According to the American Cancer Society, more than 40,000 adults will be diagnosed with primary liver cancer this year. More commonly, cancer will metastasize to the liver from another part of the body, such as the colon. It's estimated that more than 135,000 people will be diagnosed with colorectal cancer in 2017. Roughly 50 percent of people with colorectal cancer will develop liver metastases.
A minimally invasive radiation treatment for liver tumors is now available at Our Lady of Lourdes Medical Center.
Yttrium-90 (Y-90) radioembolization targets cancer by injecting special beads into the blood vessels feeding the tumor. The beads, called microspheres, deliver a high dose of short-range radiation to the tumor while sparing surrounding healthy tissue.
In this segment, Dr. Joseph Broudy discusses this promising new treatment for liver tumors and the treatment options available at Lourdes Health System.
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Y-90 Cancer Treatment
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Learn more about Joseph Broudy, MD
Joseph Broudy, MD
Joseph Broudy, MD earned his medical degree at the University Of Kentucky College Of Medicine. Following medical school, he completed a Diagnostic Radiology residency at Beth Israel Medical Center in New York City. Dr. Broudy continued his training completing a Vascular and Interventional Radiology fellowship at the Mallinckrodt Institute of Radiology at Washington University in St. Louis. Dr. Broudy is Board Certified by the American Board of Radiology.Learn more about Joseph Broudy, MD
Transcription:
Melanie Cole (Host): According to the American Cancer Society more than 40,000 adults will be diagnosed with primary liver cancer this year. More commonly, however, cancer will spread or metastasize to the liver from another part of the body, such as the colon, a minimally invasive radiation treatment for liver tumors called Why 90 radio embolization is now available at Our Lady of Lourdes Medical Center. My guest today is, Dr. Joseph Broudy, he's an interventional radiologist at Lourdes Medical Center. Welcome to the show, Dr. Broudy, so, tell us about primary versus metastasized liver tumors, so, when it comes to the liver, what are you seeing more commonly?
Dr. Joseph Broudy (Guest): Hi, good morning. Yes, well I'm at a liver transplant center at Our Lady of Lourdes Medical Center in Camden. So, we see more primary liver cancer, also known as Hepatis cellular carcinoma, and that's a cancer that can occur in anyone, any patient who has a chronic parenchymal liver disease, also known as cirrhosis, and it can develop really in anyone with cirrhosis. And so, with patients who are undergoing liver transplantation for liver disease, we do see it frequently in those patients. And so, that's our primary patient population that we've been treating with the yttrium 90. We do also have some oncology presence at our health system and we see some metastatic tumors, usually from colorectal cancer primaries.
Melanie: So, how important is early diagnosis of liver tumor, liver cancer to be crucial to improve that outcome prediction? How would we know would cirrhosis have to have been discovered already, and then now, they're high at risk for this?
Dr. Broudy: Yes, absolutely. We screen patients who are known to have cirrhosis the cirrhosis is diagnosed either with lab tests or with imaging tests that show that the liver is cirrhotic or that it's got fibrotic tissue in it from chronic disease. And at that point, we'll screen patients with imaging surveillance every six months approximately with an MRI, and the MRI is the most sensitive imaging technique to detect the hepatocellular carcinoma or primary liver cancer, and as early as possible. And so, it's really important that we detect it as early as possible because patients who have smaller tumor burdens may be candidates for curative treatments like resection, transplantation. We typically will aim for transplantation in patients with primary liver cancer because it is curative and it offers the best long-term survival, since the cirrhotic liver will always be at a high risk of another tumor occurring at a later time. We do aim to have transplantation for these patients. Some patients have tumor burden that does not allow for transplantation, transplantation because it's too extensive, and in these patients, we can offer other treatments, such as local, regional therapy one of which is yttrium 90 radio mobilization, patients with more advanced disease can receive a biologic agent called Sorafenib which is a multi-kinase inhibitor and does offer some survival benefit as well.
Melanie: So, tell us about yttrium 90, and what is radio embolization for the listeners, what are you doing, if this is for someone for whom maybe transplant or resection is not an option? Tell us what this is.
Dr. Broudy: Right. So, yttrium 90 can be used in patients who have intermediate disease, which would put their tumor, there extensive disease outside of what we call the Molon criteria. The Molon criteria is the criteria that we look at to see if the tumor burden is acceptable for transplantation, if we know that if patients receive a transplant and they're not within that criteria their survivals not as good. So, we want to make sure that we're transplanting with the greatest utility that we can, so in patients who are outside of the Molon criteria, we can use yttrium 90 to downstage their disease to Bridgeland the transplantation, and in patients who have multinodular disease were diffuse infiltrated disease. We can use the yttrium 90 for palliation to improve overall survival, but not with a curative intent or to palliate tumor related symptoms.
