Biomed Imaging Interv J 2006; 2(3):e43
© 2006 Biomedical Imaging and
Trans-arterial hepatic radioembolisation of yttrium-90 microspheres
R Murthy1,*, MD, FACP,
A Habbu1, MD,
R Salem2, MD, MBA, FSIR
1 Interventional Radiology Section, University
of Texas, Houston, United States
2 Department of Radiology, Northwestern Memorial Hospital, Chicago, United
The liver represents a frequent site for metastatic disease,
in addition to being a site for primary cancer. Hepatic metastases from certain
neoplasms, such as colon, neuroendocrine, melanoma and gastrointestinal stromal
tumour have a distinct predilection to metastasize the liver, which in many
cases may represent the only or the dominant site of disease. In these
circumstances, cytoreduction via surgery or in situ ablative techniques
aims to influence the natural history of the disease progression and improve
Liver directed therapy utilising yttrium-90 microspheres represents
a recently introduced in situ multidisciplinary cancer
therapy that has caught the attention of many physicians faced
with the challenges of treating these complex patients. Although
similar to other forms of trans-arterial liver directed therapy,
there are discrete differences and potentially fatal treatment
consequences unique to this therapy. This objective of this
review article is to provide the reader a basis for understanding
the therapeutic principles, patient exclusion criteria, pre
and post therapy investigations and salient clinical results
in the two most commonly treated disease types; metastatic colorectal
cancer and hepatocellular cancer. � 2006 Biomedical Imaging
and Intervention Journal. All rights reserved.
Keywords: Liver cancer, yttrium-90, radioembolisation,
colon cancer, hepatocellular cancer
Metastatic colorectal cancer and hepatocellular cancer are
amongst the commonest causes of cancer mortality worldwide. A total of 437,000
worldwide deaths are estimated for colorectal cancer, making it the third most
important cause of cancer mortality overall . Hepatocellular cancer is the fourth most common cause of death from cancer and rapidly increasing in incidence in the United States . Surgical resection with curative intent with or without adjuvant chemotherapy for colorectal cancer is considered to offer the highest survival rates that range from 30-58% at five years [3,4]. Recurrent, most often unresectable disease in the hepatic remnant contributes significantly to this inability to achieve long term cure rates for colorectal cancer patients . Five year survival estimates range between 30-50% following hepatic resection and less than 20% following transplantation for hepatocellular cancer .
Since mortality and morbidity in this patient group is
directly related the presence of hepatic disease, the local application of in-situ
cytoreductive therapies may favourably alter the natural history of tumour
progression. These therapies can be broadly categorised as those applied via
the transcapsular or trans-vascular routes. The myriad of therapies that
exploit the trans-arterial route are based on the premise that metastatic tumours
receive their blood supply from the arterial rather than the portal
circulation, unlike normal hepatocytes . Hepatic artery injection allows preferential delivery of material to the peri-tumoural vascular plexus . A suspension of particles injected via the
hepatic artery, such as microspheres of appropriate diameter, will
preferentially lodge in the peri-tumoural vessels, a process termed embolisation.
Radiation is tumouricidal if sufficient tumour doses can be
delivered selectively without damaging adjacent normal tissue in the process.
External beam hepatic radiotherapy is limited in efficacy in the presence of
multifocal or large tumours in the liver since the radiation exposure of normal
hepatocytes results in liver insufficiency before achieving tumour kill . Brachytherapy, wherein the therapeutic radiation source is in physical contact with the tumour, circumvents the limitation of non-selectivity of extracorporeal radiotherapy. The utilisation of this effective technology, however, is largely limited, by the frequent requirement of direct visualisation of the liver that is traditionally achieved intra-operatively and is technically prohibitive in the presence of multifocal disease.
From the above discussion, it is evident that the altered
arterial supply to hepatic tumours could potentially be exploited to deliver
lethal doses of radiation. A high energy radiation source combined with an
appropriately sized trans-hepatic arterial administered embolic microscopic
particle would allow radiation to be delivered preferentially to the tumour . A β-emitter, such as yttrium-90, would create a zone of high radiation exposure confined to the vicinity of the tumour while maintaining non-tumourous hepatic parenchymal exposure to tolerable levels. This forms the premise for the selective internal radiation therapy or SIRT. Millions of microspheres, measuring about 30� in diameter incorporating yttrium-90, are injected via a hepatic arterial catheter to the arterial supply of the tumour. SIRT is a technique that allows high average doses of radiation (200 to 300 Gy) to be given to liver tumours with minimal serious effect on the nontumourous liver .
