ORIGINAL ARTICLE – HEPATOBILIARY TUMORS

Yttrium-90 Radioembolization for Unresectable, ChemoresistantBreast Cancer Liver Metastases: A Large Single-CenterExperience of 40 Patients

Akshat Saxena, MBBS, BMedSc1,2, Jada Kapoor, MBBS, BMedSc2, Baerbel Meteling, BVetMed, PhD1,

David L. Morris, MBBS, MD, PhD2, and Lourens Bester, MBChB, BSc1

1Department of Interventional Radiology, St Vincent’s Hospital Sydney, Darlinghurst, NSW, Australia; 2UNSW

Department of Surgery, St George Hospital, Kogarah, NSW, Australia

ABSTRACT

Introduction. There are a paucity of data on the treatment

of unresectable, chemoresistant breast cancer liver metas-

tases (BRCLM) with yttrium-90 (Y90) radioembolization.

Methods. Forty patients underwent resin-based Y90 ra-

dioembolization for unresectable, chemoresistant BRCLM

between 2006 and 2012 in a single institution. All patients

were followed up with imaging studies at regular intervals

as clinically indicated until death. Radiologic response was

evaluated with the Response Criteria in Solid Tumors cri-

teria. Clinical toxicities were prospectively recorded as per

the National Cancer Institute Common Toxicity Criteria.

Survival was calculated by the Kaplan–Meier method and

potential prognostic variables were identified on univariate

and multivariate analysis.

Results. Follow-up was complete in all patients. The

median follow-up was 11.2 (range 0.6–30.5) months and the

median survival after Y90 radioembolization was

13.6 months, with a 24-month survival of 39 %. On imag-

ing follow-up of 38 patients who survived beyond 1 month

of treatment, a complete response (CR) to treatment was

observed in two patients (5 %), partial response (PR) in 10

patients (26 %), stable disease (SD) in 15 patients (39 %),

and progressive disease (PD) in 11 patients (29 %). Two

factors were associated with an improved survival on

multivariate analysis: CR/PR to treatment (vs. SD vs. PD;

p \ 0.001) and chemotherapy after radioembolization (vs.

no chemotherapy; p = 0.004). Sixteen patients (40 %)

developed clinical toxicity after treatment; all complica-

tions were minor grade I/II and resolved without active

intervention.

Conclusion. This study provides supportive evidence of

the safety and efficacy on Y90 radioembolization for the

treatment of unresectable, chemoresistant BRCLM. Further

prospective investigation is required to assess the suit-

ability of this treatment in this population.

Breast cancer is the most common malignancy in

females, with an estimated lifetime risk of 10–15 %.1

Patients with localized disease have an excellent prognosis,

with a 5-year survival exceeding 99 %.2 Unfortunately,

despite advances in adjuvant therapies, approximately

20 % of patients develop metastatic disease.3 These

patients have a poor prognosis, with a 5-year survival of

only 20–25 %.2

Breast cancer most frequently metastasizes to the skel-

eton, liver, lungs, and brain. Liver metastases are present in

approximately 15 % of patients with metastatic breast

cancer; metastatic deposits confined to the liver occur in

approximately 4–5 % of patients with metastatic breast

cancer.4,5 Breast cancer liver metastases (BRCLM) are

associated with considerable mortality and morbidity.

Surgical extirpation offers the only opportunity to cure

BRCLM but is only possible in 10–20 % of patients.6,7

Moreover, the majority of patients of isolated liver

BRCLM will still develop recurrent disease.6,8 Continued

developments in chemotherapeutic- and hormone receptor-

based therapies have significantly improved the survival

outcomes in patients with unresectable BRCLM. The

treatment of unresectable, chemoresistant BRCLM, how-

ever, remains a clinical dilemma.

� Society of Surgical Oncology 2013

First Received: 2 August 2013;

Published Online: 15 December 2013

A. Saxena, MBBS, BMedSc

e-mail: akshat16187@gmail.com

Ann Surg Oncol (2014) 21:1296–1303

DOI 10.1245/s10434-013-3436-1

Yttrium-90 (Y90) radioembolization is a promising

treatment option for unresectable, chemoresistant liver

tumors. It has shown promise across a range of tumor

types.9–11 Several prior studies have demonstrated that Y90

radioembolization may be a reasonable treatment for

BRCLM.12–15 More evidence, however, is still required.

