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
⁹⁰Ymicrosphere 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
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
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
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
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
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
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
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
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
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
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
Ridouani F et al: Relationship of radiation dose to efficacy of radioembolization of liver metastasis from breast cancer. Eur J Radiol. 136:109539, 2021
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
Salem R et al: Yttrium-90 radioembolization for the treatment of solitary, unresectable HCC: the LEGACY Study. Hepatology. 74(5):2342-52, 2021
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
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
Malhotra A et al: Radiation segmentectomy and radiation lobectomy: a practical review of techniques. Tech Vasc Interv Radiol. 22(2):49-57, 2019
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
Schiro BJ et al: Management of high hepatopulmonary shunts in the setting of Y90 radioembolization. Tech Vasc Interv Radiol. 22(2):58-62, 2019
Topcuoglu OM et al: Safety of transarterial radioembolization with Yttrium-90 glass microspheres without cystic artery occlusion. Radiol Med. 124(6):575-80, 2019
Toskich BB et al: Y90 radioembolization dosimetry: concepts for the interventional radiologist. Tech Vasc Interv Radiol. 22(2):100-11, 2019
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
Braat MN et al: Radioembolization-induced liver disease: a systematic review. Eur J Gastroenterol Hepatol. 29(2):144-52, 2017
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
Gordon AC et al: Making the case: intra-arterial therapy for less common metastases. Semin Intervent Radiol. 34(2):132-9, 2017
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
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
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
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
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
Njei B et al: Emerging trends in hepatocellular carcinoma incidence and mortality. Hepatology. 61(1):191-9, 2015
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
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
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
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
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
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
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
Lencioni R et al: Modified RECIST (mRECIST) assessment for hepatocellular carcinoma. Semin Liver Dis. 30(1):52-60, 2010
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
Ibrahim SM et al: Radiologic findings following Y90 radioembolization for primary liver malignancies. Abdom Imaging. 34(5):566-81, 2009
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
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
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
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
Geschwind JF et al: Yttrium-90 microspheres for the treatment of hepatocellular carcinoma. Gastroenterology. 127(5 Suppl 1):S194-205, 2004
Related Anatomy
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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
⁹⁰Ymicrosphere 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
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
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
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
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
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
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
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
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
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
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
Ridouani F et al: Relationship of radiation dose to efficacy of radioembolization of liver metastasis from breast cancer. Eur J Radiol. 136:109539, 2021
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
Salem R et al: Yttrium-90 radioembolization for the treatment of solitary, unresectable HCC: the LEGACY Study. Hepatology. 74(5):2342-52, 2021
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
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
Malhotra A et al: Radiation segmentectomy and radiation lobectomy: a practical review of techniques. Tech Vasc Interv Radiol. 22(2):49-57, 2019
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
Schiro BJ et al: Management of high hepatopulmonary shunts in the setting of Y90 radioembolization. Tech Vasc Interv Radiol. 22(2):58-62, 2019
Topcuoglu OM et al: Safety of transarterial radioembolization with Yttrium-90 glass microspheres without cystic artery occlusion. Radiol Med. 124(6):575-80, 2019
Toskich BB et al: Y90 radioembolization dosimetry: concepts for the interventional radiologist. Tech Vasc Interv Radiol. 22(2):100-11, 2019
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
Braat MN et al: Radioembolization-induced liver disease: a systematic review. Eur J Gastroenterol Hepatol. 29(2):144-52, 2017
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
Gordon AC et al: Making the case: intra-arterial therapy for less common metastases. Semin Intervent Radiol. 34(2):132-9, 2017
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
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
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
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
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
Njei B et al: Emerging trends in hepatocellular carcinoma incidence and mortality. Hepatology. 61(1):191-9, 2015
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
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
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
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
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
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
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
Lencioni R et al: Modified RECIST (mRECIST) assessment for hepatocellular carcinoma. Semin Liver Dis. 30(1):52-60, 2010
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
Ibrahim SM et al: Radiologic findings following Y90 radioembolization for primary liver malignancies. Abdom Imaging. 34(5):566-81, 2009
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
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
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
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
Geschwind JF et al: Yttrium-90 microspheres for the treatment of hepatocellular carcinoma. Gastroenterology. 127(5 Suppl 1):S194-205, 2004
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