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. 2023 Mar 28;9(2):123-132.
eCollection 2023 Apr 28.

Selective internal radiotherapy in Germany: a review of indications and hospital mortality from 2012 to 2019

Alexander Mertens  1 , Tobias Essing  1   2 , Peter Minko  3 , Kathrin Möllenhoff  4 , Katalin Mattes-György  5 , Frederik L Giesel  5 , Gerald Antoch  3 , Tom Luedde  1 , Christoph Roderburg  1 , Sven H Loosen  1
Affiliations

Selective internal radiotherapy in Germany: a review of indications and hospital mortality from 2012 to 2019

Alexander Mertens et al. J Clin Transl Res. .

Abstract

Background and aim: Selective internal radiotherapy (SIRT) is a minimal invasive tumor therapy for hepatocellular carcinoma (HCC), biliary tract cancer (BTC), and liver metastasis of extrahepatic tumors. Comprehensive data on past and current trends of SIRT as well as outcome parameters such as in-hospital mortality and adverse events in Germany are missing.

Methods: We evaluated current clinical developments and outcomes of SIRT in Germany based on standardized hospital discharge data, provided by the German Federal Statistical Office from 2012 to 2019.

Results: A total of 11,014 SIRT procedures were included in the analysis. The most common indication was hepatic metastases (54.3%; HCC: 39.7%; BTC: 6%) with a trend in favor of HCC and BTC over time. Most SIRTs were performed with yttrium-90 (99.6%) but the proportion of holmium-166 SIRTs increased in recent years. There were significant differences in the mean length of hospital stay between 90Y (3.67 ± 2 days) and 166Ho (2.9 ± 1.3 days) based SIRTs. Overall in-hospital mortality was 0.14%. The mean number of SIRTs/hospital was 22.9 (SD ± 30.4). The 20 highest case volume centers performed 25.6% of all SIRTs.

Conclusion: Our study gives a detailed insight into indications, patient-related factors, and the incidence of adverse events as well as the overall in-hospital mortality in a large SIRT collective in Germany. SIRT is a safe procedure with low overall in-hospital mortality and a well-definable spectrum of adverse events. We report differences in the regional distribution of performed SIRTs and changes in the indications and used radioisotopes over the years.

Relevance for patients: SIRT is a safe procedure with very low overall mortality and a well-definable spectrum of adverse events, particularly gastrointestinal. Complications are usually treatable or self-limiting. Acute liver failure is a potentially fatal but exceptionally rare complication. 166Ho has promising beneficial bio-physical characteristics and 166Ho-based SIRT should be further evaluated against 90Y-based SIRT as the current standard of care.

Keywords: Biliary tract cancer; Cancer; Cholangiocarcinoma; Hepatocellular carcinoma; Liver metastases; Selective internal radiotherapy; Transarterial radioembolization.

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Conflict of interest statement

The authors declared no conflict of interest.

Figures

Figure 1
Figure 1. Patient-related aspects of performed selective internal radiotherapy (SIRTs) as a percentage of overall performed SIRTs. (A) Sex distribution. (B) Age distribution. (C) Length of hospital stay. (D) Comorbidities.
Figure 2
Figure 2. Current trends of selective internal radiotherapy (SIRT) in Germany. (A) Percentage of used radioisotopes (2012 – 2019). (B) Performed SIRTs related to the underlying entity; HCC: Hepatocellular Carcinoma, BTC: Bile tract cancer, Filiae: Liver metastasis; four lines each consisting of 25 figurines, one figurine representing one percent. (C) Total distribution of underlying diagnosis for SIRT between 2012 and 2019. Y-axis: Number of SIRTs; X-axis: Years. Within the bars: Number of SIRTs concerning the underlying diagnosis; Left of the bars: percentage of SIRT concerning underlying diagnosis and year.
Figure 3
Figure 3. (A) Overall in-hospital mortality. (B) The proportion of complications concerning all performed selective internal radiotherapy procedures.
Figure 4
Figure 4. Regional distribution of selective internal radiotherapy (SIRT) in Germany. (A) Distribution of SIRT per federal state between 2012 and 2019 as percentage of overall performed SIRTs nationwide (n = 11,014 = 100%; very light blue: 0 – 3%; light blue: 3.1 – 5%; blue: 5.1 – 15%; dark blue: >15.1%); BB: Brandenburg, BE: Berlin, BW: Baden-Württemberg, BA: Bavaria, HE: Hesse, BR: Bremen, HA: Hamburg, MW: Mecklenburg-Western Pomerania, LS: Lower Saxony, NW: North Rhine-Westphalia, RP: Rhineland-Palatinate, SH: Schleswig-Holstein, SL: Saarland, SA: Saxony, ST: Saxony-Anhalt, TH: Thuringia. (B) Distribution of overall SIRTS (number) between 2012 and 2019 concerning the volume of the centers.
Figure 5
Figure 5. Population-based trends of selective internal radiotherapy (SIRT) in Germany. (A) SIRTs per one million residents per Federal State (very light blue: 0 – 10; light blue: 11 – 20; blue: 21 – 30; dark blue: >31); left top corner: nationwide average 2012 – 2019 (17.9). (B) Deviation (percentage) of performed SIRTs (number) in relation to nationwide average (green: +; red: -). BB: Brandenburg, BE: Berlin, BW: Baden-Württemberg, BA: Bavaria, HE: Hesse, BR: Bremen, HA: Hamburg, MW: Mecklenburg-Western Pomerania, LS: Lower Saxony, NW: North Rhine-Westphalia, RP: Rhineland-Palatinate, SH: Schleswig-Holstein, SL: Saarland, SA: Saxony, ST: Saxony-Anhalt, TH: Thuringia.
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