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Selective Internal Radiotherapy (SIRT) of Hepatic Tumors: How to Deal with the Cystic Artery

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Selective internal radiotherapy (SIRT) with the beta emitter yttrium-90 (Y90) is a rapidly developing therapy option for unresectable liver malignancies. Nontarget irradiation of the gallbladder is a complication of SIRT. Thus, we aimed to assess different strategies to avoid infusion of Y90 into the cystic artery (CA).


After hepatic digital subtraction angiography and administration of technetium-99m-labeled human serum albumin (99mTc-HSA), 295 patients with primary or secondary liver tumors underwent single-photon emission computed tomography/computed tomography (SPECT/CT). Different measures were taken before repeated Y90 mapping and SIRT to avoid unintended influx into the CA where necessary. Clinical symptoms, including pain, fever, or a positive Murphy sign, were assessed during patient follow-up.


A significant 99mTc-HSA accumulation in the gallbladder wall (higher 99mTc-HSA uptake than in normal liver tissue) was seen in 20 patients. The following measures were taken to avoid unintended influx into the CA: temporary/permanent occlusion of the CA with gelfoam (n = 5)/microcoil (n = 1), induction of vasospasm with a microwire (n = 4), or altering catheter position (n = 10). Clinical signs of cholecystitis were observed in only one patient after temporary CA occlusion with gelfoam and were successfully treated by antibiotics. Cholecystectomy was not required for any patient.


It is important to identify possible nontarget irradiation of the gallbladder. The risk for radiation-induced cholecystitis can be easily minimized by temporary or permanent CA embolization, vasospasm induction, or altering the catheter position.

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Technetium-99m-labeled human serum albumin


Cystic artery


Computed tomography


Drug-eluting bead TACE


Digital subtraction angiography


Gastroduodenal artery


Hepatocellular carcinoma


Right hepatic artery


Selective internal radiation therapy


Single-photon emission-computed tomography


Transarterial chemoembolization




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The authors thank the WTZ Research Support Service (supported in part by the Deutsche Krebshilfe Comprehensive Cancer Center financing) for editing.

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The authors declare that they have no conflict of interest.

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Correspondence to Jens M. Theysohn.

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Theysohn, J.M., Müller, S., Schlaak, J.F. et al. Selective Internal Radiotherapy (SIRT) of Hepatic Tumors: How to Deal with the Cystic Artery. Cardiovasc Intervent Radiol 36, 1015–1022 (2013).

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