Biophysical Properties of Yttrium � 90
Yttrium-90 (Y90), a pure β emitter is produced by neutron
bombardment of yttrium-89 in a reactor. Y90 has a physical half-life of 64.2
hours (2.67 days) and decays to stable zirconium 90. The average energy of the
emissions from the Y90 is 0.9367 MeV, with an average/maximal penetration range
of 2.5 mm and 11mm respectively in tissue. One gigabecquerel (27 mCi) delivers
a total absorbed radiation dose of 50 Gy/kg. In therapeutic use in which the
isotope decays to infinity, 94% of the radiation is delivered in 11 days. Y90
is the active moiety in a variety of targeted radio-immunotherapies used in the
treatment of a variety of solid organ and hematological malignancies. Two Y90
microsphere products are commercially available (Figure 1), TheraSpheres� (MDS
Nordion, Ottawa, Canada) and SIR-Spheres� (SIRTEX Medical, Sydney,
Australia) and vary in their physical composition and radioactivity levels (Table
Figure 1 (a) Electron micrograph; SirSpheres,
resin. (b) Electron micrograph; Therasphere, glass.
Multidisciplinary Treatment Approach
In order to deliver Y90 microspheres safely and effectively,
harnessing the skills of many different specialties are paramount. In the United
States, interventional radiologists, surgical oncologists, medical
oncologists, nuclear medicine physicians, radiation oncologists, medical
physicists and radiation safety experts bring invaluable expertise to the
treatment process. It is imperative that this multidisciplinary team confirms
the presence of liver dominant unresectable disease before proceeding. In
general, a performance status (ECOG ≤ 1) is correlated with reasonable
There are two absolute contraindications for liver directed
therapy with Y90 microspheres; excessive hepatopulmonary and demonstrable
gastrointestinal shunting that can lead to fatal and morbid complications
of radiation pneumonitis and gastric ulceration respectively. Fortunately the
likelihood of developing these complications can be detected before definitive
treatment by utilising Tc99m MAA as a surrogate that mimics the distribution of
the Y90 microspheres (Figure 2).
Figure 2 Planar nuclear medicine scintigraphy.
Patterns of distribution of Tc99m MAA following hepatic arterial
delivery (bold arrow-liver; thin arrow- lung; double arrows-
gut). (a) Normal distribution with no extrahepatic activity
and no significant hepato-pulmonary shunting. (b) Excessive
hepato-pulmonary shunting. A 26% shunt fraction precluded
treatment in this patient with hepatocellular carcinoma. (c)
Significant gastrointestinal reflux. Treatment is precluded
if this phenomenon is not corrected. Incidentally is also
noted of excessive hepatopulmonary shunting.
Hepatopulmonary Shunting: Pathologic arteriovenous communications develop
within hepatic neoplasia. Microspheres injected into the hepatic
artery pass through the tumour via these shunts and are carried
by the venous return to the heart via the hepatic veins and
eventually embolise within terminal pulmonary arteriolar branches.
As the magnitude of shunt increases, proportionately larger
numbers of radioactive microspheres can reach the lungs causing
clinically significant radiation pneumonitis. Maintenance of
lung exposure below a mean dose of 30Gy avoids this complication
. The magnitude of this shunting phenomenon
is calculated by a quantitative assessment of the ratio of the
gamma emission count in the lung to that in the liver corrected
for background. This numerical value assists in activity modification
when the resin microspheres are used.
Gastrointestinal Tract Deposition: Numerous named and
unnamed arteries that supply the adjacent gastrointestinal tract arise normally
and in a variant fashion from the hepatic arteries. The most common of these
arteries are the gastroduodenal and right gastric. During the delivery process,
microspheres may inadvertently reflux into these vessels resulting in their
embolisation into the gastrointestinal submucosal visceral arterioles. By
virtue of the combined ischemia and radiation effect, varying degrees of
inflammation and ischemia ensue resulting in an ulcerative diathesis that is
frequently treatment refractory. These vessels are therefore prophylactically
coil embolised at their origin at the time of the performance of the Tc-99m-MAA
shunt study thereby occluding the avenue for microsphere transit to these
extrahepatic locations and reducing the incidence of this complication .
