link
Bookmarks
Interventional Radiology
Procedures
Oncologic Procedures
Hepatic Radioembolization
Hepatic Radioembolization
Chad Davis, MD
To access 4,300 diagnoses written by the world's leading experts in radiology, please log in or subscribe.Subscribe

KEY FACTS

  • Terminology

    • Procedure

      • Post Procedure

        • Outcomes

          TERMINOLOGY

          • Definitions

            • Radioembolization or transarterial radioembolization (TARE) or selective internal radiation therapy (SIRT)
              • Anatomic & physiologic principles
                • Most normal liver parenchyma supply is via portal venous system (70-80%)
                • Most liver tumor supply is via hepatic arterial system
                • Therefore, intraarterial treatment will preferentially target tumor & spare normal liver parenchyma
              • Yttrium-90 (⁹⁰Y) is pure β emitter (electrons emitted from nucleus)
                • ~ 2/3 of energy is deposited within first 2.5 mm of tissue
                • 90% of energy deposited within 5 mm; maximum energy range of 11 mm
                • Small portion of β-particle absorption (0.01%) is due to bremsstrahlung, which results in γ radiation
                  • Treated patients do emit some γ radiation
                • Half-life of ⁹⁰Y is 64.2 hours
              • Technical objective
                • Deliver ⁹⁰Y-loaded particles throughout arterial bed of tumor
                • Dose targets vary based on tumor type & treatment intent
              • There are 2 commercially available ⁹⁰Y particles
                • Resin microspheres with median diameter of 30 μm (SIR-Spheres, Sirtex Medical)
                  • Lower radiation dose per particle (lower specific activity); therefore, significant embolization effect
                • Glass microsphere with median diameter of 25 μm (TheraSphere, MDS Nordion)
                  • Higher radiation dose per particle (higher specific activity); therefore, little embolic effect
            • Pretreatment evaluation/shunt study
              • Angiogram of hepatic arterial supply
                • (1) Define arterial supply to tumor & plan ⁹⁰Y delivery (split dose may be needed)
                • (2) Embolize (if needed) arterial branches that may be at risk for nontarget embolization
                  • Routine embolization of gastroduodenal artery (GDA) &/or right gastric artery (RGA) likely not needed unless at risk for nontarget embolization based on location of radioembolization delivery
                  • If radioembolization delivery can safely occur distal to branches, embolization may not be needed
                  • Embolization may be performed at time of mapping or on treatment day
                  • Embolization at time of mapping could cause new hepatoenteric collaterals to form
                • (3) Calculate lung shunt ratio
              • Shunt study
                • Injection of ⁹⁹mTc-macroaggregated albumin (MAA) via catheter in anticipated position of ⁹⁰Y treatment
                • Followed by radionuclide lung-liver perfusion scan ± SPECT/CT
                  • Calculate percentage activity in lung over total activity (lung & liver) to determine lung shunt
                  • If chronic obstructive pulmonary disease (COPD) or other lung disease, consider lowering acceptable shunt fraction (< 10%)
                  • SPECT/CT allows for greater anatomical resolution to evaluate for nontarget embolization
            • ⁹⁰Y microsphere administration
              • Usually performed within few weeks of mapping study
                • Some high-volume centers perform administration on same day
              • If > 6 months from shunt study, consider repeating shunt study, as tumor hemodynamics may have changed

