Y-90

- what is the physical half life of Technetium 99m - what is the kEV of Tc99m

- 6 hours - 140 kEV

- What shunt ratio is considered safe in patients with normal lung function during a Tc-99m MAA mapping study - what if they have lung disease and/or COPD - at what lung shunt value should you avoid treatment

- <15% - <10 % - >20% or >16.2 mCi (600 MBq) delivered to lung radprimer

- how much should you decrease Y90 dose for 10-15% lung shunting - how much for 15-20%

- For 10-15% shunting, decrease dose by 20-40% - For 15-20% shunting, decrease dose by 40-60%

types of patients with a prevalence of high lung shunt ratios on MAA study

- HCC - hepatic or portal vein tumor thrombus or occlusion - early hepatic vein opacification - large tumors

how do you treat hyperuricemia

- allopurinol (purine analog that inhibits xanthine oxidase) - rasburicase (recombinant uric oxidase that converts it to allantoin)

tumor lysis syndrome diagnostic criteria

- hyperkalemia, hyperphosphatemia, hyperuricemia (HIGH KPU) - hypocalcemia

what is clinical tumor lysis syndrome defined as

- presence of one or more clinical criteria not believed to be attributable to a therapeutic agent (chemotx, radiation tx) * renal inssuficiency, cardiac dysrhythmias, seizures, sudden death

strategies for preventing Tumor lysis syndrome

- prophylactic recommendations for both low- and intermediate-risk include monitoring and hydration, with allopurinol administration (option for low-risk, recommended for intermediate risk) - prophylactic rasburicase is recommended in place of allopurinol for high risk

definition of exposure definition of absorbed dose

- refers to the number of ions created in dry air by a beam of X-rays unit = Roentgen (R) - energy deposited by radiation per unit mass in tissue (Joules/Kg = Gy) *correlates with control in tumor tissue or toxicity in normal liver

- characteristic appearance of the falciform artery - 2 of the most common origins of the falciform artery

- reverse 7 appearance - LHA and MHA

TACE indications for metastatic neuroendocrine tumor

- symptoms not controlled by octreotide - disease progression despite treatment with octreotide - excessive tumor burden threatening liver function

what is laboratory tumor lysis syndrome defined as

- two or more abnormal serum values (uric acide, potassium, phosphate, calcium) identified or change by 25% within three days before or 7 days after initiation of treatment

LIRADS major imaging features

1. Arterial phase hyperenhancement 2. washout 3. enhancing capsule 4. size (largest outer-to-outer dimension) 5. threshold growth

3 item preprocedural checklist on a CT or MR to check prior to a TACE

1. Assess tumor burden - Size and location of tumor(s) - Disease confined to liver vs. extrahepatic disease - Liver parenchyma involvement of < 50% 2. Assess tumor enhancement - Strong arterial phase enhancement predicts response to therapy 3. Vascular anatomy - Assess for variant hepatic arterial anatomy and arterial supply to tumor(s) - Portal vein patency

Scenarios where should you reduce the y90 activity administered

1. Cirrhosis 2. Previous Chemotherapy 3. Portal Hypertension 4. Limited Liver Reserve 5. Lung Exposure >25 Gy

TACE contraindications

1. Extensive extrahepatic disease (control of liver tumor is unlikey to dictate survival) 2. Poor baseline liver function (greater risk of dying from liver failure than tumor) - Bilirubin >2, Child-Pugh C, liver parenchyma involvement >50% 3. Significant portal vein thrombosis without development of sufficient portal-portal collateral flow - high risk of liver failure/infarct 4. Significant arterioportal or arteriovenous shunting that cannot be safely reduced during procedure 5. Transhepatic intrajugular portosystemic shunt (Increased risk of posttreatment liver failure after arterial embolization due to limited portal venous flow to liver) 6. Poor baseline functional status and inability to recover from procedure

check list of vessels to watch for in MAA mapping

1. GDA 2. cystic 3. Right gastric artery 4. gastrohepatic trunk 5. falciform

Tumor Markers for 1. HCC 2. Colorectal cancer 3. Neuroendocrine tumor

1. HCC: alpha fetoprotein 2. Colorectal cancer: Carcinoembryonic agent 3. NET: chromogranin A

post Y90 complications to look for on follow up imaging

1. Hepatic abscess 2. biloma/biliary necrosis 3. cholecystitis 4. biliary obstruction (extrahepatic nodes) 5. biliary stricture 6. Radiation hepatitis 7. GI ulceration

LIRADS scores 1. cannot be categorized 2. definite tumor in vein 3. definitely benign 4. probably benign 5. probably or definitely malignant but not HCC specific 6. intermediate probability of malignancy 7. probably HCC 8. definitely HCC

