The Clinical Utility of Yttrium-90 PET after SIRT Dr Yung Hsiang Kao Department of Nuclear Medicine Austin Health Melbourne, Australia 2 nd Asia Pacific Symposium on Liver-Directed Y-90 Microspheres Therapy 1 st 2 nd November 2014, Singapore
Acknowledgements This presentation is the work of multi-disciplinary medical, physics and technology teams from: Singapore General Hospital (Singapore) Singapore Bioimaging Consortium (Singapore) Sir Charles Gairdner Hospital (Perth, Australia) Austin Hospital (Melbourne, Australia)
Overview Principles of Y-90 PET History of Y-90 PET Clinical utility Qualitative and Quantitative Target activity Non-target activity Research applications
Principles of Y-90 PET Ford KW. Phys Rev 98:1516 1517 (1955) Source: Nickles RJ et al. 2004 IEEE Diagram courtesy of Maarten Smits and team from University Medical Centre Utrecht, The Netherlands
Principles of Y-90 PET Time-of-Flight technology is better than non-time-of-flight Longer scan time per bed position is better to obtain more true coincidences Reconstruction method is important to balance between qualitative image quality and quantitative accuracy Pasciak et al. Front Oncol. 2014;4:38
History of Y-90 PET 2004, IEEE Yttrium-90 imaged using micro-pet in a phantom
History of Y-90 PET 2009 Y-90 PET/CT
History of Y-90 PET 2011 Y-90 PET/MR
History of Y-90 PET 2013 Y-90 PET/CT with Respiratory Gating
Yttrium-90 PET/CT Y-90 PET/CT
Yttrium-90 PET/CT Y-90 PET/CT
Clinical relevance of Y-90 PET After SIRT, we need to know: Was it technically successful, i.e. is the radiation biodistribution according to planning expectations? Is there any non-target activity? What are the radiation safety limits if there is repeat SIRT?
Clinical relevance of Y-90 PET Determine technical success : Y-90 PET has superior spatial resolution than bremsstrahlung SPECT/CT Superior spatial resolution of Y-90 PET enables greater diagnostic confidence in confirming the presence or absence of activity within targeted tumours.
Catheter-directed CT Hepatic Angiogram Y-90 PET/CT has superior spatial resolution than bremsstrahlung SPECT/CT Bremsstrahlung SPECT/CT
Hepatic Intra-arterial Cone Beam CT of Left Hepatic Artery Superior spatial resolution of Y-90 PET/CT confirms successful implantation Bremsstrahlung SPECT/CT
Baseline triphasic CT Liver Superior spatial resolution of Y-90 PET/CT confirms absence of activity Kao et al. EJNMMI Res 2013; 3:56 Y-90 PET/CT Bremsstrahlung SPECT/CT?? Triphasic CT Liver 4 mth later
Superior spatial resolution of Y-90 PET/CT improves diagnostic confidence Flow Redistribution from segments 6/7 into segments 5/8 Y-90 PET/CT Y-90 PET???? Bremsstrahlung SPECT/CT Bremsstrahlung SPECT
Clinical relevance of Y-90 PET Detection of non-target activity: Superior spatial resolution of Y-90 PET improves non-target activity detection as compared to bremsstrahlung SPECT/CT Impacts immediate clinical management to mitigate the occurrence of non-target radiation injury e.g. gastric or duodenal ulceration Toxicity depends on quantification of the radiation absorbed dose (Gy) delivered to non-target tissue
Superior spatial resolution of Y-90 PET/CT improves detection of non-target activity Y-90 PET/CT Kao et al. EJNMMI Res 2013; 3:56 Y-90 PET Bremsstrahlung SPECT/CT
Y-90 PET Quantification Kao et al. EJNMMI Res 2013; 3:57 Mean Y-90 absorbed dose to the pylorus was 65Gy
Kao et al. EJNMMI Res 2013; 3:57 Mean Y-90 absorbed dose to the pylorus was 65Gy Chronic abdominal pain Gastritis and pyloric ulceration 3 months later
Clinical relevance of Y-90 PET Guides radiation safety limits for repeat SIRT: After the 1 st SIRT, Y-90 PET quantification of radiation absorbed dose delivered to nontumorous liver and lung will serve as a new baseline to guide radiation planning for repeat SIRT
Y-90 PET quantification helps to define radiation safety limits for repeat SIRT
Research Application of Y-90 PET Despite of decades of clinical use, SIRT tissue dose-response is still unclear: Desired tumour dose >100-120Gy? (What tumour type? Dose heterogeneity?) Maximum tolerated dose to non-tumorous liver <50-70Gy? (Cirrhotic liver? Previous liver resection? Repeat SIRT? Effect of radiosensitizing chemotherapy?) Maximum tolerated dose to lung <30Gy? (COPD? Previous lung surgery? Repeat SIRT?) Tissue tolerance of non-target tissue? e.g. stomach
The Solution for Dose Heterogeneity
The Solution for Dose Heterogeneity Histogram Dose
Free download Email me yung.h.kao@gmail.com
Y-90 Dose-Volume Histogram Kao et al. EJNMMI Res 2013; 3:57
Y-90 PET Voxel Dosimetry Kao et al. EJNMMI Res 2013; 3:57 Cure the incurable: The Holy Gray to achieve complete response for hepatocellular carcinoma using SIR-Spheres is D 70 >100Gy
Research Application of Y-90 PET Recent surge in worldwide research interest into Y-90 PET: E.g. QUEST study sponsored by Sirtex (Australia) is a large international multi-centre study on Y-90 PET Contact Michael Tapner, mtapner@sirtex.com
Acknowledgements Dept of Nuclear Medicine & PET Dr Anthony Goh Dr David Ng Mr Somanesan Tay Young Soon Gabriel Lim All medical, technology, radiopharmacy, physics staff Prof David Townsend Jeffrey Steinberg Jianhua Yan Melbourne, Australia Dept of Nuclear Medicine & Centre for PET Dr Sze Ting Lee Prof Andrew Scott Dr Graeme O Keefe David Thomas Kunthi Pathmaraj Dept of Diagnostic Radiology Dr Tan Bien Soo A/Prof Tay Kiang Hiong Dr Richard Lo All interventional radiologists Clinicians Prof Pierce Chow All referring clinicians Perth, Australia Dept of Nuclear Medicine Jan Boucek A/Prof Roslyn Francis Dept of Radiology Anthony Schelleman Mark Goodwin