Melanie: So, explain to the listeners because they don't necessarily understand palliation and the palliative care would kind of be a symptom management, a sign of long care. Explain what this radio embolization is for the patient. What does it do to their liver?
Dr. Broudy: So, the radio embolization can be delivered on either resin or glass microspheres, we use the resin microspheres, known as sur-spheres. They are made by a company called Surtax, which is an Australian company. They are microspheres of a size, of approximately on average 32.5 microns, so that's 32.5-millions to the meter, very small microspheres, and the yttrium 90 is a high energy isotope that is sort of embedded on the microsphere, and when you deliver the microsphere through a small catheter into the tumor, the artery supplying the tumor. The microspheres become permanently lodged into the tumor, the tumor vascular supply and the decay, releasing the radiation energy into the tumor. And so, in this way it causes tumor destruction, and it can spare the normal healthy liver parenchyma in the surrounding tissue because the tumors do have a preferential blood supply that is greater than the normal liver. So, you end up with five to six times the density of the microspheres in the tumor, compared to the normal liver, So, we can deliver radiation doses, 40 times greater than external beam radiation and with lower side effects, minimal toxicity.
Melanie: That is absolutely fascinating, Dr. Broudy. So, basically, it's more minimal exposure to the surrounding healthy liver tissue, and how long does someone have to go through these treatments before they will start to notice a difference or before it can then be the bridge to another treatment?
Dr. Broudy: Well radiation takes some time to work, we do follow up the imaging, we usually wait at least eight weeks to see a response on imaging which would be usually an MRI. The peak response is typically about 12 weeks, and I’ll usually wait eight weeks to see if there's a response, so that we can decide our next step in treatment, sooner than we would if we were to wait a full 12 weeks because typically, we want to get patients treated sooner rather than later, and not let the disease progress any further.
Melanie: So, do you see that this might be a first line treatment, compared to its current status which, it's no longer responding to chemotherapy so we're looking to adjuvant therapies. Do you see this exciting, innovative procedure as something that might be first line, coming up?
Dr. Broudy: Yeah. Well, the use of the yttrium 90 for colorectal, liver metastases, secondary to colorectal cancers. That was the original indication from 2002, that the FDA…when the FDA approved sur-spheres for use, and they've been used since then as is typically a salvage therapy by the oncology community for metastatic colorectal metastases.
So, patients who fail second or third line chemotherapies, they have chemo-refractory tumors in the liver, that's been the primary way that the yttrium 90s been used, it’s what we call salvage therapy, and it does improve survival compared to in that setting. It does improve survival compared to chemotherapy alone or best supportive care, but there's recently been… It can also be used in patients who are intolerant to chemotherapy, which either could be first line, second line, or third line. It can be used as a chemo-vacation just to maintain as a maintenance therapy between chemotherapy doses, can be used for consolidation therapy, but recently there's been a study that came out, that was an international trial called Surflox, and Foxfire global, which were three different studies looking at overall survival, when the yttrium 90s used as a first line agent with or without chemotherapy and plus or minus biological agents, and it did show with patients who have a right side a-colon cancer, that it improved overall survival, approximately five months, and compared to patients who received only chemotherapy without the yttrium 90, so that is encouraging.
We know that the that the biology of colon cancer is different between right and left-sided tumors, but we have seen that this is encouraging a five-month improved overall survival benefit with the use of yttrium 90, as a first line agent. So, we're trying to bring that to the oncology community, and we'll see how they implement that into their clinical practice guidelines, but it's very encouraging.
Melanie: It sounds that way and, Dr. Broudy, because these are beads, is there any sort of things you want to let listeners know? Do they have to stay away from pregnant women or the elderly or immune-deficient people, because people have heard that in the media before, is there any of those kinds of rules that apply?
Dr. Broudy: Well, the answer, the simple answer is no because the beta-energy, the beta-emitting isotope, which is yttrium 90, it only has a maximum range of emission, approximately two and a half millimeters on average, and 11-millimeter maximum in tissues. So, we're talking a couple millimeters on average, very small range, very short-range energy. So, someone standing around the patient would have very, very negligible amount of exposure, and it does not get transmitted in any body fluids, it becomes permanently lodged into the small vessels in the liver. So, there really is no appreciable radiation exposure to anyone, in the patient's environment.
Melanie: That is very cool, and it's such fascinating information, Dr. Broudy, wrap it up for us with your best advice about liver cancer, liver tumors, and cancers from other areas spreading to the liver and this exciting yttrium 90, radio embolization procedure now available at Our Lady of Lourdes Medical Center.
