Skip to main content Accessibility help

We use cookies to distinguish you from other users and to provide you with a better experience on our websites. Close this message to accept cookies or find out how to manage your cookie settings.

Close cookie message
×
Hostname: page-component-7479d7b7d-jwnkl Total loading time: 0 Render date: 2024-07-15T15:52:16.484Z Has data issue: false hasContentIssue false

18 - Radioembolization for colorectal liver metastases

from Section IV - Organ-specific cancers – liver metastases

Published online by Cambridge University Press:  05 September 2016

By
Lourens Bester ,
Baerbel Meteling  and
David Boshell
Edited by
Jean-Francois H. Geschwind  and
Michael C. Soulen
Lourens Bester
Affiliation:
University of New South Wales
Baerbel Meteling
Affiliation:
University of New South Wales
David Boshell
Affiliation:
University of New South Wales
Jean-Francois H. Geschwind
Affiliation:
Yale University School of Medicine, Connecticut
Michael C. Soulen
Affiliation:
Department of Radiology, University of Pennsylvania Hospital, Philadelphia
Get access

Summary

Radioembolization is internal brachytherapy that delivers high doses of beta radiation locally into liver tumors. Glass or resin microspheres incorporating the radioactive isotope yttrium-90 (90Y) are directly injected into the hepatic arteries feeding the tumor. Resin microspheres differ from glass microspheres in that they have lower specific gravity, lower activity, and a higher number of particles. As part of the selection process for radioembolization, clinical history, laboratory values and performance status are obtained and patients are initially evaluated and staged using cross-sectional imaging techniques. Pretreatment imaging workup is required to visualize the entire liver vasculature and flow patterns, including the detection and selective occlusion of vessels which might allow 90Y microspheres to enter extrahepatic tissues. During the treatment procedure, microspheres are injected through a temporary angiographic catheter placed percutaneously via the femoral or brachial artery. Clinical toxicity is assessed at the time of treatment and approximately 2–3 months thereafter. A comprehensive review of the technical and methodological considerations in 90Y has been previously published.

Two radioembolic products are commercially available. Thera-Sphere (glass microspheres) gained a Humanitarian Device Exemption from the Food and Drug Administration (FDA) in 1999 for the treatment of unresectable hepatocellular carcinoma (HCC) in patients with or without portal vein thrombosis (PVT) who can have appropriately positioned hepatic arterial catheters. SIR-Spheres (resin microspheres) gained full premarketing approval from the FDA in 2002 for the treatment of unresectable colorectal liver metastases in conjunction with intrahepatic floxuridine (FUDR).

Both devices have approval for treatment of liver cancer in Europe and various Asian countries.

Introduction

Despite advances in systemic chemotherapy and monoclonal antibodies, the liver usually remains the site of tumor resistance and ultimately the patient's death. Approximately 60% of patients diagnosed with colorectal carcinoma eventually develop hepatic metastases, with the liver as the dominant site of disease. Complete surgical resection remains the best option for a cure. However, surgical resection is currently only possible in less than 20% of patients with metastatic colorectal cancer. Further, about 60–90% of patients treated with neoadjuvant chemotherapy and liver resection will experience a recurrence of their liver tumors. In patients with unresectable liver metastases, with or without extrahepatic disease, systemic chemotherapy is still the standard of care for first- and second-line treatment.

Type
Chapter
Information
Interventional Oncology
Principles and Practice of Image-Guided Cancer Therapy
 , pp. 158 - 164
Publisher: Cambridge University Press
Print publication year: 2016

