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Y90 in the OBL: Benefits & Considerations

Author Gabrielle Gard covers Y90 in the OBL: Benefits & Considerations on BackTable VI

Gabrielle Gard • Dec 6, 2022 • 141 hits

Moving Y90 from the hospital to the office-based lab (OBL) can be an extensive undertaking. As interventional radiologist Dr. Jayson Brower explains, there are several benefits for both providers and patients, such as control of the procedure environment, improved convenience, and increased satisfaction for patients and providers. To maximize success when implementing and performing Y90 in the OBL, special considerations regarding set-up and equipment purchases should be navigated with care.

This article features excerpts from the BackTable Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.

The BackTable Brief

• Performing Y90 in the OBL gives providers environmental control and purchasing power. This unique position allows providers to acquire updated equipment, and to increase convenience and satisfaction for patients.

• Adding a mini hot lab to the OBL allows physicians to draw and calibrate dosages on-site and enables nuclear medicine technicians to deliver dose and technetium before procedures.

• OBLs have the capacity to become full-blown interventional suites. Providers working to grow their office-based labs should consider purchasing a cone beam CT and SPECT-CT to increase the functionality of their OBLs and to provide more services on-site.

Y90 in the OBL: Benefits & Considerations

Table of Contents

(1) Benefits of Y90 in the OBL

(2) Optimizing Y90 Workflows: Mini Hot Labs & SPECT-CT Scans

(3) Expanding Your OBL: Y90 and Beyond

Benefits of Y90 in the OBL

Hospital reimbursements and insurance policies are often major factors in deciding if patients fit the criteria for certain kinds of treatment, and thus the indications for Y90 usage are limited in this setting. When Dr. Brower saw that insurance and reimbursement concerns were impacting patients and limiting the scope of the Y90 procedure, he and his group decided to push forward with their efforts to move Y90 to the OBL. That said, Dr. Brower mentions that his group had zero denials on their Y90 appeals for “off-label” uses because they stayed on top of the appeal. Moving procedures to the OBL brings other added benefits as it allows providers to control their environment and purchase state-of-the-art equipment. When managed properly, the OBL can also increase convenience and satisfaction for both providers and patients.

[Dr. Aparna Baheti]
Did anything, in particular, spur your decision to move the Y90 from the hospital to the OBL?

[Dr. Jayson Brower]
Yes, there were a couple of different things that all hit at the same time, sort of the proverbial straw that broke the camel's back. Just to touch on a couple of them, for those that are listening that are familiar with the Y90 procedure, there are really only two definitive indications; colorectal cancer and hepatocellular carcinoma. Now, like most of us, we treat a lot of things "off-label", and when we started our Y90 practice 18 years ago, we just continued on with that entrepreneurial spirit of interventional radiology, and whether it was breast cancer or melanoma or what have you, neuroendocrine, if the patient met criteria, we thought that there was a benefit of doing Y90, we would treat them.

Flash forward, I think there was a realization that perhaps there were some billing-- I'm trying to be politically correct in phrasing this, but the bottom line is, I think the hospital at one point realized that they weren't getting reimbursed on some of the cases, they missed the opportunity to file an appeal, and what they then came back to us and said was unless patients fell, and Medicare patients, in particular, unless they met criteria, either as colorectal metastases or HCC patients, they would no longer allow us to treat them with Y90 in the hospital.

[Dr. Aparna Baheti]
I see. It really limits your scope of what you can do with Y90.

[Dr. Jayson Brower]
It really does.

[Dr. Aparna Baheti]
Just on a side note, anecdotally, have you had a lot of success with the appeals for these off-label uses for Y90?

[Dr. Jayson Brower]
We have. That's the interesting thing in the OBL setting, knock on wood, we've had zero denials on any of our Y90 cases, and when you break it into--

[Dr. Aparna Baheti]
That's really interesting.

[Dr. Jayson Brower]
It all comes down to staying on top of the process and that's one of the take-home messages I would say for anybody who's considering going down this path, you really have to have good strong processes in place.

[Dr. Aparna Baheti]
Absolutely. I interrupted your story, but they weren't letting you do any off-label Y90. Anything else that really made you want to make the switch?

[Dr. Jayson Brower]
Yes. I would say there are two other main components. The nuclear medicine department in particular, while they are great, the equipment was outdated, the hospital was unable to really invest more money for state-of-the-art SPECT-CT scanning, so it presented I think, a problem when you come down to modern-day evaluation of patients, both pre and post-treatment. That was an issue.

