RL is performed by an interventional radiologist in the angiography suite, in a fashion similar to radioembolization. The procedure is composed of two different portions, a planning phase and the actual<unk> , usually performed in two different sessions: # Planning phase: the patient undergoes planning angiography of the abdominal aorta and its major vessels. The interventional radiologist accesses the femoral artery via Seldinger technique and advances a wire and catheter to the level of the superior mesenteric artery and the celiac axis, injecting contrast in order to delineate the patient's anatomy. Utilizing smaller catheters and wires, he does the same thing evaluating the common hepatic artery, gastroduodenal, proper hepatic, left hepatic, right hepatic and phrenic arteries. The purpose of this planning angiogram is to evaluate for anatomical variants and collaterals that need to be coil embolized, in order to minimize the risk of non-target radioembolization. At this point, once the vascular anatomy has been delineated and necessary vessels have been embolized, the physician will inject 4-5 mCi of tc-99m macroaggregated albumin (MAA) in order to evaluate hepatopulmonary shunting, which serves as a proxy in assessing the risk of developing<unk>  pneumonitis. The dose of yttrium-90 to be infused is calculated with the manufacturer's formula based on lung shunting, body surface area, liver and tumor volume. #<unk> : after gaining femoral artery access and advancing a catheter in the right hepatic artery (most often), 90Y microspheres are infused in a lobar fashion, optimizing tumor and parenchymal coverage. Once the procedure has been completed, the patient is usually sent to the nuclear medicine department where a Bremsstrahlung scan will demonstrate the distribution of the radioactive material and assess for non-target embolization. Often, patients are started on proton pump inhibitors (with the addition of ursodeoxycholic acid - based on each center's protocol) for gastro-hepatic protection with or without a low-dose corticosteroid for prevention of post radioembolization syndrome and a fluoroquinolone antibiotic when the gallbladder is present (both per center protocol). Follow-up Patients undergo cross-sectional imaging at approximately 30–60 days from the procedure for evaluation of the degree of hypertrophy undergone by the contralateral side (as assessed by future liver remnant) and to assess tumor burden. At this time, the surgeons and/or a multi-specialty tumor board will convene to determine if the patient can/should undergo safe surgical resection.
Radiation lobectomy
VATS lobectomy
Selective internal radiation therapy
Chemoradiotherapy
Tomotherapy
Image-guided radiation therapy
Metastasectomy
External beam radiotherapy