A radioterapia interna seletiva é uma alternativa para o tratamento do carcinoma hepatocelular. Nesta terapia, microesferas de vidro contendo radionuclídeos são introduzidas no fígado por meio de um cateter acoplado à artéria hepática dos pacientes e são retidas em regiões microvasculares que alimentam o tecido lesado. Estas micropartículas aniquilam as células cancerosas por meio da radiação β-, e, quando simultaneamente emitem raios γ, podem também ser utilizadas para imageamento do tumor. As partículas vítreas devem possuir o formato esférico para não provocar hemorragias desnecessárias e também diâmetro adequado para otimizar o bloqueio efetivo da alimentação do tumor e evitar a migração para outros órgãos que poderia causar doses em tecidos sadios. Além disso, devem ter durabilidade química adequada e não serem citotóxicas. A distribuição do tamanho de microesferas depende de muitos parâmetros como a razão de aspecto, formação de aglomerados, e temperatura de processamento. No presente trabalho é apresentado um estudo do processo de esferolização de partículas vítreas caracterizadas por difração de raios X, espectrometria de fluorescência de raios X por energia dispersiva, área superficial específica, teste de citotoxicidade e calorimetria exploratória diferencial. Foram determinadas a taxa de dissolução do vidro em água destilada a 90oC (DR~10-8g.cm-2.min-1), densidade (2,79g.cm-3), viscosidade e granulometria. A morfologia das microesferas foi avaliada por microscopia eletrônica de varredura antes e após os testes de dissolução em SBF e irradiação por feixe de nêutrons. Propõem-se o peneiramento para seleção das microesferas apropriadas para o tratamento pretendido e testes in vivo visando a sua aplicação em radioterapia interna seletiva. / The selective internal radiotherapy is an alternative method to treat hepatocellular carcinoma. Glass microspheres containing radionuclides are introduced in the liver through the hepatic artery, and they are housed preferentially in the region where the cancer cells are located. The microspheres are trapped in the arterioles which feed the tumors, and the β- particles annihilate the cancer cells. When these particles simultaneously emit γ rays, they can also be used to provide images of the tumor. The glass particles must be spherical to avoid unnecessary bleeding, and the particle size must be restricted to a range which is appropriated to trap them and avoid the migration to other parts of the body. Furthermore, they must have a good chemical durability and be nontoxic. The particle size distribution of microspheres is not easily predicted based on the original irregular particles since the variation of the aspect ratio and the presence of agglomerates can influence the final result. In the present work, the spheroidization process to obtain microspheres for radiotherapy treatment was studied. The glass microspheres were characterized by X-rays diffraction, Energy Dispersive X-rays Fluorescence Spectroscopy, Differential Scanning Calorimetry, Specific Superficial Area and cytotoxicity test. The dissolution rate in distilled water at 90ºC (DR~10-8g.cm-2.min-1), density (2.79g.cm-3), viscosity, and size particle distribution were determined. The surface morphological aspect was evaluated by Scanning Electron Microscopy before and after the chemical durability tests in SBF and after the neutron irradiation. It is proposed that the produced material should be sieved to select the most suitable microspheres, and to allow in vivo tests aiming its application in selective internal radiotherapy.