The purpose of this study was to provide corroborative

evidence on the safety and clinical efficacy of Y90 radio-

embolization for unresectable, chemoresistant BRCLM.

This is important given the relative paucity of literature on

Y90 radioembolization for BRCLM. As a secondary

objective, factors associated with improved outcomes after

Y90 radioembolization of BRCLM were identified.

METHODS

This retrospective study was approved by a local Insti-

tutional Review Board. Informed consent was obtained

from all patients. Forty patients with BRCLM were treated

by selective internal radiation therapy with Y90 micro-

spheres (SIR-spheres, Sirtex Medical, Sydney, NSW,

Australia) between May 2006 and September 2012.

Inclusion criteria were as follows: (a) radiologically proven

liver metastases from breast cancer not amenable to cura-

tive surgical resection; (b) aged 18–85 years; (c) ability to

undergo angiography and selective visceral catheterization;

(d) Eastern Cooperative Oncology Group (ECOG) perfor-

mance status of 0–2; and (e) adequate hematology

(granulocyte count C1.5 9 109/L, platelets C50 9 109/L),

renal function (creatinine level B2.0 mg/dL) and hepatic

function (bilirubin level B2.0 mg/dL). Patients with lim-

ited extrahepatic disease not deemed clinically important

were not excluded.

Prior to Y90 treatment, patients underwent routine

baseline serology including liver function tests and com-

puted tomography (CT) imaging scans of the liver. In

addition, each patient underwent a liver angiography with

99 m technetium-labeled macroaggregated albumin

(99mTc-MAA) scintigraph to identify any aberrant hepatic

anatomy and percentage of lung shunting. The total volume

of the liver and the volume of the right and left lobes were

calculated using preoperative CT scans. Similarly, the total

percentage of liver replacement by tumor and the per-

centage replacement in the right and left lobes were

calculated using preoperative CT scans. Activity of Y90

treatment was measured in gigabecquerels (GBq) and

adjusted to tumor volume and lung shunting fraction.

Dosages were calculated according to patient surface area,

as previously described.16

A standard dose of Y90 radioactivity contains approxi-

mately 50 million resin microspheres measuring 29–35 lm

each and provides 2 GBq. Y90 is a pure b emitter with a

half-life of 64.2 h and decays into stable zirconium-90. The

beta emission of Y90 has a mean tissue penetration of

2.5 mm (maximum of 10 mm) and has an average energy

emission of 0.937 MeV. The microspheres were injected

through a temporary hepatic artery catheter placed percu-

taneously through the femoral or brachial artery. In the

majority of patients, approximately two-thirds of micro-

spheres were injected into the right hepatic artery and one-

third into the left hepatic artery. In patients who had dis-

ease primarily confined to one lobe, dose distribution was

adjusted accordingly.

Following treatment, all patients were hospitalized

overnight as per the departmental protocol. The aim of this

was to optimize patient management in the instance of a

post-radioembolization adverse event. Patients were ini-

tially followed up after 1 month and then at 3-month

intervals as clinically indicated until death. Blood, bio-

chemical, and tumor markers in addition to abdominal CT

scans were obtained and assessed at each follow-up visit.

Some patients underwent concomitant radioembolization

and chemotherapy; this was defined as treatment with

chemotherapy both before and after radioembolization as

per normal chemotherapy cycles.

Study Methods

We prospectively collected and reviewed patient clini-

copathologic- and treatment-related data. The primary

outcome of this study was overall survival and radiological

hepatic tumor response. Best overall radiological response

was assessed by an experienced radiologist in accordance

with the Response Criteria in Solid Tumors (RECIST)

guidelines by comparison of each follow-up examination

with the baseline examination.17 In brief, a complete

response (CR) is defined as disappearance of lesions; par-

tial response (PR) as a C30 % decrease in the sum of the

longest diameter of the index lesions; stable disease (SD)

as a \30 % decrease or \20 % increase in the sum of the

longest diameter of the index lesions; and progressive

disease (PD) as a C20 % increase in the sum of the longest

diameter of the index lesions or appearance of new lesions.

Secondary outcomes included treatment safety and prog-

nostic factors for overall survival and treatment response.

