This document summarizes selective internal radiation therapy (SIRT) for treating liver cancer. SIRT involves delivering microspheres containing the radioactive isotope yttrium-90 to the liver tumor via injection into the hepatic artery. It is an emerging treatment for primary or metastatic liver cancers that cannot be surgically removed. Liver cancer incidence is increasing in Australia, creating a growing clinical need for new treatment options like SIRT, which has been approved for use in Australia and is being used or tested in many countries around the world.
Radioembolization of Hepatic Metastases with Yttrium 90 (1) (1) FINALBrandon Wright
This document discusses radioembolization with Yttrium-90 as a treatment for hepatic metastases caused by colorectal cancer. It provides background on the disease, current treatment options, and rationale for using radioembolization. Radioembolization involves administering Yttrium-90 microspheres via the hepatic artery to target tumor cells. The document reviews patient selection criteria, outcomes from clinical trials showing median survival of 15.5 months, and potential adverse effects including nausea, abdominal pain and fatigue.
I have uploaded the presentation on Yttrium 90 & its application in treatment of Liver Cancer. Presentation elaborates on characteristics of Y-90, how treatment is planned, workup done & aspects on radiation safety & post treatment care. I would be glad to answer queries on this new emerging exciting area of treating Inoperable Liver Cancers.
This slide deck has been created for clinician use in creating presentations detailing Colorectal Cancer Liver Metastases, the Selective Internal Radiation Therapy (SIRT) procedure available to treat this condition, supported by the clinical data that supports this treatment and and ongoing RCT trials to further document the success of this treatment. This information maybe used in its entirety or in sections, according to the material being presented and the audience to which it will be used. The sections included in this slide deck are as follows:
Colorectal Cancer Liver Metastases (mCRC)
Overview Selective Internal Radiation Therapy (SIRT)
Overview SIR-Spheres(r) microspheres
Clinical Data in mCRC Ongoing Level 1 RCT for mCRC in the liver
This document discusses Y90 radioembolization for the treatment of hepatocellular carcinoma (HCC). It provides details on how Y90 microspheres are loaded with the beta emitter Yttrium-90 which targets tumors up to 11mm in range. Guidelines from EASL-EORTC recommend Y90 for strictly BCLC B stage HCC without portal vein thrombosis. A study found Y90 had superior time to progression over transarterial chemoembolization (TACE) especially for elderly patients, large tumors, or diffuse disease. For HCC with portal vein thrombosis, Y90 provided good local control. Ongoing trials are investigating combining Y90 with sorafenib to see if
SIR-Spheres microspheres are a medical device used in selective internal radiation therapy (SIRT) to treat metastatic colorectal cancer in the liver. SIRT involves injecting radioactive microspheres into the hepatic artery to lodge in the blood vessels surrounding tumors and deliver radiation directly to the tumors to destroy cancer cells while sparing healthy liver tissue. Potential mild side effects include abdominal pain, nausea, fever and fatigue that typically subside within a few weeks. SIRT is an outpatient procedure that takes about an hour and patients are monitored for several hours after treatment.
1. Radiotherapy can play roles in both curative and palliative settings for the management of hepatocellular carcinoma (HCC).
2. For small HCC lesions within Milan criteria, stereotactic ablative radiotherapy delivers a high radiation dose in 1-4 fractions and can be used for tumors that are unresectable or ineligible for other local therapies.
3. For larger HCC lesions, radiotherapy can be combined with transarterial chemoembolization to consolidate treatment or salvage refractory lesions after repeated TACE. This combines the effects of radiation and prolonged exposure to chemoagents from TACE.
4. Radiotherapy may also help control vascular
This document summarizes research on using CyberKnife and TomoTherapy for treating liver cancer. It discusses studies from Korea, Taiwan, China, Belgium, and the US on using these technologies for inoperable primary or recurrent hepatocellular carcinoma and liver metastases. Key findings included high response rates and local control. Current research interests discussed standardizing treatment protocols and criteria across countries through guidelines. Future directions may involve regional collaboration on studies to further optimize these radiotherapy approaches for liver cancer.
Radioembolization of Hepatic Metastases with Yttrium 90 (1) (1) FINALBrandon Wright
This document discusses radioembolization with Yttrium-90 as a treatment for hepatic metastases caused by colorectal cancer. It provides background on the disease, current treatment options, and rationale for using radioembolization. Radioembolization involves administering Yttrium-90 microspheres via the hepatic artery to target tumor cells. The document reviews patient selection criteria, outcomes from clinical trials showing median survival of 15.5 months, and potential adverse effects including nausea, abdominal pain and fatigue.
I have uploaded the presentation on Yttrium 90 & its application in treatment of Liver Cancer. Presentation elaborates on characteristics of Y-90, how treatment is planned, workup done & aspects on radiation safety & post treatment care. I would be glad to answer queries on this new emerging exciting area of treating Inoperable Liver Cancers.
This slide deck has been created for clinician use in creating presentations detailing Colorectal Cancer Liver Metastases, the Selective Internal Radiation Therapy (SIRT) procedure available to treat this condition, supported by the clinical data that supports this treatment and and ongoing RCT trials to further document the success of this treatment. This information maybe used in its entirety or in sections, according to the material being presented and the audience to which it will be used. The sections included in this slide deck are as follows:
Colorectal Cancer Liver Metastases (mCRC)
Overview Selective Internal Radiation Therapy (SIRT)
Overview SIR-Spheres(r) microspheres
Clinical Data in mCRC Ongoing Level 1 RCT for mCRC in the liver
This document discusses Y90 radioembolization for the treatment of hepatocellular carcinoma (HCC). It provides details on how Y90 microspheres are loaded with the beta emitter Yttrium-90 which targets tumors up to 11mm in range. Guidelines from EASL-EORTC recommend Y90 for strictly BCLC B stage HCC without portal vein thrombosis. A study found Y90 had superior time to progression over transarterial chemoembolization (TACE) especially for elderly patients, large tumors, or diffuse disease. For HCC with portal vein thrombosis, Y90 provided good local control. Ongoing trials are investigating combining Y90 with sorafenib to see if
SIR-Spheres microspheres are a medical device used in selective internal radiation therapy (SIRT) to treat metastatic colorectal cancer in the liver. SIRT involves injecting radioactive microspheres into the hepatic artery to lodge in the blood vessels surrounding tumors and deliver radiation directly to the tumors to destroy cancer cells while sparing healthy liver tissue. Potential mild side effects include abdominal pain, nausea, fever and fatigue that typically subside within a few weeks. SIRT is an outpatient procedure that takes about an hour and patients are monitored for several hours after treatment.
1. Radiotherapy can play roles in both curative and palliative settings for the management of hepatocellular carcinoma (HCC).
2. For small HCC lesions within Milan criteria, stereotactic ablative radiotherapy delivers a high radiation dose in 1-4 fractions and can be used for tumors that are unresectable or ineligible for other local therapies.
3. For larger HCC lesions, radiotherapy can be combined with transarterial chemoembolization to consolidate treatment or salvage refractory lesions after repeated TACE. This combines the effects of radiation and prolonged exposure to chemoagents from TACE.
4. Radiotherapy may also help control vascular
This document summarizes research on using CyberKnife and TomoTherapy for treating liver cancer. It discusses studies from Korea, Taiwan, China, Belgium, and the US on using these technologies for inoperable primary or recurrent hepatocellular carcinoma and liver metastases. Key findings included high response rates and local control. Current research interests discussed standardizing treatment protocols and criteria across countries through guidelines. Future directions may involve regional collaboration on studies to further optimize these radiotherapy approaches for liver cancer.
STEREOTACTIC BODY RADIATION THERAPY USING CYBERKNIFE® FOR LIVER METASTASES: A...accurayexchange
Zhi-Yong Yuan, MD, PhD
Chun-Lei Liu, MD Ma0-Bin Meng, MD, PhD
CyberKnife Center, Department of Radiation Oncology, Tianjin Medical University Cancer Institute & Hospital
This document discusses the use of stereotactic body radiotherapy (SBRT) for treating both primary and metastatic liver tumors. SBRT allows for high, tumoricidal doses of radiation to be delivered to liver tumors while sparing the surrounding normal liver tissue. Studies have shown SBRT to be effective for treating hepatocellular carcinoma and intrahepatic cholangiocarcinoma, with local control rates of 50-80% at 1 year and median survival times of 11-15 months. SBRT has also shown promise for treating metastatic colorectal cancer in the liver, with reported 1-year local control rates of 65-84% and median overall survival of 10-17 months. Toxicity from SBR
Current Practice with Helical Tomotherapy in Yonsei Universityaccurayexchange
Helical tomotherapy has been used at Yonsei University since 2006, with 6 machines total across various hospitals. It provides superior dosimetric results compared to 3D-CRT and IMRT for liver cancer patients. Analysis of 12 patients' treatment plans found helical tomotherapy achieved better conformity and homogeneity. It also reduced the mean dose to the stomach and lowered the percentage of the remaining liver receiving high doses. While helical tomotherapy improves survival for HCC larger than 5 cm and SBRT is safe and effective for small HCC, further follow up is still needed. RTOG 1112 is a randomized phase III study comparing SBRT followed by sorafenib versus sorafenib alone in patients
Clinical Experiences of CK/HT in Hepatocellular Carcinomaaccurayexchange
Chul-Seung Kay1,3 , Seok-Hyun Son1, Myung-Soo Kim1, Jung-Hyun Kwon2
Department of Radiation Oncology1 & 2Internal Medicine2
3Catholic Comprehensive Hospital for Advanced Cancer3
Incheon St. Mary Hospital
The Catholic University of Korea
Angiogenic blockade and Tomotherapy in hepatocellular carcinomaaccurayexchange
季匡華 Kwan-Hwa Chi, M.D.