A radioterapia interna seletiva é uma alternativa para o tratamento do carcinoma hepatocelular. Nesta terapia, microesferas de vidro contendo radionuclídeos são introduzidas no fígado por meio de um cateter acoplado à artéria hepática dos pacientes e são retidas em regiões microvasculares que alimentam o tecido lesado. Estas micropartículas aniquilam as células cancerosas por meio da radiação β-, e, quando simultaneamente emitem raios γ, podem também ser utilizadas para imageamento do tumor. As partículas vítreas devem possuir o formato esférico para não provocar hemorragias desnecessárias e também diâmetro adequado para otimizar o bloqueio efetivo da alimentação do tumor e evitar a migração para outros órgãos que poderia causar doses em tecidos sadios. Além disso, devem ter durabilidade química adequada e não serem citotóxicas. A distribuição do tamanho de microesferas depende de muitos parâmetros como a razão de aspecto, formação de aglomerados, e temperatura de processamento. No presente trabalho é apresentado um estudo do processo de esferolização de partículas vítreas caracterizadas por difração de raios X, espectrometria de fluorescência de raios X por energia dispersiva, área superficial específica, teste de citotoxicidade e calorimetria exploratória diferencial. Foram determinadas a taxa de dissolução do vidro em água destilada a 90oC (DR~10-8g.cm-2.min-1), densidade (2,79g.cm-3), viscosidade e granulometria. A morfologia das microesferas foi avaliada por microscopia eletrônica de varredura antes e após os testes de dissolução em SBF e irradiação por feixe de nêutrons. Propõem-se o peneiramento para seleção das microesferas apropriadas para o tratamento pretendido e testes in vivo visando a sua aplicação em radioterapia interna seletiva. / The selective internal radiotherapy is an alternative method to treat hepatocellular carcinoma. Glass microspheres containing radionuclides are introduced in the liver through the hepatic artery, and they are housed preferentially in the region where the cancer cells are located. The microspheres are trapped in the arterioles which feed the tumors, and the β- particles annihilate the cancer cells. When these particles simultaneously emit γ rays, they can also be used to provide images of the tumor. The glass particles must be spherical to avoid unnecessary bleeding, and the particle size must be restricted to a range which is appropriated to trap them and avoid the migration to other parts of the body. Furthermore, they must have a good chemical durability and be nontoxic. The particle size distribution of microspheres is not easily predicted based on the original irregular particles since the variation of the aspect ratio and the presence of agglomerates can influence the final result. In the present work, the spheroidization process to obtain microspheres for radiotherapy treatment was studied. The glass microspheres were characterized by X-rays diffraction, Energy Dispersive X-rays Fluorescence Spectroscopy, Differential Scanning Calorimetry, Specific Superficial Area and cytotoxicity test. The dissolution rate in distilled water at 90ºC (DR~10-8g.cm-2.min-1), density (2.79g.cm-3), viscosity, and size particle distribution were determined. The surface morphological aspect was evaluated by Scanning Electron Microscopy before and after the chemical durability tests in SBF and after the neutron irradiation. It is proposed that the produced material should be sieved to select the most suitable microspheres, and to allow in vivo tests aiming its application in selective internal radiotherapy.

Radioembolization (also called selective internal radiation therapy, SIRT) with yttrium-90 (90Y)-loaded microspheres has been broadly adopted as a locoregional therapy for primary and metastatic liver cancers. Although radioembolization is a well-established therapy, efforts to personalise and refine the planning and administration of therapy are ongoing. The ability to accurately predict, plan and deliver optimal doses to tumour and non-tumour tissues, including final validation of dose distribution, is essential for successful radiotherapy. Determining the true dose absorbed by tissue compartments is the primary way to safely individualise therapy for maximal response while respecting normal tissue tolerances. The overarching objective of this work was to expand our knowledge of dosimetry in 90Y-resin-microsphere radioembolization, with the ultimate goal of improving the clinical outcomes in our patients. Initially we sought to identify the patient- and treatment-related variables that predict