NM By Myself > Therapy > Flashcards

Therapy Flashcards

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1
Q

Radiation induced liver disease

A

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

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2
Q

Radioactive I131-Lipiodol

A

TARE - - transarterial radioembolization of liver
Lipidic particles injected into hepatic artery - - retain in tumor by pinocytosis
Thyroid block
Fixed activity 65 mCi
Hospitalization for 1 week
Risk - interstitial pneumonitis

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3
Q

Re188-Lipiodol

A

Inoperable large or multifocal HCC
Higher tumor killing efficacy
Lower toxicity
T1/2 19.6h, beta 2.1 MeV, gamma 155 keV

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4
Q

Ho166-Microspheres = QuiremSpheres

A

Predict distribution before therapy
Predict radiation dose to tumor and normal liver
Highest paramagnetic properties - - MRI
T1/2 26.8h beta 1.7 MeV, gamma 81 keV
Particle 15-60 microm
340 Bq in microsphere - - 20-30 mln - - 184-275 mCi, rate 5 ml/mn
Rapid - - reflux - - saline instead of 5% glucose
Pretreatment scout dose 250 MBq (3 mln particles) - - more accurate than Tc-MAA

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5
Q

Y90-Microspheres

A

T1/2 64.2h
Pure beta emitter 0.936 MeV
Pair production 511 keV - - PET
Bremsstrahlung
Mean tissue penetration 4 mm, max 10 mm

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6
Q

Y90-Microspheres glass

A

Glass - TheraSphere - - 20-30 microm, carry 2500 Bq per particle, 1.2-8 mln are injected, 20-60 ml saline, high specific activity, total activity 81 mCi
Vial 1 ml incl 0.6 ml sterile water
Theoretical disadvantage - - influence of gravity on biodistribution

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7
Q

SIRT patient selection

A

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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8
Q

Pretreatment angiography

A

Tc-MAA inject into hepatic artery 150 MBq
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
Treatment ideally within 15 days

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9
Q

LSF

A

Planar - - scatter correction for right lung
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% - - relative contra
LSF 10-15% - - reduce activity by 20%
LSF 15-20% - - reduce activity by 40%

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10
Q

Y90-Microspheres indication

A

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

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11
Q

Y90-Microspheres administration

A

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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12
Q

Post SIRT image

A

Y90:
SPECT based on Bremsstrahlung emission - - very poor quality
PET based on beta+ - - detection of extrahepatic distribution and estimation of absorbed dose
Ho166:
Gamma - - SPECT/CT 2-5 days after
MRI - - artefacts

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13
Q

Tumor response assess
TARE

A

First lab - - 2-4 weeks after
CT - - 3 m - - modified RECIST:
CR - - no intratumoral arterial enhancement
PR - - 30% decrease in sum of diameters of target lesion
PD - - increase 20% in sum of diameters
SD - - any other case
PET in 4-6 weeks

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14
Q

HCC SIRT

A

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
No negative impact of limited extrahepatic spread - - LN, bones, adrenal

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15
Q

Intrahepatic Cholangiocarcinoma TARE

A

Improve survival, downstage
Combi with chemo - - downstage - - resectable
LN MTS no negative impact on survival - - not exclusion criteria
Solid organ MTS - - caution

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16
Q

Metastatic colorectal cancer TARE

A

Unresectable liver MTS on chemo
Up to 5 lung nodules and either LN - - limited extrahepatic spread - - reference

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17
Q

Metastatic NET TARE

A

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

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18
Q

TARE/SIRT abs contra

A

Pregnancy, breastfeeding
Life expectancy <3m
Clinical liver failure (ascites, encephalopathy)
Disseminated exctrahepitc malignant disease
Inability to prevent deposition of radiolabeled microspheres in GIT (except gallbladder, LN, falciform ligament)

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19
Q

TARE/SIRT toxicities

A

Common side effects:
Fatigue, abd pain, nausea, fever, cold chills
Transitory elevation of liver enzymes
Transitory lymphopenia
Severe adverse events:
REILD = radioembolization induced liver disease
Radiation gastritis, ulceration, upper GI bleeding, pancreatitis, pneumonitis
Avoid pregnancy 4 m