          PREPROCEDURE

          • Indications

            • Contraindications

              • Preprocedure Imaging

                • Getting Started

                  • Radioactive Microspheres

                    PROCEDURE

                    • Patient Position/Location

                      • Equipment Preparation

                        • Procedure Steps

                          • Alternative Procedures/Therapies

                            POST PROCEDURE

                            • Things to Do

                              • Postprocedure Imaging/Follow-Up

                                OUTCOMES

                                • Complications

                                  • Expected Outcomes

                                    Selected References

                                    1. My SIRT Story: What are SIR-Spheres microspheres? Reviewed March 16, 2022. Accessed March 16, 2022. http://www.mysirtstory.org.uk/sirt/what-are-sir-spheres.htm
                                    2. Benson AB et al: Hepatobiliary cancers, version 2.2021, NCCN clinical practice guidelines in oncology. J Natl Compr Canc Netw. 19(5):541-65, 2021
                                    3. Benson AB et al: Colon cancer, version 2.2021, NCCN clinical practice guidelines in oncology. J Natl Compr Canc Netw. 19(3):329-59, 2021
                                    4. Bento de Sousa JH et al: Comparison between Milan and UCSF criteria for liver transplantation in patients with hepatocellular carcinoma: a systematic review and meta-analysis. Transl Gastroenterol Hepatol. 6:11, 2021
                                    5. Cheng B et al: Determination of tumor dose response thresholds in patients with chemorefractory intrahepatic cholangiocarcinoma treated with resin and glass-based Y90 Radioembolization. Cardiovasc Intervent Radiol. 44(8):1194-203, 2021
                                    6. Depalo T et al: Assessment of radiation sensitivity of unresectable intrahepatic cholangiocarcinoma in a series of patients submitted to radioembolization with yttrium-90 resin microspheres. Sci Rep. 11(1):19745, 2021
                                    7. Ebbers SC et al: Dose-response relationship after yttrium-90-radioembolization with glass microspheres in patients with neuroendocrine tumor liver metastases. Eur J Nucl Med Mol Imaging. ePub, 2021
                                    8. Garin E et al: Personalised versus standard dosimetry approach of selective internal radiation therapy in patients with locally advanced hepatocellular carcinoma (DOSISPHERE-01): a randomised, multicentre, open-label phase 2 trial. Lancet Gastroenterol Hepatol. 6(1):17-29, 2021
                                    9. Mulcahy MF et al: Radioembolization with chemotherapy for colorectal liver metastases: a randomized, open-label, international, multicenter, phase iii trial. J Clin Oncol. 39(35):3897-907, 2021
                                    10. Paz-Fumagalli R et al: Safety and initial efficacy of ablative radioembolization for the treatment of unresectable intrahepatic cholangiocarcinoma. Oncotarget. 12(20):2075-88, 2021
                                    11. Ridouani F et al: Relationship of radiation dose to efficacy of radioembolization of liver metastasis from breast cancer. Eur J Radiol. 136:109539, 2021
                                    12. Roosen J et al: To 1000 Gy and back again: a systematic review on dose-response evaluation in selective internal radiation therapy for primary and secondary liver cancer. Eur J Nucl Med Mol Imaging. 48(12):3776-90, 2021
                                    13. Salem R et al: Yttrium-90 radioembolization for the treatment of solitary, unresectable HCC: the LEGACY Study. Hepatology. 74(5):2342-52, 2021
                                    14. Padia SA et al: Transarterial yttrium-90 radioembolization of hepatocellular carcinoma perfused by the cystic artery: multi-institutional feasibility study. J Vasc Interv Radiol. 31(12):22-2027, 2020
                                    15. Ruohoniemi DM et al: Safety and effectiveness of yttrium-90 radioembolization around the time of immune checkpoint inhibitors for unresectable hepatic metastases. J Vasc Interv Radiol. 31(8):1233-41, 2020
                                    16. Malhotra A et al: Radiation segmentectomy and radiation lobectomy: a practical review of techniques. Tech Vasc Interv Radiol. 22(2):49-57, 2019
                                    17. Salem R et al: Clinical and dosimetric considerations for Y90: recommendations from an international multidisciplinary working group. Eur J Nucl Med Mol Imaging. 46(8):1695-704, 2019
                                    18. Schiro BJ et al: Management of high hepatopulmonary shunts in the setting of Y90 radioembolization. Tech Vasc Interv Radiol. 22(2):58-62, 2019
                                    19. Topcuoglu OM et al: Safety of transarterial radioembolization with Yttrium-90 glass microspheres without cystic artery occlusion. Radiol Med. 124(6):575-80, 2019
                                    20. Toskich BB et al: Y90 radioembolization dosimetry: concepts for the interventional radiologist. Tech Vasc Interv Radiol. 22(2):100-11, 2019
                                    21. Levillain H et al: 90Y-PET/CT-based dosimetry after selective internal radiation therapy predicts outcome in patients with liver metastases from colorectal cancer. EJNMMI Res. 8(1):60, 2018
                                    22. Braat MN et al: Radioembolization-induced liver disease: a systematic review. Eur J Gastroenterol Hepatol. 29(2):144-52, 2017