radioembolization outcome in patients with intrahepatic cholangiocarcinoma (Chapter 2). Then, as a step toward personalised radioembolization in liver metastases from colorectal cancer patients, we evaluated the relationship between radioembolization real absorbed dose, as determined by 90Y positron emission tomography, and outcome (lesion-based and patient-based) (Chapter 3). In the work described in Chapter 4, we compared predictive (simulated) and post-treatment (real) dosimetry in liver metastases from colorectal cancer patients to pursue radioembolization personalisation. Finally, based on experience accumulated in previous studies and advances reported in the literature, we generated state-of-the-art recommendations to assist practitioners in performing personalised radioembolization with 90Y-resin microspheres in patients with primary and metastatic liver tumours (Chapter 5). / Doctorat en Sciences biomédicales et pharmaceutiques (Médecine) / info:eu-repo/semantics/nonPublished

La radiothérapie interne sélective (RTIS), en plein développement ces dernières années, constitue une alternative thérapeutique pour les cancers primaires et secondaires inopérables du foie. Le principe repose sur l’administration intra-artérielle de microsphères chargées d’yttrium-90 avec pour objectif la destruction des cellules tumorales par l’irradiation.L’activité d’yttrium-90 à administrer au patient est actuellement généralement prescrite à partir d’approches semi-empiriques ou peu personnalisées, faciles à mettre en place cliniquement. De nouveaux outils sont aujourd'hui disponibles semblables à ceux utilisés en radiothérapie externe. Leur utilisation encore peu répandue nécessite un retour d'expérience clinique pour mettre en avant leurs bénéfices et guider l'application clinique. Par ailleurs, le traitement RTIS est précédé d'une étape de simulation. Des différences inhérentes à cette procédure en deux temps (type de particules utilisées, modalité d’imagerie, modifications de flux vasculaires, etc.) existent et pourraient potentiellement conduire à des écarts dosimétriques entre la planification et le traitement. C’est dans ce contexte que s’inscrit le projet de cette thèse qui porte sur l'optimisation de la dosimétrie pour le traitement du carcinome hépatocellulaire par RTIS.Les doses délivrées au cours de 42 traitements par microsphères de résine réalisés entre 2012 et 2015 au CHU de Montpellier, ont été rétrospectivement calculées à l’échelle du voxel sur un logiciel de dosimétrie dédié (PLANET Dose, DOSIsoft, Cachan). Les doses délivrées ont été calculées pour le volume tumoral et le volume de foie sain définis anatomiquement, à partir de l’imagerie post-traitement TEP aux microsphères d’yttrium-90. Ce travail a mené à deux études complémentaires. La première analyse a consisté à confronter les données dosimétriques recueillies (doses moyennes, histogrammes dose-volume) à la réponse tumorale, la toxicité hépatique et la survie du patient. Les résultats obtenus, en accord avec ceux de la littérature, ont confirmé l’existence d’une relation dose-effet en RTIS. La deuxième étude a mis en évidence les limites du modèle BSA (body surface area pour surface corporelle) qui avait été utilisé pour planifier l’activité à administrer, à prédire la dose délivrée et par conséquent l’efficacité du traitement. L’absence de considérations dosimétriques et de prise en compte de l’hétérogénéité de distribution, de ce modèle ont notamment été discutées. Ces deux études ont ainsi souligné l'intérêt de planifier l'activité d'yttrium-90 à administrer en se basant sur des données dosimétriques individualisées.Une troisième étude a été conduite sur une population de 23 patients atteints de CHC, traités par microsphères de verre traités entre 2015 et 2018 au CHU de Montpellier. L’objectif a été de comparer les dosimétries prédictives et post-traitement calculées à l’échelle du voxel. Les résultats cliniques obtenus ont été appuyés par des expérimentations sur fantômes physiques (simple et anthropomorphique). Une bonne corrélation a été montrée, mettant en avant la valeur prédictive de la dosimétrie de planification. En revanche, un écart significatif a été observé et semble lié en partie à la quantification de l’imagerie TEP à l’yttrium-90. De plus, il a été montré que le geste radiologique peut influencer la distribution de particules et donc de dose, d’où la nécessité d’une reproductibilité aussi parfaite que possible entre les deux étapes. / Selective internal radiation therapy (SIRT) is a growing therapeutic alternative for unresectable primary and secondary