1. LR-NC 2. LR-TIV 3. LR-1 4. LR-2 5. LR-M 6. LR-3 7. LR-4 8. LR-5

3 of the most common origins for the right gastric artery

1. Left hepatic artery 2. middle hepatic artery 3. proper hepatic artery hint: reverse Nike swoop apperance hint #2: find the GDA and draw a 2 cm circle around it (85% of the time you'll find it in that region)

definition of 1. Overall Survival (OS) 2. Progression-free survival (PFS) 3. Time to Progression

1. OS: time from randomization or treatment to death 2. time to tumor progression or death 3. progression only, not death

Other post Y90 therapy findings to look for on follow up imaging

1. Peritumoral edema/hermorrhage 2. Ring enhancement 3. contralateral liver Hypertrophy 4. Transient perivascular edema 5. capsular retraction, hepatic fibrosis, portal hypertension 6. perihepatic fluid and pleural effusion

Contraindications to Y-90

1. Presence of nonliver-dominant metastasis (significant extrahepatic disease) 2. Poor baseline liver function - greater than 50% involvement - Child-Pugh Class C - significant hepatic encephalopathy - Refractory ascites - Total Bilirubin >2, INR >1.7, platelets <50k 3. ECOG > 2 4. Excessive hepatopulmonary shunting - goal for <30 Gy per treatment in healthy lungs - Goal for <50 Gy cumulative lifetime pulmonary dose

the 3 criteria that the Barcelona Clinic Liver Cancer (BCLC) staging system

1. Tumor Size and extent 2. Degree of liver dysfucntion (Child-Pugh score) 3. General patient functional status (ECOG and Performance Status)

Objective (radiological) Response criteria

1. WHO 2. EASL 3. RECIST 4. mRECIST

The types of targeted therapies

1. anti-VEGF (vascular endothelial growth factor) 2. anti-EGFR (epidermal growth factor receptor) 3. anti-VEGFR TKIs (tyrosine kinase inhibitor) 4. TKI/EGFR 5. MEK inhibitors (mitogen-activated protein kinase) 6. anti-PD1/PDL1 (programmed death) 7. anti CTLA-4 (cytotoxic T lymphocyte-associated antigen)

criteria used in categorizing LIRADS

1. arterial phase hyperenhancement 2. observation size 3. major features

Basic Oncology: types of tumors

1. carcinoma 2. sarcoma - connective tissue, soft tissue, oteo/chondro 3. lymphoma 4. myeloma - plasma cells 5. leukemia - blood

the four different categories assessed during objective radiological response

1. complete response 2. partial response 3. stable disease 4. progressive disease

clues to when you should suspect extrahepatic supply of tumor

1. exophytic tumor growth; invasion of adjacent organs 2. tumor in contact with bare area or suspensory ligaments of liver 3. hypertrophied extra hepatic vessels on CT 4. local recurrence of tumor at periphery of treated subcapsular tumor during follow up

factors that determine liver resection candidacy

1. hepatic distribution of tumor (solitary lesion < 5cm and confined to one lobe) 2. vascular invasion (none) 3. liver function (well-preserved) 4. size of residual liver 5. expertise of surgical team

Relative contraindications for y90 radioembolization for mCRC

1. limited hepatic reserve 2. irreversibly elevated bilirubin levels 3. compromised portal vein 4. prior radiation therapy to the liver

Patients to be careful with when treating with y90

1. low albumin 2. heave pretreatment with Chemo (CASH) 3. ECOG 2+ 4. high volume liver replacement by tumor 5. re-treatment with y90

the different targeted therapy classes 1. mab 2. (ti)nib 3. imus 4. stat 5. cept 6. zomib 7. vec

1. mab = monoclonal antibody 2. (ti)nib = tyrosine kinase inhibitor 3. imus = immunosuppressive 4. stat = enzyme inhibitor 5. cept = receptor molecule 6. zomib = proteasome inhibitor 7. vec = virus or vector

7 most common parasitized vessels supplying tumors within the liver

1. phrenic 2. cystic 3. adrenal 4. SMA 5. omental 6. intercostal 7. internal mammary

circumstances when theraspheres are preferred over Sirspheres

1. portal vein thrombosis 2. prior portal vein embolization 3. severe hepatic arteriopathy (ex: prior use of bevacizumab)

types of chemotherapy categories

1. primary/induction: primary treatment where no alternative exists 2. neoadjuvant: chemo for initial treatment of localized cancer for which localized therapies (surgery, xrt) exist 3. adjuvant: chemo to reduce local and systemic recurrence after local (eg surgery) treatment

REBOC recommendations for y90 radioembolization for mCRC

1. should have unresectable hepatic disease with liver dominant tumor burden 2. life expectancy of > 3 months

