Multimodality Imaging for Optimized ⁹⁰Y Radioembolization Therapy

Targeted CE per ARRT’s Discipline, Category, and Subcategory classification:
[Note: Discipline-specific Targeted CE credits may be less than the total Category A credits approved for this course.]

Nuclear Medicine Technology: 2.50
Procedures: 2.50
Radionuclides and Radiopharmaceuticals: 0.50
Endocrine and Oncology Procedures: 2.00

Registered Radiologist Assistant: 1.00
Procedures: 1.00
Abdominal Section: 1.00

Radiation Therapy: 1.00
Patient Care: 1.00
Patient and Medical Record Management: 1.00

Outline

1. Introduction
2. General Principles of ⁹⁰Y Radioembolization Therapy
   1. What is ⁹⁰Y
   2. Vehicles Delivering ⁹⁰Y: resin and Glass Microspheres
   3. Indications and Contraindications for ⁹⁰Y Therapy
3. Role of Imaging for ⁹⁰Y Microsphere Therapy
   1. Preprocedural Cross-sectional Imaging and Patient Evaluation
   2. Combined Preprocedural Angiographic Vascular Mapping and ^99mTc-MAA Shunt Examination
   3. ⁹⁰Y Microsphere Dose Calculation
   4. Therapy Administration: Consolidation of Multidisciplinary Effort
   5. Postprocedural Bremsstrahlung Examination
4. Multimodality Imaging Patterns: Classification to Improve Targeted Therapy
   1. Multimodality Imaging Approach
   2. Target ⁹⁰Y Distribution: Complete and Incomplete Imaging Patterns
   3. Nontarget ⁹⁰Y Distribution: Intrahepatic and Extrahepatic Imaging Patterns
5. Conclusion

Objectives

Upon completion of this course, students will:

1. describe what multidisciplinary preprocedural planning is required for a successful ⁹⁰Y microspheres treatment
2. explain the difference between glass based and resin based microspheres
3. understand how ⁹⁰Y induces cell death and the minimum absorbed dose required
4. describe acceptable absorbed dose limits for normal liver and complications that can occur when these limits are exceeded
5. describe how the specific activity of two different microspheres affect treatment dose
6. list the FDA indications for ⁹⁰Y radioembolization
7. list the contraindications associated with microsphere radioembolization
8. identify other important pre procedural information necessary for patient selection
9. explain the rationale for utilizing ^99mTcMAA prior to ⁹⁰Y therapy
10. recognize the importance for selective angiography of the superior mesenteric artery
11. describe the considerations taken into account when imaging the left hepatic artery
12. describe the physical characteristics of ^99mTcMAA that allow it to be used as a preplanning surrogate for ⁹⁰Y therapy
13. list the technical parameters required for setting up a ^99mTcMAA SPECT/CT acquisition
14. explain how waiting too long after MAA injection can compromise imaging
15. understand how the addition of SPECT/CT imaging can be of benefit for pretreatment planning
16. explain how lung shunting impacts ⁹⁰Y microsphere treatment
17. describe the advantages associated with cone beam CT when used as an angiographic technique
18. recognize the benefits of SPECT/CT fusion imaging with the incorporation of an advanced multimodality work station
19. understand the dose calculation for glass based microspheres and the targeted dose range
20. describe the methodologies employed to calculate resin based microsphere dose
21. list the multiple safety procedures that are carried out on the day of therapy
22. explain how SPECT/CT Bremsstrahlung imaging can be beneficial
23. list the technical parameters required for a successful ⁹⁰Y planar and SPECT/CT acquisition
24. explain how ⁹⁰Y PET imaging may be employed following therapy
25. identify how PET/CT or SPECT/CT can categorize patients based on target and nontarget ⁹⁰Y distributions
26. list the common sites of nontarget extrahepatic activity
27. list the options available to the radiologist during pre-therapy imaging to curtail incomplete lesion coverage and/or nontarget distribution
28. describe what contributes to incomplete distribution of ⁹⁰Y microspheres and potential corrective measures
29. explain how substantial incomplete tumoral coverage contributes to a suboptimal ⁹⁰Y therapeutic response
30. describe intrahepatic vs extrahepatic nontarget embolization
31. list potential corrective measures to reduce nontarget embolization
32. explain how extrahepatic activity to the umbilical region may be difficult to identify
33. describe a technical imaging maneuver on pre-therapy imaging that may prevent ⁹⁰Y activity within the umbilical region
34. explain why ⁹⁰Y bremsstrahlung imaging can be clinically significant for those patients identified with extrahepatic activity
35. explain how potential therapeutic complications can be mitigated through a multimodality approach