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20
Q

Radionuclide therapy Lu177

A

Beta, 490 keV
Max tissue penetration 2 mm - - better irradiation
Gamma, 208 and 113 keV - - image
T1/2 6.73 days
Freeze salivary gland for 30 min before

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21
Q

Radionuclide therapy Ra223 dichloride

A

Xofigo - - Ca analog (second group) - - replace Ca in hydroxyapatite
Alpha 5.8-7.53 MeV, penetration <100 microm - - lethal DNA damage - - lower hematological toxicity
T1/2 11.43 days
Beta and gamma - - gamma camera
Indication: castration - resistant cancer, symptomatic bone MTS, no visceral MTS
Life expectancy >6 months preferred
Accumulate: bones, areas of high bone turnover
Slow IV 1 min, 55 kBq/kg 6 administrations at 4 weeks interval
10.4 mCi for 70 kg
Only one survival benefit

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22
Q

Xofigo before treatment

A

2 weeks before: Hb>10, Abs neutrophil count >1.5*10^9 l, PLT >100
Subsequent: abs neutrophil count >1, PLT > 50
No fast, well hydration
Only limited renal excretion - - no matter GFR
Bone scan within 3 m - - osteoblastic MTS
Stop myelosuppressive treatment 6-8 weeks for long and 4 weeks for other
EBRT 2-4 weeks before

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23
Q

Xofigo side effects

A

Flare pain within 72h
Nausea, weakness, transient myelosuppression
Fecal excretion > renal - - incontinence - - hospitalization
Combi with chemo - - jaw osteonecrosis
May contain up to 54 mg of sodium per dose - - monitor BP, avoid hypertension

Dialysis after 24h

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24
Q

Lu-PSMA
Castration resistant prostate cancer (2023)

A

2 consecutive PSA progression min 2 weeks apart to 25 % increase over nadir
Or
New lesions despite hormonal therapy leading to testosterone <50 ng/dl

