Primary liver tumours (i.e. hepatocellular carcinoma (HCC) or intrahepatic cholangiocarcinoma (ICC)) are among the most frequent cancers worldwide. However, only 10-20% of patients are amenable to curative treatment, such as resection or transplant. Liver metastases are most frequently caused by colorectal cancer, which accounts for the second most cancer-related deaths in Europe. In both primary and secondary tumours, radioembolization has been shown to be a safe and effective treatment option. The vast potential of personalized dosimetry has also been shown, resulting in markedly increased response rates and overall survival. In a rapidly evolving therapeutic landscape, the role of radioembolization will be subject to changes. Therefore, the decision for radioembolization should be taken by a multidisciplinary tumour board in accordance with the current clinical guidelines. The purpose of this procedure guideline is to assist the nuclear medicine physician in treating and managing patients undergoing radioembolization treatment. PREAMBLE: The European Association of Nuclear Medicine (EANM) is a professional non-profit medical association that facilitates communication worldwide among individuals pursuing clinical and research excellence in nuclear medicine. The EANM was founded in 1985. These guidelines are intended to assist practitioners in providing appropriate nuclear medicine care for patients. They are not inflexible rules or requirements of practice and are not intended, nor should they be used, to establish a legal standard of care. The ultimate judgment regarding the propriety of any specific procedure or course of action must be made by medical professionals taking into account the unique circumstances of each case. Thus, there is no implication that an approach differing from the guidelines, standing alone, is below the standard of care. To the contrary, a conscientious practitioner may responsibly adopt a course of action different from that set out in the guidelines when, in the reasonable judgment of the practitioner, such course of action is indicated by the condition of the patient, limitations of available resources or advances in knowledge or technology subsequent to publication of the guidelines. The practice of medicine involves not only the science but also the art of dealing with the prevention, diagnosis, alleviation and treatment of disease. The variety and complexity of human conditions make it impossible to always reach the most appropriate diagnosis or to predict with certainty a particular response to treatment. Therefore, it should be recognised that adherence to these guidelines will not ensure an accurate diagnosis or a successful outcome. All that should be expected is that the practitioner will follow a reasonable course of action based on current knowledge, available resources and the needs of the patient to deliver effective and safe medical care. The sole purpose of these guidelines is to assist practitioners in achieving this objective.

Department of Medical Physics Motol University Hospital Prague Czech Republic

Department of Nuclear Medicine Cancer Institute Eugène Marquis Rennes France

Department of Nuclear Medicine Institut Jules Bordet Université Libre de Bruxelles 1000 Brussels Belgium

Department of Nuclear medicine University clinic Essen Essen Germany

Department of Nuclear medicine University hospital Marburg Marburg Germany

Department of Radiology and Nuclear Medicine University Medical Center Utrecht Heidelberglaan 100 3584 CX Utrecht The Netherlands

Institute of Radiation physics Lausanne University Hospital University of Lausanne Lausanne Switzerland

Molecular Imaging and Therapy Service Department of Radiology Memorial Sloan Kettering Cancer Center New York USA

Nuclear Medicine Department Erasmus MC Rotterdam The Netherlands

Nuclear Medicine Foundation IRCCS National Tumour Institute Milan Italy

Radiation Research Unit IEO European Institute of Oncology IRCCS Via Giuseppe Ripamonti 435 20141 Milan MI Italy

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Cremonesi M, et al. Dosimetry in peptide radionuclide receptor therapy: a review. J Nucl Med. 2006;47(9):1467–1475. PubMed

Salem R, Thurston KG. Radioembolization with (90)yttrium microspheres: a state-of-the-art brachytherapy treatment for primary and secondary liver malignancies part 1: technical and methodologic considerations. J Vasc Interv Radiol. 2006;17(8):1251–1278. PubMed

Smits MLJ, et al., Holmium-166 radioembolization for the treatment of patients with liver metastases: design of the phase I HEPAR trial. Journal of Experimental & Clinical Cancer Research, 2010. 29. PubMed PMC

