European Review for Medical and Pharmacological Sciences 2017; 21: 4014-4021 The ten commandments of hepatic radioembolization: expert discussion and report from Mediterranean Interventional Oncology (MIOLive) congress 2017 J.L. BILBAO1, R. IEZZI2, S.N. GOLDBERG3, A. SAMI4, O. AKHAN5, F. GIULIANTE6, M. POMPILI7, L. CROCETTI8, K. MALAGARI9, V. VALENTINI10, A. GASBARRINI7, C. COLOSIMO2, R. MANFREDI2 1Department of Radiology, Clínica Universidad de Navarra, Pamplona, Spain 2Department of Bioimaging, Institute of Radiology, A. Gemelli Hospital, Catholic University of the Sacred Heart, Rome, Italy 3Image-guided Therapy and Interventional Oncology Unit, Department of Radiology Hadassah Hebrew University Medical Center Ein Karem Jerusalem, Israel; Minimally Invasive Tumor Therapy Laboratory Section of Interventional Radiology, Department of Radiology Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA, USA 4Department of Radiology, Cairo University, Cairo, Egypt 5Department of Radiology, Hacettepe University School of Medicine, Sihhiye, Ankara, Turkey 6Hepatobiliary Surgery Unit, A. Gemelli Hospital, Catholic University of the Sacred Heart, Rome, Italy 7Internal Medicine, Gastroenterology and Hepatology, A. Gemelli Hospital, Catholic University of the Sacred Heart, Rome, Italy 8Department of Diagnostic and Interventional Radiology and Nuclear Medicine, Division of Interventional Radiology, Cisanello University Hospital, Pisa, Italy 92nd and 1st Department of Radiology, National and Kapodistrian University of Athens, Medical School, Evgenidion Hospital, Athens, Greece 10Gemelli Advanced Radiation Therapy Center, Fondazione Policlinico Universitario “A. Gemelli”, Catholic University of the Sacred Heart, Rome, Italy Abstract. – Microsphere and particle tech- Introduction nology represent the next-generation agents that have formed the basis of interventional oncolo- Microsphere and particle technology represent gy, an evolving subspecialty of interventional ra- the new-generation agents that have developed diology. One of these platforms, yttrium-90 mi- crospheres, is increasingly being used as a treat- the basis of interventional oncology, an evolving ment modality for primary and secondary liver tu- subspecialty of interventional radiologists. One of mors. Due to the widespread use of radioembo- these platforms, yttrium 90 (Y90) microspheres, lization, a comprehensive review of the method- is increasingly being used as a treatment modali- ologic and technical considerations seems to be ty for primary and secondary liver tumors1-4. mandatory. This article summarizes the expert Due to the widespread use of radioemboli- discussion and report from Mediterranean In- terventional Oncology Live Congress (MIOLive zation, a comprehensive review of the method- 2017) that was held in Rome, Italy, integrating ev- ologic and technical considerations seems to be idence-reported literature and experience-based mandatory. In particular, to help achieve maxi- perceptions, to assist not only residents and fel- mal technical success and limit complications, a lows who are training in interventional radiolo- series of tips and tricks of the trade should have gists but also practicing colleagues who are ap- proaching to this intra-arterial treatment. to be underlined. This work summarizes the expert discussion Key Words: and report from Mediterranean Interventional Liver, Radioembolization, HCC, Metastases, Locore- gional treatment. Oncology Live Congress (MIOLive 2017) that was held in Rome, Italy. Corresponding Author: Roberto Iezzi, MD; e-mail: [email protected]; 4014 [email protected] The ten commandments of hepatic radioembolization The aim of this paper is to integrate evi- staging, gave better results in Child-Pugh A and dence-reported literature and experience-based remarkably demonstrated, not only that RE could perceptions, attempting to make the information be safely administered in patients with tumoral easy to access using a point format, to assist portal vein thrombosis (PVTT), but also that if not only residents and fellows who are training PVTT was segmental or subsegmental, outcomes in interventional radiologists but also practic- were similar to the group without PVTT. These ing colleagues who are approaching to this series, together with several clinical trials that intra-arterial treatment. Accordingly, we have compare RE with Sorafenib, will definitively organized these principles into a “ten command- give light to understanding in which subgroups of ments” framework. BCLC B and BCLC C should be the first option of treatment6-14. I. Accurate Selection of Patients: Furthermore, several reports have also demon- Radioembolization (RE) Must be strated the clear benefit in terms of OS, PFS Administered to