Transarterial radioembolization using yttrium-90 microspheres in the treatment of hepatocellular carcinoma: a review on clinical utility and developments

Abstract

A selective intra-arterial liver injection using yttrium-90-loaded microspheres as sources for internal radiation therapy is a form of transarterial radioembolization (TARE). Current data from the literature suggest that TARE is effective in hepatocellular carcinoma (HCC) and is associated with a low rate of adverse events; however, they are all based on retrospective series or non-controlled prospective studies, since randomized controlled trials comparing the other liver-directed therapies for intermediate and locally advanced stages HCC are still ongoing. The available data show that TARE provides similar or even better survival rates. TARE is very well tolerated and has a low rate of complications; these complications do not result from the embolic effects but mainly from the unintended irradiation to non-target tissue, including the liver parenchyma. The complications can be further reduced by accurate patient selection and a strict pre-treatment evaluation, including dosimetry and assessment of the vascular anatomy. First-line TARE is best indicated for intermediate-stage patients (according to the Barcelona Clinic Liver Cancer [BCLC] staging classification) who are poor candidates for transarterial chemoembolization or patients having locally advanced disease with segmental or lobar branch portal vein thrombosis. Moreover, data are emerging regarding the use of TARE in patients classified slightly above the criteria for liver transplantation with the purpose of downstaging them. TARE can also be applied as a second-line treatment in patients progressing to transarterial chemoembolization or sorafenib; a large number of Phase II/III trials are in progress in order to evaluate the best association with systemic therapies. Given the complexity of a correct treatment algorithm for potential TARE candidates and the need for clinical guidance, a comprehensive review was carried out analyzing both the best selection criteria of patients who really benefit from TARE and the new advances of this therapy which add significant value to the therapeutic weaponry against HCC.

Trans-arterial radioembolization for intermediate-advanced hepatocellular carcinoma: a budget impact analysis

“…Furthermore, the budget impact does not take into account the sunk costs of setting up the TARE procedure in a new organization. However, provided the angiographic room and imaging equipment are already available, these costs will refer mainly to a thorough training of the staff [ 31 ].…”

Laser ablation is superior to TACE in large-sized hepatocellular carcinoma: a pilot case-control study

“…Alternative therapeutic procedures have been proposed such as transarterial radioembolization (TARE), a selective intra-arterial liver injection using yttrium-90-loaded microspheres. This type of treatment is considered a good choice in large tumours (up to 10 cm) especially with multiple satellite nodules [ 16 ]. The complete response rate after TARE is 40-50%, although the rate of efficacy derives almost exclusively by a large and heterogeneous cohort of subjects with both solitary or multifocal large HCC [ 16 ].…”

Updates on the Diagnosis and Management of Hepatocellular Carcinoma

“…Patients not amenable to TARE are the ones with metastatic HCC, decompensated cirrhosis, prior radiation to liver, and significant hepatoenteric and hepatopulmonary shunts (>20%). 89 Postprocedure complications include liver failure, radiation pneumonitis, biliary complications, radioembolization induced liver disease, and postembolization syndrome. 90 The survival benefit is not reported to be very different from TACE ranging from 14 to 16.9 months, but TARE demonstrated reduced toxicity and longer time to progression of disease (13.3 vs 8.4 months).…”