Westcott MA, et al. The development, commercialization, and clinical context of yttrium-90 radiolabeled resin and glass microspheres. Adv Radiat Oncol. 2016;1(4):351–364. PubMed PMC

Pasciak AS, et al. Radioembolization and the dynamic role of (90)Y PET/CT. Front Oncol. 2014;4:38. PubMed PMC

Lau WY, Li AK. Therapeutic aspects of radioisotopes in hepatobiliary malignancy. Br J Surg. 1992;79(7):711. PubMed

Okuda K, et al. Natural history of hepatocellular carcinoma and prognosis in relation to treatment. Study of 850 patients. Cancer. 1985;56(4):918–928. PubMed

Schafer DF, Sorrell MF. Hepatocellular carcinoma. Lancet. 1999;353(9160):1253–1257. PubMed

Lambert B, et al. 99mTc-labelled macroaggregated albumin (MAA) scintigraphy for planning treatment with 90Y microspheres. Eur J Nucl Med Mol Imaging. 2010;37(12):2328–2333. PubMed

Leung WT, et al. Measuring lung shunting in hepatocellular carcinoma with intrahepatic-arterial technetium-99m macroaggregated albumin. J Nucl Med. 1994;35(1):70–73. PubMed

Braat A, et al. Safety analysis of holmium-166 microsphere scout dose imaging during radioembolisation work-up: a cohort study. Eur Radiol. 2018;28(3):920–928. PubMed PMC

Elschot M, et al. ((9)(9)m)Tc-MAA overestimates the absorbed dose to the lungs in radioembolization: a quantitative evaluation in patients treated with (1)(6)(6)Ho-microspheres. Eur J Nucl Med Mol Imaging. 2014;41(10):1965–1975. PubMed

Dancey JE, et al. Treatment of nonresectable hepatocellular carcinoma with intrahepatic 90Y-microspheres. J Nucl Med. 2000;41(10):1673–1681. PubMed

Geschwind JF, et al. Yttrium-90 microspheres for the treatment of hepatocellular carcinoma. Gastroenterology. 2004;127(5 Suppl 1):S194–S205. PubMed

Goin JE, et al. Treatment of unresectable hepatocellular carcinoma with intrahepatic yttrium 90 microspheres: a risk-stratification analysis. J Vasc Interv Radiol. 2005;16(2 Pt 1):195–203. PubMed

Kennedy AS, et al. Pathologic response and microdosimetry of (90)Y microspheres in man: review of four explanted whole livers. Int J Radiat Oncol Biol Phys. 2004;60(5):1552–1563. PubMed

Lau WY, et al. Selective internal radiation therapy for nonresectable hepatocellular carcinoma with intraarterial infusion of 90yttrium microspheres. Int J Radiat Oncol Biol Phys. 1998;40(3):583–592. PubMed

Sharma RA, et al. Radioembolization of liver metastases from colorectal cancer using yttrium-90 microspheres with concomitant systemic oxaliplatin, fluorouracil, and leucovorin chemotherapy. J Clin Oncol. 2007;25(9):1099–1106. PubMed

Stubbs RS, Cannan RJ, Mitchell AW. Selective internal radiation therapy with 90yttrium microspheres for extensive colorectal liver metastases. J Gastrointest Surg. 2001;5(3):294–302. PubMed

Hogberg J, et al. Increased absorbed liver dose in selective internal radiation therapy (SIRT) correlates with increased sphere-cluster frequency and absorbed dose inhomogeneity. EJNMMI Phys. 2015;2(1):10. PubMed PMC

Carr BI. Hepatic arterial 90Yttrium glass microspheres (Therasphere) for unresectable hepatocellular carcinoma: interim safety and survival data on 65 patients. Liver Transpl. 2004;10(2 Suppl 1):S107–S110. PubMed

Garin E, et al. First experience of hepatic radioembolization using microspheres labelled with yttrium-90 (TheraSphere): practical aspects concerning its implementation. Eur J Nucl Med Mol Imaging. 2010;37(3):453–461. PubMed