I think finally really just patient convenience and satisfaction, and that was also a huge driving factor in moving forward with opening up the OBL. We felt we could deliver a much better product, if you will, for our patients from beginning to end.

[Dr. Aparna Baheti]
Sure. Yes, that's one of the great things about working in the OBL, is you have control over almost everything, whereas in the hospital, you'd have to interact with various administrative types and deal with staffing shortages and things that are out of your control.

Listen to the Full Podcast

Y90 in the OBL with Dr. Jayson Brower on the BackTable VI Podcast)
Ep 245 Y90 in the OBL with Dr. Jayson Brower
00:00 / 01:04

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Optimizing Y90 Workflows: Mini Hot Labs & SPECT-CT Scans

While a full hot lab is not necessary to perform Y90 in the OBL, obtaining a radiopharmaceutical delivery system is crucial for the procedures. For mapping procedures, nuclear medicine techs deliver the dose and the technetium, and they communicate with the physicians to determine the number of syringes for administration. An addition of a mini hot lab allows the physicians to draw the dose themselves and calibrate on-site. In their OBL, Dr. Brower mentions they do not have a SPECT-CT scanner, but they can send patients to a nearby center for a same-day mapping procedure. That said, having a SPECT-CT scanner on-site would improve patient convenience and is something to consider when building or expanding an OBL.

[Dr. Aparna Baheti]
What you're describing to me sounds like it's like a delivery-only setup. You just have the cabinet for waste decay and the dose calibrator and you don't have the full hot lab. Pardon my ignorance, but how do you get the radiopharmaceuticals?

[Dr. Jayson Brower]
We have the dose delivered to our little mini hot lab that we have here on-site at the OBL. We do have the ability to draw the dose. Again, with Sirtex, you do have to draw the dose that you ascribe, so we're able to tear off the dose from the mother vial. We ensure that it's calibrated accordingly, and then our nuclear medicine techs will deliver the dose to us in the lab when we're ready to administer.

[Dr. Aparna Baheti]
How do you deal with the techne MAA and measuring it in storage?

[Dr. Jayson Brower]
It's an interesting setup that we have the site where we have our OBL, we have this mini hot lab, but we don't do any other nuclear medicine imaging here. On days when we have mappings, the technetium is brought to the hot lab, it's delivered to our hot lab just as the dose is delivered. Then the nuclear medicine tech will bring us the technetium when we're doing the mapping and it's easy to decide on the fly, do we need to split out-- Probably like most people, we use a 4-millicurie dose for the most parts and whether we're dividing that into separate multi-point administrations for the mapping, or if we're just giving a single 4-millicurie dose into the common hepatic, we're able to tell our nuclear medicine tech that at the time. Then they'll show up in the room into our suite and hand us either one syringe or two or multiple syringes.

[Dr. Aparna Baheti]
That nuc med tech is an employee of your OBL, is that right?

[Dr. Jayson Brower]
Correct. They're an employee of our imaging center company and then the OBL fits under that umbrella.

[Dr. Aparna Baheti]
I got it. They're just there basically to give you the dose and then they go back to all their nuc med stuff. I guess that brings me to another point. Where do you do your SPECT-CTs? Is it on-site at the OBL or do you have them transferred to a different center?

[Dr. Jayson Brower]
That's a great question. Unfortunately, right now they go to a different center. Where we built the OBL, we did not have the ability at that point to put in a SPECT-CT scanner. Spokane, where I live and practice, it's, fortunately, a fairly compact city. The imaging center where we have our SPECT-CT is about four miles away. We don't have much in the way of traffic, so it's easy to get to.

The downside is it's a little bit more inconvenient for the patients and there's no way to sugarcoat that. For the mapping procedure, they have to go that same day after the mapping. For the administration part of it, oftentimes then it gives us a little more flexibility to either get their scan, their post-scan either that same day, or sometimes the next day just depending on their preference and scheduling availability.

[Dr. Aparna Baheti]
For the mapping, traditionally I've been taught you have to scan them within two hours afterwards. How are you able to do that with closure devices, or do you do them all from radial access? What's your way to counteract that?

[Dr. Jayson Brower]
I think we probably have a little more time or we're maybe a little more lenient on how much time we allow after the mapping, but we definitely try to get them to the scanner within four hours. For the mappings, most of the time we're still going from a groin access just because of the setup that we have with cone beam. It's a little bit tough to get-- depending on patient size and body habitus, it can be challenging from a radial access to get the type of cone beams that we need sometimes.