Pre- therapy Investigations & Therapy Planning
Serum chemical analyses also are performed to evaluate
hepatic and renal function, traditionally measured by serum bilirubin and
creatinine respectively. The presence and magnitude of elevation of tumour
markers specific to the tumour type being treated are ascertained. By
consensus, an elevated serum bilirubin level is considered a
relative contraindication to treatment with Y90 microspheres. In the
presence of renal insufficiency, care must be taken to avoid or
minimize the use of iodinated contrast material. Treatment with Y90
microspheres must be based on cross-sectional images and arteriograms in the
individual patient. The work-up should include CT or MR imaging of
the liver for assessment of tumoural and non-tumoural volume, portal
vein patency, and extent of extrahepatic disease.
Pre-procedural Cross Sectional Imaging with CT or MRI
A triple phase CT to delineate the geographical
distribution, the volume and the partition between hepatic parenchyma and tumour
is essential in therapy planning (Figure 3). Adjunct information on portal vein
patency and aberrant hepatic arterial anatomy is obtained. Distribution of the
disease is typically characterised as unilobar or bilobar, however the
correlation of tumour with hepatic arterial supply is variable and can only be
ascertained with arteriography. Ascites indicates poor hepatic reserve or
peritoneal metastasis, both of which have a poor prognosis.
Figure 3 Pre-Y90 microsphere therapy
planning evaluation in a 58 year old female with hepatic metastatic
colorectal cancer. Contrast enhanced axial CT scan demonstrates
numerous bilobar low attenuation lesions consistent with metastases.
Note patency of the portal vein.
Arteriographic Assessment and Hepatic Arterial Injection
of Tc 99m MAA
�Arteriography is essential to map the hepatic arterial
supply from the celiac and the superior mesenteric artery and is the single
most important test to exclude preventable complications. Using a percutaneous
inserted catheter, the hepatic arteries are accessed and the supply to the
liver and the adjacent gastrointestinal tract is identified. Once identified,
these gastrointestinal tract arteries are coil embolised to ensure prevention
of reflux of microspheres into the gut (Figure 4). When such arteries are not
confirmed arteriographically, the hepatic arterial infusion of 5 mCi of Tc-99m-MAA
assists to identify occult extrahepatic perfusion. This is manifested by
extra-hepatic scintigraphic activity on nuclear medicine imaging. The culprit
artery can usually be retrospectively identified on the angiogram and then
embolised before the Y90 microsphere delivery (Figure 5).
Figure 4 58 year female with hepatic
metastatic colorectal cancer undergoing pre-treatment therapy
planning arteriography and embolisation of vessels supplying
the gastrointestinal tract. (a) Celiac Arteriogram with variant
anatomy; showing Splenic artery (thin arrow) ; Common hepatic
artery (bold arrow) and the variant Gastrohepatic trunk (arrow
heads). (b) Right Hepatic Arteriogram; Catheter tip in right
hepatic artery(bold arrow); Right gastric artery (arrow heads)
could not be selectively catheterised for embolisation. (c)
GastroHepatic Trunk Arteriogram; Left gastric artery (bold
arrow)anastomosing with right gastric artery (arrowheads)
along the lesser curvature of the stomach ; note left hepatic
artery (thin arrow) supplying the left lobe of liver. (d)
Left Gastric Arteriogram; Selective 3 Fr microcatheter in
the left to right gastric artery arcade(thin arrow); Note
reflux into the right hepatic artery at the origin of the
vessel (bold arrow). (e) Right Gastric Artery embolisation;
two 3 mm fibred platinum microcoils deployed from origin of
right gastric artery. (f) Gastroduodenal arteriogram; selective
3 Fr microcatheterisation of origin in preparation for embolisation.
(g) Right Hepatic Arteriogram following embolisation of the
right gastric artery; Gastroduodenal artery (arrow heads)
demonstrating absence of flow to the gastrointestinal tract;
Note the diffuse hypervascular hepatic metastases (arrows).
Figure 5 67 year old male
with hepatic metastatic colorectal cancer undergoing pre-treatment
hepatopulmonary shunt evaluation. (a) Proper Hepatic Arteriogram;
Tc99 MAA was injected via a microcatheter placed in the proper
hepatic artery (arrow) following coil embolisation of the
gastroduodenal artery; Note opacification of the patent right
gastric artery (arrow heads). (b) Planar thoracoabdominal
scintigraphy following hepatic arterial injection of Tc99
MAA demonstrates predominant left lobe hepatic activity only
(bold arrow) and absence of extrahepatic activity (thin arrow).