Exclusion criteria for Y90 radioembolization

1. significant extrahepatic disease (life expectanacy < 3 months) 2. evidence of uncorrectable flow to the GI tract (observed at angiography or Tc99m) 3. more than 30 Gy to be delivered to lungs in single dose or more than 50 Gy in multiple doses 4. bilirubin > 2 mg/dL 5. ECOG > 2

post Y90 findings to look for when assessing response to therapy on follow up imaging and labs

1. tumor size 2. necrosis 3. angiographic avascularity 4. tumor dissapearance 5. decreased activity on PET (colorectal) 6. volume reduction 7. tumor markers 8. Increased water diffusion on DWI

spheres per vial theraspheres vs. sirpheres

1.2-8 x 10^6 vs. 40-80 x 10^6

Recommended irinotecan dose for mCRC

100 mg

recommended doxorubicin dose for HCC during TACE

100-150 mg

when are Theraspheres calibrated

12 pm on Sunday available in 6 activity sizes: 3, 5, 7, 10, 15, and 20 GBq

Target dose to the tumor in Y90

120 Gy - less than 100 Gy appears to be ineffective

max activity per dose theraspheres vs. sirspheres

20 GBq vs. 3 GBq

size of theraspheres vs. sirsperes

20-30 um vs. 32.5 um

specific activity per sphere theraspheres vs. sirspheres

2500 Bq vs. 40-70 Bq

how is tumor lysis syndrome treated

3 main principles: hydration, fix metabolic abnormalities, treat acute renal failure - aggressive fluid administration (if no CHF!) - reduction of uric acid with allopurinol or rasburicase (high risk patients should receive rasburicase prophylactically) - hyperkalemia: glucose + insulin, calcium gluconate (reduces risk of dysrhythmia); hemodialysis if refractory - hyperphosphatemia: aluminum salts or sevelamer - symptomatic hypocalcemia: calcium gluconate - hemodialysis for acute renal failure, uremia, severe electrolyte abnormalities

when are Sirspheres calibrated

6 pm the day after delivery

what is the 5-year survival for patients who had transplantation for HCC

60-75% for those within criteria 50% for those outside the criteria

average energy for a Y90 beta particle (electron)

935 KeV

what is the contraindicated radiation exposure dose to the lung during a single y90 treatment

> 30 Gy

when we assay Y90 dosage what are you actually measuring

Bremsstrahlung photons * remember - the electrons don't penetrate far enough but photons do

current classfication scheme for tumor lysis syndrome

Cairo-Bishop *LTLS is considered present or absent while CTLS is defined by maximal grade of each clinical manifestation

for nonsurgical candidates with metastatic hepatic colorectal cancer, would you use TACE or Y90 for 1st line liver-directed therapy

Evidence suggests that Y90 should be 1st line liver-directed therapy

what is FOLFIRI

FOLFIRI is a chemotherapy regimen for treatment of colorectal cancer It is made up of the following drugs: FOL - folinic acid F - fluorouracil (5-FU), a pyrimidine analog and antimetabolite which incorporates into the DNA molecule and stops synthesis IRI - irinotecan (Camptosar), a topoisomerase inhibitor, which prevents DNA from uncoiling and duplicating

what is FOLFOX

FOLFOX is a chemotherapy regimen for treatment of colorectal cancer, made up of the drugs FOL- Folinic acid F - Fluorouracil OX - Oxaliplatin

how is the Objective Response Rate calculated how is the Disease Control Rate (DCR) calculated

ORR = CR + PR (complete response + partial response) DCR = CR + PR + SD

what is a 1. phase I trial 2. Phase II trial 3. Phase III trial

Phase I - assesses the safety of a drug or device Phase II - tests the efficacy Phase III - involves randomized and blind testing

Why is MAA mapping performed (radioactivity and delivery)

Radioactivity: 1. determine lung shunt & minimize non-targeted deposition into the liver parenchyma (RILD) 2. identify extrahepatic perfusion on nuc med scan Delivery: 1. minimize non-targeted embolization to mesentery 2. assess for aberrant anatomy 3. optimize implantation through redistribution (intra and extrahepatic)

what does RECIST stand for? How is it measured? what is considered stable disease in RECIST