liver cancer. The principle is based on the intra-arterial administration of yttrium-90 loaded microspheres for tumor cell destruction through irradiation.Yttrium-90 activity to be administered to the patient is, at the moment, usually prescribed using semi-empirical or barely personalized approaches that can be easily clinically implemented. New tools, similar to the ones used in external beam radiotherapy, are available today. These tools, which are not yet widely spread, require clinical feedback to show their benefits and guide the clinical application. Besides, a simulation stage is always performed before SIRT treatment itself. This two-step procedure implies differences (in terms of particles used, imaging modality, vascular flow modifications, etc.) that could potentially lead to dose deviations between planning and treatment. The thesis project comes within this scope, dealing with dosimetry optimization for hepatocellular carcinoma SIRT.Delivered doses during 42 treatment procedures performed between 2012 and 2015 at Montpellier University Hospital, were retrospectively calculated at the voxel level using a dosimetry dedicated software (PLANET Dose, DOSIsoft, Cachan). Two complementary studies were carried out from this work. The first one analyzed dose data (average dose, dose volume histograms) versus patient follow-up including tumor response, liver toxicity and patient survival. The results obtained are consistent with the other teams, confirming the dose-effect relationship in SIRT. The second study highlighted the limitations of the BSA (body surface area) model that was used for activity planning. In particular, the limitations of this model to predict delivered dose and consequently treatment efficiency were quantitatively demonstrated. The lack of dosimetry and heterogeneity distribution considerations were also discussed. These two studies emphasized the interest for yttrium-90 activity planning based on individualized dose data.A third study was conducted on a population of 23 patients treated between 2015 and 2018 at Montpellier University Hospital. The aim was to compare predictive and post-treatment dosimetry calculated at the voxel level. The clinical results were supported by phantom (simple and anthropomorphic) experimentations. A good correlation was observed highlighting the predictive value of dosimetry planning. However, a significant deviation was noticed and seems to be partly related to yttrium-90 TEP quantification. In addition, it was also noted that the radiological gesture can affect particle distribution and consequently dose distribution, this is why reproducibility as perfect as possible is required between the two stages.

L’hypothèse prédominante de cette thèse est que les changements métaboliques tumoraux mesurés par FDG-PET/CT sous l’influence des traitements anticancéreux, apparaissent plus précocement et parfois exclusivement par rapport aux modalités d’imagerie morphologique classique. L’imagerie multimodale, en combinant les avantages de chacune des techniques, dépasse leur limitations et pourrait permettre (i) une évaluation du bénéfice du traitement plus rapide et plus adéquate ;(ii) de modifier les algorithmes thérapeutiques à différents stades de cancer colorectal et (iii) d’améliorer la compréhension des mécanismes d’échappement aux traitements anticancéreux. Pour évaluer l’apport de l’imagerie multimodale dans l’évaluation de la réponse au traitement des cancers colorectaux (CCR), nous avons poursuivi 3 séries d’expérimentation cliniques.<p><p>1) Le premier projet explore l’imagerie multimodale comme un outil d’individualisation pour la radio-embolisation (microsphères chargées en 90Yttrium) chez des patients porteurs d’un CCR métastatique au niveau du foie, pour laquelle l’imagerie morphologique classique est incapable de mesurer l’effet thérapeutique. Nous montrons que l’usage non sélectif de la radio-embolisation améliore l’histoire clinique de ces patients, bien que certains d’entre eux ne semblent pas en bénéficier. Ensuite, par une analyse multimodale lésion par lésion intégrant angiographie-CT Scan, FDG-PET/CT et scintigraphie aux macro-agrégats d’albumine marqués au 99mTechnetium, nous démontrons que la distribution pré-thérapeutique des macro-agrégats d’albumine est hétérogène entre les différentes lésions des patients et prédictive de la réponse métabolique au sein de ces lésions, permettant le développement d’un outil de prédiction et de planification pour la radio-embolisation.