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Hepatic Radioembolization
Chad Davis, MD
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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
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                                    Related Differential Diagnoses
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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
                                              • 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