Yttrium-90 Radioembolization Dosimetry: What Trainees Need to Know

Erratum: Yttrium-90 Radioembolization Dosimetry: What Trainees Need to Know

Yttrium-90 radioembolization (Y90-RE), also known as transarterial radioembolization (TARE) or selective internal radiation therapy (SIRT), is a form of brachytherapy that has become an established liver-directed therapy for primary and secondary hepatic malignancies.[1] [2] [3] [4] [5] [6] [7] While a degree of embolization and ischemia may occur, the dominant mechanism of action for Y90-RE is radiation-induced necrosis from targeted transarterial administration of millions of Y90-labeled microspheres. The Y90 within these microspheres exert their effects primarily by undergoing β-decay to stable zirconium-90, which is not known to have any clinical effects.[8] [9] [10] The β-decay of Y90 results in the release of high-energy β-particles (i.e., electrons or β−) with an average energy of 0.9267 MeV (maximum of 2.28 MeV) and a half-life of 64.04 hours (2.67 days), which translates to 94% of the Y90 radiation being delivered within 11 days. These β-particles penetrate nearby tissues an average of 2.5 mm (maximum of 11 mm), resulting in the sought-after effect of radiation damage to nearby structures.[11] Additional types of radiation also occur as a result of Y90 decay. Although these are summarized in [Fig. 1], an in-depth discussion of them is beyond the scope of this article.

Fig. 1 Yttrium-90 decay products and their clinical applications. Yttrium-90 predominantly undergoes β-decay to emit high-energy β-particles that are used clinically for targeted radiotherapy—which include direct injection of Y90 into a body cavity or space, conjugation of Y90 to an antibody for radioimmunotherapy (RIT), conjugation of Y90 to a peptide for peptide receptor radionuclide therapy (PRRT), or incorporation of Y90 to resin or glass microspheres for Y90 radioembolization (Y90-RE) therapy. As a result of the high-energy β-particle emission, a continuous spectrum of bremsstrahlung radiation occurs—which can be imaged using conventional nuclear medicine imaging systems (i.e., SPECT, SPECT/CT, planar gamma cameras). High-energy β-radiation also partakes in a phenomenon called Cherenkov radiation, which produces a continuous spectrum of ultraviolet and visible light photons (i.e., Cherenkov luminescence) which can be imaged using Cherenkov luminescence imaging (CLI). While β-decay is the predominant decay mechanism of Y90, every 32 per million Y90 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.

Currently, there are two commercially available and Food and Drug Administration (FDA)-approved radioembolization microspheres in the United States: resin microspheres (SIR-Spheres; Sirtex Medical Inc, Woburn, MA), whose original formulations were developed in the mid-20th century, and glass microspheres (TheraSphere; Boston Scientific, Marlborough, MA), which were developed in the early 1980s.[9] Properties of these biocompatible and nonbiodegradable microspheres, at the time of calibration, are outlined in [Table 1].[9] [12] [13] Resin microspheres are FDA approved only for the treatment of unresectable metastatic liver tumors (MLTs) from primary colorectal cancer with adjuvant intrahepatic artery chemotherapy (IHAC) of FUDR (Floxuridine).[14] Glass microspheres are FDA approved, under a humanitarian drug exemption, only for the sole or neoadjuvant treatment of unresectable hepatocellular carcinoma (HCC).[15] Nevertheless, both types of microspheres are frequently used off-label for the treatment of various primary or secondary hepatic malignancies.[16] [17]

Table 1 Properties of the commercially available glass and resin Y90 microspheres at the time of calibration

	Glass	Resin
Isotope attachment	Incorporated into glass matrix	Attached to resin surface
Mean diameters (μm)	25	32.5 ± 2.5
Diameter range (μm)	20–30	20–60
Microspheres per vial	1.2 million for 3 GBq; 8 mil for 20 GBq	40–80 million
Available standard doses (GBq)	3, 5, 7, 10, 15, and 20	3
Specific activity (Bq per microsphere)	2,500	50
Specific gravity (g/dL)	3.6	1.6

Notes: Please check the latest package insert for updated information, including availability of customizable doses. For reference, the specific gravity of blood is 1.05 g/dL.

