2Y-90 Radioembolization What is Yittrium-90 Radioembolization? for the treatment of metastic liver cancerFrom the Radiologist’s perpectiveFrom the Nurses’s point of viewFrom the Technologist’s perpectiveFrom the Patient’s perpective
3What is Radioembolization? Radiation therapy and embolization to treat cancer of the liver.Embolization is used to occlude blood flow.Radiation therapy uses ionizing radiation to kill cancer cells and shrink tumors.Radioembolization involves placing a radioactive material, tiny glass or resin beads called microspheres directly at the tumor site.As the incidence of metasastic liver cancer increase, clinicians are turning increasingly to minimally invasive procedures to combat these tumors in the liver, including TACE, RFA, cryoablation, and also Y-90.Y -90.
4Indications Hepatocellular carcinoma Metastatic disease Colorectal NeuroendocrineCholangiocarcinomaBreastMelanomaOthersRadioembolization is being used for many types of hepatic metasties predominantly to improve survival and/or the quality of life.
5Mechanism of ActionThere are two primary blood vessels that bring blood to the liver. Normal liver tissue receives about 75 % of its blood supply from the portal vein and about 25 percent from the hepatic artery and its branches. When a tumor grows in the liver, it receives almost all of it receives almost all of its blood supply from the hepatic artery.Radioactive microspheres are delivered through the hepatic artery, so they reach the tumor directly.
6Mechanism of Action Particles introduced via hepatic artery catheter Tumor perfusion 3 – 17 fold higher than liver parenchymaPreferential flow to tumor vesselsParticles trapped in tumor capillary bed.
11Biochemical Response: CEA CEA, carcinoembryonic antigen is a tumor marker, it is a blood test used mainly to monitor the treatment of cancer patients,
12Clinical Response Symptom relief: 50% at 3 and 6 months Radioembolization is a treatment, not a cure.Sufficient clinical evidence exists to support the safety and efficacy of radioembolization in the treatment of metastatic hepatic tumors. Patient selection, treatment, and post procedure care are key components for a successful outcome.
13Nursing perspective Greet the patient with your cup full Position your team in a positive light to improve patient outcomeRepresent reliefRepresent confidenceRepresent careBe competent
14Nursing Standard of Care ENVIRONMENT/SAFETYPRE-PROCEDURE NURSING ASSESSMENT OF PATIENTPROCEDURE NURSING ASSESSMENT and CAREPOST PROCEDURE PATIENT CARE
16Pre-procedure nursing assessment Standard pre-procedure nursing assessment.Assess home and family living situation, children in the house, responsible adult in the houseContrast precautions-Patients will be screened for the risk of allergies and risk of contrast induced nephropathy. Pre-medication is given for patients with known allergies. Following contrast administration guidelines for checking creatinine and eGFR levels.Patient education starts PRIOR to the procedure.
20Y-90 Nursing Standard of Care Pregnant care providers should not take care of patients undergoing Y-90 procedures.Wear shoe covers when entering the procedure room. Wear gloves when touching the patient or covers. After radiation has been administered, maintain a distance of 3 feet or more from patient when possible. Approach the patient from the LEFT side, when possible.Staff will have knowledge about how to manage spillsIn the event of a spill, contain contaminated areas and persons inside the room until cleared by EH&S or Nuclear Medicine. Restrict the area. Keep people two meters away from the spill. Wash affected areas with water until EH&S deemed acceptable. Remove contaminated clothing while still in the area. Remove and properly contain contaminated materials and identify as radioactive.