Sangro B, et al. Radioembolization using 90Y-resin microspheres for patients with advanced hepatocellular carcinoma. Int J Radiat Oncol Biol Phys. 2006;66(3):792–800. PubMed

Van Hazel G, et al. Randomised phase 2 trial of SIR-spheres plus fluorouracil/leucovorin chemotherapy versus fluorouracil/leucovorin chemotherapy alone in advanced colorectal cancer. J Surg Oncol. 2004;88(2):78–85. PubMed

Lam MG, et al. Safety of 90Y radioembolization in patients who have undergone previous external beam radiation therapy. Int J Radiat Oncol Biol Phys. 2013;87(2):323–329. PubMed

Young JY, et al. Radiation dose limits and liver toxicities resulting from multiple yttrium-90 radioembolization treatments for hepatocellular carcinoma. J Vasc Interv Radiol. 2007;18(11):1375–1382. PubMed

Ezziddin S, et al. 90Y radioembolization after radiation exposure from peptide receptor radionuclide therapy. J Nucl Med. 2012;53(11):1663–1669. PubMed

Braat A, et al. Radioembolization with (90)Y resin microspheres of neuroendocrine liver metastases after initial peptide receptor radionuclide therapy. Cardiovasc Intervent Radiol. 2020;43(2):246–253. PubMed PMC

Sangro B, et al. Liver disease induced by radioembolization of liver tumors: description and possible risk factors. Cancer. 2008;112(7):1538–1546. PubMed

van Hazel GA, et al. SIRFLOX: randomized phase III trial comparing first-line mFOLFOX6 (plus or minus bevacizumab) versus mFOLFOX6 (plus or minus bevacizumab) plus selective internal radiation therapy in patients with metastatic colorectal cancer. J Clin Oncol. 2016;34(15):1723–1731. PubMed

Mulcahy, M.F., et al., Radioembolization with chemotherapy for colorectal liver metastases: a randomized, open-label, international, multicenter, phase III trial. J Clin Oncol, 2021: p. JCO2101839. PubMed PMC

Wasan HS, et al. First-line selective internal radiotherapy plus chemotherapy versus chemotherapy alone in patients with liver metastases from colorectal cancer (FOXFIRE, SIRFLOX, and FOXFIRE-global): a combined analysis of three multicentre, randomised, phase 3 trials. Lancet Oncol. 2017;18(9):1159–1171. PubMed PMC

Ricke J, et al. Impact of combined selective internal radiation therapy and sorafenib on survival in advanced hepatocellular carcinoma. J Hepatol. 2019;71(6):1164–1174. PubMed

Edeline J, et al. Radioembolization plus chemotherapy for first-line treatment of locally advanced intrahepatic cholangiocarcinoma: a phase 2 clinical trial. 2019. PubMed PMC

Shady W, et al. Metabolic tumor volume and total lesion glycolysis on FDG-PET/CT can predict overall survival after (90)Y radioembolization of colorectal liver metastases: a comparison with SUVmax, SUVpeak, and RECIST 1.0. Eur J Radiol. 2016;85(6):1224–1231. PubMed PMC

Shady W, et al. Surrogate imaging biomarkers of response of colorectal liver metastases after salvage radioembolization using 90Y-loaded resin microspheres. AJR Am J Roentgenol. 2016;207(3):661–670. PubMed PMC

Fendler WP, et al. Validation of several SUV-based parameters derived from 18F-FDG PET for prediction of survival after SIRT of hepatic metastases from colorectal cancer. J Nucl Med. 2013;54(8):1202–8. PubMed

Gulec SA, et al. The prognostic value of functional tumor volume and total lesion glycolysis in patients with colorectal cancer liver metastases undergoing 90Y selective internal radiation therapy plus chemotherapy. Eur J Nucl Med Mol Imaging. 2011;38(7):1289–1295. PubMed

Soydal C, et al. The prognostic value of quantitative parameters of 18F-FDG PET/CT in the evaluation of response to internal radiation therapy with yttrium-90 in patients with liver metastases of colorectal cancer. Nucl Med Commun. 2013;34(5):501–506. PubMed

Zerizer I, et al. The role of early (1)(8)F-FDG PET/CT in prediction of progression-free survival after (9)(0)Y radioembolization: comparison with RECIST and tumour density criteria. Eur J Nucl Med Mol Imaging. 2012;39(9):1391–9. PubMed

Braat M, et al. Hepatobiliary scintigraphy may improve radioembolization treatment planning in HCC patients. EJNMMI Res. 2017;7(1):2. PubMed PMC

Vilgrain V, et al. Efficacy and safety of selective internal radiotherapy with yttrium-90 resin microspheres compared with sorafenib in locally advanced and inoperable hepatocellular carcinoma (SARAH): an open-label randomised controlled phase 3 trial. Lancet Oncol. 2017;18(12):1624–1636. PubMed

Dutton SJ, et al. FOXFIRE protocol: an open-label, randomised, phase III trial of 5-fluorouracil, oxaliplatin and folinic acid (OxMdG) with or without interventional selective internal radiation therapy (SIRT) as first-line treatment for patients with unresectable liver-only or liver-dominant metastatic colorectal cancer. BMC Cancer. 2014;14:497. PubMed PMC

Gray B, et al. Randomised trial of SIR-spheres plus chemotherapy vs. chemotherapy alone for treating patients with liver metastases from primary large bowel cancer. Ann Oncol. 2001;12(12):1711–1720. PubMed

Chow PKH, et al. SIRveNIB: selective internal radiation therapy versus sorafenib in Asia-Pacific patients with hepatocellular carcinoma. J Clin Oncol. 2018;36(19):1913–1921. PubMed

Helmberger T, et al. Clinical application of trans-arterial radioembolization in hepatic malignancies in europe: first results from the prospective multicentre observational study CIRSE registry for SIR-spheres therapy (CIRT) Cardiovasc Intervent Radiol. 2021;44(1):21–35. PubMed PMC

Schutte K, et al. Impact of extrahepatic metastases on overall survival in patients with advanced liver dominant hepatocellular carcinoma: a subanalysis of the SORAMIC trial. Liver Cancer. 2020;9(6):771–786. PubMed PMC

Kohler M, et al. Prognostic factors for overall survival in advanced intrahepatic cholangiocarcinoma treated with yttrium-90 radioembolization. J Clin Med. 2019;9:1. PubMed PMC

Hunt AP, et al. Preparation of Tc-99m-macroaggregated albumin from recombinant human albumin for lung perfusion imaging. Eur J Pharm Biopharm. 2006;62(1):26–31. PubMed

Chiesa C, Maccauro M. (166)Ho microsphere scout dose for more accurate radioembolization treatment planning. Eur J Nucl Med Mol Imaging. 2020;47(4):744–747. PubMed

Grosser OS, et al. Pharmacokinetics of 99mTc-MAA- and 99mTc-HSA-microspheres used in preradioembolization dosimetry: influence on the liver-lung shunt. J Nucl Med. 2016;57(6):925–927. PubMed

Lopez B, et al. Calculation of lung mean dose and quantification of error for (90) Y-microsphere radioembolization using (99m) Tc-MAA SPECT/CT and diagnostic chest CT. Med Phys. 2019;46(9):3929–3940. PubMed

Das A, et al. Safety and efficacy of radioembolization with glass microspheres in hepatocellular carcinoma patients with elevated lung shunt fraction: analysis of a 103-patient cohort. Eur J Nucl Med Mol Imaging. 2020;47(4):807–815. PubMed

Ho S, et al. Clinical evaluation of the partition model for estimating radiation doses from yttrium-90 microspheres in the treatment of hepatic cancer. Eur J Nucl Med. 1997;24(3):293–298. PubMed

Salem R, et al. Incidence of radiation pneumonitis after hepatic intra-arterial radiotherapy with yttrium-90 microspheres assuming uniform lung distribution. Am J Clin Oncol. 2008;31(5):431–438. PubMed

Jadoul A, et al. Comparative dosimetry between (99m)Tc-MAA SPECT/CT and (90)Y PET/CT in primary and metastatic liver tumors. Eur J Nucl Med Mol Imaging. 2020;47(4):828–837. PubMed

