Caren van Roekel

265 Discussion only induces hypertrophy, but that it also offers tumor control, in contrast with PVE. Also, it provides a test-of-time: because of the prolonged interval between radioembolization and surgery, subclinical, previously undetected metastases may become detectable (57). Moreover, radioembolization can be used to improve the secondary resectability rate: in a substudy on patients of the SIRFLOX trial, the resectability rates after treatment with chemotherapy versus treatment with chemotherapy combined with radioembolization were assessed. Thirty-eight percent of patients who were treated in the combination arm became resectable, which was significantly more than the 29% in the chemotherapy-only group (58). What patients are good candidates for treatment with radioem- bolization? Currently, radioembolization is reimbursed in The Netherlands for patients with unresectable, liver-dominant, chemotherapy-refractory disease. They have to be in relatively good clinical condition (performance status 0-2) with a life expectancy of at least three months and adequate hepatic function (albumin >30g/L and bilirubin ≤1.5*upper limit of normal). Liver-dominant disease is defined as a maximum of 5 lung nodules <1 cm and lymph nodes <2 cm (3). The question is whether one should accept extrahepatic metastases at all? Several studies indicate that the presence of extrahepatic disease at baseline is a poor prognostic factor (35, 37, 38, 59). Our own study confirms this finding: patients with extrahepatic metastases had a significantly worse median overall survival (6.5 months versus 10 months in patients without extrahepatic disease at baseline). Also, treatment response was worse: 93% was diagnosed with progressive disease at three months after treatment, versus 63% of patients without extrahepatic disease at baseline. Although this was a retrospective, observational study, its results and the results of other studies indicate that it may be better to exclude patients with extrahepatic disease from treatment with radioembolization. However, although the benefit of radioembolization seems minimal in patients with extrahepatic disease, to verify its true potential, it should be compared with best supportive care only (e.g. in a randomized clinical trial). 10