Radioactive Yttrium-90 Microspheres for the Treatment of Primary Unresectable Liver Cancer for Downstaging or as a Bridge to Transplantation or Surgery

Health Problem: Hepatocellular carcinoma (HCC) is the most common liver malignancy in the United States, accounting for approximately 90% of primary liver cancers. The definitive therapies for HCC are surgical resection, tumor ablation, and liver transplantation; however, most patients are not eligible for these therapies due to the overall burden or severity of their disease. Patients whose tumor is outside the criteria for resection or transplantation may benefit from a locoregional therapy (LRT) or systemic therapy to downstage to within criteria. Due to the lack of available donor organs, patients may elect to undergo LRTs as a means to avoid tumor progression and remain within transplantation criteria.

Technology Description: Transarterial radioembolization (TARE) with yttrium-90 (90Y) microspheres, an alternative LRT option for downstaging or bridging to resection or transplantation, allows for much higher doses of radiation to be delivered to the diseased liver compared with an external beam approach.

Controversy: There is limited evidence for the use of 90Y TARE for bridging patients to transplantation or downstaging to resection or transplantation. In terms of bridging patients to transplantation, prolonging time to tumor progression may reduce the incidence of waitlist dropout. Downstaging patients to a point at which their diagnosis is within criteria for curative treatment may provide treatment options that were previously unrealized; however, questions about long-term prognosis after curative treatment remain for these patients.

Key Questions:

  • Is 90Y TARE effective as a downstaging intervention or a bridge to transplantation or surgery?

  • How does 90Y TARE compare with transarterial chemoembolization, other LRTs, or sorafenib prior to resection or transplantation?

  • Is 90Y TARE safe?

  • Have definitive patient selection criteria been established for 90Y TARE as a downstaging intervention or bridge to transplantation or surgery?

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