Gnesin S, et al. Partition model based Tc-99m-MAA SPECT/CT predictive dosimetry compared with Y-90 TOF PET/CT posttreatment dosimetry in radioembolization of hepatocellular carcinoma: a quantitative agreement comparison. J Nucl Med. 2016;57(11):1672–1678. PubMed

Ilhan H, et al. Predictive value of 99mTc-MAA SPECT for 90Y-labeled resin microsphere distribution in radioembolization of primary and secondary hepatic tumors. J Nucl Med. 2015;56(11):1654–1660. PubMed

Wondergem M, et al. 99mTc-macroaggregated albumin poorly predicts the intrahepatic distribution of 90Y resin microspheres in hepatic radioembolization. J Nucl Med. 2013;54(8):1294–1301. PubMed

Haste P, et al. Correlation of technetium-99m macroaggregated albumin and yttrium-90 glass microsphere biodistribution in hepatocellular carcinoma: a retrospective review of pretreatment single photon emission ct and posttreatment positron emission tomography/CT. J Vasc Interv Radiol. 2017;28(5):722–730. PubMed

Garin E, et al. Boosted selective internal radiation therapy with 90Y-loaded glass microspheres (B-SIRT) for hepatocellular carcinoma patients: a new personalized promising concept. Eur J Nucl Med Mol Imaging. 2013;40(7):1057–1068. PubMed PMC

Garin E, et al. Dosimetry based on 99mTc-macroaggregated albumin SPECT/CT accurately predicts tumor response and survival in hepatocellular carcinoma patients treated with 90Y-loaded glass microspheres: preliminary results. J Nucl Med. 2012;53(2):255–263. PubMed

Chiesa C, et al. Need, feasibility and convenience of dosimetric treatment planning in liver selective internal radiation therapy with (90)Y microspheres: the experience of the National Tumor Institute of Milan. Q J Nucl Med Mol Imaging. 2011;55(2):168–197. PubMed

Ho CL, et al. Radioembolization with (90)Y glass microspheres for hepatocellular carcinoma: significance of pretreatment (11)C-acetate and (18)F-FDG PET/CT and posttreatment (90)Y PET/CT in individualized dose prescription. Eur J Nucl Med Mol Imaging. 2018;45(12):2110–2121. PubMed

Hermann AL, et al. Relationship of tumor radiation-absorbed dose to survival and response in hepatocellular carcinoma treated with transarterial radioembolization with (90)Y in the SARAH study. Radiology. 2020;296(3):673–684. PubMed

Lau WY, et al. Treatment of inoperable hepatocellular carcinoma with intrahepatic arterial yttrium-90 microspheres: a phase I and II study. Br J Cancer. 1994;70(5):994–999. PubMed PMC

Garin, E., et al., Personalised versus standard dosimetry approach of selective internal radiation therapy in patients with locally advanced hepatocellular carcinoma (DOSISPHERE-01): a randomised, multicentre, open-label phase 2 trial. Lancet Gastroenterol Hepatol, 2020 PubMed

Smits MLJ, et al. The superior predictive value of (166)Ho-scout compared with (99m)Tc-macroaggregated albumin prior to (166)Ho-microspheres radioembolization in patients with liver metastases. Eur J Nucl Med Mol Imaging. 2020;47(4):798–806. PubMed PMC

Salem R, et al. Clinical and dosimetric considerations for Y90: recommendations from an international multidisciplinary working group. Eur J Nucl Med Mol Imaging. 2019;46(8):1695–1704. PubMed

Lewandowski RJ, et al. Radiation segmentectomy: potential curative therapy for early hepatocellular carcinoma. Radiology. 2018;287(3):1050–1058. PubMed

Meiers C, et al. Safety and initial efficacy of radiation segmentectomy for the treatment of hepatic metastases. J Gastrointest Oncol. 2018;9(2):311–315. PubMed PMC

Padia SA, et al. Superselective yttrium-90 radioembolization for hepatocellular carcinoma yields high response rates with minimal toxicity. J Vasc Interv Radiol. 2014;25(7):1067–1073. PubMed