Chairman, Section of Radiation Therapy and Oncology Shin Kong Wu Ho-Su Memorial Hospital, Taiwan Professor, School of Medicine
National Yang-Ming University
Ghassan Abou-Alfa, MD, MBA, Robin K. (“Katie”) Kelley, MD, Professor Riccardo Lencioni, MD, FSIR, EBIR, and Amit Singal, MD, MS, prepared useful practice aids pertaining to HCC for this CME/MOC activity titled, "Composing Personalized HCC Treatment Strategies: Insights on Harmonizing Patient Care With a Multidisciplinary Ensemble." For the full presentation, monograph, complete CME/MOC information, and to apply for credit, please visit us at http://bit.ly/2kAyqO9. CME/MOC credit will be available until November 5, 2020.
Low Radiation Dose effect of Tomotherapy for Hepatocellular Carcinomaaccurayexchange
This document discusses the use of tomotherapy for treating hepatocellular carcinoma (HCC) and its advantages over other radiotherapy techniques. While tomotherapy can deliver high radiation doses to small tumor volumes with less damage to the surrounding liver tissue compared to other methods, it may still pose risks. Even low radiation doses below 10Gy delivered to the liver could potentially induce HBV reactivation or exacerbate chronic hepatitis B infection, especially in endemic areas. Further clinical studies are needed to directly compare the risks of HBV reactivation between tomotherapy and other radiotherapy modalities before tomotherapy can be widely applied in clinical practice for HCC patients. National insurance coverage and support for clinical trials are also required.
This document discusses the radiotherapeutic management of prostate cancer. It begins by introducing the multidisciplinary team involved in diagnosis and treatment. It then covers diagnosis, including various screening tests and pathology findings. Treatment options discussed include observation, surgery, radiation therapy and hormonal treatment. The document focuses on the evolution of radiation techniques from conventional to IMRT and brachytherapy. It compares outcomes and side effects of different local treatment modalities and discusses the role of neoadjuvant hormonal therapy.
Gastric cancer contouring panel discussion, icc 2017Ashutosh Mukherji
This document provides guidance on contouring for gastric cancers receiving radiotherapy. It discusses:
1) When radiotherapy is indicated such as neoadjuvant, adjuvant, radical or palliative settings.
2) How to define the clinical target volume to include the stomach bed, regional lymph nodes depending on tumor location, and organs at risk like the kidneys, liver and bowel loops.
3) The simulation protocol including patient positioning, CT imaging and capturing essential structures to aid treatment planning.
4) Guidance on target volume margins, overlap with organs at risk and using motion management techniques to improve target coverage and reduce normal tissue doses.
This document discusses treatment options for hepatocellular carcinoma (HCC), focusing on transarterial chemoembolization (TACE) and radiofrequency ablation (RFA). It stratifies HCC using the Barcelona criteria and examines prognostic factors. For intermediate stage HCC, TACE is the standard treatment and can provide 1, 2, and 3 year survival rates of 57%, 31%, and 26% respectively. Newer techniques like drug-eluting bead TACE may have fewer side effects than conventional TACE. RFA provides the best results for tumors under 3cm, with a 5 year survival of 40-70% for eligible patients. The document compares various locoregional therapies and their roles based on
Surgical treatment of hepatocellular carcinomaGian Luca Grazi
This document summarizes surgical treatment options for hepatocellular carcinoma (HCC). Liver resection is the main treatment for early stage HCC within Milan criteria of 1-3 tumors less than 5 cm each. While guidelines recommend resection only for patients without portal hypertension or bilirubin over 1 mg/dL, many centers extend criteria to some with portal hypertension if liver function is preserved. Five-year survival after resection in selected patients exceeds 50%. For unresectable HCC, options include liver transplantation, which offers the best survival but limited availability, and locoregional therapies like radiofrequency ablation or transarterial chemoembolization. Ongoing research aims to further expand criteria for resection and transplantation.
- CyberKnife is an option for treating inoperable or medically complex liver tumors with low toxicity. Initial results show good tumor response rates and survival benefits, especially for patients with small tumors receiving high radiation doses. Recent studies continue to show local tumor control rates over 80% and median overall survival around 10 months for hepatocellular carcinoma treated with CyberKnife. Dosimetric parameters can achieve tumor doses over 30 Gy while sparing critical structures like the liver and intestines.
Trans Arterial Chemo Embolisation (TACE) is a treatment for Hepatocellular Carcinoma (HCC) where an anticancer agent is mixed with an embolic agent and delivered via the hepatic artery. Early studies showed improved survival rates for TACE-treated HCC patients compared to controls. Patient selection is important, as TACE is best for patients with preserved liver function. More recently, techniques have improved such as using drug-eluting beads and performing highly selective TACE of tumor-feeding arteries to minimize liver damage while maximizing tumor exposure. Ongoing research continues to refine TACE as a key treatment option for HCC.
This document discusses radiotherapy (RT) for hepatocellular carcinoma (HCC) in the Asia-Pacific region. It compares outcomes between sorafenib and RT for intermediate/advanced HCC. Helical tomotherapy (HT) improves long-term survival and increases radiation dose without increased toxicity for HCC with macrovascular invasion compared to 3D conformal radiotherapy (3DCRT). HT allows delivery of higher radiation doses in a shorter treatment period with acceptable toxicity for HCC with macrovascular invasion.
The document discusses pancreatic cancer treatment and survival data from several clinical trials. It finds that chemoradiation provides a survival benefit compared to observation or chemotherapy alone in both the adjuvant and locally advanced settings. For resectable pancreatic cancer, chemoradiation improves median survival compared to surgery alone. Prospective trials also demonstrated improved 2-year survival rates with adjuvant chemoradiation. For locally advanced or borderline resectable pancreatic cancer, chemoradiation provides better local control and progression-free survival compared to chemotherapy alone.
- A 27-year-old female presented with weight loss and abdominal fullness and was found to have a hard nodular growth in her stomach.
- Biopsy revealed poorly cohesive carcinoma. PET CT found the tumor involved the stomach wall and lymph nodes.
- She underwent surgery including stomach removal and lymph node dissection. Pathology found T4aN1 stage cancer.
- She received 6 cycles of FOLFOX adjuvant chemotherapy, last administered in October 2020. Follow up PET CT in November 2020 found no signs of recurrence.
1. Radiation therapy has an emerging role in the multidisciplinary management of hepatocellular carcinoma (HCC) due to advances that allow higher radiation doses to be safely delivered to small liver volumes.
2. Stereotactic body radiation therapy (SBRT) shows promise for HCC but questions remain about safety, effectiveness for bridging to transplant, and downsizing lesions.
3. A pilot study is investigating the safety and feasibility of liver SBRT for HCC.
1. Several randomized controlled trials have consistently shown that the addition of neoadjuvant hormonal therapy (NHT) to external beam radiotherapy (EBRT) improves outcomes for men with intermediate-risk or high-risk localized prostate cancer.
2. The optimal timing and duration of NHT is still unclear, but most evidence suggests that 2-3 months of NHT combined with EBRT is adequate for intermediate-risk patients. Longer adjuvant hormonal therapy may benefit high-risk patients.
3. While the sequence of NHT relative to EBRT may impact outcomes, short-term NHT combined with EBRT appears beneficial overall based on multiple randomized trials.
This study investigated long-term survival outcomes of 320 patients who underwent radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC) or colorectal liver metastases (CLM) between 1999-2010. Minimum 5-year follow-up data was available for 89% of patients, with median follow-up of 115.3 months. For HCC patients, 5-year and 10-year overall survival rates were 38.5% and 23.4%. For CLM patients, 5-year and 10-year overall survival rates were 27.6% and 15%. The study concludes RFA can provide 10-year overall survival rates of over 23% for HCC and 15% for CLM
STEREOTACTIC BODY RADIATION THERAPY USING CYBERKNIFE® FOR LIVER METASTASES: A...accurayexchange
Zhi-Yong Yuan, MD, PhD
Chun-Lei Liu, MD Ma0-Bin Meng, MD, PhD
CyberKnife Center, Department of Radiation Oncology, Tianjin Medical University Cancer Institute & Hospital
This document discusses the use of stereotactic body radiotherapy (SBRT) for treating both primary and metastatic liver tumors. SBRT allows for high, tumoricidal doses of radiation to be delivered to liver tumors while sparing the surrounding normal liver tissue. Studies have shown SBRT to be effective for treating hepatocellular carcinoma and intrahepatic cholangiocarcinoma, with local control rates of 50-80% at 1 year and median survival times of 11-15 months. SBRT has also shown promise for treating metastatic colorectal cancer in the liver, with reported 1-year local control rates of 65-84% and median overall survival of 10-17 months. Toxicity from SBR
Current Practice with Helical Tomotherapy in Yonsei Universityaccurayexchange
Helical tomotherapy has been used at Yonsei University since 2006, with 6 machines total across various hospitals. It provides superior dosimetric results compared to 3D-CRT and IMRT for liver cancer patients. Analysis of 12 patients' treatment plans found helical tomotherapy achieved better conformity and homogeneity. It also reduced the mean dose to the stomach and lowered the percentage of the remaining liver receiving high doses. While helical tomotherapy improves survival for HCC larger than 5 cm and SBRT is safe and effective for small HCC, further follow up is still needed. RTOG 1112 is a randomized phase III study comparing SBRT followed by sorafenib versus sorafenib alone in patients
Clinical Experiences of CK/HT in Hepatocellular Carcinomaaccurayexchange
Chul-Seung Kay1,3 , Seok-Hyun Son1, Myung-Soo Kim1, Jung-Hyun Kwon2
Department of Radiation Oncology1 & 2Internal Medicine2
3Catholic Comprehensive Hospital for Advanced Cancer3
Incheon St. Mary Hospital
The Catholic University of Korea
Angiogenic blockade and Tomotherapy in hepatocellular carcinomaaccurayexchange
季匡華 Kwan-Hwa Chi, M.D.
