TRAVIS AIR FORCE BASE, Calif. – The procedure took less than an hour.
Lt. Col. (Dr.) David Gover and Maj. (Dr.) Jason Hoskins, assigned to the 60th Medical Group at Travis Air Force Base, California, performed the first Air Force-only liver cancer treatment on a patient with Y-90 radioembolization Sept. 7.
The U.S. Food and Drug Administration approved the use of one type Y-90 radioembolization 20 years ago.
“The procedure has really matured in the last six to eight years on the civilian side and gained a lot of traction for good reason,” said Hoskins. “It’s less painful for the patient than conventional treatment. There are usually fewer side-effects and post procedure medication decreases to almost zero.”
Patients undergoing conventional chemotherapy treatment usually remain in the hospital overnight for pain management.
Both interventional radiologists at David Grant USAF Medical Center, Gover and Hoskins treated patients with Y-90 radioembolization while completing fellowships – Gover in 2004 at the University of California at San Diego, and Hoskins in 2017 at Indiana University, Indianapolis, Indiana.
Air Force doctors at Brooke Army Medical Center in San Antonio, Texas, have also been treating liver cancer patients with Y-90 radioembolization for at least seven years, said Hoskins.
Hepatocellular carcinoma of the liver – referred to as HCC – is the most common type of liver cancer in adults and the second most frequent metastatic site for all cancers, according to the American Cancer Society. It also is the most common cause of death in people with cirrhosis.
“About 95 percent of individuals who get liver cancer are generally over age 50,” said Hoskins.
“The condition is roughly evenly distributed between men and women, but men are usually worse off,” he said. “Our patients are usually veterans or retirees although it is not impossible for a (family member) to get cancer to the liver that metastasized from another part of the body.”
To gain Air Force approval to treat Veterans Administration patients with Y-90 radioembolization, Gover and Hoskins had to obtain support from several medical specialties, including oncology, physics, hepatology and nuclear medicine.
They also needed approval from the U.S. Nuclear Regulatory Commission, which provides oversight for companies, facilities and hospitals that use nuclear material, and funding approval from the Air Force Medical Operations Agency.
“Importing a radioactive material was a challenge,” said Gover. “People didn’t understand it.”
Y-90 radioembolization is a minimally invasive, image-guided procedure performed on an out-patient basis.
Interventional radiologists insert a small catheter through a tiny cut in the patient’s groin or wrist, guides it through the blood vessels and into the artery that supplies blood to the tumor.
Tiny glass or resin beads filled with the radioactive isotope Y-90 flows into the blood vessel and emits cancer-killing radiation from inside the tumor. Because Y-90 is targeted directly at the tumor, radiation damage to healthy surrounding tissues is minimized.
“The arterial flow preferentially goes to the tumor which uptakes these tiny microspheres,” said Hoskins. “Y-90 emits the strongest beta-type radiation for about five days for a few millimeters around each particle. The tumors are bombarded with this radiation and are significantly affected, usually decreasing in size with slow or even no regrowth in specific cases.”
The most dangerous time during the procedure is when the isotope leaves the protective acrylic box through a tube and into the patient.
“That’s why we make sure all of the dose goes into the tumor,” said Gover.
The patient, Teddy Jones (Name changed to protect patient privacy), 67, has been treated with conventional cancer treatments 12 times at DGMC over the past four years. The Army veteran, who served two tours in Vietnam, said his liver cancer resulted from hepatitis C, which he contracted 20 years ago.
Hepatitis C is usually spread when blood from an infected person enters the body of someone who is not infected. The disease also can be contracted through contaminated food or water, according to the Centers for Disease Control and Prevention.
“I’m clean of hepatitis now,” said Jones. He said although chemotherapy treatments decreased the number of tumors in his liver, his doctors say one tumor is larger than the previous ones, which is why he agreed to Y-90 radioembolization.
“I had started reading about it some time ago, so when they suggested it, I said ‘let’s do it,’” said Jones.
Although Y-90 radioembolization is not necessarily a cure, it has been successful in shrinking liver tumors and relieving painful symptoms, said Hoskins.
“Results show that patients with hepatocellular carcinoma or metastases to the liver that are treated in this way respond very well with almost no pain and significantly improved quality of life compared to more conventional treatments,” said Hoskins.
The Y-90 treatment team includes an anesthesiologist, nuclear physician, nurse and interventional radiology technicians.
The procedure is so meticulous, the company that manufactures the beads requires its representative oversee the entire process, ensure that the precise dose of Y-90 is on hand and the treatment team follows the company’s checklist.
“We also have a physician mentor through the company if we need it,” said Hoskins.
Gover and Hoskins, two of only five interventional radiologists in the Air Force, must successfully perform the procedure under supervision two more times to be certified to treat patients with Y-90 radioembolization.
The procedure is typically performed in three sessions. The first time the patient comes in, doctors perform an angiogram of vessels in and around the liver to map regional blood supply. Vessels outside of the liver are sealed off using coil embolization.
During that visit, the treatment team simulates the delivery of the spheres carrying the radiation by injecting particles of a similar size to determine how much of the Y-90 dose would go into the liver and how much to the lungs.
“Based on that, we determine how much radiopharmaceutical to administer,” said Hoskins.
The patient returns about a week later for the procedure.
The treatment team treated one-half of Jones’s right liver Sept. 7.
“In four to six weeks, we will bring him back and treat the other half of the right liver,” said Hoskins.
Immediately following the procedure, Jones was transferred to nuclear medicine for a position emission tomography scan.
Nuclear medicine also receives the radioactive material, stores it in an acrylic container inside a lead storage container and delivers the dose to interventional radiology at the right moment during the procedure.
“We get the Y-90 beads two to three days before the procedure,” said Tech Sgt. Brian Hermes, NCO in charge of nuclear medicine. “Once the dose is administered, we bring the patient here for a PET scan to confirm that it went where it was supposed to go.”
Nuclear medicine also scans the treatment team before they leave the treatment room to ensure no one is contaminated.
Patients are usually discharged within four to six hours of the procedure and may resume normal activities within two or three days.