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

1. 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 (8): 1251–1278.Google Scholar
2. Salem, R, Thurston, KG. Radioembolization with 90yttrium microspheres: A state-of-the-art brachy-therapy treatment for primary and secondary liver malignancies: Part 2: Special topics. J Vasc Interv Radiol 2006; 17 (9): 1425–1439.Google Scholar
3. Salem, R, Thurston, KG. Radioembolization with yttrium-90 microspheres: A state-of-the-art brachy-therapy treatment for primary and secondary liver malignancies: Part 3: Comprehensive literature review and future direction. J Vasc Interv Radiol 2006; 17 (10): 1571–1593.Google Scholar
4. TheraSphere Yttrium-90 microspheres package insert. Kanata, Canada: MDS Nordion; 2004.
5. SIR-Spheres Yttrium-90 microspheres package insert. Lane Cove, Australia: SIRTeX Medical; 2004.
6. Sasson, AR, Sigurdson, ER. Surgical treatment of liver metastases. Semin Oncol 2002; 29 (2): 107–118.Google Scholar
7. Baker, M, Pelley, R. Hepatic metastases: Basic principles and implications for radiologists. Radiology 1995; 197 (2): 329–337.Google Scholar
8. Nordlinger, B, Cutsem, E Van, Rougier, P, et al. Does chemotherapy prior to liver resection increase the potential for cure in patients with metastatic colorectal cancer? A report from the European Colorectal Metastases Treatment Group. Eur J Cancer 2007; 43: 2037–2045.Google Scholar
9. Messersmith, W, Laheru, D, Hidalgo, M. Recent advances in the pharmacological treatment of colorectal cancer. Expert Opin Investig Drugs 2003; 12 (3): 423–434.Google Scholar
10. Mulcahy, MF, Benson, AB, 3rd. Bevacizumab in the treatment of colorectal cancer. Expert Opin Biol Ther 2005; 5 (7): 997–1005.Google Scholar
11. Hoff, PM. Future directions in the use of antiangiogenic agents in patients with colorectal cancer. Semin Oncol 2004; 31 (6 Suppl 17): 17–21.Google Scholar
12. Yu, AS, Keeffe, EB. Management of hepatocellular carcinoma. Rev Gastroenterol Disord 2003; 3 (1): 8–24.Google Scholar
13. Jerusalem, G, Hustinx, R, Beguin, Y, et al. Evaluation of therapy for lymphoma. Semin Nucl Med 2005; 35 (3): 186–196.Google Scholar
14. Lewandowski, RJ, Thurston, KG, Goin, JE, et al. 90Y Microsphere (TheraSphere) treatment for unresectable colorectal cancer metastases of the liver: Response to treatment at targeted doses of 135–150 Gy as measured by (18f) fluorodeoxyglucose positron emission tomography and computed tomographic imaging. J Vasc Interv Radiol 2005; 16 (12): 1641–1651.Google Scholar
15. Tellez, C, Benson, AB 3rd, Lyster, MT, et al. Phase II trial of chemoembolization for the treatment of metastatic colorectal carcinoma to the liver and review of the literature. Cancer 1998; 82 (7): 1250–1259.Google Scholar
16. Kulik, L, Carr, B, Mulcahy, M. Safety and efficacy of 90Y radiotherapy for hepatocellular carcinoma with and without portal vein thrombosis. Hepatology 2008; 47: 71–81.Google Scholar
17. Salem, R, Lewandowski, R, Roberts, C. Use of Yttrium-90 glass microspheres (TheraSphere) for the treatment of unresectable hepatocellular carcinoma in patients with portal vein thrombosis. J Vasc Interv Radiol 2004; 15: 335–345.Google Scholar
18. Liu, DM, Salem, R, Bui, JT, et al. Angiographic considerations in patients undergoing liver-directed therapy. J Vasc Interv Radiol 2005; 16 (7): 911–935.Google Scholar
19. Rhee, TK, Omary, RA, Gates, V, et al. The effect of catheter-directed CT angiography on Yttrium-90 radioembolization treatment of hepatocellular carcinoma. J Vasc Interv Radiol 2005; 16 (8): 1085–1091.Google Scholar
20. Lewandowski, RJ, Sato, KT, Atassi, B, et al. Radioembolization with 90Y microspheres: Angiographic and technical considerations. Cardiovasc Intervent Radiol 2007; 30 (4): 571–592.Google Scholar
