Procedure Guide

Y90 Radioembolization

An overview for this procedure is not yet available.

Step-by-step guidance on how to perform Y90 Radioembolization. Review tools, techniques, pearls, and pitfalls on the BackTable Web App.

Pre-Procedure Prep

Devices

• 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

Indications

• 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

Contraindications

• 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

Medications:
• 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

Y90 Radioembolization Podcasts

Ep. 137

Road to Becoming a Y90 Authorized User (While in Training!)

Dr. Rakesh Ahuja walks us through the Pathway to Becoming a Y-90 Authorized user as a Resident, as well as the standard post-training pathway.

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Ep. 92

Interventional Oncology in Private Practice (Part 2)

Interventional Radiologist Justin Lee tells us about his approach to treatment of Hepatocellular Carcinoma (HCC), including how this has changed over his years in private practice.

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Ep. 91

Interventional Oncology in Private Practice (Part 1)

Interventional Radiologist Justin Lee tells us how he started from scratch in growing a robust Interventional Oncology program in private practice, including pitfalls to avoid.

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Ep. 78

Is Radioembolization a Future Option for Prostate Cancer?

Dr. Sam Mouli from Northwestern University and Dr. Sandeep Bagla discuss new research examining Y-90 Radioembolization as a novel therapeutic option for treating prostate cancer.

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Procedure Steps

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

Y90 Radioembolization Articles

Pressure-Directed Therapy for the Treatment of Hepatocellular Carcinoma (HCC)

Effective drug delivery systems attempt to maximize homogeneous distribution of the respective agent to the entire tumor to induce cytotoxicity and tumor necrosis. Dr. Justin Lee and Dr. Terence Gade discuss how pressure-directed therapy improves drug delivery to areas of tumor burden in cases of HCC.

Surefire infusion catheter for pressure directed therapy

TACE Versus Radioablation in the Treatment of Hepatocellular Carcinoma (HCC)

Transarterial chemoembolization (TACE) and radioembolization (Y90) have individualized roles in the treatment of hepatocellular carcinoma. Dr. Justin Lee and Dr. Terence Gade discuss which patients are best suited for TACE versus Y90, as well as the advantages and disadvantages for each intervention.

TACE used to treat hepatocellular carcinoma

Procedure Kit For Pressure Directed Therapy in Y90 Radioembolization of HCC

A pressure directed device may help increase control of Y90 radioembolization delivery to the tumor in hepatocellular carcinoma (HCC). Having performed around 200 pressure directed procedures, Dr. Nutting describes his use of Surefire’s guide catheter and microcatheters when working with the Surefire Infusion System.

Interventional radiologist performing pressure directed Y90 procedure

When To Use Pressure Directed Devices with Y90 Radioembolization in Hepatocellular Carcinoma (HCC)

When treating HCC with Y90 radioembolization, a hypovascular tumor with low visibility on angiogram can indicate that a pressure directed device may help to deliver more of the intended dose to the tumor. Studies have shown that pressure directed devices increase tumor uptake and decrease non-target embolization.

Surefire pressure directed infusion system radioembolization tumor

Post-Procedure

Post-Procedure 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

Complications

• 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,

Y90 Radioembolization Demos

Spheres vs. Chemoembolization vs. Bland embolization by Dr. Charles Nutting

Dr. Charles Nutting gives a presentation comparing Spheres vs. Chemoembolization vs Bland Embolization.

Cone Beam CT and Mapping Angiography Prior to Y-90 Radioembolization using a Transradial Approach

Interventional Radiologists Dr. Edward Kim, Dr. Rahul Patel, and Dr. Mustafa Syed perform mapping angiography and cone beam CT(CBCT) prior to SIRT radioembolization in a patient with metastatic neuroendocrine tumor to the liver using a transracial approach at Mount Sinai Hospital in New York City.

Radioembolization of Liver Metastases by Dr. Florian Wolf

Key steps of a radioembolization procedure in a patient with liver metastases.

Transradial Angiography and Embolization prior to Y-90 Radioembolization

At Mount Sinai Hospital in New York City, Interventional Radiologists, Dr. Aaron Fischman, Dr. Scott Nowakowski and Dr. Gajan Sivananthan perform transradial access for mapping angiography and coil embolization prior to Y-90 radioembolization of colon cancer liver metastasis in a patient with aortic dissection.

Child-Pugh Score Calculator
The Child-Pugh Score calculator can be used to quickly assess the severity of cirrhosis, life expectancy, and risk of perioperative abdominal surgery mortality in patients with liver disease. To use this tool, you will need bilirubin, albumin, prothrombin time (INR), ascites, and encephalopathy grade. Each of these measures have corresponding categories in the Child-Pugh Score calculator that give 1, 2, or 3 points. After inputting your values, the calculator will provide the severity of cirrhosis based on Child-Pugh class, life expectancy, and abdominal surgery perioperative mortality rate.
Child-Pugh Score Calculator on BackTable
LI-RADS Calculator
2017 version of the Liver Imaging Reporting and Data System (LI-RADS) for CT and MR Imaging.
LI-RADS Calculator on BackTable
DAVYR 3 Y90 Dosimetry
Mathematical modeling tool designed to provide the user with a more clear understanding of the relationship between activity (GBq) determination, and compartmental dose (liver, tumor, lung) as relating to Trans-Arterial Radioembolization (TARE) with Yttrium-90 microspheres.
DAVYR 3 Y90 Dosimetry on BackTable

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Targeting the Tumor Microenvironment in HCC

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Podcast

Interventional Oncology in Private Practice (Part 1)

Interventional Oncology in Private Practice (Part 1) BackTable Podcast Guest Dr. Justin Lee
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Demo Video

Radioembolization of Liver Metastases by Dr. Florian Wolf

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Demo Video

Cone Beam CT and Mapping Angiography Prior to Y-90 Radioembolization using a Transradial Approach

Join The Discussion

References

[1] BackTable, LLC (Producer). (2017, November 5). Ep 16 – Pressure-Directed Therapy in Y90 [Audio podcast]. Retrieved from https://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
[3] 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.
[4] Gaba RC. Planning Arteriography for Yttrium-90 Microsphere Radioembolization. Semin Intervent Radiol. 2015;32(4):428-38.
[5] 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.
[6] Salem R, Lewandowski RJ, Sato KT, et al. Technical aspects of radioembolization with 90Y microspheres. Tech Vasc Interv Radiol. 2007;10(1):12-29.

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients.