YTTRIUM 90 MICROSPHERES THERAPY OF LIVER TUMORS

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1 YTTRIUM 90 MICROSPHERES THERAPY OF LIVER TUMORS The information regarding placement of Yttrium 90 microsphres for the management of liver tumors on the next several pages includes questions commonly asked about the procedure. While the information has been discussed with you by an Interventional Radiologist, please take a few minutes to review this packet of information. WHAT IS YTTRIUM 90 MICROSPHERES OF THE LIVER? The liver is unique in having two blood supplies- an artery (the hepatic artery) and a large vein (the portal vein). The normal liver gets about 75% of its blood from the portal vein land only 25% of its blood from the hepatic artery. When a tumor grows in the liver, it may receive almost all of its blood supply from the hepatic artery. Yttrium 90 microspheres of the liver is the injection of beads (either glass or plastic) with radioactive material directly into the arteries supplying the blood to the liver tumor. Since the beads are placed directly into the tumor vessels, it does not have the profound impact on the body when compared to other therapies such as systemic chemotherapy. Yttrium 90 therapy of the liver is used for tumors limited to or beginning in the liver, with a few exceptions (the exceptions are evaluated on an individual basis). Yttrium 90 is used for patients that are considered not to be a candidate for surgery, whose tumors are in multiple places within the liver or extremely large. Yttrium 90 is considered palliative, not curative. The goal of Yttrium 90 is to maintain or improve the quality of life and the life expectancy. Therefore, without any treatment (chemotherapy, surgery, radiation therapy, etc.), if the life expectancy is 3-6 months, the hope is to extend the life expectancy by at least 3-4 months. WHICH PATIENTS WITH LIVER TUMORS ARE CANDIDATES FOR YTTRIUM 90? Yttrium 90 of liver tumors is usually reserved for tumors beginning in the liver, such as hepatomas, or for tumors that have primarily spread to the liver, such as colon cancer, islet cell tumors, carcinoid tumors, breast cancer and some sarcomas. You must have enough normal liver tissue to be able to tolerate this procedure. The amount of normal residual liver tissue is usually based upon blood tests and a CT scan or MRI. WHAT ARE THE OPTIONS AVAILABLE FOR THE TREATMENT OF LIVER TUMORS? Your physician probably has or will discuss your treatment options with you. Several options are briefly discussed below: 1. Surgical resection of the liver The surgeon removes the liver tissue containing and surrounding the tumor. The remaining liver should be able to maintain the function of the liver. Therefore long standing damage to the liver called cirrhosis may prevent a surgical resection. Surgery requires an incision and general anesthesia; 2. Chemoembolization of the liver The interventional radiologist performs an arteriogram to identify the arteries in the liver supplying the tumor. Once the arteries are located, the physician injects chemotherapy agents and plugs the artery with PE (9/11) 1 of 6 To view: To order:

