Contemporary Techniques and Applications of Radioembolization in Patients with Hepatocellular Carcinoma: Y90 from Palliative to Curative

Key points

Planning and treatment

Once patients are deemed Y90 candidates per multidisciplinary tumor board and interventional oncology clinic evaluation, they are scheduled to undergo treatment planning procedure (angiography plus Tc 99m macroaggregated albumin [MAA] scan), which is followed by Y90 treatment 1 to 2 weeks later.

Current and evolving Y90 techniques

Radioembolization was initially performed via lobar (right or left) hepatic arteries. Modern practice allows more selective treatments, sparing non–tumor-bearing hepatic parenchyma. This flexibility has allowed new treatment strategies.

Posttreatment follow-up

Radioembolization is an outpatient procedure. Follow-up protocols vary between institutions, but typically include phone call assessments for any fatigue, pain, and other adverse events over the course of 1 month posttreatment, clinical visits in the interventional oncology clinic, and contrast enhanced MRI or CT follow-up scans at 1, 3, and 6 months post-Y90 [46,47]. It is ideal to have 2 follow-up scans within the first 6 months post-Y90 to identify tumor response to treatment [[48], [49],

Applications and outcomes

Y90 has been shown to be effective across the BCLC staging paradigm, with outcomes and prognoses varying significantly based on tumor burden and hepatic function [47,56,57].

Early-stage hepatocellular carcinoma: Barcelona Clinic Liver Cancer 0/A

According to the BCLC treatment guidelines, BCLC A patients should receive resection, ablation, or transplant. Other therapies, such as radioembolization, are typically reserved for those patients not considered adequate candidates for one of these curative intent options [23,58]. Many reasons contribute to patients not being good candidates for ablation, surgical resection candidate, or liver transplant. These reasons include advanced age, medical comorbidities, hypercoagulable states, portal

Intermediate stage hepatocellular carcinoma: Barcelona Clinic Liver Cancer B

BCLC B patients are characterized by multifocal disease that is limited to the liver without vascular invasion or performance status deterioration. BCLC B patients used to be the main target population whom LRTs were intended to treat, because these patients do not often have surgical options [61].

BCLB B patients represent a diverse group of patients; the approach to radioembolization in these patients depends on the tumor burden and distribution [22]. Sequential lobar Y90 (rather than