Safety of selective internal radiation therapy (SIRT) with yttrium-90 microspheres combined with systemic anticancer agents: expert consensus
Kennedy A (1), Brown DB (2), Feilchenfeldt J (3), Marshall J (4), Wasan H (5), Fakih M (6), Gibbs P (7), Knuth A (3), Sangro B (8), Soulen MC (9), Pittari G (3), Sharma RA (10).
(1) Radiation Oncology Research, Sarah Cannon Research Institute, Nashville, Tennessee, USA.
(2) Department of Radiology and Radiologic Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
(3) National Center for Cancer Care and Research, HMC, Doha, Qatar.
(4) Hematology and Oncology Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington DC, USA.
(5) Imperial College, Division of Cancer, Hammersmith Hospital, London, UK.
(6) Department of Medical Oncology & Therapeutics Research, City of Hope, Duarte, California, USA.
(7) Western Hospital, Footscray, Victoria, Australia.
(8) Liver Unit, Clinica Universidad de Navarra, IDISNA, CIBEREHD, Pamplona, Navarra, Spain.
(9) Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
(10) NIHR University College London Hospitals Biomedical Research Centre, UCL Cancer Institute, University College London, London, UK.
Selective internal radiation therapy (SIRT) with microspheres labelled with the β-emitter yttrium-90 (Y-90) enables targeted delivery of radiation to hepatic tumors.
SIRT is primarily used to treat inoperable primary or metastatic liver tumors. Eligible patients have usually been exposed to a variety of systemic anticancer therapies, including cytotoxic agents, targeted biologics, immunotherapy and peptide receptor radionuclide therapy (PRRT).
All these treatments have potential interactions with SIRT; however, robust evidence on the safety of these potential combinations is lacking.
This paper provides current clinical experiences and expert consensus guidelines for the use of SIRT in combination with the anticancer treatment agents likely to be encountered in clinical practice. It was agreed by the expert panel that precautions need to be taken with certain drugs, but that, in general, systemic therapies do not necessarily have to be stopped to perform SIRT.
The authors recommend stopping vascular endothelial growth factor inhibitors 4-6 weeks before SIRT, and restart after the patient has recovered from the procedure. It may also be prudent to stop potent radiosensitizers such as gemcitabine therapy 4 weeks before SIRT, and restart treatment at least 2‒4 weeks later. Data from phase III studies combining SIRT with fluorouracil (5FU) or folinic acid/5FU/oxaliplatin (FOLFOX) suggest that hematological toxicity is more common from the combination than it is from chemotherapy without SIRT.
There is no evidence to suggest that chemotherapy increases SIRT-specific gastro-intestinal or liver toxicities.
CITATION J Gastrointest Oncol. 2017 Dec;8(6):1079-1099. doi: 10.21037/jgo.2017.09.10