Prevention and treatment of complications of selective internal radiation therapy: Expert guidance and systematic review

Abstract

Selective internal radiation therapy (or radioembolization) by intra-arterial injection of radioactive yttrium-90-loaded microspheres is increasingly used for the treatment of patients with liver metastases or primary liver cancer. The high-dose beta-radiation penetrates an average of only 2.5 mm from the source, thus limiting its effects to the site of delivery. However, the off-target diversion of yttrium-90 microspheres to tissues other than the tumor may lead to complications. The most prominent of these complications include radiation gastritis and gastrointestinal ulcers, cholecystitis, radiation pneumonitis, and radioembolization-induced liver disease, which may occur despite careful pretreatment planning. Thus, selective internal radiation therapy demands an expert multidisciplinary team approach in order to provide comprehensive care for patients. This review provides recommendations to multidisciplinary teams on the optimal medical processes in order to ensure the safe delivery of selective internal radiation therapy. Based on the best available published evidence and expert opinion, we recommend the most appropriate strategies for the prevention, early diagnosis, and management of potential radiation injury to the liver and to other organs. (Hepatology 2017;66:969-982).

Histopathological changes resulting from selective internal radiotherapy (SIRT)

“…There was no significant difference in the tissue samples of chemotherapy-naïve patients (Pat. 2,6,9,12,13,15,17) and patients after chemotherapy and SIRT.…”

“…Delivery of radiation directly to liver tumors with Y 90 microspheres allows a therapeutic dose that should be preferentially absorbed by the tumor tissue . Clinical experience with Y 90 microspheres dates to the 1960s, and SIRT has emerged as a widely used therapeutic strategy . Even though many patients have been treated by SIRT, there is surprisingly little data on specific anatomic and histopathologic changes after SIRT.…”

“…2 Clinical experience with Y 90 microspheres dates to the 1960s, and SIRT has emerged as a widely used therapeutic strategy. [5][6][7] Even though many patients have been treated by SIRT, there is surprisingly little data on specific anatomic and histopathologic changes after SIRT. As most patients with metastatic cancer or primary liver tumors treated by SIRT are not scheduled for liver surgery, little tissue is available for studying the effects of internal radiation on both tumor and non-tumor liver tissues.…”

Transarterial Radioembolization for the Treatment of Advanced Hepatocellular Carcinoma Invading the Right Atrium

“…Published upper limit for resin 90 Y-microspheres shunt fraction is 20%, and treatment is not recommended beyond this limit [ 8 ]. To avoid radiation-induced lung injury (RILI), a mean lung absorbed dose up to 30 Gy for one radioembolization and a cumulative mean lung absorbed dose up to 50 Gy for repeated radioembolizations are empirically recommended for resin and glass 90 Y-microspheres [ 9 ]. For resin 90 Y-microspheres, this 30 Gy lung dose maximum is used for establishing the > 20% LSF contraindication threshold, should the entire 3 GBq-vial be administered.…”

Safety of selective internal radiation therapy (SIRT) with yttrium-90 microspheres combined with systemic anticancer agents: expert consensus

“…A recent systematic review provided further guidance on the optimal approach to managing some of the most important complications of SIRT, and this guidance is central to managing these complications when they occur in the combination settings discussed here (40).…”