I have uploaded the presentation on Yttrium 90 & its application in treatment of Liver Cancer. Presentation elaborates on characteristics of Y-90, how treatment is planned, workup done & aspects on radiation safety & post treatment care. I would be glad to answer queries on this new emerging exciting area of treating Inoperable Liver Cancers.

1. Radioembolization with microspheres ®

2. SIR-Spheres microspheres were developed in the 1980s in Australia. Since then the product and the procedure have been refined in collaboration with SIRTEX Medical Limited (SIRTEX). Meanwhile more than 7,500 patients have been treated all over the world, especially in the US, Australia, New Zealand, Hong Kong, and Europe with experience rapidly growing in other countries. 

7. SIRT – Treatment Algorithm 1-2 weeks 1-2 weeks Patient Selection *optional Tumour Mapping Bremsstrahlung Scan* Vessel Embolisation Labs Labs SIR-Spheres Delivery Treatment Plan Dosimetry Ordering Post Treatment Care CT/Hepatic Angiogram* Vessel Mapping Review Breakthrough Scan Follow Up

9. 1-2 weeks 1-2 weeks Patient Selection Tumour Mapping Vessel Mapping Review SIR-Spheres Delivery Bremsstrahlung Scan* Vessel Embolisation Labs Labs Treatment Plan Dosimetry Ordering Post Treatment Care Follow Up CT/Hepatic Angiogram* *optional Breakthrough Scan

15. 1-2 weeks 1-2 weeks Patient Selection Tumour Mapping Vessel Mapping Review SIR-Spheres Delivery Bremsstrahlung Scan* Vessel Embolisation Labs Labs Treatment Plan Dosimetry Ordering Post Treatment Care Follow Up CT/Hepatic Angiogram* *optional Breakthrough Scan

17. 1-2 weeks 1-2 weeks Patient Selection Tumour Mapping Vessel Mapping Review SIR-Spheres Delivery Bremsstrahlung Scan* Vessel Embolisation Labs Labs Treatment Plan Dosimetry Ordering Post Treatment Care Follow Up CT/Hepatic Angiogram* *optional Breakthrough Scan

18. Meticulous Mesenteric Angiography To determine the safest and most effective treatment strategy To identify all hepatic and gastric vessels , including extremely small branches , arterial variants and collaterals R.Murthy et al: RadioGraphics 2005; 25:41-55

20. Recommended Embolisation* Strategy If the right gastric artery can not be identified it is advisable to either not treat the patient or to treat bi-lobar with the catheters as far into the LHA and RHA as possible. Special care should be taken to infuse the microspheres slowly. *Sirtex does not recommend any specific form of embolisation !

26. Dosimetry – BSA Method Alternatively to the Partition Model the BSA Method can be used. It is based on a whole liver approach and the patient specific dose (A Yttrium-90 ) is given by: With: V Tumour = Volume of the total tumour mass in the liver V Total Liver = Volume of the total liver (inclusive tumour) BSA [m 2 ] = 0.20247 x height[m] 0.725 x weight [kg] 0.425 A Yttrium-90 [GBq] = (BSA-0.2) + V Tumour V Total Liver

30. Dosimetry – BSA Method To calculate the radiation dose to only a portion of the liver (either lobe or segment), the following formula may be used: A Yttrium-90 [GBq] = (BSA-0.2) V Total Liver V Treated Portion • + V Total Liver V Tumour in Treated Portion

36.  Data from patients implanted with an average of 2.1 GBq emitted the following Bremsstrahlung radiation at approximately 5-6 hours post implantation: Dose equivalent Distance to abdomen Post-Treatment – Radiation Safety 0.25m 0.0188 mSv/hr 0.50m 0.0092 mSv/hr 1.00m 0.0015mSv/hr 2.00m 0.0004mSv/hr 4.00m <0.0001mSv/hr