2 particles. Most of the remaining liver receives it food (blood and oxygen) supply from the portal vein, while tumors tend to receive their food supply from the hepatic (liver) arteries; 3. Intravenous chemotherapy and/or radiation therapy Most tumors that begin in the liver do not respond very well to this type of treatment. For tumors that have spread to the liver, the multiple chemotherapy drugs have been used without complete control of the tumor; 4. Alcohol or heat ablation----for liver tumor less than 5 cms in size (preferably less than 3 cm), either direct alcohol injection or heating the tumor and a small area of tissue around the tumor may help to shrink the tumor; or 5. Transplantation In a small number of patients with liver tumors, the patient may be a candidate for transplantation. Your liver doctor will tell you if you are a candidate for liver transplantation. Even if you are a candidate for a transplant, your doctor may decide that you need a chemoembolization or Yttrium 90 therapy procedure to prepare you for the transplantation. 6. Yttrium 90 Microspheres An Interventional Radiologist does an arteriogram of the arteries going to the liver. A Low dose radiation particle is place directly into the artery going to the liver tumor. Limited to patients that the radiation does not leak to the lungs or bowels; 7. Radiation Oncology The use of high-energy rays to damage cancer cells, stopping them from growing and dividing. 8. Do Nothing You and your physician decide that the options listed above are not in your best interest. 9. Nexavar (Sorafenib) An oral chemotherapy agent that has been approved by the FDA that interferes with the growth of cancer cells and slows their growth and spread in the body. WHO ARE NOT CANDIDATES FOR THE PROCEDURE? Patients with extensive spread of tumor outside the liver, and jaundice or confusion due to liver disease are not candidates. Patients whose liver is not functioning normally are not candidates. Patients with a history of x-ray contrast agent reactions, blood disorders, severe kidney or heart disease are at higher risk for the procedure, but these patients are assessed on an individual basis. Patients with partial blockage of the portal vein are usually candidates for Yttrium 90. The normal liver tissue receives the majority of its food supply from the portal vein. Therefore, it is important to check how good the portal vein flow is before the procedure. Your physician may recommend that you have several tests, including liver function tests, and a CT scan or a MRI of your liver prior to the Yttrium 90 procedure. The tests will assist you doctor in determining that you do not have: new tumors in other parts of your body, if the Yttrium 90 beads will stay in the liver, cirrhosis of the liver, or a blockage of the bile ducts. If any of these problems are found, you may not be a candidate for the Yttrium 90 procedure. HOW MANY TIMES WILL I NEED TO HAVE THE PROCEDURE DONE? Depending upon your tumor as well as the anatomy of the blood vessels, you may undergo two treatment sessions. Each session is separated by 4-6 weeks. 2 of 6

3 WHAT ARE THE BENEFITS OF THE PROCEDURE? While Yttrium 90 is not a cure, it does increase the life expectancy in 50% of the patients. WHAT ARE THE POTENTIAL COMPLICATIONS OF THE PROCEDURE? No procedure is without risk. The risks for Yttrium 90 to the liver include all the risks associated with an arteriogram. These risks are rare, but include bleeding, infection, kidney failure requiring dialysis, loss of limb, and a reaction to the contrast agent, to name a few. In addition to the risks associated with a routine arteriogram, the risks associated with chemoembolization are: 1. Post embolization syndrome (frequent) Post embolization syndrome describes a group of symptoms that are flu-like (pain, fever, chills, nausea, vomiting, and achy joints ) that can start a few hours after the procedure and last one to three weeks; 2. Confusion (rare) Confusion or decreased awareness in some patients can occur because liver function is decreased; 3. Injury to the gall bladder (rare) The chemotherapy and/or the plugging particles may lodge in the artery feeding blood to the gall bladder. When this happens, the gall bladder may have to be removed; 4. Liver infarction The area of the liver that contains the tumor and some surrounding areas receive less blood supply, and may actually die (infarct). In the majority of patients, this does not cause a problem; 5. Liver abscess (less than 5% of patients) The area of the liver that is embolized may develop an infected fluid pocket known as an abscess. An abscess may require another procedure or even surgery, to treat the abscess; or 6. Tumor rupture (rare) After receiving chemotherapy, tumors swell in size as cells begin to die. The swelling may result in tumor rupture. 7. Liver failure (less than 5% of patients) In a small number of patients the liver is takes longer to recover after altering the blood to the tumors. In these patients, one may notice jaundice (yellow coloring to skin or eyes), fluid around abdomen or legs or generalized not feeling well. 8. Ulceration of the stomach, small bowel or large intestines (less than 5% of patients) In a small number of patients, the Yttrium beads may damage the vessels going to the stomach, small intestines or large intestines. In this situation, the area may bleed creating a ulcer. The patient will be placed on a drug such as Prilosec for the next thirty days. WHAT DO I NEED TO DO TO PREPARE FOR THE PROCEDURE? In preparation for the procedure, a biopsy of the tumor may need to be performed to determine the type of tumor. A CT scan or a MRI will be done to determine the size and location of the tumor, portal vein blood flow, and for blockage of the bile ducts. A chest CT may be performed to rule out the presence of a tumor in the lungs. The chest CT will also show fluid or infection that may delay or prevent the performance of the procedure. Blood tests to determine your liver and kidney function, blood counts, and tumor markers will be done. An ECG (electrocardiogram) may be required but usually can be done at the time of the procedure. The patient will also be seen by Radiation Oncology to determine if you are a candidate for radiation therapy (Yttrium 90 or external beam). 3 of 6

