Is Same-Day Y-90 the Future of Y-90 Treatment?
Treatment with yttrium-90 (Y-90) is typically a process that takes place over a 1- to 2-week period to accommodate pre-treatment mapping studies and lung-shunt calculation. Recent research into same-day, or even one-hour, Y-90 treatment may allow carefully selected patient populations to receive treatment more expeditiously. In this Q&A, Riad Salem, MD, discusses patient selection, processes, and challenges surrounding same-day Y-90.
What is the typical process for Y-90 treatment?
Y-90 has been an important treatment option for the last 15 to 20 years. Before patients are treated with Y-90, they need to have a mapping angiogram with a macroaggregated albumi (MAA) study and coil embolization. After those steps, the microspheres are ordered and treatment occurs. Overall, the whole process takes about 2 or 3 weeks from first seeing the patient to treatment.
Which patients will benefit from same-day Y-90?
We believe that there is a subset of patients who can benefit from same-day Y-90. Elderly patients, patients who live far from the hospital, and international patients are some of the groups who would benefit from minimizing the number of trips to the hospital.
Can you describe the same-day Y-90 treatment process?
With same-day Y-90, we have optimized our process so that we can begin the angiogram, perform the MAA injection, coil embolize, go to nuclear medicine, and come back to IR and treat all in one day. This takes on average about 2.5 hours in the operating room, which is pretty good. We believe this time is not unreasonably long, as many complex procedures we perform in IR take up 3 to 4 hours of room time.
Is there any literature describing this approach?
Yes, we have treated more than 100 patients with this approach and published the data last year.1
What is one-hour Y-90?
Last year we published a 1,000-patient series,2 and a subset of those patients have about 1 to 3 very small tumors and an overall small disease burden. In general, these patients do not shunt. Their MAA is not needed because practically, no particles end up in the lungs. Additionally, those patients would be treated with the radiation segmentectomy technique because they have small tumors, so coil embolization is be unnecessary. This means that we have identified a group of patients who do not need coil embolization or an MAA. The remaining and vital step of the treatment is injecting the Y-90.
With one-hour Y-90, we identify those patients, order the Y-90, and bring the patient in for treatment. As operator, you perform an angiogram, identify the feeding vessel, insert the catheter, and inject the Y-90. The procedure is then completed and finished within one hour.
Are many patients eligible for one-hour Y-90?
Patient selection is very important, but in our 1,000-patient series, one-third of the patients qualified for this approach. One-third is a significant subset of patients who have the opportunity to undergo fewer procedures and be treated more quickly.
How many other centers are doing one-hour Y-90?
No one else is treating this way. Our center is providing proof of concept. Now that we have introduced the approach, we are validating the data and will publish later this year.
Have your findings on same-day Y-90 been validated?
A recently published paper from a group in Boston that treated about 35 patients reproduced our findings.3 I think that we will see more centers taking this approach with carefully selected patients. In addition to elderly patients and those who live far from treatment centers, the same-day approach could benefit patients with unfavorable vessels, or those with contrast allergy. Like everything else new, it will take a few years for the approach to spread and become standard.
Are there any objections to the same-day Y-90 approach from others in the field?
I have heard colleagues object that they do not have the team or resources in place, but my answer is that they do have a team---the nurse and the technician performing the procedure in the very same room. For same-day Y-90, the process works like this: you get access, you perform the angiogram, and you perform the MAA study. That same nurse and technician bring the patient to nuclear medicine, and the original room stays open. The shunting study is performed, the patient is brought back to the original room, and the treatment continues. The team stays the same. Thus, I don’t believe the objection that not everyone has a team is valid. Everyone has a nurse and technician. Regarding the amount of time the treatment takes, the 2.5 hours is no different than the time involved in any complex procedure.
Are there any administrative or billing challenges?
Absolutely not. There are no challenges with billing. Same-day Y-90 is no different than regular Y90.
If an IR wants to bring this approach to his or her hospital, would it be challenging to convince decision makers?
There is one regulatory challenge. In the package insert of the Y-90 products, it said that you are supposed to do the MAA for shunting. However, if shunting is unnecessary in 33% of patients, we have to work as an IR society to remove that requirement from the package label to facilitate the implementation of more efficient Y-90 treatment. I’m personally working to remove that regulatory burden because the data support removing it.
Are there any other key takeaways for your colleagues?
I think we are very cognizant of the need to make Y-90 faster. Same-day Y-90 is a step in that direction, and one-hour Y-90 is about as fast as you could imagine.
References
1. Gabr A, Kallini JR, Gates VL, et al. Same-day 90Y radioembolization: implementing a new treatment paradigm. Eur J Nucl Med Mol Imaging. 2016; 43(13):2353-2359.
2. Salem R, Gabr A, Riaz A, Mora R, et al. Institutional decision to adopt Y90 as primary treatment for hepatocellular carcinoma informed by a 1,000-patient 15-year experience. Hepatology. 2018;68(4):1429-1440.
3. Li MD, Chu KF, DePietro A, et al. Same-day yttrium-90 radioembolization: feasibility with resin microspheres. J Vasc Interv Radiol. 2019; 30(3):314-319.
