Selected Podcast

Y-90 Treatment Now Available for Liver Cancer Patients

Y-90 is a minimally-invasive option for treating liver cancer. Tiny beads coated in radioactive material are injected into the treatment area, attacking the cancer cells.

Dr. Timothy Auran, radiologist, explains how Y-90 treatment works.
Y-90 Treatment Now Available for Liver Cancer Patients
Timothy Auran, MD
Dr. Auran completed his undergraduate degree at the Ohio State University in Mechanical Engineering. He graduated Magna Cum Laude and was the President of the Mechanical Engineering Honor Society. He was interested in imaging even during his formative years, and worked with General Electric in developing various error detection routines on their most advanced CT scanner. Dr. Auran did his internship in General Surgery at Harbor-UCLA and has submitted a paper written with the joint support of Vascular Surgery and Radiology during this year, entitled “Characterization of Aortic Dissection Flap by CT Reconstruction.” Dr. Auran’s broad aptitude in imaging is reflected in his participation in composing three musculoskeletal case reviews for a book with Dr. Rajeev Varma, and creating two cases that were included in the American College of Radiology’s MRI Teaching File CD. His hard work and interpersonal skills were recognized when he was selected as the Chief Resident in Radiology for the 2006/2007 academic year. Dr. Auran is a member of the American College of Radiology, Radiological Society of North America, American Roentgen Ray Society, California Radiological Society, American Medical Association, Society of Interventional Radiology, Western Angiographic and Interventional Society, and Society of Interventional Radiology.

Prakash Chandran (Host): There are more options for cancer treatment than ever before and today we are going to talk specifically about Y90, a minimally invasive option that uses radiation therapy to treat liver cancer. Here with us to discuss is Dr. Timothy Auran, a radiologist at Sierra Vista. Dr. Auran, I appreciate you being here. I’d love to start by asking what exactly is Y90 and how long has it been around?

Timothy Auran, MD (Guest): Y90 is a treatment for certain kinds of liver cancer in which either tiny little plastic beads or glass beads are coated or filled with Yttrium-90 which is a radioactive material which is then injected into the blood supply of the liver. These little beads get stuck in the liver and then continue to irradiate the liver and the tumors around them in an attempt to kill the cancer. This is a therapy that has probably been around for about 20 or 30 years or so and only recently has become available on the Central Coast.

Prakash: So, who might be a good candidate? Who should be looking at Y90 as a solution for them?

Dr. Auran: Y90 currently is only FDA approved for use for patients that have metastatic colorectal cancer to the liver without evidence of significant disease elsewhere. So, if you have a colon cancer that has gone to the live, but really don’t have any nodal disease; then you might be a good candidate for this or hepatocellular carcinoma which is a cancer that starts in the liver, that’s also approved for that. Many patients who have tumors that are too large to be surgically resected and patients who are not immediately transplant candidates may also qualify for Y90 and it’s possible for those patients to actually have tumors shrinkage to the point where they could be removed or that they may actually get back on to a transplant list.

Prakash: Wow, that seems pretty incredible. So, is there like a particular stage that you look for where this is most effective?

Dr. Auran: Usually the candidates that we see that are best for this therapy are again, for colorectal cancer, many times it has spread to lymph nodes which would mean that disease would not be affectively treated with Y90 so, if it’s really just liver dominant metastatic disease; those are the best candidates. For patients who have hepatocellular carcinoma, typically if the tumors are quite small, we are able to treat them more effectively with other methods, but again, larger tumors in the liver can be treated very effectively with Y90 and again, sometimes actually get people back on to a transplant list if the tumors have grown too far, too quickly.

Prakash: So, let’s talk about the procedure itself. What exactly does it look like? What can patients expect when they come in?

Dr. Auran: These are minimally invasive procedures that are done only under conscious sedation, so we don’t have to put people out entirely for this procedure. We typically enter either the blood vessel that goes over the hip or the blood vessel in your wrist and we use a series of tubes and wires with an x-ray machine to guide a tube into the liver itself. There are typically three procedures that are done. The very first procedure once we get the tube into the liver; we then take a series of images of the blood vessels so that we can plan which vessels to embolize in a subsequent procedure and get a better idea of what the vascular anatomy is. Once we know what the vascular anatomy looks like; we typically look for a couple of vessels in particular that we need to shut down the blood flow in so that we don’t get Y90 beads where we don’t want them to go. This first procedure is called -typically called the mapping procedure. Once we have the vessels embolized with coils that we don’t want to – or that we want to protect from Yittrium-90 we will then let the patient recover and bring them back typically in a week or two to actually give the first dose of radiation. That’s the second procedure that actually is the first Y90 administration. Typically, we will give a set dose to the right lobe of the liver. That’s usually fairly straightforward and pretty fast to do so. We will then let the patient go home and recover again for usually a couple of weeks or so and then bring them back for the third and final procedure in which we treat the left lobe of the liver.

Prakash: Yeah and you know what, I’m told that typically for this type of treatment before it used to require those three separate visits to either LA or San Francisco, but you can just do that within San Luis Obispo right now, right?