Response Evaluation Criteria In Solid Tumors - measure long axis only (in axial plane) - Stable disease: -30 to +20% change

dosimetry method for Sirspheres vs. Theraspheres

Sirspheres: Body-Surface Area method (BSA) Theraspheres: MIRD method

extended indication for TACE

Stage 0, A, or B patients who are waiting for liver transplantation to prevent tumor from progressing while waiting ("bridge to transplant") Stage C patients who are stage C only because of small-volume, extrahepatic spread, slightly reduced PS 1, or segmental branch portal vein invasion

how far can a beta particle/electron go within tissue

about 90% of the energy from a Y90 microsphere is deposited within the first 5 mm - Maximum penetration depth is about 11-12mm but there is minimal energy deposited out this far

how long should bevacizumab (Avastin) be held prior to a procedure

at least 2 weeks

how do you categorize tumor lysis syndrome

by laboratory values (LTLS) and clinical symptoms (CTLS)

two primary processes of energy loss in Y90 beta decay

collisional energy loss - ionizations, excitations, and elastic scattering; these losses define the penetration depth of electrons from each microsphere and also the biological effect radiative losses: aka bremsstrahlung; critical for assaying treatment dose, for patient release, and safety

what is the difference between dosage vs. dose in nuclear medicine

dosage describes the rate of decay; it is prescribed dose describes how much absorbed dose to tissues

what is tumor lysis syndrome

electrolyte and metabolites abnormality that results from destruction of proliferating neoplastic cells and can cause multiorgan failure/death

what is hyperuricemia and what is it caused by

elevated uric acid caused from the rapid release of intracellular DNA which is metabolized

what does poorly bound MAA mimic

gastric and thyroid uptake

Tumors that have a higher risk of Tumor lysis syndrome

high-grade lymphoproliferative malignancies * non-Hodgkins, Burkitt lymphoma, AML, ALL

what is TNM

how most cancers are staged T - size (0-4) N - degree of nodal spread (0-3) M - degree of distant metastases (0-1)

characteristic appearance of an angiogram with a gastrohepatic trunk

inverted 7 or "tree in winter appearance

characteristic appearance of the cystic artery

inverted Y or "forked tongue" appearance

how does Y-90 decay

it decays by beta emission

how does sorafenib work

it is an oral multikinase inhbitor that suppresses tumor cell proliferation and angiogenesis for HCC

what is the definition of "dosage" in nuclear medicine

it is synonymous with activity

what is a nonspecific marker of cell turnover in tumor lysis syndrome

lactate dehydrogenase LDH

risk factors for developing tumor lysis syndrome for solid liver malignancies

large tumor burden, rapid expansion/infiltration, large areas of necrosis

symptoms of hyperkalemia

muscle weakness, cramps, paresthesias, paralysis, cardiac dysrhythmias

is portal vein thrombus (bland or tumor) a contraindication to Y90

no

has sorafenib been proven to be effective for patients with different types of Child-Pugh scores?

no - only works for Child-Pugh A

what is the definition of "curative" treatment in oncology

no evidence of disease at 5 years

what is the 5-year survival for patients who had surgical resection for HCC

non-cirrhotic: 50% (up to 70% if ideal candidate) cirrhotic: 30%

how does tumor lysis syndrome cause obstructive uropathy

precipitation of uric acid crystals and calciumphosphate crystals in the renal tubules cause an obstructive uropathy *uric acid can also cause renal vasoconstriction decreasing renal blood flow*

definition of effective dose

quantity used in radiation protection to characterize risk of stochastic effects units = Sievert (Sv) seen on your badge report

the two types of conventional surgical treatments for HCC

resection (more common) or transplant

risk factors associated with the development of tumor lysis syndrome

risk of developing TLS depends on the type of malignancy and patient characteristics *Malignancy related factors: - large mass and presence of metastasis (tumor bulk and stage) - rapid proliferation - sensitivity to therapy *predisposing patient characteristics: renal insufficiency, dehydration, oliguria, nephrotoxic substances, baseline metabolic derangments (uric acid or phosphorus)

BCLC stage which TACE is recommended

stage B/Intermediate stage: Large, multinodular HCC, Child-Pugh A-B, PS 0

the two treatment algorithms for HCC

the Barcelona Clinic Liver Cancer (BCLC) and the Hong Kong Liver Cancer (HKLC) treatment algorithms

what is the alternative to the Milan Criteria for HCC transplant

the UCSF criteria - single tumor < 6.5 cm or 2-3 lesions with none exceeding 4.5 cm and total tumor diameter < 8cm - no vascular invasion and/or extrahepatic spread

- what is the definition of "activity" in nuclear medicine - what units are used to describe decay

the rate of decay of a sample of radioactive material - Units: Bq (decay/s); mCi (37 MBq per mCi)

What is the Milan criteria and what is it used for

used for HCC transplant criteria 1. one tumor up to 5 cm or up to 3 tumors measuring 1-3 cm each 2. no vascular invasion 3. no nodal or distal metastasis (reactive portal nodes ok) - outcome of OLT in these patients is equivalent to outcome in those without HCC

what is the ideal timing of the MAA nuclear medicine scan

within 1 hour of injection * decreases the possibility of false positive extrahepatic activity due to free technetium