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Mobile Imaging for Y90 Studies

Posted on: 12.12.19

Mobile Imaging for Y90 Mapping Studies

If you diagnose or treat patients with liver cancer, then you’re probably familiar with the procedure for Yttrium-90 (Y90) studies.

In short, the patient must go through a mapping process to ensure that the medical team gets the best possible information from which to treat them. This involves examining the vasculature of the tumor and the interventional radiologist may place coils or perform embolizations; a deliberate blockage of the vasculature to limit the blood flow to and from the intended area of treatment.

With embolization complete, the patient is administered a radioactive particulate (99Tc-MAA) that is similar in size to Y90 . They are then sent for imaging using a gamma camera to assess the liver and lungs. This determines whether the patient is ready for the Y90 treatment or whether they require further embolization to to ensure that the Y90 will be directed to the intended location within the tumor.

It’s a minimally invasive process, but it still can be hard on the ill patient and somewhat inefficient for the medical facility. The type of camera you use matters, as does the modality of the camera.

Inefficiencies with Y90 procedures

Traditionally, as the patient undergoes the described process, they will be transported from the procedure room to the nuclear medicine suite for imaging. The aim of the first set of images is to check that embolization has been successful – meaning that 80% or more of the 99Tc-MAA is localized within the liver and does not shunt to the lungs.

Get the bonus content: Infographic: The Digirad Ergo

If the finding is that 20% or more of the particulate dose does go to the lungs, then the decision will often be to send the patient back for further embolization. This is done to ensure that when the Y90 is administered, it reaches the intended location within the liver.

Here’s where that traditional approach can be inefficient:

  1. You’re transporting the patient from one area of the hospital to another for imaging. This involves keeping them sedated as well as an anesthesia team to transport with them.
  2. The camera, an expensive investment for the hospital is kept open, waiting for the patient having the mapping procedure.
  3. The process may have to be repeated again if the target area is not being reached. This means that the camera is kept open for an even longer period and is unable to be used for other patients.

These points can mean that the hospital staff are unable to use their time and resources as efficiently as they could. It is usually the aim to be able to make the best use of time and equipment, so that patient throughput is maximized.

From the patient’s perspective

The patient is kept sedated throughout this process, however it is within their best interests to minimize time under anesthesia. The “transport then repeat” scenario can effectively double or more their time under sedation. It also means that more of their day is taken up undergoing the procedure.

You also should consider the risk to the patient whenever they are required to be transported in the hospital. It is well-documented that there are many risks to patients during transportation and that an approach to minimize the need for transportation is safer. For example, they risk exposure to infectious diseases, dislodgement of equipment and associated injuries.

The bottom line is that quicker studies with less time under sedation and removing the need for transport are a better experience for the patient too.

Mobile imaging: A solution for Y90 therapy

There is a more efficient solution to streamlining Y90 imaging; a mobile gamma camera can be brought into the treatment area. This removes the need to transport the patient and allows any fixed cameras to remain in use throughout the procedure. It is also a good measure to improve patient safety.

The type of camera used is also important. An issue with traditional gamma cameras is that PMTs may miss data on the images. A camera such as Ergo with its digital technology captures all data without any holes and provides a more accurate picture.

Mobile imaging can provide quicker, more efficient Y90 studies

Imaging with Ergo

The portable cameras of the past had a reputation for being bulky, loud and having limited field of view. Not so with the Ergo.

The Ergo revolutionizes the portable camera using solid-state flat panel detector technology. Since the Ergo does not use Photo-Multiplier tubes in its detector, it is quiet, compact, light, and easy to maneuver.

Imaging quality is high and will allow the physician to get real-time confirmation of whether the particulate dose and embolization have been successful. This means decisions can be made more quickly and use of clinical staff can be optimized.

