Radioembolisation

Senior Consultant Vascular and Interventional Radiologist

Radioembolisation is a minimally invasive procedure that delivers radiation directly to liver tumours while sparing healthy tissue. This treatment combines embolisation, which blocks blood supply to tumours, with radiation therapy using tiny radioactive beads called microspheres. These microspheres travel through the bloodstream to lodge in tumour vessels, where they deliver targeted radiation to the cancer cells. Radioembolisation is typically used for primary liver cancer, metastatic colorectal cancer, and other cancers that have spread to the liver.

Indications for Radioembolisation

This procedure may be recommended in a variety of clinical situations where other treatments are limited or ineffective.

Radioembolisation treats hepatocellular carcinoma (HCC) when surgical removal is not possible or when tumours are multifocal. It delivers targeted radiation to cancer cells while preserving remaining liver function.

The procedure addresses colorectal cancer that has spread to the liver and not responded to chemotherapy. It can stabilise disease progression when other options have been exhausted.

Radioembolisation manages liver metastases from neuroendocrine tumours when they cause symptoms or show progression. The targeted approach helps control hormone production in functioning tumours.

The treatment is suitable for patients with numerous liver lesions or large tumours that make surgical resection challenging. It can treat the entire affected liver lobe simultaneously.

Radioembolisation maintains tumour control while patients await liver transplantation. This prevents disease progression during the waiting period for donor organs.

Benefits of Radioembolisation

Radioembolisation offers several advantages compared to conventional therapies for liver malignancies.

Targeted Treatment

Radioembolisation delivers radiation directly to tumours while minimising exposure to healthy liver tissue. The microspheres lodge preferentially in tumour blood vessels due to their abnormal structure.

Outpatient Procedure

The treatment requires minimal hospital stay, typically allowing patients to return home the same day. Recovery time is shorter compared to open surgical procedures.

Maintained Quality of Life

Patients generally experience fewer side effects compared to systemic treatments like chemotherapy. The localised nature of the treatment reduces whole-body toxicity.

Single-Session Treatment

Most radioembolisation procedures can be completed in one session, unlike other therapies requiring multiple visits. This reduces the treatment burden on patients.

Combined Therapeutic Effect

The procedure delivers both radiation therapy and reduces blood supply to tumours. This dual mechanism enhances treatment efficacy.

Option for Advanced Cases

Radioembolisation may be offered to patients who have exhausted other treatment options. It provides an alternative when surgery, ablation, or chemotherapy are no longer viable.

Preparing for Radioembolisation

A comprehensive assessment includes blood tests to evaluate liver function, kidney function, and blood counts. Imaging studies such as CT scans, MRIs, and PET scans map the tumour extent and liver anatomy. Each case will be evaluated to determine whether radioembolisation is an appropriate treatment option.

This preliminary procedure examines the blood vessels supplying the liver and tumours. A catheter is inserted through the groin artery and guided to the hepatic arteries using X-ray guidance. The interventional radiologist identifies vessels feeding the tumour and vessels that might allow microspheres to travel to other organs. Any vessels requiring protection may be blocked with tiny coils during this procedure.

Technetium-99m labelled macroaggregated albumin (MAA) particles simulate the path the treatment microspheres will take. These particles are injected during the mapping angiogram to determine if there is significant shunting to the lungs. The results help calculate the safe radiation dose and assess whether radioembolisation can proceed.

Certain medications may need modification before the procedure. Blood thinners such as warfarin, clopidogrel, or direct oral anticoagulants require temporary discontinuation according to specific timelines. Metformin may be paused due to contrast media use.

Fasting is required before the procedure, with no solid food for 6 hours and clear liquids allowed up to 2 hours before the appointment. Diabetic patients receive specific instructions to manage blood glucose levels during fasting.

Patients start preventive medications to minimise side effects. Anti-nausea medications reduce the risk of post-embolisation syndrome. Acid-reducing medications protect the stomach from potential ulceration. Antibiotics may be prescribed if there is an increased infection risk. These medications typically begin 1-2 days before the procedure and continue for a short period afterwards.

