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Objective: To study the efficacy and safety of repeat transarterial radioembolization (TARE) to similar hepatic arterial territories., Methods: Between 3/2011 and 4/2019, 26 patients (25 males and 1 Female, Mean Age: 65 yo, SD: 11.7 yo, Range: 18-83.0 yo) received TARE with Y90 glass microspheres to treat recurrent or residual primary disease in similar hepatic arterial lobe or segments. Tumor response was evaluated by imaging using the modified-RECIST criteria. Incidence of RILD and adverse events were categorized by a standardized scale using the Common Terminology Criteria for Adverse Events (CTCAE) v.4.0., Results: Mean cumulative activity after the first treatment was 2.50 GBq (SD:1.04 GBq, Range:0.61-4.93 GBq) and second treatment was 2.27 GBq (SD:1.01 GBq, Range:0.92-5.46 GBq). Mean interval time between initial and repeat treatments was 9.6 months (Range: 1-53 months). Tumor responses were complete, partial, or progression in 73% ( n = 19/26), 23% ( n = 6/26), and 4% ( n = 1/26) in repeat treatment patients, respectively. The incidence of RILD was 0%. Toxicity after first and second treatment was seen in 19% ( n = 5/26) & 23% ( n = 6/26) patients, respectively, and were all of CTCAE Grade 2. No significant predictors of treatment toxicity for repeat treatment were identified except increased MELD score ( p = 0.04). Kaplan-Meier survival analysis in patients with repeat treatment showed a median survival of 15.0 months (95% CI 8.8-21.1 months) and 19.0 months (95% CI 8.1-29.9 months) in patients who only received one treatment with a p value of 0.485., Conclusion: Repeat TARE with glass microspheres was an effective and safe treatment strategy for disease management in patients with residual or recurrent disease to the similar hepatic arterial territories without any major treatment related toxicity., Advances in Knowledge: Although safety and efficacy of repeat radioembolism has been studied, no study has focused on repeat treatment to similar hepatic arterial territories. The current study shows that repeat treatment to the same hepatic arterial territory is as safe as single treatment to the same territory.

Purpose: Radioembolization using 90yttrium is an emerging therapy option for unresectable liver malignancies. In order to reduce the number of yttrium injections, endovascular occlusion of a segmental hepatic artery has been proposed. The aim of this study was to assess whether sufficient vascular redistribution of the occluded liver segments through intrahepatic collaterals can be observed., Materials and Methods: 27 patients with hepatocellular carcinoma (n = 16) or hepatic metastases (n = 11) were studied. Hepatic angiography was performed on average 16 days prior to radioembolization. The segment II/III artery (n = 9) or the segment IV artery (n = 18) was occluded using coils. Technectium-99m-labeled macroaggregated albumin (99mTc-MAA) was injected into the right and the remaining part of the left hepatic artery in order to identify any hepatic volume not included in the perfused area. Patients underwent a SPECT/CT on average 1 h after the 99mTc-MAA injection. Two radiologists evaluated the SPECT/CT scans regarding the presence of non-perfused hepatic segments. Furthermore, hepatic perfusion was assessed by digital subtraction angiography (DSA) on the day of radioembolization., Results: In 16/27 patients (59%) a perfusion of the occluded liver segment was visible on the SPECT/CT scan. In 8/11 patients without flow redistribution at the time of the SPECT/CT, perfusion of the occluded segment through hepatic collaterals was observed during angiography prior to radioembolization. Hence, flow redistribution was eventually found in 24/27 patients (89%)., Conclusion: Flow redistribution after the occlusion of intrahepatic arteries prior to radioembolization can be successfully induced in the majority of patients with anatomical variants of the hepatic arteries., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objective: To assess the incidence of clinical and imaging radiation pneumonitis (RP) in a cohort of patients treated with >30 Gy cumulative lung dose (CLD) using Y90 microspheres., Materials and Methods: Four hundred three patients were treated with Y90 microspheres during a 4-year period. Of these, 58 patients received >30 Gy CLD. Patients were followed for toxicities suggestive of imaging or clinical RP. Toxicities were graded using the Radiation Therapy Oncology Group/European Organisation for Research and Treatment of Cancer Late Radiation Morbidity Scoring Schema. Patients were also followed for survival from time of first treatment., Results: There were 44 men and 14 women. Forty-three patients had hepatocellular carcinoma (HCC), whereas 15 had liver metastases. Mean and median follow-up were 7.3 and 6.0 months, respectively. Mean lung shunt fraction was slightly greater in the patients with HCC versus metastases (20% vs. 16.7%, P = 0.2308). The lifetime CLD for metastases and HCC groups were not statistically different (54.04 Gy vs. 48.44 Gy, P = 0.4303). Forty-three of 53 patients demonstrated no lung imaging findings suggestive of pneumonitis. Imaging findings in 10 patients included pleural effusions, atelectasis, and ground glass attenuation. There were no cases of clinical or imaging RP. Survival varied depending on stage as well as single and CLD. None of the patient deaths were attributed to respiratory compromise., Conclusion: RP was not predicted using the currently used Y90 dosimetry models that assume uniform distribution in the lungs. Further investigation and dose escalation studies are required to more precisely define the radiation tolerance of lung parenchyma using this mode of therapy.

Background: Selective Internal Radiation (SIR) therapy with yttrium-90 microspheres has become an alternative approach to treat hepatic tumors., Methods: A single institution retrospective chart review was performed to assess the safety of SIR microspheres in twenty-one patients with hepatic malignancies. The yttrium-90 radiation dose was dependent upon the percentage of tumor involvement of the liver, with a dose modification (reduction) adjusted for macroaggregated albumin (MAA) shunted to the lung., Results: Twenty-one patients underwent twenty-five treatments with SIR microsphere therapy for primary and metastatic liver tumors. One mortality was secondary to fulminant hepatic failure after developing radiation hepatitis. Morbidities included radiation hepatitis (1) and peptic ulcer disease (6)., Conclusions: The application of SIR microspheres has been utilized for a variety of liver tumors. Although it has been a useful treatment option in selected patients, safety still remains an issue.