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25
Lu-PSMA therapy indication
PSMA positive mCRPC who progressed under at least one androgen axis drug Patient with one or more MTS lesions > liver uptake or > parotid in majority of lesions (SUV>10) Lesions >1cm with uptake <1/2 parotid or
26
Lu-PSMA contra indication
Absolute - - high grade myelosuppression Relative: Life expectancy <3 except palliative ECOG 3 or more - - high radiation burden to relatives Urinary incontinence - - catheter Hydronephrosis - - MAG3 Psychiatric disorder - - unable to be isolated Cardiovascular comorbidities - - unable to tolerate increased hydration Deterioration - - GFR<30, creatinine >2*ULN, liver enzymes >5*ULN Acute infection Myelosuppression - - WBC <2.5, ANC <1.5, PLT <75
27
Contraception after Lu-PSMA
3 months
28
Lu-PSMA procedure
Lab tests 5 days before each cycle Hydration 500-1000 ml IV saline at rate 250 ml/h 30 min before and few hours after and for 2 weeks Dexamethasone 4 mg for 5 days if cerebral, spinal MTS Slowly over 30 sec - - flush 2*more 200 mCi per cycle 6 weeks interval 6 cycles High tumor burden - - allopurinol to avoid tumor lysis syndrome first week Keep for 2h - - monitor side effects, first urination May be isolation up to 72h 1 planar scan >2h post injection to rule out extravasation and confirm biodistribution
29
PSA after Lu-PSMA
Reliable 2-3 weeks after second cycle Every increase >25% - - resistant - - image PSA response every 12 weeks and end of each series
30
Lu-PSMA side effects
Fatigue Acute hematological tox - - grade 3-4 - - postpone 2 weeks next cycle Neutropenia - - GCSF until grade 1 - - next cycle in 2 weeks Chronic renal tox - - loss GFR >40% but still >30 - - reduce 20% GFR <30 - - stop Chronic salivary tox Worsening of pain - - radiation induced edema - - steroids
31
Other bone seeking agents (not used today)
Sr89-chloride - - similar to calcium P32 sodium phosphate - - Sm153-EDTMP - - similar to MDP - - gamma camera!!
32
FDA Xofigo
Doesn't recommend combo with abiraterone and prednisone - - increased fracture and mortality
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Residual primary disease and LN >3 cm Xofigo
Palliative possible for symptomatic Reduce survival benefit
34
Xofigo condoms
1 month after last cycle
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Xofigo image
3-6 months after last cycle SPECT or PSMA
36
Radionuclide therapy indication
All patients affected by metastatic/unresectable SSTR2-expressing NET (uptake >liver) GEP, Pulmonary Pheo, Paraganglioma Neuroblastoma MTC Ideal - - well diff and moderately diff NET grade 1 or 2, Ki67 <20% Karnofsky >60% or ECOG <2 Stop somatostatin analog 4-6 weeks long, 24h short
37
Y90-DOTA-TOC and Lu177-DOTA-TATE contra
Abs: Pregnancy Severe acute illness Unmanageable psychiatric disorder Relative: Breastfeeding Creatinine >1.7, GFR <60% of mean age normal (esp Y) RBC <3, WBC <3, PLT <90 (TOC), <75 (TATE), Abs neutrophil count <1
38
Y90-DOTA-TOC and Lu177-DOTA-TATE pretreatment
Renal protection - positive L-lysine / L-arginine Inhibit proximal tubular reabsorption Reduce renal absorbed dose Hydration - over 4h,starting 30-60 min before PRRNT 25g lysine or arginine in 2L Saline
39
Y90-DOTA-TOC administration
Beta emitters, no gamma, Bremsstrahlung T1/2 64h, beta 0.9 MeV Range 4 mm - - 11 mm 100 mCi per m^2 of body surface Second cycle in 6-12 weeks Or 75-120 mCi in 2-4 cycles at 6-12 weeks interval
40
LU177-DOTA-TATE administration
Beta, gamma T1/2 6.7 days, beta 0.1 MeV, gamma 208 keV - - imaging and dosimetry 150-200 mCi 3-5 cycles at 6-12 weeks interval
41
Y90-DOTA-TOC vs Lu177-DOTA-TATE
Y90 -- higher energy beta -- more penetrating Y90 shorter T1/2 -- higher dose rate to tumor -- bulky and inhomogenous SSTR Higher kidney radiation dose - - better DOTA TOC Lu177 -- lower energy and penetration, gamma camera suitable, shorter beta range (higher dose rate to small tumor), lower nephrotoxicity DOTA TATE longer on tumor and kidney - - better Lu
42
I131-MIBG Contra
Not recommended for infants <1m Abs Pregnancy Life expectancy <3 months (unless palliative) Severe renal failure + planned dialysis Relative Unacceptable medical risk for isolation, urinary incontinence GFR <30 mL/min Severe hematological toxycities from prior treatment WBC <3, PLT <100
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I131-MIBG treatment preparation
Pretreatment scan I123 MIBG 5 mCi stop medication Thyroid block 2-3 days for I123, 5-10 days for I131 Na or K iodide 100-150 mg per day Na or K perchlorate 200-400 mg per day
44
I131-MIBG administration
5.18 MBq/kg 100-300 mCi Higher activity deliver dose faster with modest increase in toxicity but similar response Slow IV 45 min-4h to avoid nausea, vomit, hypertension Monitor vital signs over next 2-3 days - - short acting alpha and beta blockers ready Specific activity for therapy should be higher than for diagnostic purpose
