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NM By Myself > Hepatobiliary Cancer NM > Flashcards

Hepatobiliary Cancer NM Flashcards

1
Q

Hypervascular lesion in cirrhotic liver

A

HCC - - washout in portal phase
Dysplastic nodule - - no washout in portal phase

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2
Q

Hypervascular lesion in noncirrhotic liver
Benign

A

Hemangioma
Adenoma
FNH

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3
Q

Hypervascular lesion in noncirrhotic liver
Malignant

A

MTS from breast, NET, melanoma
Fibrolamellar carcinoma

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4
Q

Hypovascular lesion
Unknown primary

A

Liver cyst - - density similar to water (0-15 HU), no enhancement
Liver abscess - - hypervascular rim

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5
Q

Hypovascular lesion
Known primary

A

Cystic - - MTS from mucinous colon, ovaries
Solid - - MTS from colon, pancreas, stomach, lung, renal, adrenal or liver involvement from lymphoma

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6
Q

Liver cancer M

A

Lung
Bone
Adrenal
Peritoneum

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7
Q

Fibrolamellar carcinoma

A

Rare
Better prognosis
No cirrhosis
Younger
Sharp margins
central scar with calcification

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8
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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9
Q

Radioactive I131-Lipiodol

A

Lipidic particles injected into hepatic artery - - retain in tumor by pinocytosis
75% liver, 25% lung
Thyroid block
Fixed activity 65 mCi
Hospitalization for 1 week
Risk - interstitial pneumonitis

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10
Q

Re188-Lipiodol

A

Inoperable large or multifocal HCC
Higher tumor killing efficacy
Lower toxicity

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11
Q

Ho166-Microspheres = QuiremSpheres

A

Predict distribution before therapy
Predict radiation dose to tumor and normal liver
Highest paramagnetic properties - - MRI

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12
Q

Y90-Microspheres

A

Inoperable primary or metastatic liver tumor
Embolization of precapillary vessels
T1/2 64.2h
Pure beta emitter 0.936 MeV
Pair production 511 keV - - PET
Mean tissue penetration 2.5mm, max 10 mm

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13
Q

Y90-Microspheres type

A

Glass - TheraSphere - - 20-30 microm, carry 2500 Bq per particle, 1.2 mln are injected, high specific activity, total activity 81 mCi
Resin-Sirtex - - 20-60 microm, carry 50 Bq per particle, 40-80 mln injected, low specific activity, total activity 3 GBq

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14
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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15
Q

Pretreatment angiography

A

Tc-MAA inject into hepatic artery
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
Tc-HAS - Microspheres - - within 4h

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16
Q

LSF

A

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% - - contra
LSF 10-15% - - reduce activity by 20%
LSF 15-20% - - reduce activity by 40%

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17
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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18
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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19
Q

Post SIRT image

A

SPECT based on Bremsstrahlung emission - - very poor quality
PET based on beta+ - - detection of extrahepatic distribution and estimation of absorbed dose

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20
Q

Tumor response assess

A

AFP
CECT in 1m
NECT every 3 m
PET in 6 weeks

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21
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
Portal vein thrombosis - - better survival

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22
Q

Intrahepatic Cholangiocarcinoma TARE

A

Improve survival, downstage
Combi with chemo - - downstage - - resectable

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23
Q

Metastatic colorectal cancer TARE

A

Unresectable liver MTS on chemo
FDG

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24
Q

Metastatic NET TARE

A

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

25
Q

TARE/SIRT Contra

A

Absolute
Lung to liver shunt
Inability to prevent deposition of radiolabeled microspheres in GIT
HCC - distant MTS
Relative
Reduced pulmonary function
Poor functional liver reserve
Creatinine >2
PLT <75 - - Consider Lipiodol

26
Q

TARE/SIRT toxicities

A

Immediate - lymphopenia
Post-embolic sy - most common - fatigue, abd discomfort, pain, fever
Cholecystitis
Gastric Ulceration
Gastroduodenitis
Pancreatitis
Pneumonitis
RILD = radiation induced liver disease

27
Q

Intrahepatic Cholangiocarcinoma M

A

LN (celiac, paraaortic, paracaval)
Peritoneum
Lung
Bone
Brain

28
Q

Intrahepatic Cholangiocarcinoma risk

A

Age
Primary sclerosing Cholangitis
Smoke
Chronic ulcerative colitis

29
Q

Intrahepatic Cholangiocarcinoma

A

90% adenocarcinoma
Obstructive jaundice without malignancy - - elevated CA19-9 - - not persist after decompression
CA125–peritoneal involvement
CEA non specific
FNA of perihilar mass - - peritoneal seeding

30
Q

Pancreas Carcinoma M

A

Liver
Peritoneum

31
Q

Pancreas Carcinoma

A

No capsule - - early local spread
Perineural spread 80%
Majority from ductal structure
Head 60-70%
Body 20%
Tail 5%
Diffuse 10-20%

32
Q

Pancreas Carcinoma high risk

A

Borderline resectable
Elevated CA19-9
Large tumor
Large LN
Very symptomatic

33
Q

Pancreas Carcinoma resectable

A

No arterial contact
No contact with SMV or PV or <180° contact without vein contour irregularity
M0

34
Q

Pancreas Carcinoma unresectable

A

M1
Solid tumor contact with SMA or CA >180°
Unreconstructible SMV/PV due to tumor involvement or occlusion

35
Q

Post-op perivascular soft tissue thickening and induration

A

Local recurrence vs post op changes
Time for recurrence 20 m
Progressive thickening - - suspicious

36
Q

Liver abscess after surgery

A

Mimic MTS
Liver function abnormality
Double target sign

37
Q

Head and ulcinate tumor

A

Whipple = pancreatoduadenectomy

38
Q

Body and tail

A

Distal pancreatectomy + splenectomy

39
Q

HCC staging

A

CT preferred for MTS
MRI - local staging, most sensitive, gold standard in cirrhosis
Tc sulfur colloid - focal defect in cirrhosis
Hepatobiliary scan
Gallium scan
FDG - not recommended due to limited sensitivity

40
Q

Intrahepatic Cholangiocarcinoma FDG

A

Not for primary lesion
Limited if large fibrosis
Focal uptake + elevated CA19-9

41
Q

Pancreas imaging

A

CeCT - best for diagnosis and initial management
FDG - local extent and distant MTS esp high risk, recurrence vs fibrosis
Increased sensitivity for MTS if PET after CT
Generally increased uptake, unless mucinous
11% change management
False-negative: <8 mm, sugar >150

42
Q

Intrahepatic Cholangiocarcinoma resectable

A

Resectable - - LN at porta
Unresectable - - Celiac, retropancreatic, paraaortic LN

43
Q
A

HCC
Solitary large mass
well-defined margins
peripheral pseudocapsule

44
Q
A

Intrahepatic Cholangiocarcinoma
Arterial - peripheral contrast enhancement with progressive fill, early thick rim with patchy central enhancement
Portal - persistent enhancement, without nodular or globular pattern, > liver parenchyma

47
Q
A

Hemangioma

50
Q
A

Hemangioma

51
Q
52
Q
A

Hemangioma

53
Q
A

Breast MTS

54
Q
A

Hemangioma

57
Q
A

Intrahepatic Cholangiocarcinoma

59
Q
A

Pancreatic adenocarcinoma
Poorly enhancing
Hypoattenuating mass

NM By Myself (25 decks)

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