Chairman, Section of Radiation Therapy and Oncology Shin Kong Wu Ho-Su Memorial Hospital, Taiwan Professor, School of Medicine
National Yang-Ming University
Ghassan Abou-Alfa, MD, MBA, Robin K. (“Katie”) Kelley, MD, Professor Riccardo Lencioni, MD, FSIR, EBIR, and Amit Singal, MD, MS, prepared useful practice aids pertaining to HCC for this CME/MOC activity titled, "Composing Personalized HCC Treatment Strategies: Insights on Harmonizing Patient Care With a Multidisciplinary Ensemble." For the full presentation, monograph, complete CME/MOC information, and to apply for credit, please visit us at http://bit.ly/2kAyqO9. CME/MOC credit will be available until November 5, 2020.
Low Radiation Dose effect of Tomotherapy for Hepatocellular Carcinomaaccurayexchange
This document discusses the use of tomotherapy for treating hepatocellular carcinoma (HCC) and its advantages over other radiotherapy techniques. While tomotherapy can deliver high radiation doses to small tumor volumes with less damage to the surrounding liver tissue compared to other methods, it may still pose risks. Even low radiation doses below 10Gy delivered to the liver could potentially induce HBV reactivation or exacerbate chronic hepatitis B infection, especially in endemic areas. Further clinical studies are needed to directly compare the risks of HBV reactivation between tomotherapy and other radiotherapy modalities before tomotherapy can be widely applied in clinical practice for HCC patients. National insurance coverage and support for clinical trials are also required.
This document discusses the radiotherapeutic management of prostate cancer. It begins by introducing the multidisciplinary team involved in diagnosis and treatment. It then covers diagnosis, including various screening tests and pathology findings. Treatment options discussed include observation, surgery, radiation therapy and hormonal treatment. The document focuses on the evolution of radiation techniques from conventional to IMRT and brachytherapy. It compares outcomes and side effects of different local treatment modalities and discusses the role of neoadjuvant hormonal therapy.
Gastric cancer contouring panel discussion, icc 2017Ashutosh Mukherji
This document provides guidance on contouring for gastric cancers receiving radiotherapy. It discusses:
1) When radiotherapy is indicated such as neoadjuvant, adjuvant, radical or palliative settings.
2) How to define the clinical target volume to include the stomach bed, regional lymph nodes depending on tumor location, and organs at risk like the kidneys, liver and bowel loops.
3) The simulation protocol including patient positioning, CT imaging and capturing essential structures to aid treatment planning.
4) Guidance on target volume margins, overlap with organs at risk and using motion management techniques to improve target coverage and reduce normal tissue doses.
This document discusses treatment options for hepatocellular carcinoma (HCC), focusing on transarterial chemoembolization (TACE) and radiofrequency ablation (RFA). It stratifies HCC using the Barcelona criteria and examines prognostic factors. For intermediate stage HCC, TACE is the standard treatment and can provide 1, 2, and 3 year survival rates of 57%, 31%, and 26% respectively. Newer techniques like drug-eluting bead TACE may have fewer side effects than conventional TACE. RFA provides the best results for tumors under 3cm, with a 5 year survival of 40-70% for eligible patients. The document compares various locoregional therapies and their roles based on
Surgical treatment of hepatocellular carcinomaGian Luca Grazi
This document summarizes surgical treatment options for hepatocellular carcinoma (HCC). Liver resection is the main treatment for early stage HCC within Milan criteria of 1-3 tumors less than 5 cm each. While guidelines recommend resection only for patients without portal hypertension or bilirubin over 1 mg/dL, many centers extend criteria to some with portal hypertension if liver function is preserved. Five-year survival after resection in selected patients exceeds 50%. For unresectable HCC, options include liver transplantation, which offers the best survival but limited availability, and locoregional therapies like radiofrequency ablation or transarterial chemoembolization. Ongoing research aims to further expand criteria for resection and transplantation.
- CyberKnife is an option for treating inoperable or medically complex liver tumors with low toxicity. Initial results show good tumor response rates and survival benefits, especially for patients with small tumors receiving high radiation doses. Recent studies continue to show local tumor control rates over 80% and median overall survival around 10 months for hepatocellular carcinoma treated with CyberKnife. Dosimetric parameters can achieve tumor doses over 30 Gy while sparing critical structures like the liver and intestines.
Trans Arterial Chemo Embolisation (TACE) is a treatment for Hepatocellular Carcinoma (HCC) where an anticancer agent is mixed with an embolic agent and delivered via the hepatic artery. Early studies showed improved survival rates for TACE-treated HCC patients compared to controls. Patient selection is important, as TACE is best for patients with preserved liver function. More recently, techniques have improved such as using drug-eluting beads and performing highly selective TACE of tumor-feeding arteries to minimize liver damage while maximizing tumor exposure. Ongoing research continues to refine TACE as a key treatment option for HCC.
This document discusses radiotherapy (RT) for hepatocellular carcinoma (HCC) in the Asia-Pacific region. It compares outcomes between sorafenib and RT for intermediate/advanced HCC. Helical tomotherapy (HT) improves long-term survival and increases radiation dose without increased toxicity for HCC with macrovascular invasion compared to 3D conformal radiotherapy (3DCRT). HT allows delivery of higher radiation doses in a shorter treatment period with acceptable toxicity for HCC with macrovascular invasion.
The document discusses pancreatic cancer treatment and survival data from several clinical trials. It finds that chemoradiation provides a survival benefit compared to observation or chemotherapy alone in both the adjuvant and locally advanced settings. For resectable pancreatic cancer, chemoradiation improves median survival compared to surgery alone. Prospective trials also demonstrated improved 2-year survival rates with adjuvant chemoradiation. For locally advanced or borderline resectable pancreatic cancer, chemoradiation provides better local control and progression-free survival compared to chemotherapy alone.
- A 27-year-old female presented with weight loss and abdominal fullness and was found to have a hard nodular growth in her stomach.
- Biopsy revealed poorly cohesive carcinoma. PET CT found the tumor involved the stomach wall and lymph nodes.
- She underwent surgery including stomach removal and lymph node dissection. Pathology found T4aN1 stage cancer.
- She received 6 cycles of FOLFOX adjuvant chemotherapy, last administered in October 2020. Follow up PET CT in November 2020 found no signs of recurrence.
1. Radiation therapy has an emerging role in the multidisciplinary management of hepatocellular carcinoma (HCC) due to advances that allow higher radiation doses to be safely delivered to small liver volumes.
2. Stereotactic body radiation therapy (SBRT) shows promise for HCC but questions remain about safety, effectiveness for bridging to transplant, and downsizing lesions.
3. A pilot study is investigating the safety and feasibility of liver SBRT for HCC.
1. Several randomized controlled trials have consistently shown that the addition of neoadjuvant hormonal therapy (NHT) to external beam radiotherapy (EBRT) improves outcomes for men with intermediate-risk or high-risk localized prostate cancer.
2. The optimal timing and duration of NHT is still unclear, but most evidence suggests that 2-3 months of NHT combined with EBRT is adequate for intermediate-risk patients. Longer adjuvant hormonal therapy may benefit high-risk patients.
3. While the sequence of NHT relative to EBRT may impact outcomes, short-term NHT combined with EBRT appears beneficial overall based on multiple randomized trials.
This study investigated long-term survival outcomes of 320 patients who underwent radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC) or colorectal liver metastases (CLM) between 1999-2010. Minimum 5-year follow-up data was available for 89% of patients, with median follow-up of 115.3 months. For HCC patients, 5-year and 10-year overall survival rates were 38.5% and 23.4%. For CLM patients, 5-year and 10-year overall survival rates were 27.6% and 15%. The study concludes RFA can provide 10-year overall survival rates of over 23% for HCC and 15% for CLM
Colorectal cancer (CRC) has potential to spread within the peritoneal cavity, and this transcoelomic
dissemination is termed “peritoneal metastases” (PM).The aim of this article was to summarise the current
evidence regarding CRC patients at high risk of PM. Colorectal cancer is the second most common cause of cancer
death in the UK. Prompt investigation of suspicious symptoms is important, but there is increasing evidence that
screening for the disease can produce significant reductions in mortality.High quality surgery is of paramount
importance in achieving good outcomes, particularly in rectal cancer, but adjuvant radiotherapy and chemotherapy
have important parts to play. The treatment of advanced disease is still essentially palliative, although surgery for
limited hepatic metastases may be curative in a small proportion of patients.
