Subscribe to RSS
DOI: 10.1055/s-0044-1779715
Yttrium-90 Radioembolization Dosimetry: Dose Considerations, Optimization, and Tips
Funding/Support No funding was received to prepare this manuscript.N.K. receives research support from SIRTeX Medical.
R.T.G. is a consultant for SIRTeX Medical and Boston Scientific.
A.V. is a consultant for SIRTeX Medical.
The remaining authors have no funding/support disclosures.
As a form of brachytherapy, yttrium-90 radioembolization (Y90-RE), also known as selective internal radiation therapy (SIRT) or trans-arterial radioembolization (TARE), exerts its locoregional tumoricidal effects by its near-pure emission of beta-particles from the radioactive decay of yttrium-90 ([Table 1]). Since its early therapeutic use for the palliative treatment of patients with advanced unresectable hepatocellular carcinoma (HCC), there has been recognition that the tumor response to Y90-RE will be dependent on the relationship between the delivered activity and dose administered. This appreciation for the importance of dosimetry also stemmed from the recognition that liver toxicity can occur due to delivering “too much dose”—specifically, the recognition of radiation-induced liver disease (RILD).[1]
Abbreviation: MeV, megaelectron volts.
Note: Of note, while beta-decay is the predominant decay for yttrium-90, every 32 per million decays result in an internal pair production (gamma decay) that produces annihilation radiation that can be imaged using conventional PET/CT or PET/MRI systems.[46]
Throughout the years, the need for accurate dosimetric analysis prior to dose delivery has been demonstrated to improve outcomes.[2] With this endeavor in mind, there have been many rapid developments within the Y90 dosimetry space. This amount of rapidly developing information has left the potential new Y90-RE user with a great deal of information to digest as they learn to “how much dose to give” and how to efficiently do so. As such, the aim of this article is to provide a central and easy-to-digest source of information for Y90-RE dosimetry. Tips and considerations, with the author's opinion whenever data are lacking, will be shared as it pertains to Y90-RE of HCC—which currently has the most published data.
Authors' Contributions (Using Standardized CRediT Taxonomy)
A.V.: Conceptualization, methodology, formal analysis, resources, data curation, writing—original draft, writing—review and editing, and visualization.
J.L.D.P.: Writing—original draft, writing—review and editing, and visualization.
R.T.G.: Writing—review and editing.
N.K.: Conceptualization, methodology, resources, writing—review and editing, and supervision.
Publication History
Article published online:
14 March 2024
© 2024. Thieme. All rights reserved.
Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA
-
References
- 1 Reincke M, Schultheiss M, Doppler M. et al. Hepatic decompensation after transarterial radioembolization: a retrospective analysis of risk factors and outcome in patients with hepatocellular carcinoma. Hepatol Commun 2022; 6 (11) 3223-3233
- 2 Garin E, Guiu B, Edeline J, Rolland Y, Palard X. Trans-arterial radioembolization dosimetry in 2022. Cardiovasc Intervent Radiol 2022; 45 (11) 1608-1621
- 3 Lewandowski RJ, Salem R. Yttrium-90 radioembolization of hepatocellular carcinoma and metastatic disease to the liver. Semin Intervent Radiol 2006; 23 (01) 64-72
- 4 Snyder W, Ford M, Warner G, Watson S. MIRD Pamphlet #5: Revised: Estimates of Absorbed Fractions for Photon Sources Uniformly Distributed in Various Organs of a Heterogeneous Phantom. New York: Society of Nuclear Medicine; 1978
- 5 Reig M, Forner A, Rimola J. et al. BCLC strategy for prognosis prediction and treatment recommendation: the 2022 update. J Hepatol 2022; 76 (03) 681-693
- 6 Oken MM, Creech RH, Tormey DC. et al. Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol 1982; 5 (06) 649-655
- 7 Toskich BB, Liu DM. Y90 radioembolization dosimetry: concepts for the interventional radiologist. Tech Vasc Interv Radiol 2019; 22 (02) 100-111