45
I131-MIBG therapy indication
Inoperable pheo, paraganglioma, carcinoid Stage III or IV neuroblastoma Metastatic or recurrent MTC GEP-NET - - palliative in SSTR-negative, borderline renal function, resistant to somatostatin therapy Post treatment image - - uptake in basal ganglia and cerebellum
46
Liver blood supply
Tumor >2 cm - - >80% from hepatic artery Normal liver - - >80% from vena porta Liver MTS - - varuable vascularity: Hypervascular - - RCC, NET, thyroid Hypovascular - - colon, pancreas, breast
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TARE/SIRT relative contra
Child-Pugh >B7 - - liver decompensation rate >89% after glass High intrahepatic tumor burden - - cut off 50-70% High exctrahepitc tumor burden Hilar LN up to 2 cm and up to 5 lung nodules up to 1 cm accepted Portal vein thrombosis - - poor outcome Acute or severe renal failure - - GFR <30 ml/min Contra to hepatic artery catheterization Lung shunt - - >30 Gy per session or >50 Gy cumulative - - not abs contra because planar overestimated
48
TARE/SIRT special warning
Microspheres delivery to GIT - - acute pain, pancreatitis, peptic ulcer Prior EBRT to liver - - only limited hepatic exposure safe - - >30 Gy hepatotoxicity Repeated radioembolization less critical - - interval >3m Prior PRRT - - safe and effective - - only 5% REILD ALT, AST >5 times upper limit or elevated bilirubin - - caution
49
Radioembolization induced liver disease
Elevated biliribin Decreased albumin Ascites Onset 2-6m after
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Y90-Microspheres resin
Resin-SIR-Sphere - - 20-60 microm, carry 50 Bq per particle, 40-80 mln injected, low specific activity, total activity 81 mCi, rate 5 ml/min 1 vial - 40 mln microspheres, 3 GBq Rapid - - reflux 5% glucose solution - - reduce stasis Higher number of microspheres - - more uniform dose disribution - - higher toxicity and efficacy
52
Zevalin indication
Relapsed or refractory low grade or follicular B-cell NHL Previously untreated FL with partial or complete response to first line chemotherapy
53
Zevalin side effects
Bone marrow supression -- trombocytopenia, neutropenia
54
Contra Zevalin
>25% bone marrow involvement History of myelotoxicity Neutrophils <1500 cells/mm^2 PLT <100 (100-149 reduced dose) Hypersensitivity HAMA AB check Pregnancy, breastfeeding
55
Biodistribution of Zevalin
Diagnostic dose of surrogate In111-ibritumomab tiuxetan
56
Zevalin
Y90-ibritumomab Anti-CD20 for FL Combi with rituximab to block CD20 on normal B cells and spleen T1/2 64h Beta 0. 9 MeV Slow IV 10 min PLT >150 - - 0.4 mCi/kg - - max 32 mCi PLT 100-150 - - 0.3 mCi/kg Toxicity - bone marrow suppression, reversible
57
Zevalin preparation
Day 1 - Rituximab IV over several hours Day 7,8,9 - Rituximab I over several hours Within 4 hours after Rituximab - - Zevalin IV over 10 min 3 days Hospitalization <6h
58
Zevalin after first line chemo
6-12 weeks after last dose - - PLT >150
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Measures against nausea when pretreatment by amino acids
Antiemetic granisetron and dexamethasone Avoid hyperkalemia, hypernatremia, metabolic acidosis
62
Amino acids and Gelofusine
Gelofusine - - plasma expander - - reduce kidney absorption dose by 45% Bolus 1 ml/kg 10 min before therapy - - rate 0.02 mg/kg/min over 3 h after therapy Monitor
63
Iron and Y90
Impede labeling - - lower specific activity
64
PRRT administration
Dilute with saline till final volume 10-100 ml Vital signs monitor - - BP and pulse - - may be Hospitalization 24h
65
PRRT Combi
Y90 68-135 mCi + Lu177 150-200 mCi 2-6 cycles Interval 6-16 weeks
66
PRRT reduced renal function
Nephrology consult Hydration 2-3l Hydronephrosis - - diuretic Prefer Lu177 - - first two dialysis in isolated room
67
PRRT reduced hematological function
Hematology consult Packed RBC or PLT after therapy GCSF within 10 days after therapy
68
PRRT children
No data
69
Surrogate of Y90 DOTA TOC
IN111-DOTA TOC Y86 - DOTA TOC - - PET
70
PRRT side effects
Amino acid - - metabolic acidosis - - nausea, headache Massive liver MTS - - toxicity - - prefer Lu177 and reduce dose Avoid pregnancy 6 m Temporary impairment of fertility in men - - damage to Sertoli cells - - sperm banking before therapy Creatinine loss per year: 3.8% for Lu, 7.3% for Y Reversible severe bone marrow toxicity
71
PRRT response
First follow up Lu177 after 3 m CT every 3-6 m
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MIBG side effects
Nausea, vomit Temporary myelosuppression Deterioration of renal function Rare hypertensive crisis
74
BM acceptable radiation
2 Gy
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