21. Wang, S, Bester, L, Burnes, J, et al. Clinical care and technical recommendations for 90 yttrium microsphere treatment of liver cancer. J Med Imaging Radiat Oncol 2010; 54: 178–187.Google Scholar
22. Kim, HC, Chung, JW, Lee, W, et al. Recognizing extrahepatic collateral vessels that supply hepatocellular carcinoma to avoid complications of transcatheter arterial chemoembolization. Radiographics 2005; 25 Suppl 1: S25–S39.Google Scholar
23. Murthy, R, Nunez, R, Szklaruk, J, et al. Yttrium-90 micro-sphere therapy for hepatic malignancy: Devices, indications, technical considerations, and potential complications. Radiographics 2005; 25 Suppl 1: S41–S55.Google Scholar
24. Salem, R, Lewandowski, RJ, Sato, KT, et al. Technical aspects of radioembolization with 90Y microspheres. Tech Vasc Interv Radiol 2007; 10 (1): 12–29.Google Scholar
25. Geschwind, JF, Soulen, MC. Interventional Oncology: Principles and Practice. Cambridge, UK: Cambridge University Press; 2008, pp. 1103–1133.
26. SIRTeX Medical Training Manual. Lane Cove, Australia: SIRTeX Medical, 2005.
27. Salem, R, Thurston, KG, Carr, BI, et al. Yttrium-90 micro-spheres: Radiation therapy for unresectable liver cancer. J Vasc Interv Radiol 2002; 13(suppl): S223–S229.Google Scholar
28. Ho, S, Lau, WY, Leung, TW, et al. Clinical evaluation of the partition model for estimating radiation doses from yttrium-90 microspheres in the treatment of hepatic cancer. Eur J Nucl Med 1997; 24 (3): 293–298.Google Scholar
29. Berger, MJ. Distribution of absorbed dose around point sources of electrons and beta particles in water and other media. J Nucl Med 1971; Suppl 5: 5–23.Google Scholar
30. Snyder, W, Ford, M, Warner, G, et al. S Absorbed Dose Per Unit Cumulated Activity for Selected Radionuclides and Organs. New York: Society of Nuclear Medicine, 1975–1976.
31. Shi, S, Klotz, U. Proton pump inhibitors: An update of their clinical use and pharmacokinetics. Eur J Clin Pharmacol 2008; 64: 935–951.Google Scholar
32. South, C, Meyer, M, Meis, G, et al. Yttrium-90 microsphere induced gastrointestinal tract ulceration. World J Surg Oncol 2008; 6: 93–97.Google Scholar
33. Salem, R, Lewandowski, RJ, Atassi, B, et al. Treatment of unresectable hepatocellular carcinoma with use of 90Y microspheres (TheraSphere): Safety, tumor response, and survival. J Vasc Interv Radiol 2005; 16 (12): 1627–1639.Google Scholar
34. Murthy, R, Brown, D, Salem, R. Gastrointestinal complications associated with hepatic arterial yttrium-90 microsphere therapy. J Vasc Interv Radiol 2007; 18: 553–561.Google Scholar
35. Sjoquest, K, Goldstein, D, Bester, L. A serious complication of selected internal radiation therapy: Case report and literature review. Oncologist 2010; 15: 830–835.Google Scholar
36. Lewandowski, R, Salem, R. Incidence of radiation cholecystitis in patients receiving Y-90 treatment for unresectable liver malignancies. J Vasc Interv Radiol 2004; 15 (2 pt 2): S162.Google Scholar
37. Wong, CY, Salem, R, Qing, F, et al. Metabolic response after intraarterial 90Y-glass microsphere treatment for colorectal liver metastases: Comparison of quantitative and visual analyses by 18F-FDG PET. J Nucl Med 2004; 45 (11): 1892–1897.Google Scholar
38. Wong, CY, Salem, R, Raman, S, et al. Evaluating 90Y-glass microsphere treatment response of unresectable colorectal liver metastases by (18F) FDG PET: A comparison with CT or MRI. Eur J Nucl Med Mol Imaging 2002; 29 (6): 815–820.Google Scholar
39. Geschwind, JF, Artemov, D, Abraham, S, et al. Chemoembolization of liver tumor in a rabbit model: Assessment of tumor cell death with diffusion-weighted MR imaging and histologic analysis. J Vasc Interv Radiol 2000; 11 (10): 1245–1255.Google Scholar