- 8 Hilgard P, Hamami M, Fouly AE. et al. Radioembolization with yttrium-90 glass microspheres in hepatocellular carcinoma: European experience on safety and long-term survival. Hepatology 2010; 52 (05) 1741-1749
- 9 Miller FH, Lopes Vendrami C, Gabr A. et al. Evolution of radioembolization in treatment of hepatocellular carcinoma: a pictorial review. Radiographics 2021; 41 (06) 1802-1818
- 10 Salem R, Lewandowski RJ, Mulcahy MF. et al. Radioembolization for hepatocellular carcinoma using yttrium-90 microspheres: a comprehensive report of long-term outcomes. Gastroenterology 2010; 138 (01) 52-64
- 11 Salem R, Johnson GE, Kim E. et al. Yttrium-90 radioembolization for the treatment of solitary, unresectable HCC: the LEGACY study. Hepatology 2021; 74 (05) 2342-2352
- 12 Frantz S, Matsuoka L, Vaheesan K. et al. Multicenter evaluation of survival and toxicities of hepatocellular carcinoma following radioembolization: analysis of the RESiN Registry. J Vasc Interv Radiol 2021; 32 (06) 845-852
- 13 SIR-Spheres Package Insert. SIRTeX Medical Limited. Accessed March 29, 2020 at: https://www.sirtex.com/media/155126/ssl-us-13.pdf
- 14 Boston Scientific. Therasphere Package Insert. Accessed December 5, 2019 at: https://btgplc.com/BTG/media/TheraSphere-Documents/PDF/TheraSphere-Package-Insert_USA_Rev-14.pdf
- 15 Salem R, Padia SA, Lam M. et al. Clinical and dosimetric considerations for Y90: recommendations from an international multidisciplinary working group. Eur J Nucl Med Mol Imaging 2019; 46 (08) 1695-1704
- 16 Elsayed M, Cheng B, Xing M. et al. Comparison of Tc-99m MAA planar versus SPECT/CT imaging for lung shunt fraction evaluation prior to Y-90 radioembolization: Are we overestimating lung shunt fraction?. Cardiovasc Intervent Radiol 2021; 44 (02) 254-260
- 17 Gabr A, Ranganathan S, Mouli SK. et al. Streamlining radioembolization in UNOS T1/T2 hepatocellular carcinoma by eliminating lung shunt estimation. J Hepatol 2020; 72 (06) 1151-1158
- 18 Kessler J, Park JJ. Yttrium-90 radioembolization after local hepatic therapy: How Prior treatments impact patient selection, dosing, and toxicity. Tech Vasc Interv Radiol 2019; 22 (02) 112-116
- 19 Zimmermann M, Schulze-Hagen M, Liebl M. et al. Safety and efficacy of Y-90 radioembolization after prior major hepatic resection. Cardiovasc Intervent Radiol 2017; 40 (08) 1206-1212
- 20 Lam MGEH, Abdelmaksoud MHK, Chang DT. et al. Safety of 90Y radioembolization in patients who have undergone previous external beam radiation therapy. Int J Radiat Oncol Biol Phys 2013; 87 (02) 323-329
- 21 Lam MGEH, Louie JD, Iagaru AH, Goris ML, Sze DY. Safety of repeated yttrium-90 radioembolization. Cardiovasc Intervent Radiol 2013; 36 (05) 1320-1328
- 22 Badar W, Van Ha T, Zangan S. et al. Safety and efficacy of repeat Y90 radioembolization to the same hepatic arterial territory. Br J Radiol 2021; 94 (1119) 20200752
- 23 Srinivas S, Rose SC, Al Jammal O. et al. Boosted-dose yttrium-90 radiation segmentectomy or lobectomy for hepatocellular carcinoma refractory to prior transarterial embolization or chemoembolization: a single institution retrospective case series. Cardiovasc Intervent Radiol 2023; 46 (04) 460-469
- 24 Feng MY, Chan LL, Chan SL. Drug treatment for advanced hepatocellular carcinoma: first-line and beyond. Curr Oncol 2022; 29 (08) 5489-5507
- 25 Torkian P, Haghshomar M, Farsad K, Wallace S, Golzarian J, Young SJ. Cancer immunology: impact of radioembolization of hepatocellular carcinoma on immune response modulation. AJR Am J Roentgenol 2023; 220 (06) 863-872
- 26 Yu Q, Wang Y, Ungchusri E. et al. Introducing yttrium-90 radioembolization to atezolizumab and bevacizumab regimen for intermediate and advanced stage hepatocellular carcinoma: a preliminary report of safety and effectiveness. J Clin Oncol 2023; 41 (16 Suppl): e16231-e16231
- 27 Kennedy A, Brown DB, Feilchenfeldt J. et al. Safety of selective internal radiation therapy (SIRT) with yttrium-90 microspheres combined with systemic anticancer agents: expert consensus. J Gastrointest Oncol 2017; 8 (06) 1079-1099
