Yttrium 90 Therapy: Is the Future Surgical?
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COMMENTARY
COMMENTARY
Yttrium 90 Therapy: Is the Future Surgical? Benjamin Garlipp1
Received: 26 August 2020 / Accepted: 4 September 2020 Ó The Author(s) 2020
Surgery for malignant liver tumors has evolved greatly in the recent past, with the amount of functioning liver parenchyma remaining after resection—referred to as the future liver remnant (FLR)—now being the major determinant of resectability. Hence, the quest for methods to enhance the FLR in patients at risk for postoperative liver failure overcoming the known limitations of portal vein embolization (PVE) or portal vein ligation (PVL) has gained interest. Optimizing the PVE technique using a combination of polyvinyl alcohol particles and venous plugs or coils, the combination of transarterial embolization and portal venous embolization, liver venous deprivation (LVD) combining portal and hepatic vein embolization, as well as the ALPPS (Associating Liver Partition and Portal vein Ligation for Staged hepatectomy) procedure have all been studied in this context, with mixed results and arguments in favor of and against all of these methods. In this issue of CVIR, Gordon et al. [1] describe PVE with 90Yttrium-labeled glass microspheres infused via the portal vein (Y90 PVE) in an experimental study using 22 Sprague–Dawley rats. Animals were assigned to one of five cohorts receiving very high, high, medium, and low-dose Y90 PVE or no treatment, respectively. Seventeen rats survived until necropsy at 12 weeks following Y90 PVE. Of the surviving 13 rats in the treated group, nine demonstrated successful Y90 delivery to the target lobe at 90 Y PET/CT. MR volumetry demonstrated dose-dependent atrophy of the target lobe, with periportal fibrosis and dose& Benjamin Garlipp [email protected] 1
Otto von Guericke University, Leipziger Str. 44, 39120 Magdeburg, Germany
dependent decrease in hepatocyte proliferation seen at HE staining and Ki67 immunofluorescence histology. Y90 microspheres are used for transarterial radioembolization (TARE) in a variety of liver tumors, the greatest amount of evidence obtained from studies in hepatocellular carcinoma (HCC) and metastatic colorectal cancer (mCRC). Besides its effects on tumor tissue, induction of parenchymal hypertrophy in non-treated areas following TARE has been studied by several groups following an initial case report published in 2009 [2]. Traditional Y90 TARE has somewhat drifted out of focus in recent years following the publication of large randomized trials in HCC and treatment-naı¨ve mCRC (SARAH, SIRveNIB, SORAMIC, SIRFLOX, FOXFIRE, FOXFIRE Global), that have all failed to reach their primary endpoints of overall or progression-free survival. However, as subgroups potentially benefitting from TARE were identified in these studies and their failure has at least partly been attributed to inappropriate patient selection, the use of Y90 microspheres in the treatment of liver malignancies continues to be an area of great scientific interest. New research strategies are gradually emerging. Perhaps the m
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