The objective of this study was to evaluate the response rate and survival of hepatocellular carcinoma portal vein thrombosis (PVT) patients treated with 90 Y-loaded glass microspheres using a personalized dosimetry and intensification concept. Methods: The microspheres were administered to 41 hepatocellular carcinoma PVT patients (main 5 12; lobar/segmental 5 29). 99m Tc-macroaggregated albumin SPECT/CT quantitative analysis was used to calculate the tumor dose (TD), healthy injected liver dose (HILD), and injected liver dose (ILD). Response was evaluated at 3 mo using the criteria of the European Association for the Study of the Liver, with CT follow-up lasting until disease progression or death. Survival was assessed using the Kaplan-Meier method. Results: The mean injected activity was 3.1 ± 1.5 GBq, and mean ILD was 143 ± 49 Gy. When a TD threshold of 205 Gy was applied, 99m Tc-macroaggregated albumin SPECT/CT achieved a 100% sensitivity and 90% overall accuracy (0 false-negatives; 4 false-positives) in response prediction. On the basis of TD and HILD values, 37% of patients received an intensification of the treatment (increased injected activity with the aim of achieving a TD $ 205 Gy and HILD , 120 Gy, applying an ILD . 150 Gy). This intensification resulted in a high response rate (85%) without increased liver toxicity of grade 3 or higher (6% vs. 12% in the patients who did not receive treatment intensification; not statistically significant). For the total 41 patients, median overall survival (OS) was 18 mo (95% confidence interval, 11-25 mo). For patients with a TD of less than 205 Gy, median OS was 4.3 mo (3.7-5 mo), versus 18.2 mo (8.5-28.7 mo) for those with a TD of 205 Gy or more (P 5 0.005). Median OS was 20.9 mo for patients with a TD of 205 Gy or more and good PVT targeting (n 5 36). OS was 12 mo (3 mo to N) for patients with main PVT, versus 21.5 mo (12-28.7 mo) for those with segmental or lobar PVT (not statistically significant). For the 5 patients with complete portal vein revascularization who underwent lobar hepatectomy, median OS was not reached yet exceeded 24.5 mo and was significantly higher than that of other patients (P 5 0.0493). Conclusion: Using a 99m Tc-macroaggregated albumin SPECT/CT personalized dosimetry and intensification concept with 90 Y-loaded glass microspheres induced prolonged OS for PVT patients as compared with the standard of care (sorafenib), without increasing liver toxicity. Prospective randomized studies are therefore warranted.

We report 2 cases where blood-pool SPECT/CT had a high added value compared with standard 3-phase bone scintigraphy with only delayed SPECT/CT for the etiological diagnosis of painful ankles. Two men, aged 48 and 62 years, were referred for suspicions of medial and lateral malleoli stress fractures, respectively. Although standard planar blood-pool imaging and delayed SPECT/CT were inconclusive, blood-pool SPECT/CT showed markedly increased uptake along posterior tibial tendon and peroneal tendon, respectively, leading to diagnose tendonitises. These cases illustrate that blood-pool SPECT/CT can extend the diagnostic yield of bone scintigraphy to extraosseous origin, particularly in chronic lower extremities pain.

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