Statistical Analysis

Clinicopathological and treatment-related variables

were analyzed for an association with a good treatment

response (PR or SD) and overall survival. Categorical

variables were compared using Chi squared analysis or

Fisher’s exact test where appropriate. Survival analysis was

performed by using the Kaplan–Meier method and com-

pared using the log-rank test. Patients lost to follow-up

Radioembolization for BRCLM 1297

were censored at the last follow-up date. To assess the

variation in each liver function test over the previous fol-

low-up, we used the one-way analysis of variance. All

statistical analyses were performed using the Statistical

Package for Social Sciences for Windows (Version 17.5;

SPSS GmbH, Munich, Germany). A significant difference

was defined as p \ 0.05.

RESULTS

Patient Characteristics

A total of 40 patients with BRCLM underwent treatment

with Y90 microspheres between May 2006 and March

2012. A summary of patient clinicopathological- and

treatment-related variables is provided in Table 1. There

were 40 (100 %) females. The mean age of patients at the

time of treatment was 54.4 ± 10.4 years (range 28–77).

The majority of patients presented with bilobar disease

(n = 36; 90 %). The ECOG performance status was 0 in

33 patients (83 %) and 1 in 7 patients (17 %). Seventeen

patients (43 %) had C26 % replacement of the liver by

tumor.

At study entry, 24 patients (60 %) had histologic or

documented CT evidence of limited extrahepatic disease.

Six patients (15 %) had previously undergone a liver

resection. All patients (100 %) had been previously treated

with at least one line of systemic chemotherapy. The mean

interval between pretreatment chemotherapy and radio-

embolization was 3 months (range 0–11). The mean

interval between radioembolization and post-treatment

chemotherapy was 2 months (range 0–8). Only one patient

with extrahepatic metastases underwent concomitant che-

motherapy in the aim of treating both hepatic and

extrahepatic disease concurrently.

No patient presented with portal vein thrombosis at the

time of Y90 radioembolization. The mean dose of Y90

was 1.67 GBq (SD 0.36; range 0.79–2.38), and the esti-

mated percentage shunting to the lungs was 2.7 % (SD

1.2; range 1.1–5.5 %). Eleven (28 %) patients required

embolization of non-hepatic arteries to prevent non-tar-

geted flow. One patient (3 %) underwent concomitant

treatment with systemic chemotherapy and 15 patients

(38 %) were treated with systemic chemotherapy post

Y90 radioembolization.

In most patients without extrahepatic disease (14 of 16),

the indication was progression of liver-exclusive disease;

in the remaining two patients the indication was for

increasing symptomatology. For patients with extrahepatic

disease, the indication in most patients was discordant liver

progression (20 of 24); in the remaining four patients the

indication was for symptomatology.

TABLE 1 A summary of clinicopathological and treatment-related

factors of 40 patients with BRCLM who underwent Y90

radioembolization

Clinicopathological and treatment-related

factors

Number

of patients

Total 40

Sex

Male 0

Female 40

Age at time of resection (years)

Mean (±SD) 54.4 ± 10.4

\54 20

C54 20

Replacement of liver by tumor (%)

0–25 23

26–50 12

51–75 5

Extent of hepatic disease

Bilobar 36

Unilobar 4

Eastern Cooperative Oncology Group (ECOG) status

0 33

1 7

Previous hepatic resection

Yes 6

No 34

Number of previous lines of chemotherapy

0 0

1–2 28

3–4 10

5–6 2

Chemotherapy after radioembolization

Yes 15

No 25

Concomitant chemotherapy

Yes 1

No 39

Extrahepatic disease

Yes 24

No 16

Indication for radioembolization

Discordant hepatic progression 20

Worsening symptoms 6

Progression of liver-exclusive disease 14

Radioembolization acitivity (Gbq)

Mean (±SD) 1.7 ± 0.4

Range 0.8–2.4

Lung shunting (%)

Mean (±SD) 2.7 ± 1.2

Range 1.1–5.5

1298 A. Saxena et al.

Clinical Toxicity

A total of 16 (40 %) patients developed clinical toxicity

after treatment as per the National Cancer Institute Com-

mon Toxicity Criteria. Clinical toxicities included nausea/

vomiting in ten patients (25 %); non-specific self-limiting

abdominal pain in eight patients (20 %); fatigue in six

patients (15 %); anorexia in two patients (5 %); gallblad-

der and biliary-tree-related complications in two patients

(5 %); and shortness of breath in one patient (3 %). These

complications were minor (Grade I/II) and resolved with-

out active intervention. Post-procedural imaging findings

demonstrated ascites, pleural effusion and pulmonary

embolus in one patient (3 %) each, respectively.

