CL Activity on the Posttreatment Scan of Patients with a Sequential Or Unilobar Delivery

Supplement 1

CL activity on the posttreatment scan of patients with a sequential or unilobar delivery

A whole liver treatment with a sequential delivery was performed in 5/82 patients, of whom 3 had CL tumor involvement. In 4/5 cases 90Y-PET/CT’s were acquired after both treatments. In

3/4 cases the CL was positive for activity on the posttreatment scan. In 2 cases this was due to both LHA and RHA supply, in one case only due to RHA supply. One patient with CL tumor involvement had a negative posttreatment scan (minimal activity in the paracaval portion) after right lobar treatment, leading to insufficient treatment of the metastasis (figure 1). In one case 166Ho-SPECT/CT was performed after a sequential treatment with injection in the LHA and the segment 6/7 artery during the first session and injection in the segment 5/8 artery in the second session. CL activity was only seen after the first treatment, covering the entire CL.

3/82 patients underwent only a selective treatment of the right lobe; in 2/3 patients the CL was positive for activity on the posttreatment scan (both without CL tumor involvement). The case with a negative posttreatment scan did show some activity in the caudate process after right lobar treatment (<2/3 of the CL). A metastasis was located in the Spigelian lobe in this case.

Due to progressive disease the initially planned left lobar treatment was cancelled.

In 2/5 patients with a prior right hemihepatectomy no activity was seen in the CL.

Supplement 2 Review of the DSA of the negative and discordant 99mTc-MAA SPECT/CT and posttreatment scans

Review of the DSA of the negative posttreatment scans revealed that in all of these cases the

LHA, RHA (and sometimes the MHA) were separately injected. Secondly, the injection positions at the angiographies of the discrepant 99mTc-MAA SPECT/CT and posttreatment scans were reviewed. In 3 cases CL activity was seen on the 99mTc-MAA SPECT/CT but not on the posttreatment scan. In one case a large caliber CL artery was mistakenly interpreted as the artery of segment 4 at the pretreatment angiography and consequently intentionally bypassed at the eventual RE treatment (Figure 2 and 3 in the original manuscript). In another case the injection position at the 99mTc-MAA was slightly more proximal in the RHA than at the RE treatment, though no extra arterial branches were identified in between these 2 injection positions on the angiography. In the last case the injection positions were similar for the proximal LHA and RHA, only the MHA was injected slightly more distal at the RE treatment (<1 cm). In this last case no explanation for the discrepancy could be identified.

In the 13 cases with a negative 99mTc-MAA SPECT/CT and a positive posttreatment scan catheter positions were similar for the 99mTc-MAA injection and final treatment in all but two cases. In the first case the 99mTc-MAA was injected in the CHA, whereas the catheter was positioned in 3 distal branches of the LHA and proximal in the RHA at final RE treatment. In the last case the injection position in the RHA at the RE treatment was approximately 1 cm more proximal than at 99mTc-MAA injection. Hence, no conclusive explanation for the discrepant results between the 99mTc-MAA SPECT/CT’s and positive posttreatment scans could be identified.