The American Brachytherapy Society consensus statement for permanent implant brachytherapy using Yttrium-90 microsphere radioembolization for liver tumors

Abstract

Purpose: To develop a multidisciplinary consensus for high quality multidisciplinary implementation of brachytherapy using Yttrium-90 (⁹⁰Y) microspheres transarterial radioembolization (⁹⁰Y TARE) for primary and metastatic cancers in the liver.

Methods and materials: Members of the American Brachytherapy Society (ABS) and colleagues with multidisciplinary expertise in liver tumor therapy formulated guidelines for ⁹⁰Y TARE for unresectable primary liver malignancies and unresectable metastatic cancer to the liver. The consensus is provided on the most recent literature and clinical experience.

Results: The ABS strongly recommends the use of ⁹⁰Y microsphere brachytherapy for the definitive/palliative treatment of unresectable liver cancer when recommended by the multidisciplinary team. A quality management program must be implemented at the start of ⁹⁰Y TARE program development and follow-up data should be tracked for efficacy and toxicity. Patient-specific dosimetry optimized for treatment intent is recommended when conducting ⁹⁰Y TARE. Implementation in patients on systemic therapy should account for factors that may enhance treatment related toxicity without delaying treatment inappropriately. Further management and salvage therapy options including retreatment with ⁹⁰Y TARE should be carefully considered.

Conclusions: ABS consensus for implementing a safe ⁹⁰Y TARE program for liver cancer in the multidisciplinary setting is presented. It builds on previous guidelines to include recommendations for appropriate implementation based on current literature and practices in experienced centers. Practitioners and cooperative groups are encouraged to use this document as a guide to formulate their clinical practices and to adopt the most recent dose reporting policies that are critical for a unified outcome analysis of future effectiveness studies.

Keywords: Brachytherapy; Metastatic liver cancer; Microspheres; Transarterial radioembolization; Yttrium-90.

Fig. 1.

Angiogram of the celiac artery performed during mapping procedure. (a) shows that the catheter is too far in without reflux of contrast to the aorta demonstrating lack of enhancement of the left lobe of the liver (circle). (b) shows angiogram after repositioning of catheter more proximally within the celiac artery demonstrating a replaced left hepatic artery off the left gastric artery which was initially missed on the earlier angiogram.

Fig. 2.

Common hepatic angiogram shows the gastroduodenal artery (black arrow) and the right gastric artery (white arrow).

Fig. 3.

Left hepatic artery angiogram demonstrates filling of the falciform artery off a branch to segment 4 (black arrow).

Fig. 4.

Using post ⁹⁰Y PET/CT dosimetry to calculate radiation dose distribution in a 67 yo patient with metastatic colon cancer treated to the right lobe with 34 mCi ⁹⁰Y resin microspheres. Fig. 4a: Post-⁹⁰Y treatment PET/CT acquisition demonstrating high dose distribution in targeted areas. Fig. 4b: Isodose line representation of dose distribution.