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Background and Aims Chemoembolization is a standard treatment for hepatocellular carcinoma (HCC). Radioembolization with 90Y microspheres is a new, transarterial approach to radiation therapy. We performed a comparative effectiveness analysis of these therapies in patients with HCC. Methods We collected data from 463 patients who were treated with transarterial locoregional therapies (chemoembolization or radioembolization) over a 9-year period. We excluded patients who were not appropriate for comparison and analyzed data from 245 (122 who received chemoembolization and 123 who received radioembolization). Patients were followed for signs of toxicity; all underwent imaging analysis at baseline and follow-up timepoints. Overall survival was the primary outcome measure. Secondary outcomes included safety, response rate, and time-to-progression. Uni- and multi-variate analyses were performed. Results Abdominal pain and increased transaminase activity were more frequent following chemoembolization (P<.05). There was a trend that patients treated with radioembolization had a higher response rate than with chemoembolization (49% vs. 36%, P=0.104). Although time-to-progression was longer following radioembolization than chemoembolization (13.3 months vs 8.4 months, P=0.046), median survival times were not statistically different (17.4 months vs 20.5 months, P=0.232). Among patients with intermediate-stage disease, survival was similar between groups that received chemoembolization (17.5 months) and radioembolization (17.2 months, P=0.42). Conclusion Patients with HCC treated by chemoembolization or radioembolization with 90Y microspheres had similar survival times. Radioembolization resulted in longer time-to-progression and less toxicity than chemoembolization. Post-hoc analyses of sample size indicated that a randomized study with >1000 patients would be required to establish equivalence of survival times between patients given the different therapies.

This study was undertaken to present data from a phase 2 study in which patients with unresectable hepatocellular carcinoma (HCC) with and without portal vein thrombosis underwent radioembolization with Yttrium ( 90 Y) microspheres. Patients treated were stratified by Okuda, Child-Pugh, baseline bilirubin, tumor burden, Eastern Cooperative Oncology Group (ECOG), presence of cirrhosis and portal vein thrombosis (PVT) (none, branch, and main). Clinical and biochemical data were obtained at baseline and at 4-week intervals following treatment for up to 6 months. Tumor response was obtained using computed tomography (CT). Patients were followed for survival. One hundred eight patients were treated during the study period. Thirty-seven (34%) patients had PVT, 12 (32%) of which involved the main PV. The cumulative dose for those with and without PVT was 139.7 Gy and 131.9 Gy, respectively. The partial response rate using world Health Organization

Yttrium-90 microsphere brachytherapy of the liver exploits the distinctive features of the liver anatomy to treat liver malignancies with beta radiation and is gaining more wide spread clinical use. This report provides a general overview of microsphere liver brachytherapy and assists the treatment team in creating local treatment practices to provide safe and efficient patient treatment. Suggestions for future improvements are incorporated with the basic rationale for the therapy and currently used procedures. Imaging modalities utilized and their respective quality assurance are discussed. General as well as vendor specific delivery procedures are reviewed. The current dosimetry models are reviewed and suggestions for dosimetry advancement are made. Beta activity standards are reviewed and vendor implementation strategies are discussed. Radioactive material licensing and radiation safety are discussed given the unique requirements of microsphere brachytherapy. A general, team-based quality assurance program is reviewed to provide guidance for the creation of the local procedures. Finally, recommendations are given on how to deliver the current state of the art treatments and directions for future improvements in the therapy.

We present the correlation between radiologic and pathologic findings in HCC patients who underwent radioembolization with yttrium-90 ( 90 Y) microspheres prior to resection or transplantation. Thirty-five patients with a total of 38 lesions who underwent liver explantation after 90 Y radioembolization were studied. Imaging surrogates following treatment were evaluated; the explants were examined for assessment of necrosis by pathology. The correlation betwen radiologic and histologic findings of the treated lesions was analyzed. Twenty-three of 38 (61%) target lesions showed complete pathologic necrosis. All target lesions demonstrated some degree of histologic necrosis at explant. Complete histologic necrosis was seen in 89% of lesions with pretreatment size <3 cm. Complete pathologic necrosis was seen in 100%, 78%, and 93% of the lesions that were shown to have complete response by European Association for the Study of the Liver (EASL) necrosis criteria, partial response by World Health Organizaton (WHO) criteria, or thin rim enhancement on posttreatment imaging, respectively. In contrast, complete pathologic necrosis was seen in only 52% and 38% of the lesions that showed partial response by EASL criteria and peripheral nodular enhancement, respectively. Conclusion: Post-radioembolization imaging findings of response by EASL and WHO criteria are predictive of the degree of pathologic necrosis. Rim enhancement was an imaging characteristic that correlated well with histologic necrosis.

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Background & Aims Portal vein embolization (PVE) is a standard technique for patients not amenable to liver resection due to small future liver remnant ratio (FLR). Radiation lobectomy (RL) with 90Y-loaded microspheres (Y90) is hypothesized to induce comparable volumetric changes in liver lobes, while potentially controlling the liver tumor and limiting tumor progression in the untreated lobe. We aimed at testing this concept by performing a comprehensive time-dependent analysis of liver volumes following radioembolization. Methods 83 patients with right unilobar disease with hepatocellular carcinoma (HCC; N = 67), cholangiocarcinoma (CC; N = 8) or colorectal cancer (CRC; N = 8) were treated by Y90 RL. The total liver volume, lobar (parenchymal) and tumor volumes, FLR and percentage of FLR hypertrophy from baseline (%FLR hypertrophy) were assessed on pre- and post-Y90 CT/MRI scans in a dynamic fashion. Results Right lobe atrophy (p = 0.003), left lobe hypertrophy (p <0.001), and FLR hypertrophy (p <0.001) were observed 1 month after Y90 and this was consistent at all follow-up time points. Median %FLR hypertrophy reached 45% (5–186) after 9 months (p <0.001). The median maximal %FLR hypertrophy was 26% (−14→86). Portal vein thrombosis was correlated to %FLR hypertrophy (p = 0.02). Median Child-Pugh score worsening (6→7) was seen at 1 to 3 months (p = 0.03) and 3 to 6 months (p = 0.05) after treatment. Five patients underwent successful right lobectomy (HCC N = 3, CRC N = 1, CC N = 1) and 6 HCCs were transplanted. Conclusions Radiation lobectomy by Y90 is a safe and effective technique to hypertrophy the FLR. Volumetric changes are comparable (albeit slightly slower) to PVE while the right lobe tumor is treated synchronously. This novel technique is of particular interest in the bridge-to-resection setting.