Digital version thesis Salvage for radiorecurrent prostate cancer, Max PetersMax Peters
This document discusses salvage therapy for prostate cancer recurrences after primary radiotherapy. It notes that patients undergoing radiotherapy are at risk of recurrent disease, which is often confined to the prostate and eligible for salvage treatment. Traditionally, salvage modalities targeted the entire prostate due to difficulties assessing localized recurrences, but this resulted in significant toxicity rates. Recent advances in MRI and biopsy techniques allow for focal salvage treatments targeting only the recurrent tumor area, maintaining cancer control while decreasing toxicity. Focal salvage Iodine-125 brachytherapy appears able to provide durable disease control with minimized toxicity. However, dose constraints are needed for organs at risk to prevent complications, and constraints developed for primary radiotherapy may not apply
This document summarizes a study examining the impact of squamous cell carcinoma of the head and neck (SCCHN) on patient weight status over 5 weeks of radiation therapy treatment. The study found an average weight loss of 3.12% (2.38 kg) over 5 weeks, though the results did not reach statistical significance. Multiple linear regression identified age, gender, and tumor site as explanatory variables for 13.44% of weight change. The document provides background on SCCHN incidence, treatment complications, weight loss studies, and the importance of nutrition for cancer patients. It concludes that SCCHN causes significant nutritional problems and weight loss, which are associated with decreased survival, and identifies a need for additional research on preventing
Establishment of a Rehabilitation Clinic for Colorectal Cancer. Will it End P...daranisaha
Colorectal cancer (CRC) is the third most common diagnosis and the second most lethal malignancy in both men and women.
To establish a rehabilitation clinic in the oncology department in hospitals and address its positive effect on colorectal cancer patients’ need.
Radiotherapy plays an important role in the management of urinary bladder cancers. It can be used as part of bladder-preserving protocols for muscle-invasive bladder cancer or as palliative treatment in elderly patients. Combined modality treatment with transurethral resection and concurrent chemoradiotherapy provides 5-year overall survival of 50-65% and bladder preservation in 38-43% of patients. External beam radiotherapy is typically delivered with a 4-field box technique to the whole pelvis at 45-50 Gy followed by a bladder boost to 60-65 Gy.
Hepatocellular & Pancreatic CarcinomasRHMBONCO
The document discusses hepatocellular carcinoma (HCC) and pancreatic cancer, including their epidemiology, risk factors, screening, diagnosis, staging, and management. For HCC, risk factors include hepatitis and other liver diseases, while targeted therapies such as sorafenib have shown efficacy. Surgical resection can cure early HCC but recurrence is common. For pancreatic cancer, risk increases with age and genetic factors, while surgery offers the only chance for cure if the cancer is resectable.
Cancer survival mortality_and_incidence_7_countries_1568689974RamiroCazco2
This study analyzed cancer survival, incidence, and mortality trends for seven cancers in seven high-income countries between 1995-2014 using data from 21 population-based cancer registries. The study found that 1-year and 5-year cancer survival increased across almost all cancer types and countries over this period. Survival was generally higher in Australia, Canada, and Norway than other countries for 2010-2014. Larger survival improvements were seen for younger patients and for cancers with poor prognosis like esophagus, stomach, pancreas, and lung. Progress in cancer control was evident for stomach, colon, lung (males), and ovarian cancers, as shown by increased survival and decreased mortality and incidence over time. However, international survival disparities
How to have quality of life in Advanced ovarian malignancyRajesh Gajbhiye
This document discusses advanced ovarian malignancy and improving quality of life. It notes that ovarian cancer is a leading cause of cancer death in women and is difficult to diagnose early. While most patients present with advanced disease, improvements in surgery and chemotherapy have increased survival rates to 45% at 5 years. Quality of life factors like physical, psychological, social and sexual issues are important to consider in treatment. Managing side effects, providing social support, and palliative care can help improve patient quality of life.
This document discusses cancer outcomes for Aboriginal and Torres Strait Islander people in Australia. It notes that Indigenous Australians have higher cancer incidence and mortality than non-Indigenous Australians. The disparity is due to higher risk factors, lower screening participation, later diagnosis, and less access to treatment for Indigenous people. Various organizations are working to address this, including Cancer Australia, through frameworks, leadership groups, and care pathways to improve prevention, screening, treatment and support for Indigenous cancer patients. Primary healthcare plays a key role through awareness, screening, care coordination and supporting research.
Background: The incidence of cancers is increasing worldwide, particularly in the developing countries as shown by recent cancer stastics from the WHO. It is even anticipated that with the increase in life expentancy, consequent upon inproved standard of living and globalization, the burden of cancers will increase within this millenium. With respective to cancer of the prostate, it is the most common type of cancer in urology. In developing countries, diagnostic is done at a late stage of evolution. In Cameroon, data on prostate cancer are scanty whereas the incidence of this disease is increasing. Objective: This article is designed to describe the epidemiological features of prostate cancer at the General Hospital of Yaoundé. Patients and methods: A 4-year retrospective study of patients seen with the diagnosis of cancer at the Medical Oncology unit of the Yaoundé General Hospital between January 2012 and December 2015. The demographic pattern (age of patients, socio professional activity, marital status), clinical features (cancer diagnosis), treatment modalities and outcome were studied. Main results: Of the 7 775 patients enrolled in the Medical Oncology Service over the study period, 1.4% (n = 108) cases of prostate cancer were seen. The prevalence over the study period was 1.38% and a relatively large annual growth of cases with an annual average of 27 cases was noted. The average age of patients was 67.82 years with a range of 34-83 years. The commonest presenting symptoms were the urinary frequency (54.63%) whereas the least common were fatigue (05.5%) and straining (03.70%). PSA was obtained in 49 patients, representing about 45.4% of all patients. Only 14 (01.26%) had biopsy reports. Conclusion: Prostate cancer is a major problem facing the aging male, and inadequate facilities make early detection difficult. Therefore, treatment is mainly palliative because of late diagnosis.
This document provides guidance for physicians on appropriate use of medical imaging for common clinical
presentations. It discusses when CT, MRI, ultrasound or other modalities are most useful for evaluating abdominal
pain, chest pain, headache and other issues. The goal is to promote efficient and radiation-limiting use of imaging
to aid accurate diagnosis while avoiding unnecessary exposure or costs. Imaging choice depends on clinical
findings, but CT and MRI may help identify conditions like appendicitis, aneurysms, infections or tumors causing
abdominal, chest or neurological symptoms.
Colon cancer is the second leading cause of cancer deaths in the US. Regular screening can reduce the risk of death from colon cancer by 33% as it allows early detection and removal of pre-cancerous polyps. Dr. Rajiv Datta of the Gertrude & Louis Feil Cancer Center specializes in colon cancer surgery using minimally invasive techniques when possible and advocates for regular screening colonoscopies. Follow-up care after treatment including physical exams, colonoscopies, and CEA blood tests is important to monitor for recurrence of colon cancer.
Gastric (stomach) cancer is the fourth most common cancer worldwide and the second leading cause of cancer deaths. In India, it is estimated that 50,000 new cases will be detected by 2020. Early symptoms are often vague and non-specific, but later symptoms include difficulty swallowing and vomiting. Diagnosis involves endoscopy with biopsy. Further tests like CT, PET, and EUS are used to determine stage and plan for treatment including curative surgery, chemotherapy, or palliative care. For early stage cancers, surgery offers the best chance of cure while later stages may be treated with chemotherapy or chemoradiotherapy before or after surgery.
This document discusses thyroid cancer guidelines from ESMO. It covers:
1) Incidence and epidemiology of the main types of thyroid cancer, including higher rates in women and certain races.
2) Diagnosis using ultrasound and fine needle aspiration biopsy to evaluate nodules, with molecular testing also showing promise.
3) Treatment for differentiated thyroid cancer typically involving total thyroidectomy followed by staging and risk assessment to guide further treatment and follow-up.
This document provides information about an oncology certification program called "abc in oncology". It discusses the program's aim to provide oncology knowledge to non-oncologists across various medical specialties. The program consists of several modules covering general cancer topics and specific cancer types. It is held every 3-4 weeks for a duration of 12 months, with evaluations to assess participation and knowledge. The document also includes an agenda and details for upcoming modules on colon cancer and breast cancer.
Similar to Selective internal radiation therapy for the treatment of liver cancer (20)
External aortic root support (EARS) using the ExoVasc device provides a less invasive alternative to surgery for patients with Marfan syndrome at risk of aortic aneurysm or dissection. Evidence from three studies with 20 patients found that EARS maintained aortic diameter over a median follow up of 20 months with no device failures or deaths, though two patients required additional surgery due to ill-fitting devices. While EARS may delay or avoid more radical surgery, current evidence is limited by the small patient numbers and short term follow up. The device is not approved in Australia or many other countries. Larger and longer term studies are still needed to establish the safety and effectiveness of EARS compared to standard surgery.
This document provides an overview of a systematic review conducted by the Australian Safety and Efficacy Register of New Interventional Procedures – Surgical (ASERNIP-S) group for the World Health Organization (WHO) on medical devices needed by older people. The review focused on the top five health conditions causing disability-adjusted life years for those aged 60-79 in the Western Pacific Region: cardiovascular diseases, malignant neoplasms, respiratory diseases, sense organ diseases, and neuropsychiatric conditions. Over 1,500 studies were included in the review to identify medical devices categorized as preventative, diagnostic, or therapeutic. The review was limited by its rapid systematic review methodology but provides a foundation for improving access to appropriate
The document is a report from the Medical Services Advisory Committee (MSAC) that assesses the insertion of colonic stents for the management of malignant large bowel obstructions. The report summarizes the evidence on the safety, effectiveness and economic considerations of using colonic stents compared to surgery. It finds that colonic stents are generally safe when performed by experienced operators. Stents may be effective as a bridge to surgery or for palliation to relieve bowel obstructions in patients who are not candidates for surgery. However, the cost-effectiveness of stents compared to other treatments depends on the specific clinical scenario. The report considers the evidence and provides recommendations to inform government funding decisions.