<p><p>2) Le deuxième projet explore le domaine du CCR métastatique traité par chimiothérapie palliative. (i) Nous démontrons d’abord que la réponse métabolique (RM) tumorale après une cure de chimiothérapie cytolytique prédit plus vite et plus adéquatement que l’imagerie morphologique basée sur les critères RECIST les bénéfices cliniques du traitement. La RM précoce a une excellente valeur prédictive négative sur l’absence de réponse morphologique et met en évidence une variabilité de réponse inter-lésionnelle chez une proportion importante des patients. (ii) L’étude SoMore explore ensuite des patients présentant un CCR avancé et réfractaire, traités par capecitabine et sorafenib, et confirme l’importance pronostique des RM mixtes, suggérant une méthodologie de classification clinique basée sur la consistance de la RM. (iii) Cette classification cherche confirmation dans l’étude RegARd-C, encore en cours, évaluant les effets du regorafenib, et explorant également la signification génomique et épigénétique de la variabilité de RM. <p><p>3) Le troisième projet cherche à utiliser les propriétés de l’imagerie métabolique pour modifier l’algorithme de traitement adjuvant des patients porteurs d’un cancer du côlon de stade III. Ce projet, encore en cours, fait l’hypothèse que l’absence de RM de la lésion primitive après une cure de chimiothérapie prédit l’absence de bénéfice du traitement adjuvant complet. Une analyse intérimaire en démontre la faisabilité et confirme la présence de 40% de tumeurs présentant des caractéristiques métaboliques de chimio-résistance.<p><p>En conclusion, pour des patients porteurs d’un CCR, l’imagerie multimodale comprenant une évaluation du métabolisme tumoral permet une évaluation plus précoce et plus adéquate du bénéfice au traitement anticancéreux pour différentes modalités thérapeutiques comme la radio-embolisation, la chimiothérapie cytotoxique et les agents biologiques. L’imagerie multimodale permet de prédire et planifier les radio-embolisations et se révèle très prometteuse pour les traitements chimiothérapiques cytotoxiques ou combinés à des biologiques en situation adjuvante ou métastatique. Elle démontre par ailleurs une importante variabilité de réponse métabolique inter-lésionnelle qui représente un axe de recherche majeur sur les mécanismes moléculaires d’hétérogénéité génomique tumorale et de résistance aux traitements anti-cancéreux.<p> / Doctorat en Sciences médicales / info:eu-repo/semantics/nonPublished

Submitted in fulfillment of the requirements of the degree of the Master of Technology : Radiography, Durban University of Technology, 2014. / Research Aims The purpose of this study is to compare 2D HDR Brachytherapy planning and 3D HDR Brachytherapy planning in terms of dose distribution in order to accurately determine bladder and rectal doses. Further research questions were explored to determine whether relationships existed between Computer Tomography volumes and bladder and rectum dose. Methodology The 30 female patients that volunteered for the study were conveniently selected. Their age and ethnic group did not contribute to their selection. All participants were prepared for cervical HDR Brachytherapy. The Brachytherapy templates were computer generated and treatments were given based on the templates. They then had a Computer Tomography (CT) scan (3D data set) of the pelvis. The computer generated templates for 2D Brachytherapy planning were applied to the CT data set i.e. 2DBP. The plans were optimised to take into consideration the dose to the bladder and the rectum i.e. 3DBP. The 2DBP and the 3DBP were then evaluated in order to determine which method of planning yielded more acceptable dose distributions to the bladder and rectum. Results Significant differences in dose distribution were noted on comparison of 2DBP and 3DBP. A significant relationship was noted in respect of bladder mean dose and rectum mean dose. 3DBP proved to be more efficient in yielding lower mean dose to the bladder and the rectum. Whilst a significant relationship was noted in respect of bladder maximum dose, an insignificant relationship was noted for rectum maximum dose. Therefore, the efficiency of 3DBP to yield lower bladder maximum dose was established but its efficiency to yield lower rectum maximum dose is questionable. This has implications for the management of patients’ with cervical cancer who require cervical Brachytherapy. Recommendations It is imperative that imaging modalities be used for the accurate planning of cervical Brachytherapy. This study recommends that CT be used for HDR Brachytherapy planning by proving its greater efficiency compared to template planning.

