International recommendations for personalised selective internal radiation therapy of primary and metastatic liver diseases with yttrium-90 resin microspheres

Hugo Levillain, Oreste Bagni, Christophe M Deroose, Arnaud Dieudonné, Silvano Gnesin, Oliver S Grosser, S Cheenu Kappadath, Andrew Kennedy, Nima Kokabi, David M Liu, David C Madoff, Armeen Mahvash, Antonio Martinez de la Cuesta, David C E Ng, Philipp M Paprottka, Cinzia Pettinato, Macarena Rodríguez-Fraile, Riad Salem, Bruno Sangro, Lidia Strigari, Daniel Y Sze, Berlinda J de Wit van der Veen, Patrick Flamen, Hugo Levillain, Oreste Bagni, Christophe M Deroose, Arnaud Dieudonné, Silvano Gnesin, Oliver S Grosser, S Cheenu Kappadath, Andrew Kennedy, Nima Kokabi, David M Liu, David C Madoff, Armeen Mahvash, Antonio Martinez de la Cuesta, David C E Ng, Philipp M Paprottka, Cinzia Pettinato, Macarena Rodríguez-Fraile, Riad Salem, Bruno Sangro, Lidia Strigari, Daniel Y Sze, Berlinda J de Wit van der Veen, Patrick Flamen

Abstract

Purpose: A multidisciplinary expert panel convened to formulate state-of-the-art recommendations for optimisation of selective internal radiation therapy (SIRT) with yttrium-90 (90Y)-resin microspheres.

Methods: A steering committee of 23 international experts representing all participating specialties formulated recommendations for SIRT with 90Y-resin microspheres activity prescription and post-treatment dosimetry, based on literature searches and the responses to a 61-question survey that was completed by 43 leading experts (including the steering committee members). The survey was validated by the steering committee and completed anonymously. In a face-to-face meeting, the results of the survey were presented and discussed. Recommendations were derived and level of agreement defined (strong agreement ≥ 80%, moderate agreement 50%-79%, no agreement ≤ 49%).

Results: Forty-seven recommendations were established, including guidance such as a multidisciplinary team should define treatment strategy and therapeutic intent (strong agreement); 3D imaging with CT and an angiography with cone-beam-CT, if available, and 99mTc-MAA SPECT/CT are recommended for extrahepatic/intrahepatic deposition assessment, treatment field definition and calculation of the 90Y-resin microspheres activity needed (moderate/strong agreement). A personalised approach, using dosimetry (partition model and/or voxel-based) is recommended for activity prescription, when either whole liver or selective, non-ablative or ablative SIRT is planned (strong agreement). A mean absorbed dose to non-tumoural liver of 40 Gy or less is considered safe (strong agreement). A minimum mean target-absorbed dose to tumour of 100-120 Gy is recommended for hepatocellular carcinoma, liver metastatic colorectal cancer and cholangiocarcinoma (moderate/strong agreement). Post-SIRT imaging for treatment verification with 90Y-PET/CT is recommended (strong agreement). Post-SIRT dosimetry is also recommended (strong agreement).

Conclusion: Practitioners are encouraged to work towards adoption of these recommendations.

Keywords: Dosimetry; Liver tumours; Recommendations; SIRT.

Conflict of interest statement

HL has acted in an advisory role and received honoraria from Sirtex Medical. OB has received consultancy and proctor fees from Sirtex Medical. CMD has been a consultant for Sirtex Medical, Novartis, Terumo, AAA, Ipsen, and Bayer. AD has received lecture and honoraria fees from Sirtex Medical. SG has received lecture fees from Sirtex Medical. OSG has received lecture and consulting fees from Sirtex Medical. SCK has received research grants from Boston Scientific and GE Healthcare, and has served as a consultant for Boston Scientific, Sirtex Medical, ABK Biomedical, Varian Medical, and Terumo Medical. AK has not received any compensation from Sirtex Medical or other microsphere vendor. Sarah Cannon has been the recipient of a past grant for a phase II clinical study and fees to compensate it for AK involvement in an advisory role 2018–2020. NK has served as a consultant and has received research support from Sirtex Medical. DML receives consulting fees from Sirtex Medical and Eisai Pharmaceuticals. DCM has received consultancy fees from Sirtex Medical. AM has received research grants from Sirtex Medical and BTG/Boston Scientific Corp and is a consultant for Sirtex Medical, Boston Scientific Corp and ABK Medical. AMdlC has received proctor, consultancy and speaker fees from Sirtex Medical. DCEN has received grants from Sirtex Medical, Bayer, MSD and Norvatis, and lecture honoraria from Sirtex Medical and Bayer. PMP has received consultancy and speaker fees from Sirtex Medical. CP has received lecture fees from Sirtex Medical. MRF has received lecture fees from Sirtex Medical. RS is a consultant for Boston Scientific, Eisai, Exelixis, Genentech, Cook and Sirtex Medical. BS received lecture and/or consulting fees from Adaptimmune, Bayer, BMS, BTG, Eisai, Ipsen, Lilly, Roche and Sirtex Medical, research fees from BMS and Sirtex Medical. LS has received lecture fees from Sirtex Medical. DYS served as a consultant to Sirtex Medical. BJdWvdV has received consulting/lecture fees from Sirtex Medical. PF has acted in an advisory role and received honoraria from Sirtex Medical.

Figures

Fig. 1
Fig. 1
Overview of methodology

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