                                    23. Chansanti O et al: Tumor dose response in yttrium-90 resin microsphere embolization for neuroendocrine liver metastases: a tumor-specific analysis with dose estimation using SPECT-CT. J Vasc Interv Radiol. 28(11):1528-35, 2017
                                    24. Gordon AC et al: Making the case: intra-arterial therapy for less common metastases. Semin Intervent Radiol. 34(2):132-9, 2017
                                    25. Sangro B et al: Prevention and treatment of complications of selective internal radiation therapy: expert guidance and systematic review. Hepatology. 66(3):969-82, 2017
                                    26. Willowson KP et al: Clinical and imaging-based prognostic factors in radioembolisation of liver metastases from colorectal cancer: a retrospective exploratory analysis. EJNMMI Res. 7(1):46, 2017
                                    27. Biederman DM et al: Outcomes of radioembolization in the treatment of hepatocellular carcinoma with portal vein Invasion: resin versus glass microspheres. J Vasc Interv Radiol. 27(6):812-21.e2, 2016
                                    28. van den Hoven AF et al: Insights into the dose-response relationship of radioembolization with resin 90Y-microspheres: a prospective cohort study in patients with colorectal cancer liver metastases. J Nucl Med. 57(7):1014-9, 2016
                                    29. van Hazel GA et al: SIRFLOX: Randomized phase III trial comparing first-line mFOLFOX6 (plus or minus bevacizumab) versus mFOLFOX6 (plus or minus bevacizumab) plus selective internal radiation therapy in patients with metastatic colorectal cancer. J Clin Oncol. 34(15):1723-31, 2016
                                    30. Njei B et al: Emerging trends in hepatocellular carcinoma incidence and mortality. Hepatology. 61(1):191-9, 2015
                                    31. Dutton SJ et al: FOXFIRE protocol: an open-label, randomised, phase III trial of 5-fluorouracil, oxaliplatin and folinic acid (OxMdG) with or without interventional selective internal radiation therapy (SIRT) as first-line treatment for patients with unresectable liver-only or liver-dominant metastatic colorectal cancer. BMC Cancer. 14:497, 2014
                                    32. Eaton BR et al: Quantitative dosimetry for yttrium-90 radionuclide therapy: tumor dose predicts fluorodeoxyglucose positron emission tomography response in hepatic metastatic melanoma. J Vasc Interv Radiol. 25(2):288-95, 2014
                                    33. Gibbs P et al: Selective internal radiation therapy (SIRT) with yttrium-90 resin microspheres plus standard systemic chemotherapy regimen of FOLFOX versus FOLFOX alone as first-line treatment of non-resectable liver metastases from colorectal cancer: the SIRFLOX study. BMC Cancer. 14:897, 2014
                                    34. Lam MG et al: Prognostic utility of 90Y radioembolization dosimetry based on fusion 99mTc-macroaggregated albumin-99mTc-sulfur colloid SPECT. J Nucl Med. 54(12):2055-61, 2013
                                    35. Wang DS et al: Prophylactic topically applied ice to prevent cutaneous complications of nontarget chemoembolization and radioembolization. J Vasc Interv Radiol. 24(4):596-600, 2013
                                    36. Lau WY et al: Patient selection and activity planning guide for selective internal radiotherapy with yttrium-90 resin microspheres. Int J Radiat Oncol Biol Phys. 82(1):401-7, 2012
                                    37. Yaghmai V et al: Response to treatment series: part 2, tumor response assessment--using new and conventional criteria. AJR Am J Roentgenol. 197(1):18-27, 2011
                                    38. Lencioni R et al: Modified RECIST (mRECIST) assessment for hepatocellular carcinoma. Semin Liver Dis. 30(1):52-60, 2010
                                    39. Salem R et al: Radioembolization for hepatocellular carcinoma using Yttrium-90 microspheres: a comprehensive report of long-term outcomes. Gastroenterology. 138(1):52-64, 2010
                                    40. Ibrahim SM et al: Radiologic findings following Y90 radioembolization for primary liver malignancies. Abdom Imaging. 34(5):566-81, 2009
                                    41. Riaz A et al: Complications following radioembolization with yttrium-90 microspheres: a comprehensive literature review. J Vasc Interv Radiol. 20(9):1121-30; quiz 1131, 2009
                                    42. Shariff MI et al: Hepatocellular carcinoma: current trends in worldwide epidemiology, risk factors, diagnosis and therapeutics. Expert Rev Gastroenterol Hepatol. 3(4):353-67, 2009
                                    43. Salem R et al: Radioembolization with 90yttrium microspheres: a state-of-the-art brachytherapy treatment for primary and secondary liver malignancies. Part 2: special topics. J Vasc Interv Radiol. 17(9):1425-39, 2006
                                    44. Salem R et al: Radioembolization with 90Yttrium Microspheres: a state-of-the-art bbachytherapy treatment for primary and secondary liver malignancies: part 1: technical and methodologic considerations. J Vasc Interv Radiol. 17(8):1251-78, 2006
                                    45. Geschwind JF et al: Yttrium-90 microspheres for the treatment of hepatocellular carcinoma. Gastroenterology. 127(5 Suppl 1):S194-205, 2004
                                    Related Anatomy
                                    Loading...
                                    Related Differential Diagnoses
                                    Loading...
                                    References
                                    Tables

