Hepatic (liver) tumors result in the largest number of cancer related death and with 1/3 of all NETs presenting with liver mets it is of great importance to treat liver.  Only 10% of patients with liver mets are resectable (?)

Liver directed therapy – introduction of cells, molecules and articles in the blood supply

RFA Slide – effective for limited or focal disease – does not work well for greater spread

Intra-arterial Therapy – how can this work – liver has 2 blood supplies – 75% portal – 25% hepatic -   Tumors have most of their blood delivered via hepatic artery - Tumor always want blood flow – where as normal liver does not – 19x uptake of particle to tumor vs normal liver. 

Y90 Microsphere selection Criteria – Contraindication
Amount of tumor load (under 50%) and bilirubin <2 mg/dl
Metastatic confined to liver
Prior external beam radiation

Y90 – 30 micron in size – smaller – beads can go to other targets – over 50 is too big
Max energy 2.27 MeV – half life 64.1 hours – 2mm effect – 94% of radiation is delivered in 11 days

Glass or Resin are permanent in your body  

One lobe is treated at a time – at first both lobes were done – had a higher complication rate – with one lobe done – very low complication rates

Adverse Events
Fever – right upper quadrant pain -
Non Target Embolization – if the beads escape the liver – this is why it is done as a 2 step procedure – with protective embolization done