The new Digirad Ergo portable Gamma Camera

Ergo features

Ergo has a large field of view detector. The system delivers an intrinsic spatial resolution of 3.25mm, energy resolution of 7.9% and count rate capabilities greater than 5 Mcps. It is lightweight and easy to move without the use of a motor, and at 29” wide, has a small footprint, easily fitting through doors.

Another plus for the Ergo gamma camera is that it’s very versatile. It seamlessly moves for use in areas such as general radiology, women’s health, pediatrics, surgery and trauma. This makes it a great choice not only for Y90 imaging, but for many purposes within the medical facility.

Get the bonus content: Infographic: The Digirad Ergo

Six high performance collimator options (LEAP, LEHR, Pinhole, MEAP, Diverging, and MBI) provide the capability to provide outstanding imaging quality for a wide range of procedures for energy ranges from 50 to 350 keV. Quick release latch mechanisms and flip-up handles make changing collimators simple and fast. An optional collimator storage cart provides easy and convenient accessibility and storage for up to five collimators and one breast imaging accessory.

Point-of-care imaging is changing the way the radiology department operates for the better. It’s a great option for streamlining Y90 procedures, optimizing use of staff and space, and reducing risks associated with patient transport and longer times under anesthesia.

The in-suite imaging advantage

Yttrium-90 (Y90) studies form a key part of the treatment plan for many liver cancer patients, however the procedure is often lengthy and inefficient for both patients and clinics.

There is a better way to conduct Y90 studies, using mobile imaging. This removes back and forth between a treatment room and radiology, allowing medical facilities to optimize their use of staff and camera equipment.

The Ergo gamma camera is an ideal option for Y90 studies as well as many other imaging needs. Its portability and versatility make it a great addition to any clinical setting.

Y90 Therapy in Nuclear Medicine: What You Need to Know

Posted on: 10.31.19

Y90 Therapy in Nuclear Medicine

Radioembolization with Y90 is a minimally invasive procedure primarily used in the treatment of liver cancer. In contrast to most nuclear medicine applications, Y90 is therapeutic and designed to treat rather than simply diagnose.

It is estimated that 75% to 95% of patients see improvement from treatment, potentially extending their lives or improving survival rates. In this post we’ll take a look at Y90, what it is, and how it works.

What is Y90?

Yttrium-90 (Y90) is a commonly used isotope within the nuclear medicine and radiation oncology communities for radiation therapy. When used for the treatment, Y90 is relied upon to provide a prescribed amount of radiation to a targeted area. Y90 is most commonly used during a radioembolization therapy, an internal radiation therapy.

Radioembolization using Y90 involves the use of glass or resin beads (spheres) that are filled with the isotope. During a minimally invasive procedure, these radioactive spheres are placed directly into the blood supply of the liver tumor and become lodged within the tumor itself. Blood vessels are blocked off to prevent blood flow (embolization). Once in place, these work by radiating and destroying the surrounding tissue (tumor).

These spheres will remain in the tumor and are not removed. The Y90 has a half-life of 64.2 hours. This means that it will be non-radioactive in about a month’s time.

Get the bonus content: 99Tc-MAA Liver Mapping Protocol for Y90 Treatment Planning

When is Y90 therapy indicated?

Hepatic (liver) tumors (lesions or masses) may originate as a primary cancer of the liver such as hepatocellular cancer (90% of primary liver cancers) or may be another form of cancer that has metastasized to the region.

There are many treatment options available for hepatic lesions. The choice for treatment is generally based on how they present, physician preference and treatment options available at the facility.

Common non-surgical treatment options for hepatic lesions include chemotherapy (systemic and chemoembolization), ablation (cryoablation, radiofrequency ablation and microwave ablation), embolization (including radioembolization), immunotherapy, and radiation therapy.

Diseases treated with Y90

Currently, the FDA approves the use of Y90 spheres for the treatment of primary hepatocellular carcinoma and unresectable primary colorectal cancer that has metastasized to the liver.