                                    Tables

                                    KEY FACTS

                                    • Terminology

                                      • Procedure

                                        • Post Procedure

                                          • Outcomes

                                            TERMINOLOGY

                                            • Definitions

                                              • Radioembolization or transarterial radioembolization (TARE) or selective internal radiation therapy (SIRT)
                                                • Anatomic & physiologic principles
                                                  • Most normal liver parenchyma supply is via portal venous system (70-80%)
                                                  • Most liver tumor supply is via hepatic arterial system
                                                  • Therefore, intraarterial treatment will preferentially target tumor & spare normal liver parenchyma
                                                • Yttrium-90 (⁹⁰Y) is pure β emitter (electrons emitted from nucleus)
                                                  • ~ 2/3 of energy is deposited within first 2.5 mm of tissue
                                                  • 90% of energy deposited within 5 mm; maximum energy range of 11 mm
                                                  • Small portion of β-particle absorption (0.01%) is due to bremsstrahlung, which results in γ radiation
                                                    • Treated patients do emit some γ radiation
                                                  • Half-life of ⁹⁰Y is 64.2 hours
                                                • Technical objective
                                                  • Deliver ⁹⁰Y-loaded particles throughout arterial bed of tumor
                                                  • Dose targets vary based on tumor type & treatment intent
                                                • There are 2 commercially available ⁹⁰Y particles
                                                  • Resin microspheres with median diameter of 30 μm (SIR-Spheres, Sirtex Medical)
                                                    • Lower radiation dose per particle (lower specific activity); therefore, significant embolization effect
                                                  • Glass microsphere with median diameter of 25 μm (TheraSphere, MDS Nordion)
                                                    • Higher radiation dose per particle (higher specific activity); therefore, little embolic effect
                                              • Pretreatment evaluation/shunt study
                                                • Angiogram of hepatic arterial supply
                                                  • (1) Define arterial supply to tumor & plan ⁹⁰Y delivery (split dose may be needed)
                                                  • (2) Embolize (if needed) arterial branches that may be at risk for nontarget embolization
                                                    • Routine embolization of gastroduodenal artery (GDA) &/or right gastric artery (RGA) likely not needed unless at risk for nontarget embolization based on location of radioembolization delivery
                                                    • If radioembolization delivery can safely occur distal to branches, embolization may not be needed
                                                    • Embolization may be performed at time of mapping or on treatment day
                                                    • Embolization at time of mapping could cause new hepatoenteric collaterals to form
                                                  • (3) Calculate lung shunt ratio
                                                • Shunt study
                                                  • Injection of ⁹⁹mTc-macroaggregated albumin (MAA) via catheter in anticipated position of ⁹⁰Y treatment
                                                  • Followed by radionuclide lung-liver perfusion scan ± SPECT/CT
                                                    • Calculate percentage activity in lung over total activity (lung & liver) to determine lung shunt
                                                    • If chronic obstructive pulmonary disease (COPD) or other lung disease, consider lowering acceptable shunt fraction (< 10%)
                                                    • SPECT/CT allows for greater anatomical resolution to evaluate for nontarget embolization
                                              • ⁹⁰Y microsphere administration
                                                • Usually performed within few weeks of mapping study
                                                  • Some high-volume centers perform administration on same day
                                                • If > 6 months from shunt study, consider repeating shunt study, as tumor hemodynamics may have changed

