Y90 Radioembolization

Y90 Radioembolization

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• Resin - SIR-Spheres (Sirtex)
• Sphere diameter between 20-60 μm
• Lower activity per sphere compared to glass
• Glass - Therasphere (BTG)
• Mean sphere diameter 25 μm
• Higher activity per sphere compared to resin

• Primary and secondary hepatic malignancies
• Hepatocellular carcinoma (HCC)
• Cholangiocarcinoma
• Metastatic colorectal (mCRC)
• metastatic neuroendocrine (mNET)
• Potential applications for metastatic tumors: breast, melanoma, and renal cell

• Poor performance status, ECOG >2
• Extensive extrahepatic disease
• Hepatopulmonary shunting with expected dose to lungs > 30-Gy
• Active hepatic infection
• Pregnancy
• Poor liver function - depends on degree of liver dysfunction and amount of liver being treated. Considerations for liver dysfunction include:
• Extensive hepatic tumor involvement
• Child-Pugh C
• Hepatic encephalopathy and uncontrolled ascites
• Total bilirubin >2 mg/dl, INR > 2.0

Initial Steps:
• Consult with H&P
• Oncologic pathology and staging
• Performance status
• Prior chemotherapy, locoregional therapy and surgery
• Labs: liver function, coagulation, renal function and tumor markers
• Review/Order preprocedural imaging
• Evaluate tumor burden and potential liver segments involved
• Arterial supply to liver. Look for variant anatomy and potential arteries which predispose patient to non-target embolization
• Portal vein patency

• Moderate sedation: consider using minimal sedation for mapping as high quality angiography depends on patient complying with multiple breath hold maneuvers.

For y90 treatment procedure
• Premedications vary between institutions and operators
• Consider: 10 mg Dexamethasone, 4-8 mg Zofran
• Somatostatin analogs for mNET - 500 mcg of octreotide SC
• Antibiotics: at discretion of operator for low risk patients
• Some institutions treat with ciprofloxacin if cystic duct embolization is expected
• Moxifloxacin recommended in patients with incompetent/absent sphincter of oddi


Mapping procedure
Arterial access, sheath placement, 5 or 6-Fr
Recommended all angiography performed with power injector and breath hold maneuvers. Goal is to clearly define hepatic arterial anatomy, delineate tumor vascular supply and identify extrahepatic vessels at risk for nontarget embolization.
Suggested injection rates are in italics and should be modified based on anatomy, equipment and operator preferences.
SMA (3 ml/s for 18 seconds)
Carry run out to portal phase to confirm patency
Celiac artery (4 ml/s for 12 seconds)
Left gastric artery (1 ml/s for 6 seconds)
Not always necessary
If using Sos to access celiac, apply back tension to catheter until catheter points cephalad. With catheter directed superiorly, usually possible to direct the microcatheter into the left gastric.
Sometimes easier to access the right gastric retrograde via left gastric. Need continuous anastomosis between the two vessels
Common hepatic artery (3 ml/s for 12 seconds)
Gastroduodenal artery (2 ml/s for 8 seconds)
evaluate for accessory vessels and
parasitization of flow to liver
Proper hepatic artery (3 ml/s for 12 seconds)
Good opportunity to identify the right gastric artery
Left hepatic artery (2 ml/s for 8 seconds)
Right hepatic artery (2 ml/s for 10 seconds)
Vessels which may result in nontarget embolization
Injecting MAA and treating distal to takeoff may be best approach
If possible to catheterize, coil embolize vessels
Potential vessels include: GDA, right gastric, supraduodenal, falciform, left phrenic, gastroesophageal branch, left gastric
Infuse 99mTc-MAA from the expected treatment locations
4 to 5 mCi of 99mTc-MAA
Can split amounts if treating from multiple locations
Safer to have nuclear medicine split the MAA doses before doses are called to cath lab
Strongly consider the routine use of cone-beam CT in available
Good to identify potential sites of non-target embolization
Can more accurately delineate the volume and segments of liver which will receive treatment

Y90 administration procedure
• Arterial access, sheath placement, 5 or 6-Fr
• Repeat diagnostic angiography from appropriate positions.
• Place microcatheter at expected treatment location, same location MAA was administered from
• Repeat diagnostic angiography to confirm appropriate and safe position
• Administer radioembolic
• Remove microcatheter and endhole catheter with radiation precautions.
• Dispose of catheters and glove in appropriate containers.