4 WHEN SHOULD THE PROCEDURE BE DONE? The procedure should be done when there are no signs or symptoms of an infection (cough, fever, burning with urination, or chills). The Yttrium 90 therapy should be done before signs of liver failure are present. Yttrium 90 should be done before there are tumors in other organs or blood vessels in your body. HOW LONG WILL I BE IN THE HOSPITAL? You will come to the hospital the day of the procedure and can expect to stay overnight. You will be discharged when you are able to eat solid foods, your pain is controlled by oral medications, and you have no signs of infection. HOW LONG WILL THE YTTRIUM 90 PROCEDURE TAKE? The procedure is a two-three stage procedure. Each procedure usually takes 2-4 hours. CAN I EAT BEFORE THE PROCEDURE? You should not eat any solid food 6 hours before prior to the day of the procedure. You can have clear liquids during the night and morning of the procedure. In fact we encourage you to drink several glasses of clear liquids during the night. If you are diabetic or take other medications on a regular basis let us know so that we can adjust your medications as necessary. WHAT DO I DO ABOUT MY MEDICATIONS? Most medications do not need to be stopped or held before the procedure. However, medications such as glucophage and insulin sometimes do need to be adjusted. The insulin dose is adjusted for the morning dose. Glucophage will be held for 2 days before and 2 days after the procedure. Any elevation in blood sugar will be managed with insulin during those 2 days. High blood pressure medications should be taken as usual. If you are on a blood thinner (heparin or coumadin), it will need to be withheld for several days prior to the procedure. If you have an allergy to contrast dye (IVP or X-ray dye), please let us know so that we can prescribe a medication to reduce your risk of a dye reaction. WHERE DO I COME THE DAY OF THE PROCEDURE? Interventional Radiology is located on the first floor of the hospital in the Expansion Wing at the University of Virginia in Charlottesville. Please report ot Radiology Registration just off the East Wing Elevators, The phone number is WHAT DOES THE EMBOLIZATION PROCEDURE ITSELF INVOLVE? Upon your arrival in the department, a nurse will accompany you to the recovery area. The nurse will help you change into a hospital gown and then start an IV line. Any necessary blood work will be done. The IV allows us to give you medications to help you relax and decrease any discomfort that you may have during the procedure. The IV will also allow us to give you antibiotics as well as medications to decrease the nausea and pain associated with the procedure. A physician or nurse practitioner will meet with you to complete your history and physical examination, explain the procedure, and ask you to sign an informed consent form. A nurse and X-ray tech will take you to a special procedure suite, where the evaluation for the Yttrium 90 procedure will be performed. After placing you on the x-ray table, your groin areas will be cleaned with a special soap and you will be covered with sterile drapes. A physician will numb the area of your groin and insert a small needle into your artery. A small tube, called a catheter, will then be inserted into the artery in your groin. The catheter will be positioned to allow us to see the arteries supplying your liver and the tumor 4 of 6