                                            PREPROCEDURE

                                            • Indications

                                              • Contraindications

                                                • Preprocedure Imaging

                                                  • Getting Started

                                                    • Radioactive Microspheres

                                                      PROCEDURE

                                                      • Patient Position/Location

                                                        • Equipment Preparation

                                                          • Procedure Steps

                                                            • Alternative Procedures/Therapies

                                                              POST PROCEDURE

                                                              • Things to Do

                                                                • Postprocedure Imaging/Follow-Up

                                                                  OUTCOMES

                                                                  • Complications

                                                                    • Expected Outcomes

                                                                      Selected References

                                                                      1. My SIRT Story: What are SIR-Spheres microspheres? Reviewed March 16, 2022. Accessed March 16, 2022. http://www.mysirtstory.org.uk/sirt/what-are-sir-spheres.htm
                                                                      2. Benson AB et al: Hepatobiliary cancers, version 2.2021, NCCN clinical practice guidelines in oncology. J Natl Compr Canc Netw. 19(5):541-65, 2021
                                                                      3. Benson AB et al: Colon cancer, version 2.2021, NCCN clinical practice guidelines in oncology. J Natl Compr Canc Netw. 19(3):329-59, 2021
                                                                      4. Bento de Sousa JH et al: Comparison between Milan and UCSF criteria for liver transplantation in patients with hepatocellular carcinoma: a systematic review and meta-analysis. Transl Gastroenterol Hepatol. 6:11, 2021
                                                                      5. Cheng B et al: Determination of tumor dose response thresholds in patients with chemorefractory intrahepatic cholangiocarcinoma treated with resin and glass-based Y90 Radioembolization. Cardiovasc Intervent Radiol. 44(8):1194-203, 2021
                                                                      6. Depalo T et al: Assessment of radiation sensitivity of unresectable intrahepatic cholangiocarcinoma in a series of patients submitted to radioembolization with yttrium-90 resin microspheres. Sci Rep. 11(1):19745, 2021
                                                                      7. Ebbers SC et al: Dose-response relationship after yttrium-90-radioembolization with glass microspheres in patients with neuroendocrine tumor liver metastases. Eur J Nucl Med Mol Imaging. ePub, 2021
                                                                      8. Garin E et al: Personalised versus standard dosimetry approach of selective internal radiation therapy in patients with locally advanced hepatocellular carcinoma (DOSISPHERE-01): a randomised, multicentre, open-label phase 2 trial. Lancet Gastroenterol Hepatol. 6(1):17-29, 2021
                                                                      9. Mulcahy MF et al: Radioembolization with chemotherapy for colorectal liver metastases: a randomized, open-label, international, multicenter, phase iii trial. J Clin Oncol. 39(35):3897-907, 2021
                                                                      10. Paz-Fumagalli R et al: Safety and initial efficacy of ablative radioembolization for the treatment of unresectable intrahepatic cholangiocarcinoma. Oncotarget. 12(20):2075-88, 2021
                                                                      11. Ridouani F et al: Relationship of radiation dose to efficacy of radioembolization of liver metastasis from breast cancer. Eur J Radiol. 136:109539, 2021
                                                                      12. Roosen J et al: To 1000 Gy and back again: a systematic review on dose-response evaluation in selective internal radiation therapy for primary and secondary liver cancer. Eur J Nucl Med Mol Imaging. 48(12):3776-90, 2021
                                                                      13. Salem R et al: Yttrium-90 radioembolization for the treatment of solitary, unresectable HCC: the LEGACY Study. Hepatology. 74(5):2342-52, 2021
                                                                      14. Padia SA et al: Transarterial yttrium-90 radioembolization of hepatocellular carcinoma perfused by the cystic artery: multi-institutional feasibility study. J Vasc Interv Radiol. 31(12):22-2027, 2020
                                                                      15. Ruohoniemi DM et al: Safety and effectiveness of yttrium-90 radioembolization around the time of immune checkpoint inhibitors for unresectable hepatic metastases. J Vasc Interv Radiol. 31(8):1233-41, 2020
                                                                      16. Malhotra A et al: Radiation segmentectomy and radiation lobectomy: a practical review of techniques. Tech Vasc Interv Radiol. 22(2):49-57, 2019
                                                                      17. Salem R et al: Clinical and dosimetric considerations for Y90: recommendations from an international multidisciplinary working group. Eur J Nucl Med Mol Imaging. 46(8):1695-704, 2019
                                                                      18. Schiro BJ et al: Management of high hepatopulmonary shunts in the setting of Y90 radioembolization. Tech Vasc Interv Radiol. 22(2):58-62, 2019
                                                                      19. Topcuoglu OM et al: Safety of transarterial radioembolization with Yttrium-90 glass microspheres without cystic artery occlusion. Radiol Med. 124(6):575-80, 2019
                                                                      20. Toskich BB et al: Y90 radioembolization dosimetry: concepts for the interventional radiologist. Tech Vasc Interv Radiol. 22(2):100-11, 2019
                                                                      21. Levillain H et al: 90Y-PET/CT-based dosimetry after selective internal radiation therapy predicts outcome in patients with liver metastases from colorectal cancer. EJNMMI Res. 8(1):60, 2018
                                                                      22. Braat MN et al: Radioembolization-induced liver disease: a systematic review. Eur J Gastroenterol Hepatol. 29(2):144-52, 2017
                                                                      23. Chansanti O et al: Tumor dose response in yttrium-90 resin microsphere embolization for neuroendocrine liver metastases: a tumor-specific analysis with dose estimation using SPECT-CT. J Vasc Interv Radiol. 28(11):1528-35, 2017
                                                                      24. Gordon AC et al: Making the case: intra-arterial therapy for less common metastases. Semin Intervent Radiol. 34(2):132-9, 2017
                                                                      25. Sangro B et al: Prevention and treatment of complications of selective internal radiation therapy: expert guidance and systematic review. Hepatology. 66(3):969-82, 2017
                                                                      26. Willowson KP et al: Clinical and imaging-based prognostic factors in radioembolisation of liver metastases from colorectal cancer: a retrospective exploratory analysis. EJNMMI Res. 7(1):46, 2017
                                                                      27. Biederman DM et al: Outcomes of radioembolization in the treatment of hepatocellular carcinoma with portal vein Invasion: resin versus glass microspheres. J Vasc Interv Radiol. 27(6):812-21.e2, 2016
                                                                      28. van den Hoven AF et al: Insights into the dose-response relationship of radioembolization with resin 90Y-microspheres: a prospective cohort study in patients with colorectal cancer liver metastases. J Nucl Med. 57(7):1014-9, 2016
                                                                      29. van Hazel GA et al: SIRFLOX: Randomized phase III trial comparing first-line mFOLFOX6 (plus or minus bevacizumab) versus mFOLFOX6 (plus or minus bevacizumab) plus selective internal radiation therapy in patients with metastatic colorectal cancer. J Clin Oncol. 34(15):1723-31, 2016