21Environmental safetyDose prepared in Nuclear Medicine and brought into IR roomThe room is secured, no entry is allowed by non-involved staff.Place disposable floor coverings and drapes to capture potential spills.Alert radiation safety officer and Nuclear Med staff
23Nursing Perspective Medications used during Y-90 Antibiotics CorticosteroidsProton-pump inhibitorsAnalgesicsAntiemeticsFirst dose of antibiotic before Y-90 administration. Fluoquinolones favored, Levofloxacin or Cipro-usually a 5 day course.Corticosteroids to counteract fatigue syndrome.Protection against radiation bowel injuryFirst dose 7 days before Y-90Continue for 4 weeks after Y-90Longer if bowel injury is suspectedAny PPI acceptableCheck what is covered by patient’s insuranceOmeprazole 20mg PO QD
24Environmental safetyFor gama radiation protection: Use ALARA doses. Know principles for time, distance, and proper shielding. Wear proper lead protection during procedure when x-ray is in use.For beta radiation protection: Pregnant care providers should not take care of patients undergoing Y-90 procedures.Wear shoe covers when entering the procedure room. Wear gloves when touching the patient or covers. Use absorbent towels to capture potential leaks from the Y-90 syringe. Have the radiation safety officer (present during case) check you for contamination prior to leaving the procedure room. After radiation has been administered, maintain a distance of 3 feet or more from patient when possible. Approach the patient from the LEFT side, when possible. When patient is in the Holding Area, no children or pregnant visitors allowed.Staff will have knowledge about how to manage spills as described in the Radiation Safety Handbook. In the event of a spill, contain contaminated areas and persons inside the room until cleared by EH&S or Nuclear Medicine. Restrict the area. Keep people two meters away from the spill. Wash affected areas with water until EH&S deemed acceptable. Remove contaminated clothing while still in the area. Remove and properly contain contaminated materials and identify as radioactive.
25Radiation Safety: Recovery Y90 is safe for caregiversBeta particle penetration in tissue 2.5 mmLow-dose Bremsstrahlung scatterTypical surface dose 2-10 mrem/hrTypical dose at 1 meter mrem/hrSafe dose < 100 mrem
26Patient recovery Minimize time and Maximize distance Reasonable precautionsStay more than 3 feet away from the patientDo not approach patient from treated sideMinimize handling of urine (SIR-Sphere only).
27Road to Recovery Patient follow up in clinic Post procedure phone callsPatient instructionsHelp patients look towards the future
28Nuclear Medicine Tech Role The Nuc Med Tech receives, prepares and assists with the administration of the Y90. It is our responsibility to make sure the isotope, amount of activity, patient identification and orders are all correct for the procedure. Through all of this, we also make sure radiation safety rules are followed so exposure to IR personnel is minimized.
29Nuclear Medicine Tech Role Receive Y90 and add to inventory Measure Y90 activity prior to administration Verify correct activity is drawn for procedure Measure exposure rate of dose Prepare supplies needed for administration Assist with verbal instructions during admin. Verify procedures during administration Post measurement of dose after admin. Calculate Y90 dose given to patient Always follow ALARA principles
30Yttrium-90 Pure beta-emitter Average particle energy 0.9367 MeV Average penetration in tissue 2.5 mmPhysical half-life 64.2 hours (2.7 days)Decays to zirconium-90 at deposition siteMinimal (< 2%) renal excretion (SIR-sphere).
42Patient’s perspective Life is put on hold and things are out of controlThe information is overwhelmingFeeling desperate and a sense of despairToo many questions without answersWill I survive? How? Who’s going to…..What does all this mean?The medications?....The appointments?....Will I have pain?
43Patient’s perspective Patients with advanced liver cancer have few options, so this offers optimism. This is an option for patients who have been told they are not candidates for other treatments. It gives patients hope, which is a magical thing.The aim is to extend life and feel better, even though it’s not a cure. In some cases, it may allow for more curative options such as surgery or liver transplantation.It is a minimally invasive procedure, and patients can go home several hours after the treatment.This is the lastest weapon against inoperable liver cancer. These patients are not candidate for surgery or lilver transplantation. This procedure helps slow down the growth of the disease and alleviate symptoms. These patients are motivated to do this procedure because it gives them hope.
44From the Patient’s perspective How much does this cost?This does effect the patient’s experience.The estimate for the Y90 is $106,This includes pro fees, lab, pharmacy, supplies.
45Patient’s perspective Sedation and pain medication is helpful because the procedure can last over an hour.Few patients experience some side effects called post-embolization syndrome, including nausea, vomiting and fever. These side effects usually subside within three to five days and may be alleviated with medication.Although the groin puncture is painless, some patients may experience brief pain when the microspheres are injected. Pain that continues for more than six to eight hours usually means an ulcer has developed in the patient’s stomach or duodenum.
46Patient Instructions Sleep alone x 3 days Abstain from work x 3 days Maximize distance to caregivers x 3 daysLimit contact with children x 12 days.