(c) SPECT images (a) demonstrate activity corresponding to
the CT (b) images of the left lobe of the liver (bold arrow)
and in the stomach (thin arrow) not noted on the planar image.
Y90 Microsphere Treatment
Solitary or multiple lesions distributed in a lobe or both
lobes can be treated with single and multiple microsphere treatments
successfully. Nomenclature for the current convention for whole liver treatment
by first treating one lobe and then the other in 4-6 weeks is termed
�sequential� or �lobar� delivery; as opposed to the whole liver at one setting
in which case it is termed �bilobar� in the absence of a lobectomy. The current
practice in the United States is to allow a 4-6 week interval between infusions
if treatment was intended to be delivered sequentially to allow for recovery
after any treatment related toxicities.
Y90 microspheres are unlike a traditional
radiopharmaceutical or brachytherapy device and share the characteristics of
both. At present the dose calculation methodology described in the package
insert is recommended, however improvements in dosimetry represent an area of
intense investigation . CT treatment planning with reconstruction of the liver volumes assists to calculate the required activity for treatment.
Glass Y90 Microsphere Activity Calculation & Delivery:
The dose determination for glass microspheres is based on a nominal average
target dose (150 Gy/kg), and the patient's liver mass is determined from the CT
data and assumes the uniform distribution of the microsphere throughout liver
In this equation, A is the activity, D is the nominal target
dose, and M is the mass of the targeted liver tissue.
Resin Y90 Microsphere Activity Calculation and Delivery:
Resin microspheres are received in a vial as a 3 GBq dose, and the individual
medical centers remove the prescribed activity. This process differs from that
for glass microspheres where a predetermined dose is delivered to the facility.
Due to the higher specific activity with glass microspheres and therefore the
relative low volume of the spheres per dose, embolic occlusion of the parent
artery has not been observed arteriographically. However, the prescribed
activity of resin spheres cannot always be delivered completely  due to embolic arterial occlusion. In these instances, the residual activity in the delivery vial is measured and the delivered dose is the difference between the prescribed and the residual dose. The manufacturer recommends one of the two methods for activity determination for the resin microsphere; the Body Surface Area method (BSA) and the Empiric Method (EM). However, most experienced practicing physicians recommend the use of the BSA for resin microsphere dose calculation since the delivered dose more closely resembles the activity calculated by the BSA methodology.
Body Surface Area Method
Activity calculated for whole liver delivery based on tumour
replacement as demonstrated on CT.
Secondary gamma emission, Bremsstrahlung, scans are possible
due to the interaction of the high energy Beta emission interacting with
matter. Unfortunately, such Bremsstrahlung emissions represent a broad spectrum
of energy emissions rendering relatively poor point to point discrimination.
Currently the planar and/or SPECT images obtained from such an acquisition are
mostly qualitative and allow the operator to discern the relative distribution
of the Y90 microspheres within the liver. Extrahepatic activity may warn
clinicians of impending gastrointestinal complications and serve as a quality
assurance tool (Figure 6).
Figure 6 Bremsstrahlung imaging assists
in confirming successful targeting of hepatic metastatic deposits
from carcinoid tumour. Representative axial, coronal and sagittal
CT images(first column), SPECT images (second column) and
SPECT/CT fusion images (third column) obtained with a dual-modality
imaging system) Hawkeye GE Medical Systems, Milwaukee, Wis)
show selective activity in the left hepatic lobe (arrow) approximately
24 hours after intraarterial infusion of 90Y- bearing resin
microspheres at a dose of 23.9 mCi (884.3 MBq).
Post Treatment Course
The most common side effect following treatment is mild to
moderate fatigue and abdominal pain generally lasting less than 2 weeks. Nausea
and vomiting are less common and if severe may be a harbinger for a more
gastrointestinal deposition. Patients are usually seen in clinic weekly or
fortnightly for a month and then once every month. At the time of clinic visits
complete blood count, serum tumour markers and liver function tests are
assayed. Cross sectional imaging with CT/MRI is performed between 60-90 days
following treatment to avoid radiation therapy tumour edema as erroneously
being interpreted as progression. These decrease attenuation changes in the
hepatic parenchyma may be noted on CT and are largely reversible . 18F-fluorodeoxyglucose Positron Emission Tomography (PET) scans may be of use in cases of discordance where tumour markers are not elevated and CT scans suggest progression or to distinguish the site of progression in the presence of extra-hepatic disease when not evident by other standard means .
