The role of 90Y-radioembolization in downstaging primary and secondary hepatic malignancies: a systematic review

Abstract

Radioembolization (RE) is an emerging treatment strategy for patients with primary hepatic malignancies and metastatic liver disease. Though RE is primarily performed in the palliative setting, a shift toward the curative setting is seen. Currently, hepatic resection and in selected cases liver transplantation are the only curative options for patients with a hepatic malignancy. Unfortunately, at diagnosis most patients are not eligible for liver surgery due to the imbalance between the necessary liver resection and the remaining liver remnant. However, in borderline resectable cases, tumor volume reduction and/or increasing the future liver remnant can lead to a resectable situation. The combination of selective tumor treatment, the induction of hypertrophy of untreated liver segments, and its favourable toxicity profile make RE an appealing strategy for downstaging. The present review discusses the possibilities for RE in the preoperative setting as a downstaging tool or as a bridge to liver transplantation.

Keywords: Bridge to transplant; Downstaging; Future liver remnant; Radioembolization.

Fig. 1

Induction of hypertrophy after 2 RE-treatments in a patient with CRLM. a CT scan prior to the first treatment with a CRLM located centrally in the right hemiliver, also involving the caudate lobe. b Three months after a whole liver treatment a decrease in the lesion size is seen. Segment 2–3 have hypertrophied (degree of hypertrophy: 16 %). c ⁹⁰Y-PET/CT after a second selective treatment with glass microspheres (8 months after the first RE treatment): an intense accumulation of ⁹⁰Y is seen in the lesion (*). d CT scan 2 months after the second treatment. The lesion in the right hemiliver has further decreased in size. A wedge-shaped hypodense area surrounds the lesion, consistent with radiation changes of the surrounding parenchyma (corresponding to the normal parenchyma with intense ⁹⁰Y uptake on c (*). The hypertrophy of segment 2–3 has increased (degree of hypertrophy: 25 %). Also, segment 4 has hypertrophied (degree of hypertrophy: 20 %)

Fig. 2

Decrease in ^99mTc-mebrofenin uptake after right lobar ⁹⁰Y-RE treatment. a A solitary, hypervascular lesion is present in segment 5 with wash-out (arrow) on the later obtained portal venous phase (b), consistent with an HCC. c The liver has a cirrhotic appearance (note the nodular surface). No lesions are seen elsewhere in the liver. d Hepatobiliary scintigraphy before RE-treatment shows a fairly homogeneous uptake of ^99mTc-mebrofenin (cMUR: 3.0 %/min). e ⁹⁰Y-PET/CT one day after right lobar treatment. ⁹⁰Y has heterogeneously distributed in the right lobe with a higher dose in segment 4 and 8 (arrow in d, e and f). f Hepatobiliary scintigraphy 3 months after treatment. The uptake of ^99mTc-mebrofenin is decreased in segment 4 and 8, corresponding to the area of higher ⁹⁰Y deposit on the ⁹⁰Y-PET/CT