The document summarizes extracorporeal photopheresis (ECP) for the treatment of graft-versus-host disease (GVHD). ECP involves separating a patient's white blood cells from red blood cells, treating the white cells with a photosensitizing agent and ultraviolet light, and returning the treated cells to the patient. A case series of 27 pediatric patients found that ECP induced complete or partial remission in 11 of 21 acute GVHD patients and 3 of 6 chronic GVHD patients, with a median time to response of two to four cycles. Adverse events were mild. ECP may provide an effective treatment option for GVHD patients who fail standard steroid therapies.
1. The document provides an update on evidence for the use of the InteguSeal® microbial sealant to reduce surgical site infections following cardiac surgery.
2. Two studies were included in the update - a randomized controlled trial and a pseudo-randomized controlled trial comparing the sealant to standard cleaning and draping.
3. The sealant forms a continuous, breathable barrier on the skin to immobilize bacteria and prevent migration into incision sites, with the goal of reducing surgical site infections.
This document assesses the use of ultrasound guidance for major vascular access and percutaneous neural blockade. It finds:
1) Ultrasound guidance improves the technical success and first attempt success of vascular access procedures compared to traditional palpation or landmark techniques. It reduces complications.
2) For percutaneous neural blockade, ultrasound guidance improves the accuracy of needle placement compared to electrical nerve stimulation alone or traditional landmark-based techniques. It has comparable effectiveness to electrical nerve stimulation for providing effective neural blockade, but with fewer complications.
3) Ultrasound guidance is more costly upfront than traditional techniques due to equipment and training costs. However, it may reduce downstream costs associated with procedure complications or additional attempts.
Selective internal radiation therapy for the treatment of liver cancer
1. HealthPACT
Health Policy and Advisory Committee
on Technology
Australia and New Zealand
Technology Brief
Selective internal radiation therapy for the
treatment of liver cancer
(v1.0)
August 2011
3. TECHNOLOGY BRIEF
REGISTER ID WP022 (V1.0)
NAME OF TECHNOLOGY SELECTIVE INTERNAL RADIATION THERAPY
PURPOSE AND TARGET GROUP TREATMENT OF PATIENTS WITH NON-RESECTABLE
HEPATOCELLULAR CARCINOMA OR LIVER METASTASES
STAGE OF DEVELOPMENT (IN AUSTRALIA)
Yet to emerge Established
Established but changed indication
or modification of technique
Experimental
Investigational Should be taken out of use
Nearly established
AUSTRALIAN THERAPEUTIC GOODS ADMINISTRATION APPROVAL
Yes ARTG number 149332
No
Not applicable
INTERNATIONAL UTILISATION
LEVEL OF USECOUNTRY
Trials underway or
completed
Limited use Widely diffused
Australia
Canada
Egypt
Europe
Hong Kong
India
Israel
Kuwait
Malaysia
New Zealand
Philippines
Saudi Arabia
Singapore
South Africa
South Korea
Switzerland
Taiwan
Thailand
Turkey
United States of America
Selective internal radiation therapy for the treatment of liver cancer: August 2011 1
4. IMPACT SUMMARY
Selective internal radiation therapy (SIRT) is a new modality for the treatment of primary
and metastatic liver cancer. Radioactive microspheres containing the beta radiation emitting
isotope yttrium-90 are delivered to the tumorous part of the liver via injection into the
hepatic artery.
BACKGROUND
Liver cancers can be primary or secondary/metastatic. Hepatocellular carcinoma (HCC) is
the most common form of primary liver cancer in adults. It is commonly caused by chronic
liver diseases such as hepatitis and cirrhosis (Russell et al 2004). Patient prognosis largely
depends on the TNM staging*
of the disease at the time of diagnosis, its histological pattern
and coexistent cirrhosis (Balis and Lauwers 2004). Secondary liver cancer or liver
metastases are often due to primary colorectal cancer. Metastases from colorectal cancer may
spread by local extension or through the blood stream or lymphatic system (most commonly
via the portal vein) (Russell et al 2004). According to the National Institute for Health and
Clinical Excellence (NICE) in the United Kingdom, the five-year survival rate after
diagnosis of colorectal cancer is approximately 45 per cent (NICE 2004). The National
Comprehensive Cancer Network in the United States of America (USA) affirms that the
remaining 50–60 per cent of colorectal cancer patients eventually develop metastases
(NCCN 2009). The liver is often the first site of metastases and may be the only site of
spread in 30–40 per cent of patients with advanced colorectal cancer (Simmonds et al 2006).
Surgical resection is the best curative option for liver cancer. In the case of isolated HCC,
liver transplantation is a treatment option. Ablation techniques such as cryotherapy,
radiofrequency thermal ablation, microwave coagulation and laser electrocoagulation are
treatment options in patients for whom resection presents a risk. However, the majority of
liver cancers are not eligible for surgery or ablation at the time of diagnosis (Gray et al
2001).
Chemotherapy plays an important role in the treatment of liver metastases. Patients may
benefit in terms of both survival and quality of life (QOL) by receiving a combination of
chemotherapy and best supportive care†
(Ahmed et al 2004). Patients with unresectable
metastatic disease have a median survival of < 10 months if treated by best supportive care
alone, while an improved median survival of 15 to 21.5 months may be achieved by
*
TNM staging is based on the number and size of the primary tumour (T), the extent of the spread to nearby lymph nodes
(N) and the presence of metastases (M) (American Cancer Society 2011).
†
According to the European Organization for Research and Treatment of Cancer (EORTC) Pain and Symptom Control Task
Force, best supportive care for cancer patients is defined as multi-professional attention to the patient’s overall physical,
psychosocial, spiritual and cultural needs, and should be available at all stages of the illness, for patients of all ages, and
regardless of the current intention of any anti-cancer treatment (Ahmedzai et al 2001).
5. administering a combination chemotherapy regimen (Delaunoit et al 2005; Grothey et al
2004; Tournigand et al 2004). A minority of initially unresectable patients (3.3–12.5%)
become resection candidates following chemotherapy (Delaunoit et al 2005). Chemotherapy
for liver metastases can be either systemic or regional (administered via the hepatic artery),
and use agents such as fluoropyrimidines (commonly 5-fluorouracil with irinotecan or
oxaliplatin).
SIRT, also known as radio-embolisation or transarterial radio-embolisation (TARE), is a new
and developing modality for managing liver cancers that are not amenable to surgery. High-
energy beta particles of yttrium-90 (with a half-life of 64 hours and maximum tissue
penetration of 11 mm) are delivered via the hepatic artery, through either a surgically
implanted permanent hepatic artery port or a percutaneous transfemoral hepatic artery
catheter. The latter technique has been the technique of choice since 2002. The increased
yttrium concentration within the microvasculature of the liver tumour produces a local radio-
therapeutic effect.
Two products were identified for use in SIRT at the time of writing: SIR-Spheres® (Sirtex
Medical Limited, Australia) and TheraSphere®
(Nordion, Canada).
CLINICAL NEED AND BURDEN OF DISEASE
The incidence of liver cancer has steadily increased in recent years (AIHW 2010). During
2001, 853 new cases of primary liver cancer were reported in Australia, excluding HCC
caused by hepatitis B and C (AIHW 2010). By 2007 this number had increased to 1,169 and
accounted for 1,109 deaths (AIHW 2010). The incidence and prevalence of hepatitis B and C
have also steadily increased over time, with a total of 242,000 Australians reported to have
been infected in 2004 (including 14,499 new cases in that year alone) (National Centre in
HIV Epidemiology and Clinical Research 2004).
Many patients with colorectal cancer will develop metastatic liver disease. Colorectal cancer
is the second most common cancer in Australia, making up 13.1 per cent of all reported
cancers in 2007 (males 12.6%, females 13.9%) (AIHW 2010). From 1982 to 2007 the
incidence of colorectal cancer in males increased from 67 to 75 cases per 100,000 and in
females from 50 to 55 cases per 100,000 (AIHW 2010). Interactive National Hospital
Morbidity Data reported that 1,731 patient days‡
were utilised during 1998–99 due to
malignant neoplasm of the liver and intrahepatic bile ducts, which increased to 3,371 patient
days by 2007–08 (AIHW 2011). These data may describe the burden for both primary and
secondary liver cancers.
‡
Patient days were defined as “the total number of days for patients who were admitted for an episode of care and who
separated during a specified reference period. A patient who is admitted and separated on the same day is allocated 1 patient
day”.
6. DIFFUSION
SIR-Spheres are microspheres labelled with yttrium-90 that are delivered direct to the
tumour via a catheter in the hepatic artery. This product is available in the USA, Europe,
Australia, New Zealand, Hong Kong, Switzerland, Turkey, Taiwan, South Korea, Singapore,
Malaysia, India, Philippines, Thailand and Egypt.
SIR-Spheres microspheres were first listed on the Australian Register of Therapeutic Goods
(ARTG) on February 27, 1998 as a medical device under AUSTL No 63369 and were
subsequently approved as an Active Implantable Medical Device on January 21, 2008 under
ARTG number 149332 (under the Therapeutic Goods Administration (TGA) revised
legislation). The TGA defines SIR-Spheres as radionuclide permanent implants for the
treatment of inoperable liver cancer (TGA 2008).
In the USA, SIR-Spheres are fully approved by the Food and Drug Administration (FDA) for
use in the treatment of inoperable liver metastases secondary to colorectal cancer. SIR-
Spheres microspheres were issued with a European CE Mark approval by British Standards
Institution, acting as an official Notified Body, on October 16, 2002 (No CE 60079) (Sirtex
Medical Limited 2011).