As a result of the mounting evidence for a clear dose–effect relationship,[10] the goal of Y90-RE has evolved to reflect a classical principle of oncology—which is to deliver the maximum tolerated dose. Achieving this goal requires understanding of the multiple steps in the pre-, peri-, and posttherapy phases of Y90-RE. Several articles have sought to comprehensively explain the rationale and technical challenges found in each of these steps.[18] [19] However, a paucity of literature comprehensively describing the technical strengths and challenges of the commonly used Y90-RE dosimetry models remains. As an integral part of the team and an authorized user of Y90-RE devices, the interventional radiologist must have a fundamental understanding of the involved dosimetry. Therefore, the aim of this article is to provide a fundamental background of the rationale, limitations, and strengths involved in Y90-RE dosimetry planning, and the strategies employed in clinical practice when treating patients with Y90-RE.

Publication History

Article published online:
11 December 2020

• References

• 1 Ahmadzadehfar H, Biersack H-J, Ezziddin S. Radioembolization of liver tumors with yttrium-90 microspheres. Semin Nucl Med 2010; 40 (02) 105-121
• 2 Kennedy A, Nag S, Salem R. et al. Recommendations for radioembolization of hepatic malignancies using yttrium-90 microsphere brachytherapy: a consensus panel report from the radioembolization brachytherapy oncology consortium. Int J Radiat Oncol Biol Phys 2007; 68 (01) 13-23
• 3 Salem R, Lewandowski RJ, Sato KT. et al. Technical aspects of radioembolization with 90Y microspheres. Tech Vasc Interv Radiol 2007; 10 (01) 12-29
• 4 Wang S-C, Bester L, Burnes JP. et al. Clinical care and technical recommendations for ⁹⁰yttrium microsphere treatment of liver cancer. J Med Imaging Radiat Oncol 2010; 54 (03) 178-187
• 5 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
• 6 Lau WY, Lai ECH. Salvage surgery following downstaging of unresectable hepatocellular carcinoma--a strategy to increase resectability. Ann Surg Oncol 2007; 14 (12) 3301-3309
• 7 Murthy R, Habbu A, Salem R. Trans-arterial hepatic radioembolisation of yttrium-90 microspheres. Biomed Imaging Interv J 2006; 2 (03) e43
• 8 Tong AKT, Kao YH, Too CW, Chin KFW, Ng DCE, Chow PKH. Yttrium-90 hepatic radioembolization: clinical review and current techniques in interventional radiology and personalized dosimetry. Br J Radiol 2016; 89 (1062): 20150943
• 9 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
• 10 Bastiaannet R, Kappadath SC, Kunnen B, Braat AJAT, Lam MGEH, de Jong HWAM. The physics of radioembolization. EJNMMI Phys 2018; 5 (01) 22
• 11 Wright CL, Zhang J, Tweedle MF, Knopp MV, Hall NC. Theranostic imaging of yttrium-90. BioMed Res Int 2015; 2015: 481279
• 12 TheraSphere Yttrium-90 Microspheres Package Insert, Boston Scientific Corporation. Accessed March 30, 2020 at: https://btgplc.com/BTG/media/TheraSphere-Documents/PDF/10093509-Rev8_English-searchable.pdf
• 13 SIR-Spheres Package Insert, SIRTeX Medical Limited. Accessed March 30, 2020 at: https://www.sirtex.com/media/155126/ssl-us-13.pdf
• 14 FDA, SIR-Spheres—Summary of Safety and Effectiveness Data. Accessed July 15, 2020 at: https://www.accessdata.fda.gov/cdrh_docs/pdf/P990065b.pdf
• 15 FDA, TheraSphere—Summary of Safety and Probable Benefit. Accessed July 15, 2020 at: https://www.accessdata.fda.gov/cdrh_docs/pdf/H980006B.pdf
• 16 Vente MAD, Wondergem M, van der Tweel I. et al. Yttrium-90 microsphere radioembolization for the treatment of liver malignancies: a structured meta-analysis. Eur Radiol 2009; 19 (04) 951-959
