Y-90
RADIOEMBOLIZATION
2012 ARIN FALL SYMPOSIUM
Y-90 RADIOEMBOLIZATION
• What is Yittrium-90 Radioembolization?
for the treatment of metastic liver cancer
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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.
INDICATIONS
• Hepatocellular carcinoma
• Metastatic disease
• Colorectal
• Neuroendocrine
• Cholangiocarcinoma
• Breast
• Melanoma
• Others
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
IMAGING RESPONSE: PET
Before
3 months
after
BIOCHEMICAL RESPONSE: CEA
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
Patient/Procedure Assessment
Nursing Interventions
ENVIRONMENT/SAFETY
*Prior to patient admission: Evaluate
*Replace missing items as needed.
Procedure room for functioning suction with Yankauer tip, *Ensure availability of various sizes of oral/nasal airways/face masks, Ambu bag
airway supplies (nasal, oral and face mask), oxygen (nasal
cannula & non-rebreather set-up) & Ambu bag
Ensure monitoring equipment is working properly.
*Location of emergency numbers/code button
*Location and integrity of emergency cart/emergency
medications
Have emergency drug box available and supplies ready for emergency use.
The exam table is clean and prepared for a procedure.
Radiology staff is responsible to clean and disinfect all x-ray and exam table surfaces with Sani-wipe
clothes. All patient care items are disposable after use.
Y-90 dose is prepared in Nuclear Medicine.
• Dose prepared in nuclear medicine and brought into IR room
• Case done in IR Room 10. The room is secured, no entry is allowed by non-involved staff.
• Place disposable drapes to capture potential spills of Y-90.
• Alert radiation safety officer and nuc med staff in case of spill
(refer to Radiation Safety Handbook)
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
PRE-PROCEDURE NURSING ASSESSMENT OF
PATIENT
Use the Nursing Assessment to evaluate patient and
document,
Pre-Procedure:
Nursing Intervention
*Obtain/validate medical history to include allergies, previous anesthetic/sedation problems
*Identify and document nursing problems and interventions
Check Surgical consent; blood consent (if indicated); H & P within 30 days of procedure with a 24
hour update if needed;
 Time out form
The team suspends all other activities and participates in
the Universal Protocol checklist.
Radiation protection:
 Patients of childbearing age will be screened for pregnancy. Gonadal shielding will be placed
under the table pad per policy. ALARA will be used. All staff will wear lead protection.
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.
Review patient education information with patient and family to answer any questions they may
have. Prepare post procedure written instructions to be given after the procedure is completed.
Patient Education
PROCEDURE NURSING ASSESSMENT
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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
PROCEDURE NURSING ASSESSMENT
Nursing Intervention
Patient positioning: Patient is to lie supine on the table.
Support bony prominences with cushioning.
Monitoring:
Monitor EKG, BP, O2 sat, capnography, respirations,
level of consciousness, and physical response to sedation /
procedure.
Preparation of sterile tray and supplies
Monitor vital signs and patient response to procedure continuously.
Sterile technique used and maintained throughout procedure
Prepping and Draping: The patient is prepped and Sterile techniques and practices are observed in the sterile area
draped for the procedure. Sterile practices are in place in
the sterile field.
Chlorhexadine scrub - Pour Hibiclens (chlorhexadine) onto sterile 4x4 sponge gauge and apply to skin
Patient Skin prep
in a circular fashion, scrub to cleanse the skin for 60 seconds.
Positioning support:
Patients are on a narrow table.
Wedge cushions and Velcro straps are used around the patient to ensure that the patient is safely and
properly positioned for the procedure.
Airway management: Observe constantly for open and
clear airway.
Suction is to be ready for suctioning of oral secretions at all times. Prompt assessment and intervention
by a well-trained team and appropriate use of available equipment for monitoring and airway support
are essential in preventing iatrogenic complications.
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
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Medications used during Y-90
Antibiotics
Corticosteroids
Proton-pump inhibitors
Analgesics
Antiemetics
ENVIRONMENTAL SAFETY
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
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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
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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
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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
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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.
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.
PATIENT INSTRUCTIONS
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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.