Scott Webb (Host): There have been so many advances in the diagnosis and treatment of various cancers in the past few years. And today, Interventional Radiologist, Dr. Juan Rodriguez, is here to tell us about radioembolization radiation therapy, or the Y90 treatment that's being used at Salinas Valley Health to treat liver cancer.

 This is Ask the Experts, the podcast from Salinas Valley Health. I'm Scott Webb. Doctor it's nice to have you here today. We're talking about Y90 or radioembolization radiation therapy, and definitely easier for me to say Y90 and using that for treating liver cancer. So maybe just start by explaining the Y90 treatment, how it works inside the liver.

Juan Rodriguez, MD: Thank you. Thank you, Scott, very much for giving me this opportunity to talk about this new novel technique to our community. The procedure consists on the delivery of a radioactive element, in this case, Yttrium 90, directly into the tumors in liver. So what we do is we get access to the arterial system via either a vessel in the groin or in the wrist.

We get to the liver, we determine what vessels are feeding the tumor and we deliver these beads that contain a beta meter called Yttrium 90, that has a half life of about two and a half days. Those beads act killing cells around each bead about a millimeter to two millimeters of contact or distance to have that killing effect on cells.

So they need to be delivered right within the tumor. The advantage is you're basically killing cells in proximity, respecting other organs and respecting the rest of the liver.

Host: In doing my research for this and planning for this, it seems like it's very targeted, which seems to be the sort of maybe present and future of treating cancer, so as to not to damage all the things around the, in this case, the liver. And so if I hear you right, you're doing this now, right? You're performing this at Salinas Valley Health?

Juan Rodriguez, MD: Yes, yes. We started at the beginning of this year. I moved into the community at the beginning of 2024. We are five intervention radiologists in this hospital. We wanted to bring the technology to our community, and took a little bit of time to meet all the regulatory requirements to be able to deliver this agent. We started, our first case was in January of this year.

Host: Okay. Yeah, it's really amazing. I love doing these podcasts on just to the advances in science and medicine and delivery, and in this case Y90. So let's talk about who's a good fit for this treatment and maybe are there any specific stages or types of liver cancer that it's better for?

Juan Rodriguez, MD: We're targeting two different type of patients. One is the patient that has metastatic disease to liver, almost exclusively, or predominantly to liver. The ideal patient would be a colorectal cancer patient with metastasis to liver. And the other group of patients are primary liver tumors, livers that originating in liver, liver cancer, and biliary duct cancer, cholangiocarcinomas and hepatocellular carcinomas.

Host: Yeah. And, folks, uh, Doctor I'm sure have heard of chemotherapy and certainly surgery. So maybe you can sort of compare and contrast how does Y90 stack up, if you will, against maybe these, you know, more traditional treatments?

Juan Rodriguez, MD: It's another tool added to our armamentarium, our toolbox. Obviously if the patient can be resected, that is the ideal way of treatment. We are lucky to have a liver surgeon also on the staff, so we're working collaboratively with the rest of the members of the oncology community, radiation oncology, medical oncology and surgery.

If a patient can be resected, that is the first option. If the patient can receive a liver transplant, that would be another option for certain patients with primary liver cancers. If they are not resectable, then this is something that can be offered to the patient, as a way of treatment of the metastasis.

So, or for primary liver cancers as a way of eradicating the lesions and maintaining ultimately these patients on a transplant list to receive a, a new liver.

Host: Sure. Yeah. I always love hearing, that brings a smile to my face when I hear, uh, sort of the multidisciplinary teams, you know, working to help patients and another tool in the toolbox, as you say. And I, I guess I'm just wondering, are there some side effects that patients might experience? And if so, like how serious are they?

Juan Rodriguez, MD: We tailor to patients with a good functional status and good liver reserve. Some of our patients have cirrhosis. So their livers are weaker. They have not healthy livers to start with. And other patients obviously have experienced months or years of treatment and their livers could be seriously affected by multiple lesions.

So, they have to have a good liver reserve. The good thing about this techniques is that it's very respectful of normal liver. So the fact that we deliver these beads specifically to the tumor beds in the liver of the microcirculation of the tumor, we respect as much as possible, nearby liver that has no cancer.

So, it's a good alternative to achieve treatment, killing cancer cells, respecting nearby normal liver cells.

Host: Right. Do you have a sense yet, doctor of you know, how much Y90 is extending people's lives or at least improving the quality of their lives?

Juan Rodriguez, MD: It is a significant enough that is approved, you know, by all insurance carriers and Medicare. You know, it's, it's proved that patients with metastatic cancer, when they are not responding to systemic therapy, meaning chemotherapy, this is something that can add lifespan.

