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Y-90 Radioembolization

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

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Y-90 Radioembolization

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  1. Y-90 Radioembolization 2012 ARIN Fall symposium

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

  3. 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.

  4. Indications • Hepatocellular carcinoma • Metastatic disease • Colorectal • Neuroendocrine • Cholangiocarcinoma • Breast • Melanoma • Others

  5. 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.

  6. 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.

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

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

  9. Usually quoted HCC Response

  10. Imaging Response: PET 3 months after Before

  11. Biochemical Response: CEA

  12. 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.

  13. 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

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

  15. Y-90 Nursing Standard of Care

  16. 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.

  17. Y-90 Nursing Standard of Care

  18. 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

  19. Y-90 Nursing Standard of Care

  20. 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.

  21. Environmental safety

  22. Radiation safety

  23. Nursing Perspective • Medications used during Y-90 • Antibiotics • Corticosteroids • Proton-pump inhibitors • Analgesics • Antiemetics

  24. Environmental safety

  25. 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

  26. 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).

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

  28. 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.

  29. 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

  30. 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).

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

  32. 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

  33. 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

  34. Low LSF

  35. High LSF

  36. 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.

  37. TheraSphere Administration Set

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

  39. Measure Dose Exposure Rate

  40. Measure Post Dose Exposure

  41. Measure and Cover Spills

  42. 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?

  43. 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.

  44. 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.

  45. 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.

  46. 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.

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