What is Radioembolization?
Radioembolization is a minimally invasive treatment used to treat primary or metastatic liver cancer. It may also be called intra-arterial brachytherapy or Selective Internal Radiation Therapy (SIRT). It uses microspheres with Yttrium-90, which are radioactive beads, to treat the cancer. These tiny beads, or microspheres, are placed directly into the tumor. The beads emit high radiation for approximately 10-12 days from inside of the tumor to shrink it.
This type of treatment is considered palliative, not a curative treatment and can be used to treat liver cancer that cannot be removed with surgery. It has the potential to shrink tumors or downstage them so you are eligible for other treatments, surgery, or a liver transplant. In some cases, this treatment has been shown to extend patients lives while improving quality of life for patients living with cancer.
Radioembolization is the only interventional treatment approved in the United States to treat primary liver cancer in patients with portal vein thrombosis (PVT).
A planning session consisting of a “mapping” angiogram and scans is done to confirm that radioembolization is a treatment option for you. You can expect to be at the hospital for 6-8 hrs on this day.
One week after the planning visit, the patient will return for the radioembolization treatment session. You can expect to be at the hospital for 4-6 hrs for this treatment.
Why is Y-90 done?
Radioembolization is a palliative treatment for patients who are not candidates for curative treatments such as surgery or percutaneous ablation. This means it is done to control the disease and not to cure it. In some instances, after radioembolization, the tumor may decrease in size to the point that other curative therapies such as surgery or ablation may be feasible.
With this treatment, the radiation destroys the tumor cells from within the tumor causing minimal injury to the surrounding healthy liver tissue. This lessens the side effects you feel from the radiation.
What are the risks?
As with any interventional procedure, there is a small risk of bleeding at the catheter insertion site. Most of the time we use a small plug to avoid this problem and the overall risk is small.
The goal of the procedure is to kill and shrink the tumor. The resulting necrotic material releases inflammatory chemicals into the bloodstream. This can cause something called tumor embolization syndrome. This syndrome is manifested with fever, pain, nausea and vomiting, but tends to resolve spontaneously. Another potential complication of radioembolization is the development of an infection or abscess within the necrotic tumor.
There is a small chance of allergic reaction to the contrast material used to view your vessels with X-ray. There is also a risk for kidney damage, especially for patients with diabetes or pre-existing kidney disease. The effects from the contrast vary for every patient. Medicines and IV fluids are given to help prevent or relieve most of these side effects. Also, steps can be taken before the procedure to prevent allergic reactions to contrast and lessen the chance of kidney damage for those at risk.
Even after safety screening, there is a very small risk (less than 1%) that the radioactive particles become lodged in the lungs or digestive tract resulting in organ damage. Some of the potential problems could include shortness of breath, lung fibrosis, pancreatitis, intestinal perforation and gastric ulcer. These complications are rare.
Will Y-90 harm my healthy liver tissue?
Despite the fact that Y-90 has a minimal effect on normal (healthy) liver tissue, irradiation of both the tumor and normal tissue will occur. Because of this, patients with diseases that alter the normal functioning of the liver, or have high tumor burden, may be at greater risk for liver function impairment following treatment.
Reasons to avoid this procedure?
Patients who have abnormal liver function cannot undergo this procedure. The procedure is also contraindicated in patients with a large tumor burden.
Also, patients with abnormal blood vessels may not be candidates for this procedure, due to the higher risk of non-targeted embolization. Therefore, it is important to perform the planning angiogram session to identify those patients who are candidates.
How do you prepare?
Usually, this procedure is performed with IV sedation known as moderate or “twilight” sedation and local anesthesia. You will need to be fasting for 8 hours before the procedure. We recommend no eating or drinking after midnight before the procedure. Generally, you should take your daily morning medications with a small sip of water.
If you take blood thinners you will need to stop them before the procedure. Please refer to pre-procedure instructions for detailed instructions about your medications.
Please leave all valuables such as jewelry, credit cards, and money at home on the day of the procedure. Family members may wish to bring a magazine or book to read during the extended wait time.
After checking in at Patient Registration, you will be directed to the Short Stay pre-procedure unit on 2B. Once in the department, a nurse will prepare you for the procedure. This preparation will include changing into a gown, a nurse taking your vital signs, starting an IV in your arm, lab tests and giving you IV fluids and IV medications (antibiotics, anti-nausea, etc).
How is the procedure done?
The treatment involves two visits in the hospital. The first visit is for evaluation and planning, also known as the “mapping” angiogram visit and the second visit is for the actual treatment.