• 17 Devcic Z, Rosenberg J, Braat AJA. et al. The efficacy of hepatic 90Y resin radioembolization for metastatic neuroendocrine tumors: a meta-analysis. J Nucl Med 2014; 55 (09) 1404-1410
• 18 Kim SP, Cohalan C, Kopek N, Enger SA. A guide to ⁹⁰Y radioembolization and its dosimetry. Phys Med 2019; 68: 132-145
• 19 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
• 20 Lewandowski RJ, Salem R. Yttrium-90 radioembolization of hepatocellular carcinoma and metastatic disease to the liver. Semin Intervent Radiol 2006; 23 (01) 64-72
• 21 Snyder W, Ford M, Warner G, Watson S. Revised: estimates of absorbed fractions for photon sources uniformly distributed in various organs of a heterogeneous phantom. MIRD Pamphlet #5. 1978
• 22 Kao YH, Magsombol BM, Toh Y. et al. Personalized predictive lung dosimetry by technetium-99m macroaggregated albumin SPECT/CT for yttrium-90 radioembolization. EJNMMI Res 2014; 4 (01) 33
• 23 Cerrito L, Annicchiarico BE, Iezzi R, Gasbarrini A, Pompili M, Ponziani FR. Treatment of hepatocellular carcinoma in patients with portal vein tumor thrombosis: Beyond the known frontiers. World J Gastroenterol 2019; 25 (31) 4360-4382
• 24 Strasberg SM, Belghiti J, Clavien P-A. et al. The Brisbane 2000 terminology of liver anatomy and resections. HPB (Oxford) 2000; 2 (03) 333-339
• 25 Germain T, Favelier S, Cercueil JP, Denys A, Krausé D, Guiu B. Liver segmentation: practical tips. Diagn Interv Imaging 2014; 95 (11) 1003-1016
• 26 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
• 27 Gaba RC, Zivin SP, Dikopf MS. et al. Characteristics of primary and secondary hepatic malignancies associated with hepatopulmonary shunting. Radiology 2014; 271 (02) 602-612
• 28 Xing M, Lahti S, Kokabi N, Schuster DM, Camacho JC, Kim HS. 90Y radioembolization lung shunt fraction in primary and metastatic liver cancer as a biomarker for survival. Clin Nucl Med 2016; 41 (01) 21-27
• 29 Kallini JR, Gabr A, Hickey R. et al. Indicators of lung shunt fraction determined by technetium-99 m macroaggregated albumin in patients with hepatocellular carcinoma. Cardiovasc Intervent Radiol 2017; 40 (08) 1213-1222
• 30 Olorunsola OG, Kohi MP, Behr SC. et al. Imaging predictors of elevated lung shunt fraction in patients being considered for yttrium-90 radioembolization. J Vasc Interv Radiol 2015; 26 (10) 1472-1478
• 31 Haste P, Tann M, Persohn S. et al. Correlation of technetium-99m macroaggregated albumin and yttrium-90 glass microsphere biodistribution in hepatocellular carcinoma: a retrospective review of pretreatment single photon emission CT and posttreatment positron emission tomography/CT. J Vasc Interv Radiol 2017; 28 (05) 722-730.e1
• 32 Garin E, Rolland Y, Laffont S, Edeline J. Clinical impact of (99m)Tc-MAA SPECT/CT-based dosimetry in the radioembolization of liver malignancies with (90)Y-loaded microspheres. Eur J Nucl Med Mol Imaging 2016; 43 (03) 559-575
• 33 Uliel L, Royal HD, Darcy MD, Zuckerman DA, Sharma A, Saad NE. From the angio suite to the γ-camera: vascular mapping and 99mTc-MAA hepatic perfusion imaging before liver radioembolization -- a comprehensive pictorial review. J Nucl Med 2012; 53 (11) 1736-1747
• 34 Allred JD, Niedbala J, Mikell JK, Owen D, Frey KA, Dewaraja YK. The value of ^99mTc-MAA SPECT/CT for lung shunt estimation in ⁹⁰Y radioembolization: a phantom and patient study. EJNMMI Res 2018; 8 (01) 50
• 35 Lopez B, Mahvash A, Lam MGEH, Kappadath SC. Calculation of lung mean dose and quantification of error for ⁹⁰ Y-microsphere radioembolization using ^99m Tc-MAA SPECT/CT and diagnostic chest CT. Med Phys 2019; 46 (09) 3929-3940
• 36 Boston Scientific, TheraSphere Package Insert. Accessed December 6, 2019 at: https://btgplc.com/BTG/media/TheraSphere-Documents/PDF/TheraSphere-Package-Insert_USA_Rev-14.pdf