Biederman DM, et al. Radiation segmentectomy versus selective chemoembolization in the treatment of early-stage hepatocellular carcinoma. J Vasc Interv Radiol. 2018;29(1):30–37. PubMed

Garin E, et al. Personalized dosimetry with intensification using 90Y-loaded glass microsphere radioembolization induces prolonged overall survival in hepatocellular carcinoma patients with portal vein thrombosis. J Nucl Med. 2015;56(3):339–346. PubMed

Konijnenberg M., et al. EANM position paper on article 56 of the Council Directive 2013/59/Euratom (basic safety standards) for nuclear medicine therapy. Eur J Nucl Med Mol Imaging. 2021:48(1);67–72 PubMed PMC

Ho S, et al. Partition model for estimating radiation doses from yttrium-90 microspheres in treating hepatic tumours. Eur J Nucl Med. 1996;23(8):947–52 PubMed

Chiesa C, et al. Radioembolization of hepatocarcinoma with (90)Y glass microspheres: development of an individualized treatment planning strategy based on dosimetry and radiobiology. Eur J Nucl Med Mol Imaging. 2015;42(11):1718–1738. PubMed

Chiesa C, Bardies M, Zaidi H. Voxel-based dosimetry is superior to mean absorbed dose approach for establishing dose-effect relationship in targeted radionuclide therapy. Med Phys. 2019;46(12):5403–5406. PubMed

Dewaraja YK, et al. Prediction of tumor control in (90)Y radioembolization by logit models with PET/CT-based dose metrics. J Nucl Med. 2020;61(1):104–111. PubMed PMC

Kappadath SC, et al. Hepatocellular carcinoma tumor dose response after (90)Y-radioembolization with glass microspheres using (90)Y-SPECT/CT-based voxel dosimetry. Int J Radiat Oncol Biol Phys. 2018;102(2):451–461. PubMed

Chiesa, C., et al. EANM dosimetry committee series on standard operational procedures: a unified methodology for 99m Tc-MAA pre- and 90 Y peri-therapy dosimetry in liver radioembolization with 90 Y microspheres. EJNMMI Phys. 2021:8(1);77 PubMed PMC

Roosen, J., et al., To 1000 Gy and back again: a systematic review on dose-response evaluation in selective internal radiation therapy for primary and secondary liver cancer. Eur J Nucl Med Mol Imaging, 2021. PubMed PMC

Salem R, et al. Yttrium-90 radioembolization for the treatment of solitary, unresectable hepatocellular carcinoma: the LEGACY study. Hepatology. 2021. PubMed PMC

Lewandowski RJ, et al. (90) Y radiation lobectomy: outcomes following surgical resection in patients with hepatic tumors and small future liver remnant volumes. J Surg Oncol. 2016;114(1):99–105. PubMed

Palard X, et al. Dosimetric parameters predicting contralateral liver hypertrophy after unilobar radioembolization of hepatocellular carcinoma. Eur J Nucl Med Mol Imaging. 2018;45(3):392–401. PubMed PMC

Chiesa C, et al. Radioembolization of hepatocarcinoma with (90)Y glass microspheres: treatment optimization using the dose-toxicity relationship. Eur J Nucl Med Mol Imaging. 2020;47(13):3018–3032. PubMed

Shepherd FA, et al. A phase I dose escalation trial of yttrium-90 microspheres in the treatment of primary hepatocellular carcinoma. Cancer. 1992;70(9):2250–2254. PubMed

Bourien H, et al. Yttrium-90 glass microspheres radioembolization (RE) for biliary tract cancer: a large single-center experience. Eur J Nucl Med Mol Imaging. 2019;46(3):669–676. PubMed

Mouli S, et al. Yttrium-90 radioembolization for intrahepatic cholangiocarcinoma: safety, response, and survival analysis. J Vasc Interv Radiol. 2013;24(8):1227–1234. PubMed PMC

