Review articleComplications Following Radioembolization with Yttrium-90 Microspheres: A Comprehensive Literature Review
Section snippets
Primary Tumors
THE most common primary malignancy of the liver is hepatocellular carcinoma (HCC); its incidence is increasing worldwide. It ranks as the sixth most common malignancy and third most common cause of cancer-related mortality (1, 2). The management of liver tumors has seen significant advancement in the past decade with the development of new screening, diagnostic, and therapeutic modalities. Primary liver tumors include HCC and intrahepatic cholangiocarcinoma. Surgical resection is considered
Pretreatment Evaluation
HCC is diagnosed on imaging if there is a lesion greater than 2 cm with arterial-phase enhancement and venous washout (17). Biopsy is performed in lesions that do not have the typical radiologic findings as defined by the European Association for the Study of the Liver and American Association for the Study of Liver Diseases guidelines (18). The role of α-fetoprotein in diagnosis of HCC is not yet established. Secondary liver tumors are diagnosed by imaging with fluorodeoxyglucose positron
Yttrium-90
90Y is a pure β-emitter. It has an average β-energy emission of 0.9367 MeV and a maximum of 2.1 MeV. The mean tissue penetration is 2.5 mm with a maximum of 10 mm.
TheraSphere
TheraSphere particles (MDS Nordion, Ottawa, ON, Canada) are glass microspheres 20–30 μm in size with 90Y as anintegral constituent (26). One 3-GBq vial contains 1.2 million particles. Given the low particle number, the particles impart a minimal embolic effect (27). This device was approved by the Food and Drug Administration for use
Complications of Radioembolization
The complications occurring after radioembolization can be broadly classified into the following groups: postradioembolization syndrome (PRS), hepatic dysfunction, biliary sequelae, portal hypertension, radiation pneumonitis, GI ulceration, vascular injury, lymphopenia, and a miscellaneous category. These will be discussed in the following evidence-based review of the published literature.
PRS
Patients may experience a mild PRS that consists of the following clinical symptoms: fatigue, nausea, vomiting, anorexia, fever, abdominal discomfort, and cachexia. Hospitalization is usually not required. PRS is less severe than the posttreatment syndromes observed after other embolic therapies in which fatigue and constitutional symptoms predominate (11, 27, 32, 33). Mild abdominal pain may be experienced after radioembolization (21, 33). As a result of the lack of macroscopic embolization
Conclusion
The mild adverse events and constitutional symptoms after radioembolization rarely require hospitalization. Serious adverse events can be mitigated if proper patients are selected, accepted dosimetry models used, and meticulous technique employed (Table 2). Patients with poor liver function before treatment are more prone to develop RILD. Derangement in liver function can be prevented by lobar or segmental injection and avoidance of whole-liver treatment (35). Biliary sequelae occur mostly
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R.S. is a paid consultant for MDS Nordion (Ottawa, Ontario, Canada) and has served on advisory boards for Sirtex Medical (Lane Cove, Australia). None of the other authors have identified a conflict of interest.