PMC5660797_01
Magnetic resonance (MR) and positron emission tomography-computed tomography with 18-fluorodeoxyglucose (18-FDG PET-CT) imaging. (a-c) Axial MR images in the portal phase (left column) and axial 18-FDG PET-CT images (right column) showing the evolution of the largest hypovascular and hypermetabolic liver nodule in the right lobe: (a) at admission, (b) 30 days after the first SIRT session, and (c) 45 days after the second SIRT session. (d-f) Axial MR images in the portal phase (left column) and axial 18-FDG PET-CT (right column) showing evolution of the largest hypovascular and hypermetabolic liver nodules in the left lobe: (d) at admission, (e) 30 days after the first SIRT session (note that the lesions had grown), and (f) 45 days after the second SIRT session.
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fig1
An abdominal, contrast-enhanced computed tomography (CT) scan and magnetic resonance imaging (MRI) showed multiple, unresectable hypovascular liver nodules in both lobes (Figures 1(a) and 1(d)). Activity Calculator (http://apps01.sirtex.com/smac/) to calculate the appropriate dose and administered a Y-90 dose of 1.36 GBq (37 mCi equivalent) through the right hepatic artery and a dose of 0.34 GBq through the artery branch for segment VIII (part of the nodule in segment IV was being fed by this branch) (Figures 3(a), 3(b), and 3(c)). A follow-up MRI 30 days after the first administration of SIRT showed that the nodules in the treated right lobe of the liver had shrunk, whereas the lesions in the untreated left lobe had grown (Figures 1(b) and 1(e), Table 2). A PET-CT scan 45 days later showed only a slight heterogeneous distribution of 18-FDG in the region of the previously observed lesions (Figures 1(c) and 1(f)), and the maximum standardized uptake value had declined to 4.2 from the pretreatment value of 8.5.
Histopathology of the resected pancreas. (a) Neoplasm with a solid acinar architectural microscopic pattern (hematoxylin and eosin, 20x); (b) positive immunostaining (brown; counterstained with hematoxylin and eosin) for alpha-1-antitrypsin in neoplastic cells.
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The neoplastic cells were arranged in solid nests and in some areas formed an acinar arrangement (Figure 2(a)), with round or oval nuclei, moderate pleomorphism, prominent nucleoli, and eosinophilic granular cytoplasm. In an immunohistochemical study, the tumor cells were diffusely immunoreactive for CK18 and focally positive for CK7, alpha-1-antitrypsin (Figure 2(b)), and alpha-1-antichymotrypsin.
Digital subtraction angiography: (a) Angiogram showing the anatomy of the common hepatic artery. (b) Late phase showing some of the nodules. (c) Angiogram of the right hepatic artery before SIRT. (d) Catheterization of the arterial branch feeding segments IV/VIII. (e) Angiogram of the left hepatic artery before SIRT.
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fig3
Activity Calculator (http://apps01.sirtex.com/smac/) to calculate the appropriate dose and administered a Y-90 dose of 1.36 GBq (37 mCi equivalent) through the right hepatic artery and a dose of 0.34 GBq through the artery branch for segment VIII (part of the nodule in segment IV was being fed by this branch) (Figures 3(a), 3(b), and 3(c)). A follow-up MRI 30 days after the first administration of SIRT showed that the nodules in the treated right lobe of the liver had shrunk, whereas the lesions in the untreated left lobe had grown (Figures 1(b) and 1(e), Table 2). In the second SIRT treatment, a pulmonary shunt of 5% was detected, and a dose of 0.25 GBq (6.7 mCi) was delivered through the right hepatic artery branch to segments IV and VIII (to treat the remaining portion of segment IV), and 0.65 GBq (17.5 mCi) was delivered through the left hepatic artery (Figures 3(d) and 3(e)).
Comparison of baseline magnetic resonance imaging (MRI) (August 1, 2015) with computed tomography (CT) imaging performed on December 16, 2016. (a, b) Axial MRI images, portal phase, showing the hepatic nodules in the right (a) and left (b) lobes at admission. (c, d) Axial CT images, portal phase, showing regression of the hepatic nodules in the right (c) and left (d) lobes 15 months after the second SIRT and after several lines of chemotherapy.
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CT images obtained on December 16, 2016 (490 days after the initial SIRT), indicated that the tumors had shrunk considerably (Figure 4).