Treatment Response

Thirty-eight patients (95 %) were followed-up beyond

1 month after initial radioembolization therapy and

underwent follow-up CT imaging from which hepatic

tumor response was assessed in accordance with RECIST

criteria. Overall, a CR to treatment was observed in 2 of 38

patients (5 %), PR to treatment was observed in 10 patients

(26 %), SD in 15 patients (39 %), and PD in 11 patients

(29 %). One patient (3 %) who had a PR to treatment was

downstaged to resection after treatment.

Overall Survival

No patient was lost to follow-up. One patient (3 %) died

24 days after treatment following a sudden desaturation

during an extended hospital stay, likely secondary to a fatal

pulmonary embolus. This patient initially tolerated radio-

embolization well. Twenty (50 %) patients had died at the

last time of follow-up. The median follow-up period for all

patients after Y90 radioembolization was 11.2 months

(range 0.6–30.5 months). The median survival after the first

treatment with Y90 radioembolization was 13.6 months,

with 6-month and 12-, 18-, 24-, and 30-month survival of

73, 61, 39, 39, and 39 %, respectively (Fig. 1). The median

time to progression was 6.8 months. Univariate analysis

identified three prognostic factors associated with survival:

extent of replacement of hepatic parenchyma by tumor (\25

vs. 26–50 vs. C51 %; p = 0.030), chemotherapy after ra-

dioembolization (yes vs. no; p = 0.015) and radiological

response to treatment (CR/PR vs. SD vs. PD; p \ 0.001).

Table 2 demonstrates the significance of clinicopathologi-

cal- and treatment-related prognostic factors for overall

survival.

On multivariate analysis, a poor radiological response to

treatment (HR 8.83; 95 % CI 3.06–25.46; p \ 0.001)

(Fig. 2) was associated with a poorer prognosis. Conversely,

chemotherapy after radioembolization was associated with

an improved prognosis (HR 0.167; 95 % CI 0.050–0.571;

p = 0.004) (Figs. 3, 4, 5).

DISCUSSION

This study on 40 patients who underwent Y90 radi-

eombolization of unresectable, chemoresistant BRCLM

demonstrated a median survival of 13.6 months with a

24-month survival of 39 %. These survival data are com-

parable to those reported in previous studies. Jakobs et al.13

evaluated 30 patients who were treated with resin micro-

spheres in Germany and reported a median survival of

11.7 months. Stuart et al.18 reported a median survival of

20.9 months in a small sample of seven patients who

underwent treatment with resin microspheres. In an ana-

lysis of 58 patients who underwent treatment with resin

microspheres, Haug et al.19 reported median survival of

10.8 months, with a 24-month survival of 11 %. Overall, a

TABLE 1 continued

Clinicopathological and treatment-related

factors

Number

of patients

Preoperative blood parameters

Bilirubin (mean ± SD; lmol/L) 10.0 ± 5.3

Albumin (mean ± SD; g/L) 40.9 ± 3.9

Aspartate transaminase (mean ± SD; U/L) 62.3 ± 55.1

Alanine aminotransferase (mean ± SD; U/L) 47.3 ± 33.6

Hemoglobin (mean ± SD; g/L) 115.8 ± 21.8

Platelet (mean ± SD; 9 109/L) 219.2 ± 69.1

Creatinine (mean ± SD; lmol/L) 60.7 ± 18.3

100

80

60

40

20

300

Survival (months)

Cumulativesurvival (%)

6 12 18

Radioembolization for BRCLMn = 40, MS = 13.6 months

243 9 15 21 27

FIG. 1 Overall survival of 40 patients with BRCLM who underwent

Y90 radioembolization

Radioembolization for BRCLM 1299

collective analysis of the published literature demonstrates

a median survival in patients who underwent radioembo-

lization for BRCLM of between 6.88 and 20.9 months.14,20

TABLE 2 Association of clinicopathological and treatment-related

factors with overall survival on univariate analysis

Clinicopathological and

treatment-related factors

Number of

patients

Median

survival

(months)

p value

Total 40

Age at time of resection

(years)

0.764

\54 20 13.6

C54 20 13.5

Replacement of liver by tumor

(%)