40. Gray, B, Hazel, G Van, Hope, M, et al. Randomized trial of SIR-Spheres plus chemotherapy vs. chemotherapy alone for treating patients with liver metastases from primary large bowel cancer. Ann Oncol 2001; 12 (12): 1711–1720.Google Scholar
41. Hazel, G Van, Blackwell, A, Anderson, J, et al. Randomized phase 2 trial of SIR-Spheres plus fluorouracil/leucovorin chemotherapy versus fluorouracil/leucovorin alone in advanced colorectal cancer. J Surg Oncol 2004; 88 (2): 78–85.Google Scholar
42. Sharma, R, Hazel, G Van, Morgan, B, et al. Radioembolization of liver metastases from colorectal cancer using yttrium-90 microspheres with concomitant systemic oxaliplatin, fluorouracil, and leucovorin chemotherapy. J Clin Oncol 2007; 25 (9): 1099–1106.Google Scholar
43. Hazel, G Van, Pavlakis, N, Goldstein, D, et al. Treatment of fluorouracil-refractory patients with liver metastases from colorectal cancer by using yttrium-90 resin microspheres plus concomitant systemic irinotecan chemotherapy. J Clin Oncol 2009; 27 (25): 4089–4095.Google Scholar
44. Lim, L, Gibbs, P, Yip, D. A prospective evaluation of treatment with selective internal radiation therapy (SIR-Spheres) in patients with unresectable liver metastases from colorectal cancer previously treated with 5-FU based chemotherapy. BMC Cancer 2005; 5: 132.Google Scholar
45. Hendlisz, A, den Eynde, M Van, Peeters, M, et al. Phase III trial comparing protracted intravenous fluorouracil infusion alone or with yttrium-90 resin microspheres radioembolization for liver-limited metastatic colorectal cancer refractory to standard chemotherapy. J Clin Oncol 2010; 28 (23): 3687–3694.Google Scholar
46. Seidensticker, R, Denecke, T, Kraus, P, et al. Matched-pair comparison of radioembolization plus best supportive care versus best supportive care alone for chemotherapy refractory liver-dominant colorectal metastases. Cardiovasc Intervent Radiol 2012; 35 (5): 1066–1073.Google Scholar
47. Cosimelli, M, Golfieri, R, Cagol, P, et al. Multi-centre phase II clinical trial of yttrium-90 resin microspheres alone in unresectable, chemotherapy refractory colorectal liver metastases. Br J Cancer 2010; 103 (3): 324–331.Google Scholar
48. Kennedy, A, Coldwell, D, Nutting, C, et al. Resin 90Y-microsphere brachytherapy for unresectable colorectal liver metastases: modern USA experience. Int J Radiat Oncol Biol Phys 2006; 65 (2): 412–425.Google Scholar
49. Mulcahy, MF, Lewandowski, RJ, Ibrahim, SM, et al. Radioembolization of colorectal hepatic metastases using yttrium-90 microspheres. Cancer 2009; 115 (9): 1849–1858.Google Scholar
50. Goin, JE, Dancey, JE, Hermann, GA, et al. Treatment of unresectable metastatic colorectal carcinoma to the liver with intrahepatic Y-90 microspheres: A dose-ranging study. World J Nucl Med 2003; 2: 216–225.Google Scholar
51. Hazel, GA Van, Heinemann, V, Sharma, NK, et al. SIRFLOX: Randomized phase III trial comparing first-line mFOLFOX6 (plus or minus bevacizumab) versus mFOLFOX6 (plus or minus bevacizumab) plus selective internal radiation therapy in patients with metastatic colorectal cancer. J Clin Oncol 2016; 34 (15): 1723–31.Google Scholar
52. Ruers, T, Punt, CJA, Coevorden, F Van, et al. Radiofrequency ablation (RFA) combined with chemotherapy for unresectable colorectal liver metastases (CRC LM): Long-term survival results of a randomized phase II study of the EORTC-NCRI CCSG-ALM Intergroup 40004 (CLOCC). J Clin Oncol 2015; 33 (15) A3501. http://meetinglibrary.asco.org/content/151361-156 Google Scholar

Save book to Kindle

To save this book to your Kindle, first ensure [email protected] is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Available formats
×

Save book to Dropbox

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Dropbox.

Available formats
×

Save book to Google Drive

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Google Drive.

Available formats
×