CHAPTER 6. RADIONUCLIDE THERAPY
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Recent work has used
131
I-Lipiodol in an adjuvant setting to treat patients
with 0.9 GBq
131
I-Lipiodol six weeks after surgical resection. The theory for this
treatment is that, as the liver starts to regenerate after surgery, microscopic
daughter tumours can be stimulated. If these were pre-ablated by
131
I-Lipiodol,
there would be a lower chance of recurrence. A Hong Kong group working on
this question has shown that after 24 months there is a significant increase in
both the disease-free interval and the overall survival in those receiving
131
I-Lipiodol compared with age matched controls. Unfortunately the numbers
studied were small, and confirmation in a larger group of patients is required.
6.10.3.3. Patient preparation
Patients being considered for
131
I-Lipiodol must have a full understanding
of the risks and possible benefits of the procedure, including the angiographic
as well as the Lipiodol therapy.
In all patients, a diagnosis of HCC should be established or be strongly
suspected. This can be based on the judgement of the hepatologist involved and
on information from imaging and a raised AFP level in the presence of
evidence for hepatitis B or C.
If a biopsy is required, a laparoscopic rather than a transdermal approach
is generally recommended. The patient should not have a blocked portal vein
and should have a tumour that is deemed non-resectable by a specialist liver
surgeon. There should be no evidence of disease outside the liver on an
abdominal and chest CT or in bone scintigraphy.
The patient should be clinically staged using the Okuda staging (or the
Child–Pugh staging). Patients should only be treated if they are at Okuda stage
1 or 2.
In patients with a large right lobe tumour that is greater than 50% of the
right lobe, evidence should be sought of a shunt, which would allow tracer to
pass into the right lung. If there is any doubt, the patient should have a Lipiodol
angiogram with non-radioactive Lipiodol, and Lipiodol seepage into the lungs
should be sought by a chest radiography or CT. An alternative is to use
99m
Tc-
MAA injected into the right hepatic artery and, with a gamma camera image,
to determine the percentage activity seen in the lungs after two hours. If this is
less than 5%, treatment should continue.
The patient should have normal clotting and a platelet count of more than
100 000 mm
–3
. Platelet infusions can be given but should be discontinued two
hours before the angiogram. Since the Lipiodol very rarely leaves the liver, and
given the very high ratio of non-radioactive to radioactive Lipiodol, no
blockage of the thyroid is required for this treatment.