5 within your liver. Pictures will be taken using a small amount of contrast dye. After the physician has located the arteries to be blocked, the physician will use the special x-ray equipment in the room to take some CT-like pictures of the liver to better see the tumors. After the pictures, he will inject a protein marker into the artery of the tumor. This marker is the very similar in size as the beads used in the Yttrium 90 therapy. Once the physician has placed the marker into the arteries, you will be returned to the recovery room. The catheter in your groin will be removed and pressure will be placed on the artery in your groin. You will be moved to Nuclear Medicine where you will be placed under a special camera to show where the protein marker is in your body. The hope is that the marker is in your liver with a very small amount in your bowels. If the marker leaks to your lungs or there is a large amount in your bowels you will not be a candidate for the Yttrium 90 procedure. You will be observed for a brief period of time in the recovery room before you go to your regular hospital room. You will be discharged either later that day or early the next day. Once the arteriogram and the nuclear medicine scan are completed, the interventional radiologist (the doctor who did the arteriogram), a radiation oncologist and a radiation physicist (determines the dose of the Yttrium 90) will meet to determine if you can have the procedure. If it is decided that you are a candidate for the procedure, the team of doctors will find a date for to return for the Yttrium 90 therapy. This is usually 2-4 weeks after the first procedure. At the time of the second procedure, the process is repeated. This time the team will place the Yttrium 90 microspheres in your liver tumor. At the time of this procedure, the team may need to block small arteries to your stomach or bowels to control the leakage of the beads to your stomach or bowels. This procedure will take about 2 3 hours. You will again return to Nuclear Medicine and be placed under the special camera to look for leakage outside your liver. In some cases, the process will be repeated for the other side of liver. This is usually done about 4-6 weeks after the placement of the Yttrium 90 microspheres. WHAT CAN I EXPECT AFTER THE PROCEDURE? You will be admitted to a hospital bed on a regular nursing unit where someone will monitor your blood pressure, heart rate, temperature and pulse at frequent intervals. They will also check the puncture site in your groin area for any signs of bleeding or bruising. You will also receive instructions on what to do if you have to cough, sneeze or vomit. You will be on strict bedrest for several hours after the procedure. After that time, you will be allowed out of bed. When you can get out of bed you should take it easy. Some patients complain of pain in the upper right area of the abdomen (belly) as well as nausea after the procedure. The doctors will order a pain medicine that can be given to you in your IV. The pain usually decreases over the next hours. Before going home, the physician will change the medications to a medicine that you can take by mouth. The doctors will also order medicines to help control any nausea the patient may have. The nausea, when it occurs, usually decreases over the next hours. It is common for you to have flu-like symptoms for 1-2 weeks after the procedure. Mild fever, nausea, aching and pain can usually be managed with medications. Many patients complain of low energy for up to 3 weeks after the procedure. 5 of 6

6 It is common for your appetite to be decreased after the procedure. However, for effective healing to occur, there must be good nutrition and hydration. Please try to drink at least 8 glasses of fluids each day. If regular foods do not appeal to you, try one of the nutritional supplements on the market (ensure, sustacal, etc.) to supplement your diet. WHEN SHOULD I CALL MY PHYSICIAN? Some patients experience flu-like symptoms after the procedure. The symptoms go away over a period of 1-2 weeks, although mild symptoms may persist for longer. However, you need to contact your primary physician or us for: 1. a temperature greater than 101 degrees and /or chills; 2. persistent pain, not relieved by the prescribed pain medications; 3. persistent nausea and vomiting; or 4. the development of confusion or jaundice. 5. change in stool color 6. change in urine color especially if the urine becomes tea-colored. 7. blood in stool or vomit. If you notice bleeding or a bruise growing around the puncture site in your groin, place pressure on the groin and have someone call Interventional Radiology at between 8:00 A.M. and 5:00 P.M., and ask for the physician on call. Between 5:00 P.M. and 8:00 A.M., call and ask for the physician on call for Interventional Radiology. Please give the operator your name and your phone number. Otherwise, you should call an ambulance and go to the nearest Emergency Room. WHAT IS THE FOLLOW-UP SCHEDULE FOR YTTRIUM 90 MICROSPHERES OF LIVER TUMORS? Currently we are requesting patients have the following: 1. Blood work approximately one week after discharge from the hospital. This can be done at your local doctor s office. We will provide a fax number for the lab work. 2. A CT scan of the abdomen done at 4 weeks after the procedure; 3. Blood work to check liver function and tumor markers at 4 weeks; 4. Follow-up office visits by your primary physician or surgeon and the Interventional Radiologist at UVA at 4 weeks; 5. In most instances, a repeat session at chemoembolization at 4 weeks; and 6. The tumor s response and your health will determine the need for further follow-up visits (at 3 and 6 months). DOES INSURANCE PAY FOR YTTRIUM 90 MICROSPHERES? Each insurance policy is different. At the time that we are contacted to evaluate you for Yttrium 90 therapy we will contact your insurance company to determine if they will pay. In some cases insurance will deny. If a denial occurs you may be told to appeal the denial. We will receive a copy of the denial letter. If the letter instructs us to appeal, we will send a letter of appeal. If you have further questions, please call and ask to speak to one of the nurse practitioners in Interventional Radiology. 6 of 6

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