                                                                      30. Njei B et al: Emerging trends in hepatocellular carcinoma incidence and mortality. Hepatology. 61(1):191-9, 2015
                                                                      31. Dutton SJ et al: FOXFIRE protocol: an open-label, randomised, phase III trial of 5-fluorouracil, oxaliplatin and folinic acid (OxMdG) with or without interventional selective internal radiation therapy (SIRT) as first-line treatment for patients with unresectable liver-only or liver-dominant metastatic colorectal cancer. BMC Cancer. 14:497, 2014
                                                                      32. Eaton BR et al: Quantitative dosimetry for yttrium-90 radionuclide therapy: tumor dose predicts fluorodeoxyglucose positron emission tomography response in hepatic metastatic melanoma. J Vasc Interv Radiol. 25(2):288-95, 2014
                                                                      33. Gibbs P et al: Selective internal radiation therapy (SIRT) with yttrium-90 resin microspheres plus standard systemic chemotherapy regimen of FOLFOX versus FOLFOX alone as first-line treatment of non-resectable liver metastases from colorectal cancer: the SIRFLOX study. BMC Cancer. 14:897, 2014
                                                                      34. Lam MG et al: Prognostic utility of 90Y radioembolization dosimetry based on fusion 99mTc-macroaggregated albumin-99mTc-sulfur colloid SPECT. J Nucl Med. 54(12):2055-61, 2013
                                                                      35. Wang DS et al: Prophylactic topically applied ice to prevent cutaneous complications of nontarget chemoembolization and radioembolization. J Vasc Interv Radiol. 24(4):596-600, 2013
                                                                      36. Lau WY et al: Patient selection and activity planning guide for selective internal radiotherapy with yttrium-90 resin microspheres. Int J Radiat Oncol Biol Phys. 82(1):401-7, 2012
                                                                      37. Yaghmai V et al: Response to treatment series: part 2, tumor response assessment--using new and conventional criteria. AJR Am J Roentgenol. 197(1):18-27, 2011
                                                                      38. Lencioni R et al: Modified RECIST (mRECIST) assessment for hepatocellular carcinoma. Semin Liver Dis. 30(1):52-60, 2010
                                                                      39. Salem R et al: Radioembolization for hepatocellular carcinoma using Yttrium-90 microspheres: a comprehensive report of long-term outcomes. Gastroenterology. 138(1):52-64, 2010
                                                                      40. Ibrahim SM et al: Radiologic findings following Y90 radioembolization for primary liver malignancies. Abdom Imaging. 34(5):566-81, 2009
                                                                      41. Riaz A et al: Complications following radioembolization with yttrium-90 microspheres: a comprehensive literature review. J Vasc Interv Radiol. 20(9):1121-30; quiz 1131, 2009
                                                                      42. Shariff MI et al: Hepatocellular carcinoma: current trends in worldwide epidemiology, risk factors, diagnosis and therapeutics. Expert Rev Gastroenterol Hepatol. 3(4):353-67, 2009
                                                                      43. Salem R et al: Radioembolization with 90yttrium microspheres: a state-of-the-art brachytherapy treatment for primary and secondary liver malignancies. Part 2: special topics. J Vasc Interv Radiol. 17(9):1425-39, 2006
                                                                      44. Salem R et al: Radioembolization with 90Yttrium Microspheres: a state-of-the-art bbachytherapy treatment for primary and secondary liver malignancies: part 1: technical and methodologic considerations. J Vasc Interv Radiol. 17(8):1251-78, 2006
                                                                      45. Geschwind JF et al: Yttrium-90 microspheres for the treatment of hepatocellular carcinoma. Gastroenterology. 127(5 Suppl 1):S194-205, 2004