Indications and Patient Selection
- HCC — BCLC A/B, portal vein invasion (advantage over TACE)
- Colorectal liver metastases — salvage, DEBIRI alternative
- Neuroendocrine liver metastases — refractory to PRRT
- Hepatic-dominant metastatic disease — selected tumor types
- Portal vein thrombosis — tolerated better than TACE
- Bridge or downstage to transplant — BCLC B/C HCC
- Contraindication — lung shunt fraction >20% (pulmonary toxicity)
- Contraindication — uncorrectable GI shunting, bilirubin >2
TheraSphere vs SIR-Spheres
- TheraSphere (glass) — high activity per sphere (~2500 Gy/sphere)
- SIR-Spheres (resin) — lower activity, more spheres per dose
- TheraSphere — FDA HDE for HCC with portal vein thrombosis
- SIR-Spheres — FDA PMA for colorectal metastases + FUDR
- Dosimetry — Medical Internal Radiation Dose (MIRD) or BSA model
- Partition model — preferred for precise tumor/non-tumor dosimetry
- Lung shunt fraction — Tc-99m MAA mapping session required
- MAA mapping — 1–2 weeks before treatment; CT or SPECT/CT
Full Y-90 Radioembolization Playbook
MAA mapping, dosimetry, treatment delivery, post-procedure management, and response assessment
Dosimetry and Complications
- Lung shunt fraction <10% — safe; 10–20% — reduce dose
- Target tumor dose — 120–150 Gy (HCC), higher for mets
- Radiation hepatitis (REILD) — dose-limiting toxicity
- GI ulceration — non-target microspheres via GDA or RGA
- Radiation pneumonitis — lung shunt >20% uncorrected
- Post-TARE syndrome — fatigue, low-grade fever, self-limited
- mRECIST response — 4–6 week post-treatment MRI/CT
- PET response — FDG-avid metastases; SUV normalization