Disease incidence treated with Y90

Based on the available statistics for the United States, it is estimated that 1 in 3,210 individuals annually will be diagnosed with primary colorectal cancer that will metastasize to the liver. Similarly, 1 in 7,675 individuals each year will be diagnosed with primary liver cancer. Annually, this equates to roughly 1 potential Y90 candidate for every 5,442 people.

Y90 mapping and its role with radioembolization therapy

There is a great deal of planning prior to performing a Y90 radioembolization. Here are a few steps:

  1. The first step in the process is referred to as the “mapping”. The mapping process involves a very similar process to the radioembolization treatment itself; the patient is brought into interventional radiology and the vasculature of the liver tumor is examined. During this time, the interventional radiologist may place coils or perform embolizations; a deliberate blockage of the vasculature to limit the blood flow to and from the intended area of treatment. The blockages are created to direct the delivery of the radioactive spheres and ensure that they lodge in the desired location.
  2. Once the embolization process is complete, the interventional radiologist will then administer a radioactive particulate that is very similar in size to the Y90. This is performed with a radiopharmaceutical that is commonly referred to as 99Tc-MAA. Once administered, the patient will undergo imaging that utilizes a nuclear medicine gamma camera.Traditionally, this would mean transporting the patient to the nuclear medicine suite post-procedure, however now, mobile cameras (such as the Ergo) can be brought into the interventional suite instead. This offers not only better efficiency but improved safety without the need to transport the patient. The patient doesn’t have to be kept sedated for as long and doesn’t need an anesthesia team to transport with them.
  3. Images are acquired of the liver and of the lungs and the medical team will perform an analysis of the images. Ideally, the radiologist wants to ensure that 80% or more of the 99Tc-MAA is localized within the liver and does not shunt to the lungs. If more than 20% of the administered mapping dose goes to the lungs, the patient may be required to undergo further embolization to ensure that the Y90 will be directed to the intended location within the tumor.The type of camera used is important. An issue with traditional gamma cameras is that PMTs may miss data on the images. A camera such as the Ergo with its digital technology captures all data without any holes and provides a more accurate picture.
  4. After the mapping process is complete, the images are further analyzed by the medical team and then an exact amount of Y90 is prescribed to treat the lesion. The entire viability of the therapy depends on quality images and data that are acquired during the mapping process. It is of utmost importance to provide the medical team with the best and most accurate information available.
Y-90 Nuclear Imaging Study

Patient flow and coding reference guide

Y-90 Patient Flow and Coding Reference Guide

Patient precautions and side-effects

The radioembolization procedure is generally painless for patients. For a small number of patients, ulcers may develop in the stomach or duodenum – these are treated as any other type of ulcer.

Get the bonus content: 99Tc-MAA Liver Mapping Protocol for Y90 Treatment Planning

Post-embolization syndrome (PES) is a side effect that is experienced by a few patients. This consists of vomiting, nausea, fever and pain, usually within the first 72 hours after treatment and subsiding after that. The most common side effect is pain due to the blood supply being cut off to the treated areas. This is controlled via oral or IV medications.

Patients may experience low-grade fever, fatigue and lethargy for up to a week, but most can resume normal activities within a day or two.

As a precaution, the following is recommended:

  • Contact with others is limited over the week as the radiation diminishes
  • Patients shouldn’t sleep in the same bed as a partner over that week
  • Patients should avoid public transport that requires them to sit next to another person for more than two hours
  • Patients should avoid close contact with children or pregnant women.

Final thoughts

Radioembolization with Y90 utilizes nuclear medicine to treat hepatic lesions. Most patients will see some improvement in their liver and it may improve survival and life expectancy rates, depending on the type of cancer.

This treatment is not recommended in cases of severe kidney or liver dysfunction, abnormal blood clotting or blockages of the bile ducts. Radioembolization may be performed in small amounts over multiple procedures to try to minimize the effects on the liver.

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