Step-by-Step Procedure

Anaesthesia Administration: Radioembolisation is performed under conscious sedation, using intravenous sedatives and pain medications to ensure comfort while maintaining consciousness. Vital signs are continuously monitored, and a local anaesthetic is applied at the catheter insertion site, typically in the groin area.
Arterial Access: A small incision is created over the femoral artery in the groin. A hollow needle accesses the artery, followed by insertion of a guide wire. A vascular sheath is placed over the wire to maintain arterial access throughout the procedure. The catheter system is then advanced through this sheath under X-ray guidance.
Catheter Navigation: The catheter is directed from the femoral artery through the aorta to the hepatic artery. Contrast material injection creates real-time images of the blood vessels, allowing precise navigation. A smaller microcatheter is then advanced through the main catheter into the specific branches supplying the tumour. The catheter position is verified with additional contrast injections before microsphere delivery.
Microsphere Delivery: The prepared radioactive Y-90 microspheres are transferred from their shielded container to the delivery system. The microspheres are slowly injected through the microcatheter while monitoring for any resistance or reflux. The delivery rate is carefully controlled to ensure optimal distribution throughout the tumour vessels.
Catheter Removal and Haemostasis: After microsphere delivery, the catheter system is removed. Pressure is applied to the arterial access site to prevent bleeding. Alternatively, a vascular closure device may seal the arterial puncture. A sterile dressing is placed over the access site.

Post-Procedure Care and Recovery

Immediate Monitoring: Patients remain under observation for 4-6 hours following radioembolisation. Regular monitoring includes vital signs, catheter insertion site checks, and intravenous hydration to support kidney function. Pain management is provided as needed, though severe pain is uncommon after this procedure.
Post-Embolisation Syndrome: Many patients experience temporary symptoms including fatigue, mild fever, nausea, and abdominal discomfort lasting 3-7 days. Medications help manage these symptoms. Maintaining adequate hydration and following a light diet is recommended initially. These symptoms gradually resolve as the body adjusts to the treatment.
Activity Guidelines: Avoid strenuous activities for approximately one week after the procedure. Light walking is encouraged to prevent blood clots, while heavy lifting should be avoided to prevent strain at the insertion site. Driving is restricted for 24 hours due to sedation effects. Most patients resume normal activities within 7-10 days.
Follow-up Imaging: Diagnostic imaging (CT, MRI, or PET scans) assesses treatment response approximately 4-6 weeks after radioembolisation, with additional imaging at 3-month intervals. Treatment effectiveness may not be fully apparent on initial scans as radiation effects continue over time.

Potential Risks and Complications

Radioembolisation carries specific risks that should be discussed before treatment. These include radiation-induced liver disease (presenting as jaundice and fluid accumulation), gastric or duodenal ulceration from untargeted microspheres, temporary liver function deterioration, radiation pneumonitis if microspheres reach the lungs, and access site complications. Fatigue typically lasts 2-4 weeks after treatment. Less common complications include biliary damage, radiation cholecystitis, and vascular injury. Long-term side effects remain uncommon due to localised radiation exposure and Y-90’s short half-life.

Dr Suresh Babu

Senior Consultant Vascular and Interventional Radiologist

Dr Suresh is one of the leading specialists in vascular and non-vascular radiological interventions, interventional oncology, pain relief in interventional radiology and neuro interventional procedures in Singapore and Southeast Asia.

MBBS (Madras)
DMRD (Liverpool)
FRCP (Dublin)
FRCR (London)
FCIRSE (Europe)
EBIR (Europe)
MBA (Birmingham)

His training includes comprehensive programmes in Radiology and Interventional Radiology in the UK and Canada, equipping him with the skills to manage even the most complex procedures.

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Radioembolisation

Frequently Asked
Questions

How long do the radioactive microspheres remain active in the body?

Yttrium-90 has a physical half-life of approximately 64 hours, meaning half the radioactivity decays every 2.7 days. After about 11 days (5 half-lives), less than 5% of the initial radioactivity remains. The microspheres themselves stay permanently embedded in the tumour blood vessels but become non-radioactive.

Can radioembolisation be repeated if needed?

Yes, the procedure can be repeated in many cases. Patients may receive additional treatment after assessing their prior response and current liver function. The cumulative radiation dose and liver reserve must be carefully evaluated before any repeat procedures.

How soon will I know if the treatment worked?

Response to radioembolisation develops gradually. Initial assessment with imaging typically occurs at 4-6 weeks post-treatment, though this provides only preliminary information. More definitive response evaluation happens at 3 months. Some patients experience symptom relief earlier, but tumour shrinkage takes time as radiation effects accumulate over several weeks.

Radioembolisation

Indications for Radioembolisation