- 28 Westcott MA, Coldwell DM, Liu DM, Zikria JF. The development, commercialization, and clinical context of yttrium-90 radiolabeled resin and glass microspheres. Adv Radiat Oncol 2016; 1 (04) 351-364
- 29 TheraSphere Now - Boston Scientific. Accessed October 6, 2023 at: https://www.bostonscientific.com/en-US/products/cancer-therapies/therasphere-y90-glass-microspheres/ordering-information/therasphere-now.html
- 30 Sirtex - FLEXdose Delivery Programme. Accessed October 6, 2023 at: https://www.sirtex.com/eu/professionals/specialties/interventional-radiology/flexdose-delivery-programme/
- 31 Salem R, Padia SA, Lam M. et al. Clinical, dosimetric, and reporting considerations for Y-90 glass microspheres in hepatocellular carcinoma: updated 2022 recommendations from an international multidisciplinary working group. Eur J Nucl Med Mol Imaging 2023; 50 (02) 328-343
- 32 Levillain H, Bagni O, Deroose CM. et al. International recommendations for personalised selective internal radiation therapy of primary and metastatic liver diseases with yttrium-90 resin microspheres. Eur J Nucl Med Mol Imaging 2021; 48 (05) 1570-1584
- 33 Kokabi N, Arndt-Webster L, Chen B. et al. Voxel-based dosimetry predicting treatment response and related toxicity in HCC patients treated with resin-based Y90 radioembolization: a prospective, single-arm study. Eur J Nucl Med Mol Imaging 2023; 50 (06) 1743-1752
- 34 Villalobos A, Arndt L, Cheng B. et al. Yttrium-90 radiation segmentectomy of hepatocellular carcinoma: a comparative study of the effectiveness, safety, and dosimetry of glass-based versus resin-based microspheres. J Vasc Interv Radiol 2023; 34 (07) 1226-1234
- 35 Jernigan SR, Osborne JA, Mirek CJ, Buckner G. Selective internal radiation therapy: quantifying distal penetration and distribution of resin and glass microspheres in a surrogate arterial model. J Vasc Interv Radiol 2015; 26 (06) 897-904.e2
- 36 Snoeijink TJ, Vlogman TG, Roosen J, Groot Jebbink E, Jain K, Nijsen JFW. Transarterial radioembolization: a systematic review on gaining control over the parameters that influence microsphere distribution. Drug Deliv 2023; 30 (01) 2226366
- 37 Walrand S, Hesse M, Chiesa C, Lhommel R, Jamar F. The low hepatic toxicity per Gray of 90Y glass microspheres is linked to their transport in the arterial tree favoring a nonuniform trapping as observed in posttherapy PET imaging. J Nucl Med 2014; 55 (01) 135-140
- 38 Chiesa C, Sjogreen-Gleisner K, Walrand S. et al. EANM dosimetry committee series on standard operational procedures: a unified methodology for 99mTc-MAA pre- and 90Y peri-therapy dosimetry in liver radioembolization with 90Y microspheres. EJNMMI Phys 2021; 8 (01) 1-44
- 39 Kurilova I, Beets-Tan RGH, Ulaner GA. et al. 90Y resin microspheres radioembolization for colon cancer liver metastases using full-strength contrast material. Cardiovasc Intervent Radiol 2018; 41 (09) 1419-1427
- 40 Maxwell AWP, Mendoza HG, Sellitti MJ. et al. Optimizing 90Y particle density improves outcomes after radioembolization. Cardiovasc Intervent Radiol 2022; 45 (07) 958-969
- 41 Struycken L, Patel M, Kuo P, Hennemeyer C, Woodhead G, McGregor H. Clinical and dosimetric implications of calculating lung shunt fraction for hepatic 90Y radioembolization using SPECT/CT versus planar scintigraphy. AJR Am J Roentgenol 2022; 218 (04) 728-737
- 42 Alsultan AA, Smits MLJ, Barentsz MW, Braat AJAT, Lam MGEH. The value of yttrium-90 PET/CT after hepatic radioembolization: a pictorial essay. Clin Transl Imaging 2019; 7 (04) 303-312
- 43 Louie JD, Kothary N, Kuo WT. et al. Incorporating cone-beam CT into the treatment planning for yttrium-90 radioembolization. J Vasc Interv Radiol 2009; 20 (05) 606-613
- 44 O'Connor PJ, Pasik SD, van der Bom IM, Bishay V, Radaelli A, Kim E. Feasibility of yttrium-90 radioembolization dose calculation utilizing intra-procedural open trajectory cone beam CT. Cardiovasc Intervent Radiol 2020; 43 (02) 295-301
- 45 Yang ZF, Poon RTP. Vascular changes in hepatocellular carcinoma. Anat Rec (Hoboken) 2008; 291 (06) 721-734