• 37 Ho S, Lau WY, Leung TW, Chan M, Johnson PJ, Li AK. 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 (03) 293-298
• 38 Leung TWT, Lau WY, Ho SKW. et al. Radiation pneumonitis after selective internal radiation treatment with intraarterial 90yttrium-microspheres for inoperable hepatic tumors. Int J Radiat Oncol Biol Phys 1995; 33 (04) 919-924
• 39 Margolis LW, Phillips TL. Whole-lung irradiation for metastatic tumor. Radiology 1969; 93 (05) 1173-1179
• 40 Salem R, Parikh P, Atassi B. et al. Incidence of radiation pneumonitis after hepatic intra-arterial radiotherapy with yttrium-90 microspheres assuming uniform lung distribution. Am J Clin Oncol 2008; 31 (05) 431-438
• 41 Bilbao JI, Reiser MF. eds. Yttrium-90 microspheres for other liver metastases. In: Liver Radioembolization with 90Y Microspheres. Berlin: Springer-Verlag; 2014: 57-58
• 42 Committee on Medical Internal Radiation Dose (MIRD)—SNMMI. Accessed February 25, 2020 at: http://www.snmmi.org/AboutSNMMI/CommitteeContent.aspx?ItemNumber=12475&navItemNumber=763
• 43 Snyder W, Ford M, Warner G, Watson S. MIRD Pamphlet #11: S, Absorbed Dose per Unit Cumulated Activity for Selected Radionuclides and Organs. January 1975
• 44 Gulec SA, Mesoloras G, Stabin M. Dosimetric techniques in 90Y-microsphere therapy of liver cancer: the MIRD equations for dose calculations. J Nucl Med 2006; 47 (07) 1209-1211
• 45 Toohey RE, Stabin MG, Watson EE. The AAPM/RSNA physics tutorial for residents: internal radiation dosimetry: principles and applications. Radiographics 2000; 20 (02) 533-546 , quiz 531–532
• 46 Ho S, Lau WY, Leung TW. et al. Partition model for estimating radiation doses from yttrium-90 microspheres in treating hepatic tumours. Eur J Nucl Med 1996; 23 (08) 947-952
• 47 Gnesin S, Canetti L, Adib S. et al. Partition model-based 99mTc-MAA SPECT/CT predictive dosimetry compared with 90Y TOF PET/CT posttreatment dosimetry in radioembolization of hepatocellular carcinoma: a quantitative agreement comparison. J Nucl Med 2016; 57 (11) 1672-1678
• 48 Wondergem M, Smits MLJ, Elschot M. et al. 99mTc-macroaggregated albumin poorly predicts the intrahepatic distribution of 90Y resin microspheres in hepatic radioembolization. J Nucl Med 2013; 54 (08) 1294-1301
• 49 Ilhan H, Goritschan A, Paprottka P. et al. Predictive value of 99mTc-MAA SPECT for 90Y-labeled resin microsphere distribution in radioembolization of primary and secondary hepatic tumors. J Nucl Med 2015; 56 (11) 1654-1660
• 50 Tafti BA, Padia SA. Dosimetry of Y-90 microspheres utilizing Tc-99m SPECT and Y-90 PET. Semin Nucl Med 2019; 49 (03) 211-217
• 51 Vauthey JN, Abdalla EK, Doherty DA. et al. Body surface area and body weight predict total liver volume in Western adults. Liver Transpl 2002; 8 (03) 233-240
• 52 Kao YH, Tan EH, Ng CE, Goh SW. Clinical implications of the body surface area method versus partition model dosimetry for yttrium-90 radioembolization using resin microspheres: a technical review. Ann Nucl Med 2011; 25 (07) 455-461
• 53 Riaz A, Gates VL, Atassi B. et al. Radiation segmentectomy: a novel approach to increase safety and efficacy of radioembolization. Int J Radiat Oncol Biol Phys 2011; 79 (01) 163-171
• 54 Lau WY, Kennedy AS, Kim YH. et al. Patient selection and activity planning guide for selective internal radiotherapy with yttrium-90 resin microspheres. Int J Radiat Oncol Biol Phys 2012; 82 (01) 401-407
• 55 Malhotra A, Liu DM, Talenfeld AD. Radiation segmentectomy and radiation lobectomy: a practical review of techniques. Tech Vasc Interv Radiol 2019; 22 (02) 49-57
• 56 Vouche M, Habib A, Ward TJ. et al. Unresectable solitary hepatocellular carcinoma not amenable to radiofrequency ablation: multicenter radiology-pathology correlation and survival of radiation segmentectomy. Hepatology 2014; 60 (01) 192-201
