Recommended in the guidelines

ESMO, EASL and NCCN guidelines acknowledge the potential benefits of SIR-Spheres® Y-90 resin microspheres for treatment of hepatocellular carcinoma.

Hepatocellular carcinoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up (2018)¹

SIRT is not recommended as first-line therapy for HCC patients in intermediate and advanced stage.

BCLC 0-A
SIRT may be considered instead of TACE to avoid drop out from a transplant list in reducing tumour progression

BCLC B
SIRT may be considered as an alternative treatment option in patients with liver-confined disease and preserved liver function after TACE (after TACE failure/ refractoriness)

BCLC C
SIRT may be considered as an alternative treatment option in patients with liver-confined disease and preserved liver function in whom systemic therapy is not feasible.

EASL Clinical Practice Guidelines: Management of hepatocellular carcinoma (2018)²

BCLC A(/B)

• SIRT showed better tumour control than TACE and could therefore reduce drop-out from transplant waiting list
• SIRT induces substantial contralateral hypertrophy and might prepare or select patients with borderline resectable HCC for surgery

BCLC B (SIRT vs. TACE)

• SIRT induces less toxicity
• SIRT provides significantly longer TTP and better tumour control but no better OS
• SIRT maintains higher QoL

BCLC C (SIRT vs. Sorafenib – SARAH / SIRveNIB)

• No statistically significant differences in OS were observed
• Response rates were significantly higher with SIRT
• Survival benefit compared to sorafenib is still not proven hence SIRT should only be adopted after MDT discussion

NCCN Guidelines Version 2.2019; Hepatobiliary Cancers³

• Loco-regional therapies^# such as SIRT* should be considered in patients who are not candidates for surgical curative treatments
• As arterially directed therapy^‡ SIRT is relatively contraindicated in patients with bilirubin >3 mg/dL unless segmental treatment can be performed
• SIRT with yttrium-90 microspheres has an increased risk of radiation-induced liver disease in patients with bilirubin over 2 mg/dL
• All tumours irrespective of location may be amenable to SIRT

BCLC A 

• SIRT should be considered as bridge for other curative therapies
• SIRT may be used as monotherapy or in combination with ablation to treat lesions 3 to 5 cm to prolong survival
• SIRT should be considered for unresectable/inoperable lesions >5 cm

BCLC B

• See above: All tumours irrespective of location may be amenable to SIRT

BCLC C

• SIRT should be considered in highly selected patients in the presence of limited tumour invasion of the portal vein
• Sorafenib may be appropriate following SIRT in patients with adequate liver function once bilirubin returns to baseline if there is evidence of residual/recurrent tumour not amenable to additional local therapies

# Loco-regional therapies: ablation, arterially directed therapies, and radiotherapy
*SIRT: Selective Internal Radiation Therapy, also known as Radioembolisation (RE)
‡ Arterially directed therapies: bland trans-arterial embolisation (TAE), trans-arterial chemoembolisation [TACE, DEB-TACE] and radioembolisation (RE) with yttrium-90 microspheres

1. Vogel A et al. Ann Oncol 2018; 29: iv238–iv255.
2.Galle P et al. J Hepatol 2018; 69:182-236.
3.NCCN Guidelines version 2.2019 Hepatobiliary Cancers.