Expanding Your OBL: Y90 and Beyond

While the initial focus was moving Y90 to the OBL, Dr. Brower discusses that they envisioned the OBL to be a comprehensive “full-blown interventional suite,” and they have currently expanded their services for prostate procedures and UFEs. This mindset led them to purchase certain equipment like the cone beam CT. Dr. Brower also mentions their forward-looking mindset in regards to dosimetry in their OBL. Instead of using the standard BSA partition model, they use MIM, a software package, and voxel-based dosimetry. This software-based coding allows a more personalized approach for dosing and helps providers with billing as the software allows for add-on codes.

[Dr. Aparna Baheti]
So you do have a cone beam CT in your OBL. That's awesome. That was really important for you when building it out probably because you were going to do Y90s there, is that right?

[Dr. Jayson Brower]
Absolutely. Not only from the Y90 standpoint, we really envision this center, and we may talk about this a little bit later, but to do all sorts of interventions. We're doing our prostates here, we're doing our UFEs here. Not that you need-- certainly for UAE, you don't need a cone bean, but for prostates, I think it's really important. When we set out to buy the equipment for this lab, it was always with the intention that it would be a full-blown interventional suite.

[Dr. Aparna Baheti]
It's nice that you had that foresight from the beginning, and you're able to plan that in rather than having to fix it afterwards. You might understand this question a little bit better than me, Jayson, but for dosimetry coding, can we get into that a little bit? Do you use the standard SIR-recommended ones or do you use dosimetry software and bill for the Rad Onc code for dose mapping?

[Dr. Jayson Brower]
I think that's a great question. It's interesting because I think as our understanding of dosimetry starts to evolve, I'll speak for our practice, we've moved past the standard BSA partition model type of approach, and we employ a software package called MIM, and the concept behind that is to really move towards something called voxel-based dosimetry.

In order to do that, you need this advanced software package. The best way I could think of describing it, it really comes down to personalized dosimetric evaluation of the patient's liver and then the blood supply not only to the normal liver but to the tumor as well. That's why I think both the cone beam is important, but the SPECT-CT, and when you start to look at how you put all these pieces together, you're now-- instead of guesstimating how much blood supply goes to the tumor or how much blood supply goes to the normal liver, you're actually measuring counts of activity within both of those structures and you get a much more personalized approach to coming up with your intended dose. It's a very long-winded way of saying we've now incorporated the software-based coding and billing into our practice.

[Dr. Aparna Baheti]
I'd love to know a little bit more about dosimetry codes for the uninitiated. Do you mind just giving a really quick overview of that?

[Dr. Jayson Brower]
Yes, and I may start to get outside of my knowledge box a little bit, but it comes down to with this MIM dosimetry and the advanced dosimetric codes, you can bill for the mapping, and then you bill for the implantation. It's a separate add-on code that you get on top of your supervision and your implantation. It's specifically for this software.

[Dr. Aparna Baheti]
That's interesting. Were the MIM software people able to help you understand the coding and billing for that stuff, or was it something that you were able to figure out on your own?

[Dr. Jayson Brower]
Yes, I would say we primarily figured it out on our own. Again, the same partner of mine who's our nuclear medicine guy-- it's funny, when I saw the software, I was just wise enough to think to myself, this could be interesting, but had no idea how we would implement it. I, again, voluntold my partner who is really-- Doug Murray is just an incredible guy. He worked with the MIM folks. They had no algorithm, they had no process for how to incorporate what we wanted to do with their software.

Doug's been working with them now for about two years. We actually have a research project going on with them. Doug was really, again, the brains behind figuring out how we could really utilize MIM. When we started out, the IR physicians were doing all the contouring, and we just were doing a not great job with it and we run a--

[Dr. Aparna Baheti]
Oh my God, the drawing of the circles, I would be so happy if I never had to draw another circle around a liver tumor ever in my life again.

[Dr. Jayson Brower]
It's miserable. We actually trained our 3D techs and our 3D lab to do it and we have one who's in charge of it and she's fantastic. She can do a whole MIM processing in about 15 minutes and it's spot on every time.

Podcast Contributors

Dr. Jayson Brower discusses Y90 in the OBL on the BackTable 245 Podcast

Dr. Jayson Brower

Dr. Jayson Brower is an interventional radiologist and interventional oncologist with Inland Imaging in Spokane, Washington.

Dr. Aparna Baheti discusses Y90 in the OBL on the BackTable 245 Podcast

Dr. Aparna Baheti

Dr. Aparna Baheti is a practicing Interventional Radiologist in Tacoma, Washington.

Cite This Podcast

BackTable, LLC (Producer). (2022, September 23). Ep. 245 – Y90 in the OBL [Audio podcast]. Retrieved from https://www.backtable.com

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. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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