Currently, three Medicare Benefit Schedule (MBS) item numbers relate to SIR-Spheres. One
refers to the dosimetry, preparation and injection of SIR-Spheres by a nuclear medicine
specialist (35404) and the remaining two describe the interventional radiologist’s
catheterisation process for administering SIR-Spheres into the liver (35406, 35408) (MBS
2011a; MBS 2011b; MBS 2011c). Medicare does not appear to cover the cost of the SIR-
Spheres product itself. However, SIR-Spheres (including delivery apparatus) appear on the
Prosthesis List, as a temporary listing pending review, with a minimum benefit of $8,230.00.
The TheraSphere medical device delivers yttrium-90 loaded glass microspheres to the
tumorous part of the liver and is intended for use during SIRT in HCC. TheraSphere is
available in Canada, USA, Europe (Belgium, France, Germany, Italy and Spain), Turkey,
Egypt, Saudi Arabia, India, Kuwait and South Africa (Nordion 2011a). Nordion has not
sought TGA approval for ThereSphere in Australia. TheraSphere received humanitarian
device exemption for the treatment of HCC in the USA (Nordion 2011b).
COMPARATORS
Treatment for liver cancer depends on TNM stage. Surgical resection is the ideal option and
ablation techniques may also be useful. However, the majority of liver cancers are not
eligible for surgical resection or local ablation at the time of diagnosis (Gray et al 2001).
Patients with advanced liver cancer who receive best supportive care would benefit in both
survival and QOL by also receiving chemotherapy, which should be considered the primary
comparator to SIRT. Chemotherapy may be administered either systemically or regionally
7. via the hepatic artery, using agents such as the fluoropyrimidines (commonly 5-fluorouracil
together with irinotecan or oxaliplatin).
SAFETY AND EFFECTIVENESS ISSUES
Three randomised controlled trials (RCTs) reporting on the use of SIRT for the treatment of
liver metastases were identified (Gray et al 2001; Hendlisz et al 2010; Van Hazel et al 2004).
No RCTs were identified for the use of SIRT for HCC.
Study profiles
Hendlisz et al (2010) conducted a prospective, open label phase III RCT at three sites in
Belgium to assess the safety and efficacy of intra-arterial yttrium-90 resin microspheres
(SIR-Spheres). Patients were over 18 years of age with histologically-proven colorectal
adenocarcinoma that had metastasised only to the liver. None were candidates for curative
resection or ablation and all were resistant to, or intolerant of, standard chemotherapy.
Patients were also required to have adequate function of bone marrow, liver and kidneys.
Patients were randomised using the minimisation technique, with institution and type of
progression (while on chemotherapy or 6 months post-chemotherapy) as stratification
factors. Of 46 randomised patients, 44 were eligible, of whom 21 were assigned to the
interventional group and 23 to the control group.
The control group received intravenous (IV) fluorouracil 300 mg/m2
for 14 days every three
weeks until progression. The intervention group received isotope yttrium-90 bound to resin
microspheres (radio-embolisation) via a hepatic intra-arterial injection. The intervention
group also received IV fluorouracil 225 mg/m2
for 14 days followed by a one week break,
and then 300 mg/m2
for 14 days, every three weeks. All patients were followed up for a
median duration of 24.8 months (range 2–41 months).
Van Hazel et al (2004) conducted a phase II RCT that compared a single administration of
SIR-Spheres plus systemic chemotherapy with systemic chemotherapy alone in patients with
liver metastases due to advanced colorectal cancer (with or without extra-hepatic
metastases). This study was based at the Mount Hospital (Western Australia (WA)), Sir
Charles Gairdner Hospital (WA) and Greenslopes Hospital (Queensland) and was designed
to detect a 20 per cent difference in grade 4 toxicity event rate, with a required sample size of
18 patients. A total of 21 patients were recruited. Selection criteria included histologically-
proven large bowel adenocarcinoma with unequivocal computed tomography (CT) scan
evidence of liver metastases that could not be treated by resection or any locally ablative
method, plus adequate haematological, hepatic and renal function. Patients who previously
received chemotherapy or radiotherapy for liver metastases, and those who had cerebral
metastases and evidence of cirrhosis, ascites or portal hypertension, were excluded. Patients
were stratified before randomisation by hospital, according to the presence/absence of extra-
8. hepatic metastases and the extent of tumour involvement in the liver (> or < 25%
involvement). Randomisation occurred through an independent body using a computer-based
program. Blinding of patients and treatment providers was not logistically possible; however,
all serial CT scans were read by a blinded independent person.
Both treatment groups received systemic chemotherapy, which consisted of 5-fluoruracil 425
mg/m2
body surface area (BSA) per day plus leucovorin 20 mg/m2
per day for five
consecutive days, repeated at four-weekly intervals. This was continued until evidence of
unacceptable toxicity or disease progression were apparent, or until patients requested
cessation. Patients in the intervention group received SIR-Spheres into the hepatic artery via
a transfemoral catheter on the third or fourth day of the second cycle of chemotherapy. Five
patients in the intervention group received the standard dose of 2.5 gigabecquerel (GBq) of
yttrium-90, while the remaining six received a dose from 1.5 to 2.1 GBq of yttrium-90,
according to a formula based on BSA and percentage tumour involvement. Minimum
follow-up duration was not mentioned; however, at 42.5 months following randomisation
only one patient was still alive.
Finally, Gray et al (2001) conducted an early phase III RCT that compared SIRT and
chemotherapy with chemotherapy alone. This study enrolled 74 patients at the Royal Perth
Hospital (WA) and the Sir Charles Gairdner Hospital (WA) from 1991–97. Several authors
were common to the study by Van Hazel et al (2004) above. Patients were diagnosed with
bi-lobar, non-resectable and non-ablatable metastases in the liver and regional lymph nodes
arising from primary adenocarcinoma of the large bowel, without distant metastases. All
patients had undergone complete surgical resection of a primary adenocarcinoma of the large
bowel. Previous systemic chemotherapy for the metastases was acceptable but patients who
had received hepatic radiotherapy were excluded. Of the initial 74 patients, 70 were
ultimately eligible for trial inclusion. Patients were stratified into three groups based upon
tumour involvement of the liver prior to randomisation (< 25% involvement, 25–50%
involvement, > 50% involvement). Randomisation took place using the blinded envelope
batch method and was controlled by an independent person; however, the method used to
develop the randomisation sequence was not reported. Patients received either a regimen of
hepatic artery chemotherapy with floxuridine (control group) or the same chemotherapy with
a single injection of SIR-Spheres (intervention group). Chemotherapy was administered in
12-day cycles every four weeks. The dosage of the SIR-Spheres injection was determined by
tumour size and ranged from 2–3 GBq of yttrium-90. Follow-up tests consisted of monthly
physical examination, haematological screening, liver function tests, and serum carcino-
embryonic antigen (CEA) in addition to three-monthly CT scans of the abdomen. All
patients were followed up for a minimum of 3.5 years.
Additional study characteristics for the three identified RCTs are presented below in Table 1.
9. Table 1: Study characteristics of included studies
Pre-interventional patient and tumour characteristicsStudy na
/Nb
SIRT Comparator
Male
(%)
Mean age
(years)
Primary
cancer
Extra-
hepatic
metastases
(%)
> 25%
Liver
involved
(%)
Prior treatment
with
chemotherapy
(%)
Hendlisz et al
2010
44/46 SIR-Spheres
(n=21)
Systemic
chemotherapy
(n=23)
64 62
(SIRT 62;
comparator 62)
Colorectal 0 NR 100
Van Hazel et
al 2004
21/21 SIR-Spheres
(n=11)
Systemic
chemotherapy
(n=10)
86 65
(SIRT 64;
comparator 65)
Colorectal 24 29 0
Gray et al
2001
70/74 SIR-Spheres
(n=36)
HAC (n=34) 77 61
(SIRT 62;
comparator 59)
Colorectal 0 31 14
HAC: hepatic artery chemotherapy; NR: not reported; SIRT: selective internal radiation therapy
a
Number completing trial.
b
Number originally enrolled.
Selective internal radiation therapy for the treatment of liver cancer: August 2011 7
10. Safety
The safety outcomes measured included treatment-related toxicity, adverse events and
mortality. All three studies reported the frequency of grade 3 and 4 toxicity (Table 2).
Table 2: Reported adverse events and treatment-related deaths
Hendlisz et al
2010
Van Hazel et al
2004
Gray et al 2001Event
SIRT
(n=21)
Comp
(n=22)
SIRT
(n=11)
Comp.
(n=10)
SIRT
(n=36)
Comp
(n=34)
Grade 3 and 4 toxicity events
Low haemoglobin or
granulocytopenia NR NR 3 0 0 1
GI events (nausea, vomiting,
diarrhoea, stomatitis, anorexia) 0 2 8 5 1 3
Liver abscess NR NR 1 0 NR NR
Radiation-induced cirrhosis NR NR 1a
0 NR NR
Liver function test abnormality NR NR 0 0 22 19
Fatigue 0 6 NR NR NR NR
Pulmonary events 0 2 NR NR NR NR
Allergy 0 1 NR NR NR NR
Hand-foot syndrome 1 0 NR NR NR NR
Total number of grade 3 and 4
toxicity events 1 11 13 5 23 23
Treatment related deaths NR NR 1b
0 NR NR
GI: gastrointestinal; comp: comparator; NR: not reported.
a
Very small patient and SIRT dose considered excessive.
b
Death due to chemotherapy-induced neutropenia and associated sepsis after the fourth cycle of treatment.
Hendlisz et al (2010) showed an advantage of SIR-Spheres over systemic chemotherapy
in terms of toxicity, although the difference was not statistically significant (p = 0.10). In
contrast, Van Hazel et al (2004) showed 13 grade 3 and 4 toxicities and one treatment-
related death in the intervention group, compared with only five toxicities in the control
group (no statistical analysis provided). Gray et al (2001) reported that the risk of death
from progression of liver metastases was 3.1 times higher in the control group (95%
confidence interval (CI); [1.1, 8.8], p=0.03) compared with the interventional group. In
Selective internal radiation therapy for the treatment of liver cancer: August 2011 8
11. Selective internal radiation therapy for the treatment of liver cancer: August 2011 9
this study, the addition of SIR-Spheres did not create statistically significant, clinically
relevant, treatment-related toxicity, as both groups experienced the same number of grade
3 and 4 toxicities (n=23).
Effectiveness
The effectiveness outcomes measured included tumour response rate, time to disease
progression in the liver, survival rate and QOL.
Hendlisz et al (2010) reported hepatic response according to the Response Evaluation
Criteria in Solid Tumours (RECIST) criteria§
for target lesions. Most patients had a
minimum of two lesions at the time of randomisation. The median sum of diameters of
targeted lesions was 176.5 mm for the interventional group and 216 mm for the control
group. Two patients from the interventional group had tumour response (9.5%) compared
with none in the control group (p = 0.22). The disease control rate was calculated by
adding partial response and stable diseases rates. Significantly more intervention patients
than control patients recorded disease control (18/21, 86% versus 8/23, 35%, p = 0.001).
The primary endpoint was time to liver progression, and the median time was 5.5 months
in the intervention group and 2.1 months in the control group (Hazard ratio [HR] 0.38;
95% CI [0.20, 0.72], p = 0.003). The overall time for tumour progression was 4.5 months
for the intervention group versus 2.1 months for controls (HR 0.51; 95% CI [0.28, 0.94],
p = 0.03). Overall survival was measured as the time elapsed between randomisation and
death). Median overall survival was 10 months for the intervention group compared with
7.3 months for the control group (HR 0.92; 95% CI [0.47, 1.78], p = 0.80). Notably, for
ethical reasons, 25/44 patients received further treatment after disease progression
(including 10 control group patients who received radio-embolisation treatment).
Van Hazel et al (2004) also measured tumour response using the RECIST criteria. No
complete responses were recorded in either group, and the differences in tumour response
rates were not statistically significant. Several patients in the intervention group showed
partial response, with CT evidence of tumour replacement by small dense calcifications.
Time to progressive disease was significantly longer in the intervention group (18.6
months versus 3.6 months in the control group) (p < 0.0005). Median survival was
significantly longer in the intervention group (29.4 months versus 12.8 months in the
control group, HR 0.33; 95% CI [0.12, 0.91], p = 0.025). QOL and patient well-being
were measured at randomisation and at 3-month intervals using the validated 23-point
§
RECIST Criteria: Complete Response (CR): Disappearance of all target lesions, Partial Response (PR): At least a 30%
decrease in the sum of the longest diameter (LD) of target lesions, taking as reference the baseline sum LD, Stable
Disease (SD): Neither sufficient shrinkage to qualify for PR nor sufficient increase to qualify for PD, taking as
reference the smallest sum LD since the treatment started, Progressive Disease (PD): At least a 20% increase in the sum
of the LD of target lesions, taking as reference the smallest sum LD recorded since the treatment started or the
appearance of one or more new lesions (adapted from National Cancer Institute 2011).
12. Functional Living Index - Cancer questionnaire and the Spitzer index. Neither showed
statistically significant differences between the treatment groups (p = 0.96 and p = 0.98,
respectively).
Finally, in the study by Gray et al (2001) tumour response was measured by two
independent medical practitioners according to tumour volume, serum CEA changes and
tumour area. For tumour volume, a partial response was defined as ‘an objectively
measured decrease in tumour size by 50 per cent on two or more successive CT scans not
less than four weeks apart, after randomisation and before evidence of progressive
disease in the liver’ and a complete response was defined as ‘the disappearance of all
tumour on two successive CT scans not less than four weeks apart, after randomisation
and before evidence of progressive disease in the liver.’ Significantly more patients in the
intervention group achieved either a complete or partial response in tumour volume (50%
versus 24% of the control group, p = 0.03). Serum CEA changes were measured only for
patients in whom the serum CEA was elevated before the start of protocol treatment.
Patients in the intervention group experienced a significantly larger change in serum CEA
levels compared with the control group (72% versus 47%, p = 0.004), indicating a greater
proportion of these patients responded to treatment. To measure tumour area, cross-
sectional diameters of all measurable lesions seen on serial CT scans were summed.
Significantly more patients in the intervention group achieved either a complete or partial
response (44% versus 18% for control group patients, p = 0.01). Time to disease
progression was significantly longer in the intervention group than in the control group in
terms of tumour area (15.9 versus 9.7 months, p = 0.001) and tumour volumes (12.0
versus 7.6 months, p = 0.04). Survival time from randomisation to death or last follow up
was not different according to a Kaplan-Meier analysis, although a non-significant trend
favoured the intervention group. Cox regression analysis suggested that patients who
received the SIRT treatment and who survived more than 15 months experienced a
survival advantage compared with those who received chemotherapy alone. With respect
to QOL, differences between treatment groups were not statistically significant.
A summary of the statistically significant findings reported in the three included RCTs is
provided in Table 3. All of these results significantly favoured SIRT for treatment of liver
metastases.
Selective internal radiation therapy for the treatment of liver cancer: August 2011 10
13. Table 3: Statistically significant findings reported in the included RCTs
Outcome SIRT group Comparator
group
P value
Hendlisz et al 2010
Disease control rate 86% 35% 0.001
Median time to liver progression 5.5 months 2.1 months 0.003
Overall time to tumour progression 4.5 months 2.1 months 0.03
Van Hazel et al 2004
Time to disease progression 18.6 months 3.6 months <0.0005
Median survival time 29.4 months 12.8 months 0.025
Gray et al 2001
Tumour response: tumour volume 50% 24% 0.03
Tumour response: serum CEA changes 72% 47% 0.004
Tumour response: tumour area 44% 18% 0.01
Time to disease progression: tumour area 15.9 months 9.7 months 0.001
Time to disease progression: tumour volume 12 months 7.6 months 0.04
COST IMPACT
A 2002 Medical Services Advisory Committee (MSAC) report stated that, at that time, it
was not possible to give a reliable estimate of cost per life year saved or cost per quality
adjusted life year due to the lack of reliable evidence regarding the benefit of the
outcomes achieved using SIRT (Howard and Stockler 2002). MSAC concluded that a
comprehensive, Australian-based assessment of costs and effects associated with
systemic chemotherapy, hepatic arterial chemotherapy and SIRT was needed, to provide
a basis for a comparison between systemic therapy and hepatic chemotherapy with or
without SIRT (Howard and Stockler 2002).
Subsequently, in an abstract published in the Italian Journal of Public Health, Norris and
Coleman (2005) presented cost data pertaining to the use of SIRT for the treatment of
colorectal liver metastases. In what they considered a highly conservative cost
effectiveness analysis, an incremental cost effectiveness ratio (ICER) of $21,033 per life
Selective internal radiation therapy for the treatment of liver cancer: August 2011 11
14. year gained was reported, with one- and two-way sensitivity analyses ranging from
$12,002 - $86,172 per life year gained. The authors stated that, considering the average
survival gain of 12 months per patient and the ICER of $21,033 per life year gained, the
addition of SIRT to systemic chemotherapy represents good value for money for a
population of patients with otherwise poor prognosis.
According to the manufacturer of SIR-Spheres, the cost of one dose is $8,230 plus GST,
which is fully funded by health funds (i.e. there is no gap payment) (Sirtex Medical
Limited, pers. comm., 5 May 2011). The manufacturer also stated that the associated cost
of equipment for the work-up procedure in the angiography suite (including guide wires,
micro catheters and contrast media), CT/positron emission tomography (PET) scans and
the implantation procedure are covered by all health funds (with gap payments dependent
upon the health fund) (Sirtex Medical Limited, pers. comm., 5 May 2011).
ETHICAL, CULTURAL OR RELIGIOUS CONSIDERATIONS
There were no issues identified from the retrieved material.
OTHER ISSUES
All three included studies may be associated with a risk of bias. Hendlisz et al (2010)
permitted patients with documented progression to cross over from the control to the
interventional group at the investigator’s discretion and 10 patients did so. The SIR-
Spheres used in the study were supplied by Sirtex and one author received honoraria from
this manufacturer. Van Hazel et al (2004) reported that two patients in the control group
were removed from treatment due to rapid deterioration. It was also noted that the control
group received more chemotherapy cycles compared with the intervention group.
Gray et al (2001) reported the presence of extra hepatic disease that was not balanced
between the treatment groups at baseline. A majority (77%) of the intervention group
were reported to have had extra-hepatic malignancy, compared with only half of the
control group. Additionally, the study was originally designed to enrol 95 patients in
order to detect a 30 per cent increase in median survival, but was closed after entering 74
patients. Authors listed the reasons for insufficient enrolment as: ‘increasing patient and
physician reluctance to undergo randomisation, a decision by the FDA to accept
treatment-related response and time to disease progression as acceptable criteria for
premarket application approval, and lack of funding to complete the study.’
Sirtex is currently sponsoring a post-marketing RCT on SIR-Spheres microspheres across
sites in Australia, New Zealand, Europe, the Middle East and the USA (with sites in Asia
anticipated to open shortly), with the aim of recruiting 460 patients. There are also two
Selective internal radiation therapy for the treatment of liver cancer: August 2011 12
15. RCTs (funded by Sirtex) underway for the treatment of HCC with SIR-Spheres, one in
Singapore and another in Germany. A third in France is expected to commence shortly.