Dr. Auran: Correct. One of the benefits of this procedure is that it is an outpatient procedure and we don’t have to admit patients to the hospital afterward. Although we are administering radiation to the patient; the radiation actually does stay within the liver, so they are not really a hazard to be around anyone else. But that becomes a problem if you are in San Luis and this therapy is only offered in San Francisco or Los Angeles. You typically have to go to that other city and then spend the night in a hotel beforehand, go have the procedure done then typically you are not really in a state to want to drive three hours home, so then you spend another night that night and then you have to drive home the following day. So, it ends up consuming three days for each procedure with two overnight stays and then you have to do it three times. So, it ends up many times that patients who are referred out for this kind of procedure; simply didn’t have it done because it was – the out-of-pocket expenses were quite high associated with simply getting to the hospital and having it done and too inconvenient. The people really weren’t willing to spend that much time to get this kind of therapy done. Now that it’s actually offered in town; we simply can have people come from home and return to home and there are minimal outside expenses from the procedure itself.

Prakash: That’s so amazing and so convenient just due to the fact that it saves time, it saves money, it saves so much - saves stress. So, that’s great that it’s just offered right there. I want to go back to the procedure. You mentioned a couple of things that I certainly didn’t understand. You were saying embolizing the vessel. Does that mean just blocking out a vessel that you don’t want the Y90 to go into?

Dr. Auran: Correct. For the first mapping procedure; we actually do a series of angiograms to determine what blood vessels are present and which parts of the liver they feed. The larger blood vessels that come off of the aorta before they make it to the liver actually feed areas of your gut. So, there are a number of vessels that feed your stomach and your small bowel, and we want to make sure that we don’t actually get any of the radioactivity into those vessels. It is possible to have radiation burns if you end up having what we call a non-target embolization meaning that the Yttrium-90 spheres end up somewhere where we don’t want them to go. So, during the mapping procedure, after we figure out what the anatomy is; then we will typically use small metal coils and place those in several of the blood vessels that could become a problem if we ended up having Y90 get into those vessels. So, we could prevent any blood flow and prevent the subsequent Y90 administration from going where we don’t want it to go.

Prakash: That is so amazing how far technology has advanced that you are able to do these things, so it really sounds like you can very precisely get right inside that tumor and almost fight it from the inside out right?

Dr. Auran: Correct. It’s a very, very targeted therapy. There are a number of nuances into how this is done even more recently where we can change where the administration into the liver is being done. So, we can then instead of simply radiating the entire liver or getting a large field of tumor burden, we can actually go down into very specific vessels as well that may be feeding the tumor and give very high doses of radiation with the intent on entirely and completely killing the tumor as well as the liver in that area. It’s something called a radiation segmentectomy which in the past would have to be done surgically and would be a fairly big operation to recover from and now if that is an appropriate therapy for a patient; we can effectively remove a segment of the liver by irradiating it as an outpatient procedure.

Prakash: So, we talked about how easy it is now to get these three simple outpatient procedures done within the central coast; let’s talk a little bit about the specific side effects. So, what can people expect after having this done?

Dr. Auran: Usually after the initial mapping procedure, there really isn’t too much side effect at all. We give conscious sedation medications which usually nearly completely wear off within about two hours or so and so most people are feeling fine afterwards. We do either have to make a puncture into the vessel over your hip or into your wrist so there’s always a possibility of having some soreness at that puncture site. But after the mapping procedure itself, usually people feel fine. After we administer the Y90, however, some people do feel like they have a cold or a mild flu for maybe two or three days after the procedure. It’s possible to have some pain in your upper abdomen after we are done. That does seem to vary from person to person. Personally, I have had some people that had fairly significant pain that we did need to keep under control with oral pain medications for about a week and there are other patients who have had zero pain at all and it really seems to be very, variable based on the patient themselves.

Prakash: Right, but it does seem like compared to some other treatments that you have previously had to use that this is much easier to go through. That’s what it seems like at least.

Dr. Auran: Correct. I mean even in the worst cases where they have – we have had patients with moderate pain, they still were at home and they were still able to take care of themselves and go about doing what they needed to do. They just were a little uncomfortable for several days until the pain resolved on its own.

Prakash: So, I’m interested. You mentioned that it’s been around for 20 plus years, why are we just seeing it now kind of or hearing about it now? Like what has taken so long?

Dr. Auran: Well this largely has been done in major academic centers or major hospital systems simply because the needs of administering this dose can be quite significant. There’s radiation safety office that needs to be involved. The interventional radiologist who performs the procedure or a nuclear medicine physician needs to be what’s called an authorized user and have specific training and permission from the state to give these kinds of doses and the procedure was largely being done only for certain subset of cancers. It’s recently become more available because training programs are now training virtually all interventional radiologists to become authorized users to administer these kinds of drugs and the studies that have been performed show that this is a fairly safe and straightforward procedure to be done which now opens it to being used more frequently in the outpatient community hospital setting as well.

Prakash: It is really an exciting option and it’s so great to have it readily available within San Luis Obispo. For a referral to a board-certified physician please call the Sierra Vista Regional Medical Center and Twin Cities Community Hospital physician referral line at 866-966-3680. My guest today has been Dr. Timothy Auran. I’m Prakash Chandran. Thanks so much for listening.