Evaluation and Planning Visit- “Mapping” Angiogram
The procedure is performed in the catheterization laboratory, also called “cath lab”. An entire team will be taking care of you during the procedure including 2 nurses, a radiology technologist and the physician. In the Interventional Radiology procedure room, the nurse will help you lie on an exam table. You will be connected to heart rate, oxygen saturation and blood pressure monitors. IV medicine will be given to relax you (sedation). Your groin area will be shaved and washed with a special soap and covered with sterile sheets. Numbing medicine is injected into the area. You will feel some burning as the medicine is given. Once it takes effect, the area will be numb. The procedure time varies, but usually takes 1 to 2 hours. Throughout the procedure, medication is given through your IV throughout the procedure to keep you comfortable. Your oxygen saturation, blood pressure and pulse are checked closely during and after the procedure.
A small catheter will then be inserted through the groin into the femoral artery. Using x-rays the interventional radiologist will be able to navigate the catheter into the specific artery supplying the liver. Through this catheter the interventional radiologist performs an arteriogram to identify the branches of the hepatic artery supplying the tumor(s) and then threads smaller catheters into these branches.
We will perform 3 important steps during the angiogram:
1. Identify the specific arteries that are going to the tumor.
2. Look for any small arteries that go to your stomach or intestines. If these arteries are close to the radiation site, small coils are inserted to block the blood supply in these arteries. This prevents any of the radiation beads from getting into your stomach or intestines and causing an ulcer. Other blood vessels will compensate for those vessels that are blocked. Not every patient needs this portion of the procedure.
3. Small particles are then injected into your liver. These particles are the same size as the radioembolization spheres but contain only a minimal amount of radioactive tracer. This way we can “test” where they will go. We want to be sure the particles stay in your liver and do not travel to other organs causing possible problems. These particles are harmless proteins that break down on their own and are excreted through your stool and urine within 24 hours.
After the injection of the tracer spheres, the radiology nurse will take you to the Nuclear Medicine department where a scan is done to trace the location of the diagnostic particles. In the nuclear medicine department, you will lie on a firm table with your arms above your head. Your arms will be supported for comfort. The nurse will monitor your condition and make sure you are comfortable. Pain medicine may be given as needed. The scan takes about 2 hours. After the scan, you will return to the recovery unit where you will be able to meet your family members. You will also be able to eat and drink. Before going home, the nurse will monitor your vital signs, assist you out of bed, and help you to walk.
The Treatment Visit
In the treatment visit, things should be faster, since all the planning was done in the prior visit. You will undergo another angiogram, which will be very similar to the prior visit. The radiation beads will then be injected into the tiny arteries (that were seen during the “mapping” angiogram) supplying blood to the tumors. You will not need imaging studies after the angiogram and you will be discharged home the same day, usually 2-3 hours after the procedure.
What can you expect after the procedure?
After the procedure you will be taken to a room on Unit 2B at El Camino Hospital. Your nurse will monitor your blood pressure and pulse. They will also check your groin site (where the catheter was placed and removed) for bleeding or bruising and check the pulses in your feet. It is important to lie flat during this time and keep your leg straight and motionless. This prevents bleeding at the groin site. Most patients need to be on bed rest for only 2 hours. However, in some situations, you may be on bed rest and required to lie flat for up to 6 hours.
After the procedure some patients may have the following:
● Fever (short-term in 10% of patients)
● Nausea/vomiting (nausea can last up to 2 weeks, vomiting for a couple of days)
● Upper right abdominal discomfort (can last from a couple days to a week)
If necessary, pain medicine is given through your IV on the post procedure unit. You will receive IV antibiotics before and after the procedure. Follow up blood tests are done to see how your liver is tolerating the treatment.
What precautions should I take after the procedure?
Once you have received the radioactive microspheres, the external radiation exposure to other individuals is very low to none and highly unlikely to cause harm. Nevertheless, It is recommended to minimize contact with children under the age of 10 and pregnant women for 2 weeks post treatment.
If you anticipate traveling via airplane over the next 30 days, please ask the physician for a letter explaining the circumstances as the security screening equipment may detect low radiation levels as a result of your treatment.
You should follow up with the interventional radiologist 1-2 weeks after the procedure for a check up.
Repeat CT/MRI and/or PET scans will be ordered along with blood tests 4 weeks after the procedure. After these are completed, another follow up appointment (4-5 weeks after initial radiation treatment) should be made with the interventional radiologist to review the studies.
Some people may require a second radiation treatment 6 weeks after the first radiation treatment. This is patient specific and dependent on size of tumor and response to first radiation treatment. This will be determined by the interventional radiologist at the 4-5 week follow up appointment.