SUMMARY OF FINDINGS
All three RCTs reported safety issues relating to grade 3 and 4 toxicity. One study
showed the superiority of SIR-Spheres in terms of potential toxicity (Hendlisz et al
2010). Similarly, in one study the risk of death from disease progression was three times
higher in the control group compared with the interventional group (P = 0.03) (Gray et al
2001). In contrast, the study by Van Hazel et al (2004) reported more incidents of severe
toxicity in the intervention group compared with the control group (13 versus 5; no
statistical analysis provided).
In all three RCTs, SIRT patients demonstrated higher tumour response rates than patients
who received comparator treatments; however, these differences were not statistically
significant. SIRT patients also showed better outcomes in terms of hepatic progression,
with one study showing statistical significance. Progression-free survival and overall
survival were better in SIRT patients; however, again none of these differences were
statistically significant. Two of the included studies reported QOL outcomes, and these
were not significantly different between treatment groups.
Overall, this technology brief does not identify alarming safety issues related to the use of
SIRT instead of standard treatments. In the three included studies, the likelihood of
achieving better tumour response, and time to progression or progression-free survival,
appears to be higher using SIRT.
HEALTHPACT ASSESSMENT
Available evidence appears promising and highlights the potential benefits of SIRT for
the treatment of liver cancer; however, a company-based trial is currently underway, the
results of which are scheduled to be presented to MSAC in due course. As such,
HealthPACT have recommended that no further assessment of SIRT is required at this
time.
NUMBER OF STUDIES INCLUDED
Total number of studies 3
Total Level II studies 3
REFERENCES
Ahmed N, Ahmedzai S, et al. Supportive care for patients with gastrointestinal cancer.
Cochrane Database of Systematic Reviews 2004; Issue 3.
Selective internal radiation therapy for the treatment of liver cancer: August 2011 13
16. Ahmedzai SH, Lubbe A, Van den Eynden B, 2001, ‘Towards a European standard for
supportive care of cancer patients. A coordinated activity funded by DGV’, final report
for EC on behalf of the EORTC Pain and Symptom Control Task Force, pp. 1–25.
American Cancer Society, Liver cancer, American Cancer Society, USA, 2011, viewed
April 2011, <http://www.cancer.org/cancer/livercancer/detailedguide/liver-cancer-
staging>.
Australian Institute of Health and Welfare (AIHW) 2010, Cancer in Australia: an
overview, AIHW, Canberra.
Australian Institute of Health and Welfare (AIHW), Interactive national hospital
morbidity database, AIHW, Canberra, 2011 viewed 6 May 2011,
<http://www.aihw.gov.au/data-cube/?id=10737418525&libID=10737418524>.
Balis UJ and Lauwers GY. Pathology and natural history of hepatocellular carcinoma. In:
Abbruzzese JL, Evans DB, Willett CG, Fenoglio-Preiser C. Gastrointestinal Oncology.
New York: Oxford University Press, 2004; 507–514.
Delaunoit T, Alberts SR, et al. Chemotherapy permits resection of metastatic colorectal
cancer: experience from Intergroup N9741. Annals of Oncology 2005; 16(3): 425–429.
Gray B, Van Hazel G, et al. Randomised trial of SIR-Spheres plus chemotherapy vs.
chemotherapy alone for treating patients with liver metastases from primary large bowel
cancer. Annals of Oncology 2001; 12(12): 1711-1720.
Grothey A, Sargent D, Goldberg RM, Schmoll HJ. Survival of patients with advanced
colorectal cancer improves with the availability of fluorouracil-leucovorin, irinotecan and
oxaliplatin in the course of treatment. Journal of Clinical Oncology 2004; 22(7): 1209-
1214.
Hendlisz A, Van den Eynde M, et al. Phase III trial comparing protracted intravenous
fluorouracil infusion alone or with Yttrium-90 resin microspheres radioembolization for
liver-limited metastatic colorectal cancer refractory to standard chemotherapy. Journal of
Clinical Oncology 2010; 28(23): 3687-3694.
Howard K, Stockler M. Selective internal radiation therapy for hepatic metastases using
SIR-Spheres®. Medical Services Advisory Committee Application 1034 Assessment
Report. Canberra: Commonwealth of Australia, 2002.
Medicare Benefits Schedule (MBS), MBS item number 35404, Australian Government
Department of Health and Ageing, Canberra, 2011a, viewed 6 May 2011,
<http://www9.health.gov.au/mbs/search.cfm?q=35404&sopt=I>.
Medicare Benefits Schedule (MBS), MBS item number 35406, Australian Government
Department of Health and Ageing, Canberra, 2011b, viewed 6 May 2011,
<http://www9.health.gov.au/mbs/search.cfm?q=35406&sopt=I>.
Medicare Benefits Schedule (MBS), MBS item number 35408, Australian Government
Department of Health and Ageing, Canberra, 2011c, viewed 6 May 2011,
<http://www9.health.gov.au/mbs/search.cfm?q=35408&sopt=I>.
National Cancer Institute (NCI), RECIST criteria, National Institutes of Health, USA,
2011, viewed 18 May 2011, <www3.cancer.gov/bip/RECIST.htm>.
Selective internal radiation therapy for the treatment of liver cancer: August 2011 14
17. National Centre in HIV Epidemiology and Clinical Research. HIV/AIDS, viral hepatitis
and sexually transmissible infections in Australia Annual Surveillance Report. Sydney:
the University of New South Wales, 2004.
National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines
in Oncology – Colon Cancer. 3rd
edn. Fort Washington: National Comprehensive Cancer
Network, 2004.
National Institute of Clinical Excellence (NICE). Improving outcomes in colorectal
cancer. London: NICE, 2004.
Nordion, TheraSpheres, treatment centres, Nordion, Canada, 2011a, viewed May 2011,
<http://www.nordion.com/therasphere/treatmentcenters_intl/europe.asp>.
Nordion, TheraSpheres, physicians, Nordion, Canada, 2011b, viewed May 2011,
<http://www.nordion.com/therasphere/physicians_us/indications.asp>.
Norris S, Coleman K. Clinical and cost-effectiveness of SIRT for colorectal liver
metastases: an application for reimbursement in Australia [abstract]. 2nd
Annual HTAi
meeting, 2005, June 20-22, Rome, Italy. Italian Journal of Public Health 2005 2(2):
(Supplement 1): 272.
Russell RCG, Williams NS, Bulstrode CJK. Bailey and Love’s Short Practice of Surgery.
24th edn. New York: Oxford University Press, 2004.
Simmonds PC, Primrose JN, et al. Surgical resection of hepatic metastases from
colorectal cancer: a systematic review of published studies. British Journal of Cancer
2006; 94(7): 982–999.
Sirtex Medical Limited, About SIR Spheres microspheres, Sirtex Medical Limited,
Australia, 2011a, viewed May 2011,
<http://www.sirtex.com/content.cfm?sec=usa&MenuID=1110&ID=F4CC8517>.
Therapeutic Goods Administration (TGA), ARTG entry 149332, Australian Government
Department of Health and Ageing, Canberra, 2008, viewed 18 May 2011,
<https://www.ebs.tga.gov.au/servlet/xmlmillr6?dbid=ebs/PublicHTML/pdfStore.nsf&doc
id=149332&agid=(PrintDetailsPublic)&actionid=1>.
Tournigand C, Andre T, et al. FOLFIRI followed byFOLFOX6 or the reverse sequence in
advanced colorectal cancer: a randomized GERCOR study. Journal of Clinical Oncology
2004; 22(2): 229-237.
Van Hazel G, Blackwell A, et al. Randomised phase 2 trial of SIR-Spheres plus
fluorouracil/leucovorin chemotherapy versus fluorouracil/leucovorin chemotherapy alone
in advanced colorectal cancer. Journal of Surgical Oncology 2004; 88(2): 78-85.
SOURCES OF FURTHER INFORMATION
Andrews JC, Walker SC, et al. Hepatic radioembolization with yttrium-90 containing
glass microspheres: preliminary results and clinical follow-up. Journal of Nuclear
Medicine 1994; 35(10): 1637-1644.
Gray BN, Anderson JE, et al. Regression of liver metastases following treatment with
yttrium-90 microspheres. Australian and New Zealand Journal of Surgery 1992; 62(2):
105-110.
Selective internal radiation therapy for the treatment of liver cancer: August 2011 15
18. Selective internal radiation therapy for the treatment of liver cancer: August 2011 16
Gray BN, van Hazel G, et al. Treatment of colorectal liver metastases with SIR-Spheres
plus chemotherapy. GI Cancer 2000; 3(4): 249-257.
Ho S, Lau WY, Leung TW, et al. Clinical evaluation of the partition model for estimating
radiation doses from yttrium-90 microspheres in the treatment of hepatic cancer.
European Journal of Nuclear Medicine 1997; 24(3): 293-298.
Lau WY, Ho S, et al. Selective internal radiation therapy for nonresectable hepatocellular
carcinoma with intraarterial infusion of 90 yttrium microspheres. International Journal of
Radiation Oncology, Biology, Physics 1998; 40(3): 583-592.
Stubbs RS, Cannan RJ, Mitchell AW. Selective internal radiation therapy with 90 yttrium
microspheres for extensive colorectal liver metastases. Journal of Gastrointestinal
Surgery 2001; 5(3): 294-302.
SEARCH CRITERIA TO BE USED
Selective internal radiation therapy OR selective internal radiation
SIR-Spheres OR TheraSpheres
Liver cancer OR hepatocellular carcinoma OR liver metastases