• 57 Padia SA, Johnson GE, Horton KJ. et al. Segmental yttrium-90 radioembolization versus segmental chemoembolization for localized hepatocellular carcinoma: results of a single-center, retrospective, propensity score-matched study. J Vasc Interv Radiol 2017; 28 (06) 777-785.e1
• 58 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
• 59 Lewandowski RJ, Donahue L, Chokechanachaisakul A. et al. (90) Y radiation lobectomy: outcomes following surgical resection in patients with hepatic tumors and small future liver remnant volumes. J Surg Oncol 2016; 114 (01) 99-105
• 60 Vouche M, Lewandowski RJ, Atassi R. et al. Radiation lobectomy: time-dependent analysis of future liver remnant volume in unresectable liver cancer as a bridge to resection. J Hepatol 2013; 59 (05) 1029-1036
• 61 Gaba RC, Lewandowski RJ, Kulik LM. et al. Radiation lobectomy: preliminary findings of hepatic volumetric response to lobar yttrium-90 radioembolization. Ann Surg Oncol 2009; 16 (06) 1587-1596
• 62 Siddiqi NH, Devlin PM. Radiation lobectomy-a minimally invasive treatment model for liver cancer: case report. J Vasc Interv Radiol 2009; 20 (05) 664-669
• 63 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
• 64 Ahmadzadehfar H, Meyer C, Ezziddin S. et al. Hepatic volume changes induced by radioembolization with 90Y resin microspheres. A single-centre study. Eur J Nucl Med Mol Imaging 2013; 40 (01) 80-90
• 65 Edeline J, Lenoir L, Boudjema K. et al. Volumetric changes after (90)y radioembolization for hepatocellular carcinoma in cirrhosis: an option to portal vein embolization in a preoperative setting?. Ann Surg Oncol 2013; 20 (08) 2518-2525
• 66 Fernández-Ros N, Silva N, Bilbao JI. et al. Partial liver volume radioembolization induces hypertrophy in the spared hemiliver and no major signs of portal hypertension. HPB (Oxford) 2014; 16 (03) 243-249
• 67 Garlipp B, de Baere T, Damm R. et al. Left-liver hypertrophy after therapeutic right-liver radioembolization is substantial but less than after portal vein embolization. Hepatology 2014; 59 (05) 1864-1873
• 68 Teo JY, Goh BKP, Cheah FK. et al. Underlying liver disease influences volumetric changes in the spared hemiliver after selective internal radiation therapy with 90Y in patients with hepatocellular carcinoma. J Dig Dis 2014; 15 (08) 444-450
• 69 SIRTeX Medical SIR-Sphere Training Program: Physicians and Institutions: Page 35 of 111. SIRTEX Medical Limited
• 70 Gulec SA, Mesoloras G, Dezarn WA, McNeillie P, Kennedy AS. Safety and efficacy of Y-90 microsphere treatment in patients with primary and metastatic liver cancer: the tumor selectivity of the treatment as a function of tumor to liver flow ratio. J Transl Med 2007; 5: 15
• 71 Birgin E, Rasbach E, Seyfried S. et al. Contralateral liver hypertrophy and oncological outcome following radioembolization with 90 y-microspheres: a systematic review. Cancers (Basel) 2020; 12 (02) E294
• 72 Cremonesi M, Chiesa C, Strigari L. et al. Radioembolization of hepatic lesions from a radiobiology and dosimetric perspective. Front Oncol 2014; 4: 210
• 73 Vouche M, Degrez T, Bouazza F. et al. Sequential tumor-directed and lobar radioembolization before major hepatectomy for hepatocellular carcinoma. World J Hepatol 2017; 9 (36) 1372-1377
• 74 Teo JY, Allen Jr JC, Ng DC. et al. A systematic review of contralateral liver lobe hypertrophy after unilobar selective internal radiation therapy with Y90. HPB (Oxford) 2016; 18 (01) 7-12
• 75 Toskich BB, Liu DM. Y90 radioembolization dosimetry: concepts for the interventional radiologist. Tech Vasc Interv Radiol 2019; 22 (02) 100-111