- 46 Villalobos A, Soliman MM, Majdalany BS. et al. Yttrium-90 radioembolization dosimetry: what trainees need to know. Semin Intervent Radiol 2020; 37 (05) 543-554
- 47 Bastiaannet R, Kappadath SC, Kunnen B, Braat AJAT, Lam MGEH, de Jong HWAM. The physics of radioembolization. EJNMMI Phys 2018; 5 (01) 22
- 48 Gabr A, Kulik L, Mouli S. et al. Liver transplantation following yttrium-90 radioembolization: 15-year experience in 207-patient cohort. Hepatology 2021; 73 (03) 998-1010
- 49 Johnson GE, Padia SA. Yttrium-90 radiation segmentectomy. Semin Intervent Radiol 2020; 37 (05) 537-542
- 50 Gabr A, Riaz A, Johnson GE. et al. Correlation of Y90-absorbed radiation dose to pathological necrosis in hepatocellular carcinoma: confirmatory multicenter analysis in 45 explants. Eur J Nucl Med Mol Imaging 2021; 48 (02) 580-583
- 51 Gates VL, Hickey R, Marshall K. et al. Gastric injury from (90)Y to left hepatic lobe tumors adjacent to the stomach: fact or fiction?. Eur J Nucl Med Mol Imaging 2015; 42 (13) 2038-2044
- 52 Ahmed A, Stauffer JA, LeGout JD. et al. The use of neoadjuvant lobar radioembolization prior to major hepatic resection for malignancy results in a low rate of post hepatectomy liver failure. J Gastrointest Oncol 2021; 12 (02) 751-761
- 53 Entezari P, Gabr A, Kennedy K, Salem R, Lewandowski RJ. Radiation lobectomy: an overview of concept and applications, technical considerations, outcomes. Semin Intervent Radiol 2021; 38 (04) 419-424
- 54 Palard X, Edeline J, Rolland Y. et al. Dosimetric parameters predicting contralateral liver hypertrophy after unilobar radioembolization of hepatocellular carcinoma. Eur J Nucl Med Mol Imaging 2018; 45 (03) 392-401
- 55 Ali A, Ahmed M, Weinstein J. et al. Abstract No. 559 Radiation lobectomy with resin microspheres using medical internal radiation dosimetry model. J Vasc Interv Radiol 2020; 31 (03) S244
- 56 Villalobos A, Gandhi RT, Kokabi NA. Practical, Case-Based Approach to Yttrium-90 Radioembolization Dosimetry in the Liver. Endovascular Today. Published October 2021 . Accessed October 23, 2023 at: https://evtoday.com/articles/2021-oct/a-practical-case-based-approach-to-yttrium-90-radioembolization-dosimetry-in-the-liver
- 57 Matsumoto MM, Mouli S, Saxena P. et al. Comparing real world, personalized, multidisciplinary tumor board recommendations with BCLC algorithm: 321-patient analysis. Cardiovasc Intervent Radiol 2021; 44 (07) 1070-1080
- 58 Braat AJAT, Smits MLJ, Braat MNGJA. et al. 90Y hepatic radioembolization: an update on current practice and recent developments. J Nucl Med 2015; 56 (07) 1079-1087
- 59 Garin E, Tselikas L, Guiu B. et al; DOSISPHERE-01 Study Group. 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 2021; 6 (01) 17-29
- 60 Webster LA, Villalobos A, Cheng B. et al. Correlation of non-tumoral liver dose with treatment-related adverse events in patients with hepatocellular carcinoma treated with glass-based yttrium-90 radioembolization. Cardiovasc Intervent Radiol 2023; 46 (01) 60-68
- 61 Khan A, Sayles HR, Dhir M. Liver resection after Y-90 radioembolization: a systematic review and meta-analysis of perioperative morbidity and mortality. HPB (Oxford) 2022; 24 (02) 152-160
- 62 Teyateeti A, Mahvash A, Long JP. et al. Survival outcomes for yttrium-90 transarterial radioembolization with and without sorafenib for unresectable hepatocellular carcinoma patients. J Hepatocell Carcinoma 2020; 7: 117-131
- 63 Thomas MA, Mahvash A, Abdelsalam M, Kaseb AO, Kappadath SC. Planning dosimetry for 90 Y radioembolization with glass microspheres: evaluating the fidelity of 99m Tc-MAA and partition model predictions. Med Phys 2020; 47 (10) 5333-5342
- 64 Salem R, Thurston KG. Radioembolization with 90yttrium microspheres: a state-of-the-art brachytherapy treatment for primary and secondary liver malignancies. Part 1: Technical and methodologic considerations. J Vasc Interv Radiol 2006; 17 (08) 1251-1278
- 65 Chiesa C, Mira M, Bhoori S. et al. Radioembolization of hepatocarcinoma with 90Y glass microspheres: treatment optimization using the dose-toxicity relationship. Eur J Nucl Med Mol Imaging 2020; 47 (13) 3018-3032