d 3/

4 To

xizi

tät

6 Wochen3 Monate

bilobar sequential(n=17) (n=17)

Liver toxicity: grade 3 or 4

p=0.4

Seidensticker CVIR 2011

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13,210,2

19,1

10,4

52,3

18,7

0

10

20

30

40

50

60

Bili

rubi

n [µ

mol

/l]

vor RE6 Wochen3 Monate

bilobar sequential(n=17) (n=17)

Results: bilirubin

Bilirubin elev. 3months post RE: p=0.02

Seidensticker CVIR 2011

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Next step: liver protection

•Current protocol: ELDORADO, NCI 2078864

•Preventive effect of low dose heparine, ursodesoxicolic acid and pentoxyfiline after HDR single fraction irradiation of liver metastases

•Sponsor: University of Magdeburg

•Endpoint: Uptake of Gd-EOB-DTPA at 6 and 12 weeks in relation to dose exposure

Seidensticker, Ricke EASL 2014

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Ursodeoxycholic acid3 x 250 mg daily,oral administration

Pentoxiphylline3 x 400 mg dailyoral administration

Enoxaparin1 x 40 mg dailysubcutaneous injection

Study medicationRationale:Improvement of biliary excretion

Improvement of blood flow in sinusoids and ventral veins

Improvement of blood flow in sinusoids and ventral veins

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6 weeks 3 monthsafter HDR brachytherapy

beforeHDR brachytherapy

Control Group

No protective medication administered!

Images: Ricke

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Medication Group

6 weeks 3 monthsafter HDR brachytherapy

Baseline

Medication given for 8 weeks after therapy!

Images: Ricke

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• 56y old male, mCRC, total liver Tx– Salvage post 3rd line, Tu-load 50%

• Weight gain of 6kg • Massive Ascites • Bilirubin 6md/dl

– AST, ALT ↑

– AP ↑ ↑ ↑

Y90-Radioembolisation hazards

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Gianturco venous stent

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Take home RILD

•Ascites 6 weeks post Y90 RE is not tumor progression!•Recommended treatment:

– Symptomatic relief (e.g. paracenthesis, diuresis)– Treat RILD directly:

• Ursodeoxycholic acid 3 x 250 mg daily• Pentoxiphylline 3 x 400 mg daily• Enoxaparin 40mg s.c.

– Cortisone maybe considered for long term outcome

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