Διευρεύνηση της μεθόδου του ακτινοεμβολισμού με μικροσφαιρίδια Υ-90 για τη αντιμετώπιση ηπατικών όγκων. Βελτίωση της image-based δοσιμετρίας προτείνοντας PET ιχνηθέτες. / Investigation of the method of radioembolization with Y90 microspheres for the treatment of liver malignancies. Improvement of the image-based dosimetry proposing the use of PET tracers.

Hepatocellular carcinoma is a primary liver cancer.Among treatment options for hepatocellular carcinoma, Yttrium-90 radioembolization is a promising transarterial therapy.This thesis investigates potential clinical applications of radioembolization in the treatment of the hepatocellular carcinoma (techniques of radiation segmentectomy and radiation lobectomy), and adress the problematic of the response Assessment after radioembolization. / Doctorat en Sciences médicales (Médecine) / info:eu-repo/semantics/nonPublished

Le Carcinome Hépatocellulaire a une incidence mondiale élevée et est associé à un mauvais pronostic. Les traitements curatifs existants ne sont applicables qu’à une minorité de patients. La radiothérapie sélective interne (SIRT) est un traitement palliatif de plus en plus utilisé. Elle consiste à l’injection sélective intra-tumorale de microsphères d’yttrium-90 par infusion intra-artérielle, et repose sur deux étapes : une étape pré-thérapeutique de simulation du traitement avec l’injection de macroagrégats d’albumines marqués au 99mTc et le traitement en lui-même. Cependant les caractéristiques de ces deux vecteurs diffèrent et peuvent conduire à des variations de biodistribution et à une dosimétrie approximative. Ce travail a pour but de développer un vecteur radiothéranostique unique pour la SIRT : les microparticules à base d’amidon (SBMP), afin de pallier aux différents problèmes rencontrés en clinique. L’optimisation du radiomarquage par le 68Ga et le 188Re sous forme de kits lyophilisés prêts-à-l’emploi, a permis d’obtenir une pureté radiochimique > 98 % et > 95 % respectivement. Une étude préliminaire par imagerie TEP/TDM in vivo chez le rat, suite à l’injection intraartérielle des 68Ga-SBMP a montré une biodistribution spécifique des microparticules avec plus de 95 % de l’activité retrouvée dans le foie et plus particulièrement dans les tumeurs. Les SBMP offrent plusieurs avantages répondant à différents problèmes actuels et constituent un agent théranostique prometteur pour la SIRT. Une présentation de la SIRT, des différentes microparticules en développement pour la SIRT et des modèles animaux de tumeur hépatique existants seront également développées dans ce travail. / The Hepatocellular Carcinoma has a high incidence worldwide and is associated with a bad prognostic. The existing curative treatments can only be apply in a minority of cases. The selective internal radiation therapy (SIRT) is a palliative treatment that is increasingly used. This technique is define by the selective intratumoral injection of yttrium-90microspheres via intra-arterial infusion. It involves two steps : a pre-therapeutic one for treatment simulation purpose with the injection of serum albumin macroaggregates radiolabeled with 99mTc and the treatment itself. However the characteristics of these two vectors are different and can lead to variations in biodistribution and approximate dosimetry. This works aims to develop a unique radiotheranostic vector for the SIRT: the starch-basedmicroparticles (SBMP), in order to overcome the different currents clinical problems. The optimization of the radiolabeling by the 68Ga and the 188Re in the form of ready-to-use radiolabeling kits allowed to obtain a radiochemical purity > 98 % and > 95 % respectively. A preliminary in vivo study by PET/CT imaging in rat, following the intra-arterial injection of 68Ga-SBMP displayed a specific biodistribution of the microparticles with more than 95 % of the activity found in the liver and mostly in the tumors. The SBMP offer several advantages that answer different current issues and area promising theranostic agent for the SIRT. A presentation of the SIRT, the different microparticles in development and the existing animal models of hepatic tumor will also be developed in this work.