4.4. Results

microspheres require a higher volume, it would in theory produce a greater ischemic/embolic effect that would decrease the efficacy of delivering the full radiation dose. That being said, technical differences between the microspheres have not resulted in differences for overall survival in HCC [38]. Moreover computational studies comparing the resin and glass microspheres have demonstrated that particle trajectory in vessels have very little dependence on particle size. Indeed the authors concluded that the carrier fluid provides enough momentum

Aside from the multidisciplinary approach, patients should have a life expectancy greater than 3 months with an ECOG status less than 2. Radioembolization is often used an adjuvant therapy to chemotherapy and/or salvage therapy after failure of first-line chemotherapy. This

Absolute contraindications would include poor liver function with an elevated total bilirubin or increasing bilirubin, previous radiation to the liver, or significant hepatopulmonary lung shunting as that would lead to radiation pneumonitis. TARE should not be used as first line therapy in

Radioembolization is usually performed in an outpatient setting. Pre-procedural angiogram and nuclear medicine Technetium macro-aggregated albumin (Tc-MAA) scan are necessary

The angiogram determines anatomy including replaced right or left hepatic arteries. The origin of the right gastric should be identified. Coil embolization of any gastro-intestinal vessels originating from the right or left hepatic artery must be performed. Tc-MAA is needed to assess lung shunt fraction and consequently lung dose as tumor vascularity often have arteriovenous shunts. The lungs dose cannot exceed 30 Gy in one treatment session or 50 Gy cumulative dose [40]. Several strategies have been employed with high lung shunt fraction including no treatment, reduction of SIRsphere dose, bland embolization of the shunt, and balloon

A 7–10 day course of proton pump inhibitors may be given to prevent gastric ulceration.

Post-procedural MRI should be obtained no earlier than 2 months to assess tumor response. In addition, tumor markers and liver function tests are obtained 4–6 weeks post-procedure.

Post-radioembolization syndrome is a constellation of abdominal pain, fatigue, nausea, vomiting, and fever. This is usually managed conservatively with hydration and over the

Radioembolization induced liver disease (REILD) presents as jaundice, ascites without tumor progression, biliary obstruction, or elevated alkaline phosphatase. Histopathology reveals

CRC and should be avoided in patients with extensive extra-hepatic disease burden.

to overcome the range of microspheres characteristics [39].

technique is also preferred in patients with portal vein thrombosis.

occlusion of the hepatic vein during microspheres delivery.

4.1. Indications and contraindications

58 Medical Imaging and Image-Guided Interventions

4.2. Management

prior to treatment.

counter medications.

4.3. Complications

For HCC, the average response rate is between 35 and 47% with median survival of 15–24 months [44–47].

SARAH, an open-label, multicenter phase III trial (France), compared patients treated with SIRT versus Sorafenib alone in patients with unresectable HCC. SIRveNIB was an open label randomized controlled trial (Asia Pacific) that compared SIRT versus Sorafenib in locally advanced HCC. Both trials had a superiority design with overall survival as the primary endpoint. Both trials did not meet endpoint as there was no statistical difference in overall survival or progression-free survival. Indeed, overall survival was 8.0 months versus 9.9 months in the SARAH trial and 8.8 months versus 10 months in the SIRveNIB trial for SIRT and Sorafenib respectively [48]. However, patients treated with SIRT showed higher tumoral response rates, and increased quality of life in the intent to treat population which increased over time [49]. Moreover major criticism of these trials include inexperienced sites, a high TACE failure rate among patients, and 26.8% of the SIRT cohort in SARAH and 28.8% of the SIRT cohort in SIRveNIB did not receive SIRT as intended.

For metastatic colorectal cancer (mCRC) disease to the liver, the average response rate was between 35 and 43% with a median survival of 5–14 months [50]. TARE has demonstrated its role in second line or salvage therapy.

Three multi-center, randomized controlled phase III trials (FOXFIRE, SIRFLOX, and FOXFIRE-Global) examined the role of TARE (Y-90 resin microspheres) in combination with chemotherapy as first line therapy versus chemotherapy alone (FOLFOX or OxMdG) for liver-only or liver-dominant mCRC. Although an improvement of liver progression free survival was seen, overall progression free survival was not altered and the combination of the three studies did not demonstrate an improvement of overall survival but an increase in adverse events with the combination [51]. Careful patient selection is necessary for proper integration of SIRT in the management of mCRC and it should not be performed as first line therapy.

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