Caren van Roekel

39 Radioembolization FIGURE 6. The upper row shows contrast-enhanced CT images of a 60-year-old woman with hepatic metastases of a neuro-endocrine carcinoma, before treatment with radioembolization. The lower row shows contrast-enhanced CT images after treatment with 166 Ho-radioembolization, with the development of REILD (impaired hepatic function and ascites). REILD is usually defined as : ‘a symptomatic post-radioembolization deterioration in the ability of the liver to maintain its (normal or preprocedural) synthetic, excretory and detoxifying functions. It is characterized by jaundice and the development of or increase in ascites, hyperbilirubinemia and hypoalbuminemia developing at least two weeks – four months after radioembolization, in the absence of tumor progression or biliary obstruction’ (74). Histopathologically, REILD is characterized by veno-occlusive disease with congestion of the central veins and sinusoids (78). The incidence of REILD is reported to be 0-5.4%. The natural course of REILD is highly variable: it can either result in fulminant hepatic failure and death, or it can be transient and self-limiting. Reported risk factors for REILD include previous liver-directed therapies, such as chemotherapy, external beam radiation therapy (EBRT), radioembolization and other intra- arterial therapies. Furthermore, a high absorbed dose and single-session whole liver treatment also increase the risk of hepatotoxicity (74). Other risk factors are exposure to chemotherapy within 2 months after radioembolization, a liver volume <1.5 L, and increased baseline bilirubin and aspartate aminotransferase (79). Treatment options consist mainly of supportive measures, such as the reduction of ascites or pleural effusion and the avoidance of hepatotoxic drugs (74). To reduce the excessive extravascular volume, diuretics (spironolactone 100 mg and/or furosemide 40 mg daily) can be tried. When liver function 2