• 76 Abouchaleh N, Gabr A, Ali R. et al. 90 Y radioembolization for locally advanced hepatocellular carcinoma with portal vein thrombosis: long-term outcomes in a 185-patient cohort. J Nucl Med 2018; 59 (07) 1042-1048
• 77 Garin E, Rolland Y, Edeline J. et al. Personalized dosimetry with intensification using 90Y-loaded glass microsphere radioembolization induces prolonged overall survival in hepatocellular carcinoma patients with portal vein thrombosis. J Nucl Med 2015; 56 (03) 339-346
• 78 Garin E, Rolland Y, Edeline J. ⁹⁰Y-loaded microsphere SIRT of HCC patients with portal vein thrombosis: high clinical impact of 99mTc-MAA SPECT/CT-based dosimetry. Semin Nucl Med 2019; 49 (03) 218-226
• 79 Somma F, Stoia V, Serra N, D'Angelo R, Gatta G, Fiore F. Yttrium-90 trans-arterial radioembolization in advanced-stage HCC: the impact of portal vein thrombosis on survival. PLoS One 2019; 14 (05) e0216935
• 80 Sangro B, Gil-Alzugaray B, Rodriguez J. et al. Liver disease induced by radioembolization of liver tumors: description and possible risk factors. Cancer 2008; 112 (07) 1538-1546
• 81 Riaz A, Lewandowski RJ, Kulik LM. et al. Complications following radioembolization with yttrium-90 microspheres: a comprehensive literature review. J Vasc Interv Radiol 2009; 20 (09) 1121-1130 , quiz 1131
• 82 Lam MGEH, Louie JD, Iagaru AH, Goris ML, Sze DY. Safety of repeated yttrium-90 radioembolization. Cardiovasc Intervent Radiol 2013; 36 (05) 1320-1328
• 83 Elsayed M, Ermentrout RM, Sethi I. et al. Incidence of radioembolization-induced liver disease and liver toxicity following repeat 90Y-radioembolization: outcomes at a large tertiary care center. Clin Nucl Med 2020; 45 (02) 100-104
• 84 McNeillie P, Kennedy AS, Dezarn W, Sailer SL, England M, Overton C. Liver tolerance to repeat 90Y-microsphere radioembolization. J Med Device 2008; 2 (02) 027539
• 85 Riaz A, Awais R, Salem R. Side effects of yttrium-90 radioembolization. Front Oncol 2014; 4: 198
• 86 Gil-Alzugaray B, Chopitea A, Iñarrairaegui M. et al. Prognostic factors and prevention of radioembolization-induced liver disease. Hepatology 2013; 57 (03) 1078-1087
• 87 Piana PM, Gonsalves CF, Sato T. et al. Toxicities after radioembolization with yttrium-90 SIR-spheres: incidence and contributing risk factors at a single center. J Vasc Interv Radiol 2011; 22 (10) 1373-1379
• 88 Gaba RC. Planning arteriography for yttrium-90 microsphere radioembolization. Semin Intervent Radiol 2015; 32 (04) 428-438
• 89 Vesselle G, Petit I, Boucebci S, Rocher T, Velasco S, Tasu JP. Radioembolization with yttrium-90 microspheres work up: practical approach and literature review. Diagn Interv Imaging 2015; 96 (06) 547-562
• 90 Lopera JE. The Amplatzer vascular plug: review of evolution and current applications. Semin Intervent Radiol 2015; 32 (04) 356-369
• 91 Meek J, Fletcher S, Gauss CH, Bezold S, Borja-Cacho D, Meek M. Temporary balloon occlusion for hepatic arterial flow redistribution during yttrium-90 radioembolization. J Vasc Interv Radiol 2019; 30 (08) 1201-1206
• 92 Sirtex - FLEXdose Delivery Program. Accessed April 13, 2020 at: https://www.sirtex.com/us/clinicians/flexdose-delivery-program/
• 93 TheraSphere™ Y-90 Glass Microspheres - TheraSphere-iDOC - Boston Scientific. Accessed April 13, 2020 at: https://www.bostonscientific.com/en-US/products/cancer-therapies/therasphere-y90-glass-microspheres/ordering-information/therasphere-idoc.html
• 94 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
• 95 Yang Y, Si T. Yttrium-90 transarterial radioembolization versus conventional transarterial chemoembolization for patients with hepatocellular carcinoma: a systematic review and meta-analysis. Cancer Biol Med 2018; 15 (03) 299-310