Dr. Broudy: Yes, the yttrium 90, we’ve now started our program, a few months ago, and we've been doing quite a few cases, we actually have one today. We've treated patients with primary liver cancer, with colorectal metastases to the liver, we're treating patients with squamous oma metastasis, really any metastatic disease to the liver, that liver pre-dominant, is a patient who can be treated. And we have survival data that shows that yttrium 90 does improves survival with primary liver cancer and metastatic colorectal cancer, and we're excited to bring this, this treatment to our health system, and to our community here.
Melanie: Thank you so much, Dr. Broudy, for being with us today. You're listening to Lourdes Health Talk, and for more information you can go to, LourdesNet.org, that's, LourdesNet.org. This is Melanie Cole, thanks so much for listening.
Melanie Cole (Host): According to the American Cancer Society more than 40,000 adults will be diagnosed with primary liver cancer this year. More commonly, however, cancer will spread or metastasize to the liver from another part of the body, such as the colon, a minimally invasive radiation treatment for liver tumors called Why 90 radio embolization is now available at Our Lady of Lourdes Medical Center. My guest today is, Dr. Joseph Broudy, he's an interventional radiologist at Lourdes Medical Center. Welcome to the show, Dr. Broudy, so, tell us about primary versus metastasized liver tumors, so, when it comes to the liver, what are you seeing more commonly?
Dr. Joseph Broudy (Guest): Hi, good morning. Yes, well I'm at a liver transplant center at Our Lady of Lourdes Medical Center in Camden. So, we see more primary liver cancer, also known as Hepatis cellular carcinoma, and that's a cancer that can occur in anyone, any patient who has a chronic parenchymal liver disease, also known as cirrhosis, and it can develop really in anyone with cirrhosis. And so, with patients who are undergoing liver transplantation for liver disease, we do see it frequently in those patients. And so, that's our primary patient population that we've been treating with the yttrium 90. We do also have some oncology presence at our health system and we see some metastatic tumors, usually from colorectal cancer primaries.
Melanie: So, how important is early diagnosis of liver tumor, liver cancer to be crucial to improve that outcome prediction? How would we know would cirrhosis have to have been discovered already, and then now, they're high at risk for this?
Dr. Broudy: Yes, absolutely. We screen patients who are known to have cirrhosis the cirrhosis is diagnosed either with lab tests or with imaging tests that show that the liver is cirrhotic or that it's got fibrotic tissue in it from chronic disease. And at that point, we'll screen patients with imaging surveillance every six months approximately with an MRI, and the MRI is the most sensitive imaging technique to detect the hepatocellular carcinoma or primary liver cancer, and as early as possible. And so, it's really important that we detect it as early as possible because patients who have smaller tumor burdens may be candidates for curative treatments like resection, transplantation. We typically will aim for transplantation in patients with primary liver cancer because it is curative and it offers the best long-term survival, since the cirrhotic liver will always be at a high risk of another tumor occurring at a later time. We do aim to have transplantation for these patients. Some patients have tumor burden that does not allow for transplantation, transplantation because it's too extensive, and in these patients, we can offer other treatments, such as local, regional therapy one of which is yttrium 90 radio mobilization, patients with more advanced disease can receive a biologic agent called Sorafenib which is a multi-kinase inhibitor and does offer some survival benefit as well.
Melanie: So, tell us about yttrium 90, and what is radio embolization for the listeners, what are you doing, if this is for someone for whom maybe transplant or resection is not an option? Tell us what this is.
Dr. Broudy: Right. So, yttrium 90 can be used in patients who have intermediate disease, which would put their tumor, there extensive disease outside of what we call the Molon criteria. The Molon criteria is the criteria that we look at to see if the tumor burden is acceptable for transplantation, if we know that if patients receive a transplant and they're not within that criteria their survivals not as good. So, we want to make sure that we're transplanting with the greatest utility that we can, so in patients who are outside of the Molon criteria, we can use yttrium 90 to downstage their disease to Bridgeland the transplantation, and in patients who have multinodular disease were diffuse infiltrated disease. We can use the yttrium 90 for palliation to improve overall survival, but not with a curative intent or to palliate tumor related symptoms.
Melanie: So, explain to the listeners because they don't necessarily understand palliation and the palliative care would kind of be a symptom management, a sign of long care. Explain what this radio embolization is for the patient. What does it do to their liver?