Early studies demonstrated the feasibility of Y90 microsphere
therapy for a variety of disease types [18,19].Y90 microsphere therapy have since been applied principally for the treatment of unresectable hepatic metastatic colorectal and hepatocellular carcinoma.
One of the first systematic application towards the
treatment of a specific tumour type was seen for colorectal cancer . The application of Y90 resin microspheres to a patient population with hepatic colorectal metastases demonstrated favorable responses, augmented with the addition of hepatic arterial 5FU [21,22]. Encouraged by these results, a phase III trial in patients with laparotomy proven hepatic-only metastatic disease and resected primary was performed. In this pivotal trial, patients were randomised to receive intra-arterial FUDR with or without a single dose of the resin microspheres . The results demonstrated a benefit in all
clinical indices favoring the combination therapy, specifically a time to
tumour progression of 15.9 versus 9.7 months (p<0.01) and formed the basis
for FDA approval in the US. An important lesson was learnt during this trial;
the majority of patients developed extra-hepatic disease that adversely
affected survival and this observation was supported by a separate large
clinical experience . Furthermore, with the introduction of
irinotecan and oxaliplatin with systemic 5 FU, liver directed therapy with
intra-arterial FUDR was no longer the standard of care at the time of trial
In order to address these shortcomings, a phase II randomised trial and two
phase I trials that combined systemic 5 FU/LV and the 5 FU based
regimens of oxaliplatin and irinotecan respectively, were performed
with enrollment in Australia and Europe. In the randomised phase
II trial, responses were significantly augmented with the addition
of the Y90 microspheres (8 PR versus 0 PR) .
The phase I trials unequivocally demonstrated that these systemic
therapies could be safely combined. Furthermore such combinations
were within the dose ranges administered in clinical practice
and generated robust responses (PR + CR of 90% with FOLFOX-4
regimen) [26, 27].
In the United States however, the application of this
therapy has been relegated to treating patients who have failed multiple
chemotherapy regimens most often as a single agent and then without a fixed
combinatorial chemotherapy regimen (Figure 7). Responses in this highly
pre-treated population have been demonstrated, but as expected, are
significantly lower than the chemo-na�ve population .
Figure 7 Partial response to Y90 microsphere
therapy with the use of 1.61 GBq glass microspheres in an
83 yr old man with metastatic colorectal cancer; Contrast
enhanced CT scan (a) before treatment demonstrates a low attenuation
area in the right lobe of the liver (arrow) consistent with
a metastasis with (b) significant reduction in size 12 months
The other major therapeutic area that has been used with Y90
microsphere therapy has been in the treatment of unresectable hepatocellular
carcinoma (HCC). Extensive experience has been gained in the treatment of HCC
with resin microspheres in Asia and with glass spheres in the United States.
In Asia, Y90 resin microspheres as an effective treatment
option was first delineated by an 18 patient phase I/II trial and supported by
a observational study in 71 patients conducted by the same group. These studies
found that tumour response and clinical benefit was proportional to the dose
delivered; patients receiving >120 Gray survived 55.9 weeks compared with
26.2 weeks for those patients that received <120 Gray. Repeat treatments
with Y90 microspheres provided additional survival benefits [28, 29]. A Canadian study published in 2000 reported on 22 patients to determine response parameters, survival and toxicity after intra-arterial injection of 90Y glass microspheres . 20 were evaluated for efficacy including 9 patients who were Okuda stage I and II, and 11 patients who were Okuda stage III. The median dose delivered was 104 Gy (range 45-145 Gy). Interestingly the median survival of 54 weeks (range 7-180 weeks) and the trend for enhanced survival with higher doses (> 104 Gy) was similar to the results seen for resin microspheres.