the Most Appropriate and clinical and analytical improvement of the Candidates use of RE for the treatment of liver metastases Discussions within multidisciplinary board from neuroendocrine tumors15. They have proven (MDB) should be based on published scientific a marked increase in the tumoral response in evidence, as well as a personalized approach to patients with other metastatic disease such as each patient´s circumstance. There is now in- breast, pancreas, and melanoma16. creased evidence (SIRFLOX study) that RE with Sir-Spheres provides a remarkable increase in II. Preserve as much Healthy Liver as the Progression-Free Survival (PFS) in the liver is Possible: Any Patient Could Potentially (7.9 months in median PFS, from 12.6 to 20.5 Become a Surgical Candidate months) in patients with metastatic colorectal While discussing in the Multidisciplinary Tu- carcinoma (mCRC), with 31% reduction in risk mor Board how to design the treatment strategy of progression and 3-fold increase in complete for every particular patient, some of them will response rate in the liver5. The study, however, be allocated to receive a palliative treatment de- failed to show a significant improvement in the pending on the staging, the tumor burden, and the overall PFS. Yet, it is important to consider that presence of comorbidities. Some others will be almost 10% of the RE arm (intention to treat) did guided towards a curative method (surgery and/or not receive RE and that approximately 50% of percutaneous ablation) and some will be initially the cases had synchronous liver metastases and/ treated by non-curative methods, but, depending or an unresected primary tumor. In spite of these on the response and if correctly downstaged/ unfavorable characteristics, RE has demonstrat- downsized, could in theory ultimate once again ed control of the liver metastases. The inclusion become candidates to receive surgery/ablation. of the SIRFLOX data with respect to the over- Taking into consideration the above, when defin- all survival (OS), a secondary objective of the ing how RE should be administered if selected, study, will be incorporated into another two it is highly recommend to treat just the tumoral randomized trials (Foxfire and Foxfire Global) area and avoid, as much as possible, to irradiate which are designed to obtain data, concerning healthy tissue. The reasons for this strategy are, OS, based upon a target recruitment of more basically, two: first by sparing healthy liver, the than one thousand patients. The information possibility of provoking RadioEmbolization In- will be achieved in 2017 and will help facilitate duced Liver Disease (REILD) (ascites and, with defining the role of RE in the first line treatment the absence of bile obstruction, jaundice) mark- of mCRC. RE has demonstrated a definitive edly decreases, and second because RE will trig- increase in OS and in PFS in patients in whom ger a mechanism of hypertrophy of the remnant RE has been incorporated after several lines of liver quite similar (8 weeks) to that obtained with chemotherapy (refractory cases) when compared Portal Vein Embolization (PVE)7,18. However, it with best supportive care (BSC). should be noted that RE is a treatment option for Three articles published in 2010-2011 (com- liver tumors (radiation lobectomy) whereas PVE prising >700 patients) offered important informa- is a technique to increase the volume of healthy tion with respect to RE (both glass and resin) for liver parenchyma19,21. As said, sparing healthy liv- the treatment of hepatocellular carcinoma (HCC). er allows its hypertrophy and if the tumor is cor- They showed differences according to the BCLC rectly downstaged the patient can receive a cu- 4015 J.L. Bilbao, R. Iezzi, S.N. Goldberg, A. Sami, O. Akhan, F. Giuliante, M. Pompili, et al. rative treatment, something that, for sure, would carried out just with microcatheters. Moreover, not be so easy if the whole liver has been treated to avoid any endothelial damage, in patients in with RE and the remnant liver is insufficient22,23. whom the right gastric artery needs to be occlud- ed, it may be recommended to access to its origin III. Careful Evaluation of Liver Anatomy, using a reverse approach via the left gastric, tak- Using Angio-CT/MR, to Avoid ing advantage of the connections between the left Undertreated Areas and the right gastric arteries34. The technical improvement of sectional imag- ing methods (CT and MR) currently allows ob- V. Embolize Only if Needed: Over taining accurate and precise informations about Embolization or Unneeded Occlusions the visceral vascular anatomy. It is highly recom- may Provoke the Opening of Collaterals mended to carefully analyze the vascular anato- The selection of the treatment