And at the same time, I think that is important not only adding months, but also minimizing side effects, right? I mean, the, the question is to treat somebody, but at the same time trying to be as respectful as possible, in the sense of the tolerance for the treatment. Meaning we don't, we don't want to have those patients being affected by significant side effects, you know, or complications.

Host: Yeah. Maybe you can give us a sense, Doctor, you know, when we think about the Y90 treatment, what folks can expect, patients can expect, kind of, you know, from start to finish, if you will.

Juan Rodriguez, MD: Yeah, normally we determine the benefit of this procedure as a, in a multidisciplinary venue. We discuss these cases as a group with oncology and surgery. We meet the patient, we go over their history, laboratory data, make sure that liver function is adequate, functional status is good.

We review their imaging studies. And then the procedure itself requires of two visits to us, two visits to the angiography suite. The first visit, we do what is called a planning procedure. Basically, we map the vessels in the liver. We determine the blood supply to the tumors. We deliver a very small amount of radioactivity in the form of, it's a different agent. It's called technetium, that we use it for imaging. We don't use it for therapy, but it's basically simulating what the Y90 is going to do. So helps us to determine the dose of Y90 that we're going to deliver. And another thing is safety. For safety reasons, we do this planning to make sure that the beads obviously are not going to go anywhere else, because these beads add act by contact, so we don't want them going anywhere else. Primarily will be the lungs. You know, if, there's anomalous communications in the tumors between arteries and veins, the beads will escape through those shunts, through those anomalous communications and end up in the lungs. The same we don't want these beads to go into stomach or gallbladder, for example, because wherever they end up are going to be killing cells nearby. So that's the first is that, is a planning angiography. Mapping the anatomy, mapping the vessels, determine the doses, make sure that the beads are going to be, seeding into the tumor and nowhere else. It is a procedure done under moderate sedation as an outpatient. It's about an hour in the angiography suite, and then we bring them to nuclear medicine to do some scans and determine that, determine the dose and the amount of shunting to the lungs. The patient then, the same day, they go home. We work on the images that we have, and then about seven to 10 days after that first planning angiogram, we bring them back. And now we deliver the beads to the territory that we're already familiar and that, and the dose that we have already determined with that first planning procedure.

Again, it's an outpatient procedure. For the patient, the planning angiogram, and the treatment angiogram are similar, there is nothing different from one to the other.

Host: Okay.

Juan Rodriguez, MD: The side effects are minimum. I think one of the advantage of this treatment versus what we used to do before that was chemo embolization was basically delivering beads with chemo agents inside.

Actually it was worse tolerated in the sense that some of that chemo circulated through the body. These beads are basically staying within the lesion, so, they're very well tolerated. Patients go home the same day with very minimum side effects.

Host: Yeah, just wondering, is this like a, a one time only thing, you know, or is it more like chemotherapy where patients may have to go through Y90 multiple times? How does that work?

Juan Rodriguez, MD: We can treat them more than once. The, the beads, the Y90 has a half life of about two and a half days. And so I tell my patients that for 11 days, the dose is being delivered. 98% of the effect happens in the first 11 days. So for 11 days, these beads are delivering radiation by contact beta emission.

And killing cells. We follow those patients, make sure that they're doing okay. We image again, the livers with MRI or CT scan about two months, two to three months after the procedure. And then we go from there, we could retreat. The main limiting factor would be the dose that the lungs are going to receive, but we can repeat treatments. Yes.

Host: Well, I know that we could speak for much longer, and I know that you're planning on doing a Spanish episode as well. I just want to give you a chance here at the end, final thoughts and takeaways. You know, when it comes to Y90 and how you're using it, how it's affecting and helping patients. Final thoughts.

Juan Rodriguez, MD: I think we're very optimistic as I said, this is another tool in the toolbox of cancer therapy. I think it has a role on cancer therapy. I think it's effective in treating tumors, minimizing side effects and complications. So we're very happy and very optimistic that this is going to make a change in our community, our cancer community, and the way we deliver treatment to our patients. So, I used to talk to, you know, my grandfather and tell him what I do now, and, and,

Host: Sure.

Juan Rodriguez, MD: It amazes me how technology continues to advance and the, the capabilities that we have now are amazing.

Host: Amazing. That's the word that always comes to mind when I host podcasts like this for Salinas Valley Health is, yeah. That's amazing. You know, and no surprise of course, that Salinas Valley Health is on the cutting edge and they have you and the team. All good stuff. Thank you so much.

Juan Rodriguez, MD: Thank you.

Host: And to listen to more of our podcasts, please visit salinasvalleyhealth.com/podcasts. And if you found this podcast to be helpful, please be sure to tell a friend, neighbor, or family member. And subscribe, rate and review this podcast, and check out the entire podcast library for additional topics of interest. This is Ask the Experts from Salinas Valley Health. I'm Scott Webb. Stay well, and we'll talk again next time.