Several retrospective patient studies have emerged from the
centers treating with glass Y90 microspheres in the USA. In an analysis by Carr
et al. in 65 patients, 38% had partial responses while the median survival
duration for Okuda Stage I and II patients was 649 and 302 days respectively . Geschwind reported on 80 patients from a relatively large database of 121 patients who were treated with glass microspheres . Patients were staged using the Child-Pugh, Okuda, or Cancer of the Liver Italian Program (CLIP) scoring systems. Survival was found to be 628 and 324 days for Okuda I (68%) and II (32%) patients respectively. Data from an in-depth subset analysis in 121 patients elucidated factors that predicted high 3-month mortality. These included infiltrative tumour, liver replacement by tumour � 70%, elevation in liver enzymes (ALT/AST) � 5 x ULN, a combination of tumour volume � 50% and albumin < 3 g/dL, bilirubin
elevation � 2 mg/dL . Y90 microsphere treatment has resulted in the downstaging of non-resectable disease to either be treatable by transplantation, resection or RFA  or transplant  (Figure 8).
Figure 8 Portal vein invasion from right
lobe hepatocellular carcinoma; (a) before and (b) after treatment
with 2.39 GBq glass microspheres in a 72 yr old man. A partial
response with regression of the tumour thrombus (arrows) is
noted. Complete normalisation of tumour marker (AFP) was obtained.
In summary, the tumours treated with Y90 microspheres have
responded to therapy. This is evidenced by reduction in tumour
volume and markers, ability to convert to a resectable status,
and improvements in the time to tumour progression. However,
there are many unanswered critical questions; who would be the
�optimal� patient? Should the radiation dose be fractionated?
and at what dose and frequency? Does a dose response to tumour
volume correlation exist? Can other newly developed systemic
therapies be integrated safely? If so, what sequence should
the therapy be initiated? Randomised clinical trials and registry
data will assist answering these important questions.
The incidence of complications is low if patient selection
is appropriate and delivery technique is meticulous. Post treatment fatigue
occurs uniformly with varying degrees of severity and is almost always
transient lasting 10-14 days. Abdominal pain, nausea and vomiting are common
but manageable via conservative means. Severe symptoms are relatively uncommon
and should alert the clinician about possible extrahepatic microsphere
deposition and consequences thereof.
Pancytopenia that had been reported in the earliest version of the Y90 microsphere
has not been reported with the newer agents that are in current
clinical use . Radiation pneumonitis
following lung exposure can occur when the dose to the lung
exceeds 30Gy . As a testament to the
validity of utilising Tc99m MAA scan to calculate potential
lung exposures, in over 3000 doses administered in the US, no
cases of this complication have been reported. Radiation gastritis
and gastrointestinal ulceration occur in less than 10% of cases;
the vast majority of such cases have been managed conservatively
without sequelae . Gall bladder wall
edema is a common finding following treatment, but cholecystitis
requiring a cholecystectomy is rare .
Radiation induced liver disease (RILD), erroneously called radiation
hepatitis, a form fruste of hepatic veno-occlusive disease.
This presents clinically as a triad of hepatomegaly and anicteric
ascites. Steroids have been the mainstay of therapy and have
a poor and variable success at altering the natural history
of the disease process and in most instances hepatic insufficiency
associated morbidity ensues. Fortunately the reported incidence
of RILD is low. Translation of dosimetry research may eventually
mitigate the incidence of this entity.
Y90 microspheres represent an intriguing therapy for the
treatment of liver cancer. However, the utility of Y90 microsphere therapy
remains to be determined within the context of the other currently available
therapies. Standardisation of dosimetry and treatment techniques, achievable
only in the robust randomised clinical trials, are necessary to arrive at
conclusions that support clinical effectiveness. Registry data will be
necessary to provide guidance on therapeutic effectiveness and for disease
types for which clinical trials are not historically feasible due to their low
incidence and for many patients who do not meet traditional eligibility
criteria. Such efforts are underway.
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Kim DY, Kwon DS, Salem R, et al. Successful embolization of hepatocelluar carcinoma with yttrium-90 glass microspheres prior to liver transplantation. J Gastrointest Surg 2006;10(3):413-6.
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|Received 31 May 2006; received in revised form 10 July 2006; accepted 3 September 2006
Correspondence: Division of Diagnostic Imaging, Interventional Radiology Section, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 325, Houston, Texas 77030-4009, United States. Tel: +713-745-0856; Fax: +713-792-4098; E-mail: firstname.lastname@example.org (Ravi Murthy).
Please cite as: Murthy R, Habbu A, Salem
Trans-arterial hepatic radioembolisation of yttrium-90 microspheres, Biomed Imaging Interv J 2006; 2(3):e43
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