0.030

0–25 23 NR

26–50 12 13.5

51–75 5 4.5

Extent of hepatic disease 0.564

Bilobar 36 13.5

Unilobar 4 13.7

Eastern Cooperative Oncology

Group (ECOG) status

0.214

0 33 13.6

1 7 4.5

Previous hepatic resection 0.054

Yes 6 NR

No 34 12.3

Number of previous lines of

chemotherapy

0.081

1–2 28 NR

C3 12 8.2

Chemotherapy after

radioembolization

0.015

Yes 15 NR

No 25 8.5

Concomitant chemotherapy 0.072

Yes 1 3.0

No 39 13.6

Radiological response \0.001

Complete response/partial

response

12 NR

Stable disease 15 13.6

Progressive disease 11 3.0

Aspartate transaminase (AST) 0.362

\62 U/L 29 16.2

C62 U/L 11 13.5

Alanine aminotransferase

(ALT)

0.740

\47 U/L 25 13.6

C47 U/L 15 12.3

Hemoglobin (Hb) 0.667

\116 g/L 16 NR

C116 g/L 24 13.6

Creatinine (Cr) 0.312

\61 lmol/L 18 13.7

TABLE 2 continued

Clinicopathological and

treatment-related factors

Number of

patients

Median

survival

(months)

p value

C61 lmol/L 22 12.6

Bilirubin (Bi) 0.853

\10 lmol/L 21 13.6

C10 lmol/L 19 13.7

100

80

60

40

20

0

Survival (months)

Cumulativesurvival (%) P < 0.001

6 12 18 243 9 15 21

CR/PR (n = 12)SD (n = 15)PD (n = 11)

FIG. 2 Overall survival, stratified by radiological response to Y90

radioemboliation

100

80

60

40

20

0

Survival (months)

Cumulativesurvival (%) P = 0.004

6 12 18 243 9 15 21

Post-radioembolizationchemotherapy (n = 15)

No post-radioembolizationchemotherapy (n = 25)

FIG. 3 Overall survival, stratified according to administration of

chemotherapy after Y90 radioembolization

1300 A. Saxena et al.

These data are impressive considering the dismal natural

history of this disease. Median survival in patients with

chemoresistant, unresectable BRCLM is approximately

3–10 months.21 Furthermore, the majority of patients in the

current study had end-stage disease with a high tumor

burden, a history of several systemic therapies, and a high

incidence of extrahepatic disease. Currently, the treatment

of these metastatic deposits is usually through the use of

systemic agents, the choice of which depends on the

location and extent of metastasis, hormone receptor status

of the tumor, HER-2/neu status, and previous treatments

administered.22–25 The response rate to treatment of met-

astatic breast cancer, however, drops with each line of

failed treatment. Tumors have an initial imaging response

rate of between 30 and 65 % and a progression-free sur-

vival (PFS) of up to 11 months. This response rate

dramatically drops to 0–15 %, with a PFS of 1–4 months,

with second, third, and fourth lines of treatment as per the

RECIST and the International Union against Cancer

(UICC) guidelines.21,25,26

In contrast, the 71 % of patients in the current study had

an objective response (CR/PR) or SD. Encouragingly, 5 %

had a CR to treatment and a further 26 % had a PR. This

finding replicates those from earlier studies where disease

control (CR, PR, or SD) has ranged between 78 and 96 %.

Cianni et al.15 reported a hepatic disease control rate of

78 % at 8 weeks after treatment; of these, 44 % of patients

had a CR. Jakobs et al.13 reported a disease control rate of

96 % at a median of 4.2 months after treatment; of these,

no patient had a CR but 61 % had a PR. These encouraging

data may have a biological basis; BRCLM are more likely

to be hypervascular than many other tumor types, including

colorectal cancer. Hence, the ratio between the amount of

microspheres delivered at the tumor level compared with

the amount of microspheres delivered to the healthy liver is

likely higher in patients with BRCLM than in other cor-

responding tumor types. Unlike colorectal cancer,

however, metastatic breast cancer is less typically confined

to the liver. This limits the effectiveness of liver-directed

therapies from a prognostic viewpoint. There is a need,

therefore, to prospectively evaluate a combination of

locoregional treatment of liver metastases with systemic

therapy to target extrahepatic disease in patients with

BRCLM. There is also a need to further evaluate the

impact of extrahepatic disease and its treatment on survival

and recurrence outcomes.