Dr. Broudy: So, the radio embolization can be delivered on either resin or glass microspheres, we use the resin microspheres, known as sur-spheres. They are made by a company called Surtax, which is an Australian company. They are microspheres of a size, of approximately on average 32.5 microns, so that's 32.5-millions to the meter, very small microspheres, and the yttrium 90 is a high energy isotope that is sort of embedded on the microsphere, and when you deliver the microsphere through a small catheter into the tumor, the artery supplying the tumor. The microspheres become permanently lodged into the tumor, the tumor vascular supply and the decay, releasing the radiation energy into the tumor. And so, in this way it causes tumor destruction, and it can spare the normal healthy liver parenchyma in the surrounding tissue because the tumors do have a preferential blood supply that is greater than the normal liver. So, you end up with five to six times the density of the microspheres in the tumor, compared to the normal liver, So, we can deliver radiation doses, 40 times greater than external beam radiation and with lower side effects, minimal toxicity.
Melanie: That is absolutely fascinating, Dr. Broudy. So, basically, it's more minimal exposure to the surrounding healthy liver tissue, and how long does someone have to go through these treatments before they will start to notice a difference or before it can then be the bridge to another treatment?
Dr. Broudy: Well radiation takes some time to work, we do follow up the imaging, we usually wait at least eight weeks to see a response on imaging which would be usually an MRI. The peak response is typically about 12 weeks, and I’ll usually wait eight weeks to see if there's a response, so that we can decide our next step in treatment, sooner than we would if we were to wait a full 12 weeks because typically, we want to get patients treated sooner rather than later, and not let the disease progress any further.
Melanie: So, do you see that this might be a first line treatment, compared to its current status which, it's no longer responding to chemotherapy so we're looking to adjuvant therapies. Do you see this exciting, innovative procedure as something that might be first line, coming up?
Dr. Broudy: Yeah. Well, the use of the yttrium 90 for colorectal, liver metastases, secondary to colorectal cancers. That was the original indication from 2002, that the FDA…when the FDA approved sur-spheres for use, and they've been used since then as is typically a salvage therapy by the oncology community for metastatic colorectal metastases.
So, patients who fail second or third line chemotherapies, they have chemo-refractory tumors in the liver, that's been the primary way that the yttrium 90s been used, it’s what we call salvage therapy, and it does improve survival compared to in that setting. It does improve survival compared to chemotherapy alone or best supportive care, but there's recently been… It can also be used in patients who are intolerant to chemotherapy, which either could be first line, second line, or third line. It can be used as a chemo-vacation just to maintain as a maintenance therapy between chemotherapy doses, can be used for consolidation therapy, but recently there's been a study that came out, that was an international trial called Surflox, and Foxfire global, which were three different studies looking at overall survival, when the yttrium 90s used as a first line agent with or without chemotherapy and plus or minus biological agents, and it did show with patients who have a right side a-colon cancer, that it improved overall survival, approximately five months, and compared to patients who received only chemotherapy without the yttrium 90, so that is encouraging.
We know that the that the biology of colon cancer is different between right and left-sided tumors, but we have seen that this is encouraging a five-month improved overall survival benefit with the use of yttrium 90, as a first line agent. So, we're trying to bring that to the oncology community, and we'll see how they implement that into their clinical practice guidelines, but it's very encouraging.
Melanie: It sounds that way and, Dr. Broudy, because these are beads, is there any sort of things you want to let listeners know? Do they have to stay away from pregnant women or the elderly or immune-deficient people, because people have heard that in the media before, is there any of those kinds of rules that apply?
Dr. Broudy: Well, the answer, the simple answer is no because the beta-energy, the beta-emitting isotope, which is yttrium 90, it only has a maximum range of emission, approximately two and a half millimeters on average, and 11-millimeter maximum in tissues. So, we're talking a couple millimeters on average, very small range, very short-range energy. So, someone standing around the patient would have very, very negligible amount of exposure, and it does not get transmitted in any body fluids, it becomes permanently lodged into the small vessels in the liver. So, there really is no appreciable radiation exposure to anyone, in the patient's environment.
Melanie: That is very cool, and it's such fascinating information, Dr. Broudy, wrap it up for us with your best advice about liver cancer, liver tumors, and cancers from other areas spreading to the liver and this exciting yttrium 90, radio embolization procedure now available at Our Lady of Lourdes Medical Center.
Dr. Broudy: Yes, the yttrium 90, we’ve now started our program, a few months ago, and we've been doing quite a few cases, we actually have one today. We've treated patients with primary liver cancer, with colorectal metastases to the liver, we're treating patients with squamous oma metastasis, really any metastatic disease to the liver, that liver pre-dominant, is a patient who can be treated. And we have survival data that shows that yttrium 90 does improves survival with primary liver cancer and metastatic colorectal cancer, and we're excited to bring this, this treatment to our health system, and to our community here.
Melanie: Thank you so much, Dr. Broudy, for being with us today. You're listening to Lourdes Health Talk, and for more information you can go to, LourdesNet.org, that's, LourdesNet.org. This is Melanie Cole, thanks so much for listening.
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