Postprocedure Care
• Monitor patient 1-6 hours after mapping & treatment
• Recovery time primarily driven by radial or femoral access precautions
• Discharge patient same day
• Home care
• Mapping procedure: typically no pain medications or antiemetics needed
• Treatment procedure:
• Adequate pain control: usually narcotic not neccessary
• Antiemetics PRN - Ondastetron 4-8 mg
• Protonix (pantoprazole) - may reduce gastrointestinal irritation. Can initiate at time of mapping and continue 1 month after the final treatment session
• Avoid medications with acetaminophen

Follow-up and Outcome Assessment:
• After final treatment session, 1 month clinic visit with labs to assess liver function.
• Assess energy level and reassess ECOG
• Pain palliation response
• LFTs and tumor markers - calculate Child-Pugh score

Tumor markers:
• Radiologic response will vary from institution and provider - consider standardization within your institution
• Consider 1 month CT/MRI: may not reflect treatment changes this early. Interpret with caution as there can be paradoxical increase in tumor size related to hemorrhage, edema and necrosis.
• Consider follow up at 3-6 month intervals after treatment
• CT vs MRI: varies from institution. Keep consistent from pretreatment to postprocedure
• mRECIST guidelines and EASL for enhancing tumors like HCC
• RECIST for solid tumors

• Radioembolization-induced liver disease (REILD): 0-4% of patients
• Spectrum of liver dysfunction which can progress to hepatic failure
• Typically occurs 1-2 months post treatment
• Patients present with jaundice and ascites with increased bilirubin and LFTs. Absence of tumor progression or biliary obstruction.
• Treat with high dose steroids
• Radiation pneumonitis: <1%
• Radiation cholecystitis: attempt to embolize distal to origin of cystic artery if possible
• Consider prophylactic ciprofloxacin if gallbladder is within the radiation field.
• Antibiotics, hydration and pain control. Few may require cholecystectomy or cholecystostomy
• GI ulcers: <5%
• Can result from nontarget embolization of GDA, right/left gastric or supraduodenal arteries
• Present hours to days after delivery: abdominal pain, nausea, vomiting and possible GI bleed
• Should confirm GI ulceration with endoscopy
• Treatment to include protonix, sucralfate, pentoxifylline and vitamin E. Some may need surgery.
• Postembolization syndrome: abdominal pain, low-grade fever, nausea, vomiting, malaise within 1 week of treatment
• Other: hepatic abscess, pancreatitis and bile duct injury/biloma,

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[1] BackTable, LLC (Producer). (2017, November 5). Ep 16 – Pressure-Directed Therapy in Y90 [Audio podcast]. Retrieved from http://www.backtable.com/podcasts[2] Salem, R., Lewandowski, R. J., Sato, K. T., Atassi, B., Ryu, R. K., Ibrahim, S., … Murthy, R. (2007). Technical Aspects of Radioembolization with90Y Microspheres. Techniques in Vascular and Interventional Radiology, 10(1), 12–29. http://doi.org/10.1053/j.tvir.2007.08.001
[2] Padia SA, Lewandowski RJ, Johnson GE, et al. Radioembolization of Hepatic Malignancies: Background, Quality Improvement Guidelines, and Future Directions. J Vasc Interv Radiol. 2017;28(1):1-15.
[3] Gaba RC. Planning Arteriography for Yttrium-90 Microsphere Radioembolization. Semin Intervent Radiol. 2015;32(4):428-38.
[4] Joo I, Kim HC, Kim GM, Paeng JC. Imaging Evaluation Following Y Radioembolization of Liver Tumors: What Radiologists Should Know. Korean J Radiol. 2018;19(2):209-222.
[5] Salem R, Lewandowski RJ, Sato KT, et al. Technical aspects of radioembolization with 90Y microspheres. Tech Vasc Interv Radiol. 2007;10(1):12-29.

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