CIO 2022-3 Updated Clinical and Dosimetric Recommendations for Yttrium-90 Glass Microspheres in Hepatocellular Carcinoma

Purpose: The TheraSphere Global Dosimetry Steering Committee (DSC) reconvened to update the clinical and dosimetric recommendations for the treatment of unresectable hepatocellular carcinoma (HCC) with yttrium-90 (90Y) glass microspheres. Recommendations for treatment standardization under various clinical presentations are presented, considering treatment planning and delivery, patient selection, dosing, and follow-up.

Materials and Methods: The DSC consisted of a global, multidisciplinary panel of providers treating patients with HCC with 90Y glass microspheres. DSC experience, with insights from 2019 to 2021 publications, informed the recommendations. Treatment intent, clinical status, liver function, tumor load, macrovascular invasion/portal vein thrombosis (MVI/PVT) targeting, tumor vascularity, and previous treatments were considered.

Results: DSC consensus expanded recommendations from four or five clinical scenarios with key updates as follows. Curative intent: radiation segmentectomy; single compartmental dosimetry (SCD) is preferred with a target absorbed dose to the perfused treatment volume of 400 Gy or greater. Radiation lobectomy: Using SCD, 140 to 150 Gy lobar absorbed dose limited to Child-Pugh (CP) A status. Using a multicompartmental dosimetry (MCD), minimum tumor absorbed dose (TAD) of 205 Gy or greater (>250 Gy when possible), and normal tissue absorbed dose (NTAD) in the perfused liver of 120 Gy or less in patients with 30% or greater hepatic reserve is recommended. Modified radiation lobectomy: SCD as per radiation segmentectomy plus a second administration of 100 Gy to the lobe to induce hypertrophy. Palliative intent: Multifocal* unilobar disease without MVI/PVT: MCD attaining a TAD of 205 Gy or greater (>250 Gy when possible) and NTAD in the perfused liver of 120 Gy or less in patients with 30% or greater hepatic reserve. Using SCD, 150 Gy to the perfused lobe can be given. Multifocal* bilobar disease without MVI/PVT: Using MCD, preferably treating lobes sequentially. For small tumors, 40 to 70 Gy absorbed dose to the entire healthy tissue may be administered in patients with CP A status. With SCD, target 120 Gy to the perfused tissue. HCC with MVI/PVT*: As per multifocal disease ensuring good upfront MVI/PVT targeting.

Conclusions: Updated consensus recommendations include new dosing recommendations for various clinical scenarios, facilitating standardized personalized treatment to improve outcomes.

*TheraSphere is not approved for use in patients with multifocal disease or MVI/PVT in the United States.

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