Y-90 Radioembolization 2012 ARIN Fall symposium

Y-90 Radioembolization What is Yittrium-90 Radioembolization? for the treatment of metastic liver cancer From the Radiologist’s perpective From the Nurses’s point of view From the Technologist’s perpective From the Patient’s perpective

What 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.

Indications Hepatocellular carcinoma Metastatic disease Colorectal Neuroendocrine Cholangiocarcinoma Breast Melanoma Others Radioembolization is being used for many types of hepatic metasties predominantly to improve survival and/or the quality of life.

Mechanism of Action There 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.

Mechanism of Action Particles introduced via hepatic artery catheter Tumor perfusion 3 – 17 fold higher than liver parenchyma Preferential flow to tumor vessels Particles trapped in tumor capillary bed.

HCC: Radiographic Response Baseline 3 months later Geschwind, et al. Gastroenterology 2004; 17: S194

HCC: Radiographic Response Baseline 3 months later Geschwind JF, et al. Gastroenterology 2004; 17: S194

Usually quoted HCC Response A recent study showed 80% of 84 patients treated with radioembolization for symptomatic hepatic carcinoid tumors reported relief of their symptoms.

Imaging Response: PET 3 months after Before

Biochemical Response: CEA CEA, carcinoembryonic antigen is a tumor marker, it is a blood test used mainly to monitor the treatment of cancer patients,

Clinical 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.

Nursing perspective Greet the patient with your cup full Position your team in a positive light to improve patient outcome Represent relief Represent confidence Represent care Be competent

Nursing Standard of Care ENVIRONMENT/SAFETY PRE-PROCEDURE NURSING ASSESSMENT OF PATIENT PROCEDURE NURSING ASSESSMENT and CARE POST PROCEDURE PATIENT CARE

Y-90 Nursing Standard of Care

Pre-procedure nursing assessment Standard pre-procedure nursing assessment. Assess home and family living situation, children in the house, responsible adult in the house Contrast 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.

Y-90 Nursing Standard of Care

Procedure nursing assessment Patient positioning Monitoring Preparation of sterile tray and supplies Prepping and Draping Patient Skin prep Positioning support Airway management Pain Management Antibiotic Prophylaxis Arterial Access Hydration

Y-90 Nursing Standard of Care

Y-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 spills 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.

Environmental safety Dose prepared in Nuclear Medicine and brought into IR room The 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

Radiation safety

Nursing Perspective Medications used during Y-90 Antibiotics Corticosteroids Proton-pump inhibitors Analgesics Antiemetics First 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 injury First dose 7 days before Y-90 Continue for 4 weeks after Y-90 Longer if bowel injury is suspected Any PPI acceptable Check what is covered by patient’s insurance Omeprazole 20mg PO QD

Environmental safety For 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.

Radiation Safety: Recovery Y90 is safe for caregivers Beta particle penetration in tissue 2.5 mm Low-dose Bremsstrahlung scatter Typical surface dose 2-10 mrem/hr Typical dose at 1 meter 0.1-0.5 mrem/hr Safe dose < 100 mrem

Patient recovery Minimize time and Maximize distance Reasonable precautions Stay more than 3 feet away from the patient Do not approach patient from treated side Minimize handling of urine (SIR-Sphere only).

Road to Recovery Patient follow up in clinic Post procedure phone calls Patient instructions Help patients look towards the future

Nuclear 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.

Nuclear 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

Yttrium-90 Pure beta-emitter Average particle energy 0.9367 MeV Average penetration in tissue 2.5 mm Physical half-life 64.2 hours (2.7 days) Decays to zirconium-90 at deposition site Minimal (< 2%) renal excretion (SIR-sphere).

Y-90 Agents 1Approved under Humanitarian Device Exemption (HDE). Administration requires Institutional Review Board oversight

Lung Toxicity Prevention TheraSphere contraindicated if Normal pulmonary reserve Lung dose > 30 Gy per treatment Lung dose > 50 Gy cumulative COPD Lung dose > 15 Gy per dose Lung dose > 30 Gy cumulative SIR-Sphere

Determine Lung Shunt Fraction Tc-99m macroaggregated albumin (MAA) perfusion scan MAA particles 10-90 μm 1 mCi injected via hepatic artery catheter Lung shunt fraction calculated Y-90 dose depends on LSF

Low LSF

High LSF

Room Preparation Absorbent paper taped to the floor Universal precautions Cap and gown Double gloves Double shoe covers Radiation safety officer in the room Plastic “mayo jar” with acrylic shield.

TheraSphere Administration Set

SIR-Sphere Administration Set Maximize distance from delivery unit Use additional shielding Foot covers

Measure Dose Exposure Rate

Measure Post Dose Exposure

Measure and Cover Spills

Patient’s perspective Life is put on hold and things are out of control The information is overwhelming Feeling desperate and a sense of despair Too many questions without answers Will I survive? How? Who’s going to….. What does all this mean? The medications?.... The appointments?.... Will I have pain?

Patient’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.

From the Patient’s perspective How much does this cost? This does effect the patient’s experience. The estimate for the Y90 is $106,212.66. This includes pro fees, lab, pharmacy, supplies.

Patient’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.

Patient Instructions Sleep alone x 3 days Abstain from work x 3 days Maximize distance to caregivers x 3 days Limit contact with children x 12 days.