Padia SA, et al. Yttrium-90 radiation segmentectomy for hepatic metastases: a multi-institutional study of safety and efficacy. J Surg Oncol. 2021;123(1):172–178. PubMed

Alsultan, A.A., et al., Dose-response and dose-toxicity relationships for yttrium-90 glass radioembolization in patients with colorectal cancer liver metastases. J Nucl Med, 2021. PubMed PMC

Lewandowski RJ, et al. Twelve-year experience of radioembolization for colorectal hepatic metastases in 214 patients: survival by era and chemotherapy. Eur J Nucl Med Mol Imaging. 2014;41(10):1861–1869. PubMed

Levillain, H., et al., International recommendations for personalised selective internal radiation therapy of primary and metastatic liver diseases with yttrium-90 resin microspheres. Eur J Nucl Med Mol Imaging, 2021 PubMed PMC

Levillain H, et al. Personalised radioembolization improves outcomes in refractory intra-hepatic cholangiocarcinoma: a multicenter study. Eur J Nucl Med Mol Imaging. 2019;46(11):2270–2279. PubMed

van den Hoven AF, et al. Insights into the dose-response relationship of radioembolization with resin 90y-microspheres: a prospective cohort study in patients with colorectal cancer liver metastases. J Nucl Med. 2016;57(7):1014–1019. PubMed

Bastiaannet R, et al. First evidence for a dose-response relationship in patients treated with (166)Ho radioembolization: a prospective study. J Nucl Med. 2020;61(4):608–612. PubMed

van Roekel C, et al. Dose-effect relationships of (166)Ho radioembolization in colorectal cancer. J Nucl Med. 2021;62(2):272–279. PubMed

Vauthey JN, et al. Body surface area and body weight predict total liver volume in Western adults. Liver Transpl. 2002;8(3):233–240. PubMed

Ahmadzadehfar H, et al. Evaluation of the delivered activity of yttrium-90 resin microspheres using sterile water and 5% glucose during administration. EJNMMI Res. 2015;5(1):54. PubMed PMC

Giammarile F, et al. EANM procedure guideline for the treatment of liver cancer and liver metastases with intra-arterial radioactive compounds. Eur J Nucl Med Mol Imaging. 2011;38(7):1393–1406. PubMed

Lhommel R, et al. Feasibility of 90Y TOF PET-based dosimetry in liver metastasis therapy using SIR-spheres. Eur J Nucl Med Mol Imaging. 2010;37(9):1654–1662. PubMed

Selwyn RG, et al. A new internal pair production branching ratio of 90Y: the development of a non-destructive assay for 90Y and 90Sr. Appl Radiat Isot. 2007;65(3):318–327. PubMed

Kesim S, et al. Unexpected radiation pneumonitis after SIRT with significant decrease in DLCO with internal radiation exposure: a case report. BMC Med Imaging. 2020;20(1):52. PubMed PMC

Auditore L, et al. Monte Carlo (90)Y PET/CT dosimetry of unexpected focal radiation-induced lung damage after hepatic radioembolisation. Phys Med Biol. 2020;65(23):235014. PubMed

Scott NP, McGowan DR. Optimising quantitative (90)Y PET imaging: an investigation into the effects of scan length and Bayesian penalised likelihood reconstruction. EJNMMI Res. 2019;9(1):40. PubMed PMC

Elschot M, et al. Quantitative evaluation of scintillation camera imaging characteristics of isotopes used in liver radioembolization. PLoS One. 2011;6(11):e26174. PubMed PMC

van de Maat GH, et al. MRI-based biodistribution assessment of holmium-166 poly(L-lactic acid) microspheres after radioembolisation. Eur Radiol. 2013;23(3):827–835. PubMed PMC

John, L., Discharge of patients undergoing treatment with radioactive substances, A.R.P.a.N.S. Agency, Editor. 2002: Australia

Prince JF, et al. Radiation emission from patients treated with holmium-166 radioembolization. J Vasc Interv Radiol. 2014;25(12):1956–1963e1. PubMed

Laffont S, et al. Occupational radiation exposure of medical staff performing (9)(0)Y-loaded microsphere radioembolization. Eur J Nucl Med Mol Imaging. 2016;43(5):824–831. PubMed

Taleb J, et al. Radiation dose measurements for staff members involved in holmium-166 preclinical trial. Radiat Meas. 2013;58:75–78.

