Selective Internal Radiation Therapy for Unresectable Colorectal Metastases in the Liver

Overview

This guidance replaces NICE interventional procedures guidance on selective internal radiation therapy for non-resectable colorectal metastases in the liver (IPG401).

This specialist Guidelines summary provides recommendations on selective internal radiation therapy for unresectable colorectal metastases in the liver in adults. This involves injecting beads that emit radiation directly into the tumour.

This summary is intended for use in a secondary care setting by oncologists. Please refer to the full guideline for further information.

Recommendations

• Evidence on the safety of selective internal radiation therapy (SIRT) for unresectable colorectal metastases in the liver shows there can be serious complications, but these are well recognised and infrequent.
  • in people who cannot tolerate chemotherapy or have liver metastases that are refractory to chemotherapy, there is evidence of efficacy but this is limited, particularly for important outcomes such as quality of life. Therefore, in these people, this procedure should only be used with special arrangements for clinical governance, consent, and audit or research. Find out what special arrangements mean on the NICE interventional procedures guidance page.
  • in people who can have chemotherapy, evidence on overall survival and quality of life is inadequate in quality. Therefore, in these people, this procedure should only be used in the context of research. Find out what only in research means on the NICE interventional procedures guidance page.
• Clinicians wishing to do SIRT for unresectable colorectal metastases in the liver, in people who cannot have chemotherapy or have liver metastases that are refractory to chemotherapy, should:
  • Inform the clinical governance leads in their NHS trusts.
  • Give patients clear written information to support shared decision making, including NICE's information for the public.
  • Ensure that patients understand the procedure's safety and efficacy, as well as any uncertainties about these.
  • Audit and review clinical outcomes of all patients having the procedure. Clinicians should enter details for all patients having SIRT for unresectable colorectal metastases in the liver onto a suitable register.
• Patient selection should be done by a specialist hepatobiliary cancer multidisciplinary team that can offer the full range of treatment options for this condition.
• This procedure should only be done by clinicians with specific training in SIRT including techniques to minimise the risk of damage to surrounding tissue.
• Further research should report details of patient selection, whether the primary colorectal tumour arose in the left or right side of the colon, extrahepatic disease, and tumour‑to‑liver volume. Outcomes should include survival and quality of life.
• NICE may update the guidance on publication of further evidence.

The Condition

• Around 30% to 50% of people with colorectal cancer have liver metastases at the time of presentation or develop them during the course of the disease.

Current Treatments

• Treatment of liver (hepatic) metastases depends on their extent and location. For unresectable tumours, treatment options include thermal ablation techniques, chemotherapy, different types of arterial embolisation therapy and external beam radiotherapy.

The Procedure

• Selective internal radiation therapy (SIRT; also known as radioembolisation) can be used as palliative treatment for unresectable colorectal metastases in the liver.
• SIRT involves delivering microspheres containing radionuclides that emit beta radiation directly into the tumour. This aims to minimise the risk of radiation damage to surrounding healthy tissue. Using local anaesthesia and fluoroscopic guidance, the radioactive microspheres are injected into branches of the hepatic artery supplying the tumour. A percutaneous approach is used through the femoral or radial artery. The microspheres lodge in small arteries within and surrounding the tumour, releasing high doses of radiation directly into it. The procedure may be repeated depending on the response.