An analysis of the prognostic factors confirmed that

response to treatment was a powerful predictor of overall

survival. Two-year survival in patients with PR/CR, SD, or

PDs was 92, 39, and 0 %, respectively (p \ 0.001).

Unfortunately, it is not currently possible to identify

patients most likely to have a favorable response to treat-

ment. Survival outcomes generally worsen as the amount

of hepatic parenchyma by tumor increases. In our study,

median survival was not reached in patients with 0–25 %

replacement of liver by tumor; conversely, median survival

was only 4.5 months in patients with 51–75 % replacement

of liver by tumor. This significant disparity highlights the

need to carefully evaluate the suitability of patients with

extensive liver disease for Y90 radioembolization.

The use of chemotherapy after radioembolization was

also independently associated with an improved survival.

Two-year survival was 56 % in patients who received

post-treatment chemotherapy compared with 30 % in

patients who did not. Given this association, it is

imperative to explore the potentially synergistic rela-

tionship between Y90 radioembolization and systemic

FIG. 4 Computed tomography (CT) scan of a patient with three

lesions in segments 5 and 6 prior to treatment with Y90

radioembolization

FIG. 5 Post-treatment CT scan of a patient demonstrating complete

response of the three lesions

Radioembolization for BRCLM 1301

chemotherapy in a prospective setting. The extent of

replacement of the liver by tumor has been previously

identified as a prognostic factor; in our study, it was

prognostic on univariate, but not multivariate, analysis.

Encouragingly, our study showed no association between

the presence of extrahepatic disease and a poor outcome.

Other liver-directed therapies have been evaluated for

the treatment of BRCLM. Disease control rates have

varied widely from 33 to 70 %, with median survival

ranging from 7 to 47 months.5,27 In a multi-institutional

study, Martin et al.5 recently evaluated the safety and

efficacy of transarterial chemoembolization (TACE) with

drug-eluting beads loaded with doxorubicin in 40 patients

with liver-dominant metastatic breast cancer. The authors

demonstrated that the treatment was well tolerated, with a

total of eight patients sustaining 13 adverse events within

30 days of treatment. After a median follow-up of

12 months in all patients, the median PFS was 17 months,

with a median overall survival of 47 months from the

time of initial diagnosis. The authors reported an objec-

tive response rate (CR, PR, SD) of 80 % at 6 months

post-treatment. The authors concluded that in comparison

to chemotherapy alone, consideration of hepatic-directed

therapy is warranted in patients with liver-dominant

metastatic disease. Vogl et al.28 employed TACE in the

neoadjuvant setting before treating patients with laser-

induced thermotherapy (LITT); these patients initially

presented with unresectable liver metastases that were too

large for LITT alone. In the subset of patients with

BRCLM (n = 25), the authors reported an objective

response rate of 56 %, with a median overall survival of

25 months. Intra-arterial administration of chemotherapy

has been evaluated in several small series, with response

rates and median survival varying widely from 33 to

70 % and 7 to 25 months, respectively.5 Unfortunately,

the paucity of data from large, prospective studies, and

the heterogeneity of the published studies, preclude a

meaningful conclusion from being drawn regarding the

role of liver-directed therapies in the management of

BRCLM.

Our study confirmed previous reports that Y90 radio-

embolization is safe; the overall morbidity rate was 40 %

and most events were self-limiting (Grade I/II). No

patient died as a result of treatment. The most common

toxicities were nausea/vomiting (n = 10; 25 %), non-

specific self-limiting abdominal pain (n = 8; 20 %), and

fatigue (n = 6; 15 %). Previous studies showed that Y90

radioembolization is associated with a small risk of

procedural mortality (0–1 %) and severe complications

such as gastrointestinal ulceration (0–4 %), but these are

generally uncommon and were not observed in the cur-

rent study.

CONCLUSION

These data demonstrate that Y90 radioembolization is a

safe and effective treatment for patients with liver-domi-

nant, chemoresistant BRCLM. The survival out-

comes observed in this study are significantly superior to

historical controls. Given the absence of effective chemo-

therapeutic agents for chemoresistant BRCLM, the role of

Y90 radioembolization in the management of BRCLM

warrants further prospective investigation. The utility of

concomitant chemotherapy for the treatment of concurrent

extrahepatic metastases should also be explored.

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Radioembolization for BRCLM 1303