Gulec SA, Mesoloras G, Stabin M. Dosimetric techniques in 90Y-microsphere therapy of liver cancer: the MIRD equations for dose calculations. J Nucl Med. 2006;47(7):1209–1211. PubMed

Metyko J, et al. Long-lived impurities of 90Y-labeled microspheres, TheraSphere and SIR-spheres, and the impact on patient dose and waste management. Health Phys. 2012;103(5 Suppl 3):S204–S208. PubMed

Elsayed M, et al. Incidence of radioembolization-induced liver disease and liver toxicity following repeat 90Y-radioembolization: outcomes at a large tertiary care center. Clin Nucl Med. 2020;45(2):100–104. PubMed

Lam MG, et al. Safety of repeated yttrium-90 radioembolization. Cardiovasc Intervent Radiol. 2013;36(5):1320–1328. PubMed

Masthoff M, et al. Repeated radioembolization in advanced liver cancer. Ann Transl Med. 2020;8(17):1055. PubMed PMC

Zarva A, et al. Safety of repeated radioembolizations in patients with advanced primary and secondary liver tumors and progressive disease after first selective internal radiotherapy. J Nucl Med. 2014;55(3):360–366. PubMed

Prajapati HJ, et al. mRECIST and EASL responses at early time point by contrast-enhanced dynamic MRI predict survival in patients with unresectable hepatocellular carcinoma (HCC) treated by doxorubicin drug-eluting beads transarterial chemoembolization (DEB TACE) Ann Oncol. 2013;24(4):965–973. PubMed

Lencioni R, Llovet JM. Modified RECIST (mRECIST) assessment for hepatocellular carcinoma. Semin Liver Dis. 2010;30(1):52–60. PubMed

Shim JH, et al. Which response criteria best help predict survival of patients with hepatocellular carcinoma following chemoembolization? A validation study of old and new models. Radiology. 2012;262(2):708–718. PubMed

Gillmore R, et al. EASL and mRECIST responses are independent prognostic factors for survival in hepatocellular cancer patients treated with transarterial embolization. J Hepatol. 2011;55(6):1309–1316. PubMed

European Association for the Study of the Liver. Electronic address, e.e.e. and L. European Association for the Study of the, EASL clinical practice guidelines: management of hepatocellular carcinoma. J Hepatol, 2018. 69(1): p. 182–236 PubMed

Pollock RF, et al. Association between objective response rate and overall survival in metastatic neuroendocrine tumors treated with radioembolization: a systematic literature review and regression analysis. Expert Rev Anticancer Ther. 2020;20(11):997–1009. PubMed

Braat A, et al. Radioembolization with (90)Y resin microspheres of neuroendocrine liver metastases: international multicenter study on efficacy and toxicity. Cardiovasc Intervent Radiol. 2019;42(3):413–425. PubMed

Memon K, et al. Radioembolization for neuroendocrine liver metastases: safety, imaging, and long-term outcomes. Int J Radiat Oncol Biol Phys. 2012;83(3):887–894. PubMed PMC

Beuzit L, et al. Comparison of Choi criteria and response evaluation criteria in solid tumors (RECIST) for intrahepatic cholangiocarcinoma treated with glass-microspheres yttrium-90 selective internal radiation therapy (SIRT) Eur J Radiol. 2016;85(8):1445–1452. PubMed

Camacho JC, et al. Modified response evaluation criteria in solid tumors and European Association for the Study of the liver criteria using delayed-phase imaging at an early time point predict survival in patients with unresectable intrahepatic cholangiocarcinoma following yttrium-90 radioembolization. J Vasc Interv Radiol. 2014;25(2):256–265. PubMed

Akinwande O, et al. Comparison of tumor response assessment methods in patients with metastatic colorectal cancer after locoregional therapy. J Surg Oncol. 2016;113(4):443–448. PubMed