A Mexico-based IR group's first experience with Y-90
By Jesus Beltran Perez, MD Summer 2018
The incidence of hepatocellular carcinoma (HCC) currently occupies the fifth place worldwide among all malignant neoplasms in humans. In Mexico, it is ranked 14th among fatal diseases, causing the death of approximately 5,393 people per year (7.3 percent of total deaths per year). Because HCC is typically diagnosed in advanced stages as a local or metastatic disease, patients have relatively few therapeutic options—particularly since most patients are not candidates for surgical removal (the ideal therapy), due to the advanced stage of the disease or their deteriorating health.|
José Luis Ríos-Reina, MD, a Mexico-based IR with more than 40 years of experience, had used transarterial chemoembolization (TACE) for many years to treat HCC. In 2016, to expand the range of available options, he began exploring ways to incorporate Y-90 treatment into his practice.
He first obtained a permit from the Mexican Commission for Protection Against Health Risks (COFEPRIS), a regulatory body governed by the Mexican Ministry of Health. COFEPRIS has many responsibilities that impact health care in Mexico, such as reviewing and controlling all health care facilities there and strictly controlling all health products imported and exported to and from the country. Dr. Ríos-Reina also needed to obtain a permit from the National Commission for Nuclear Security and Safeguards, a government agency in charge of the handling of materials that emit radioactive energy.
To further prepare for implementation of Y-90 treatment, Dr. Rios-Reina completed “TheraSphere® Center of Excellence,” a BTG course on radioembolization held at Northwestern Memorial Hospital in Chicago. The course was led by Riad Salem, MD, MBA, FSIR, a world authority in the treatment for hepatocarcinoma.
In November 2017, the first candidate was sent from the state of Chiapas, located in southern Mexico, with a diagnosis of a liver tumor detected by ultrasound. A percutaneous biopsy was performed on the tumor, resulting in a pathological diagnosis of HCC. The assessment protocol that was conducted included routine tests such as blood count and liver function tests. Patient functionality was evaluated using the ECOG scale and tumor vascularity was assessed with a hepatic angiotomography, detecting a hypervascular and heterogeneous tumor, contained in segment VI. The nuclear medicine study to assess pulmonary shunts was satisfactory (showing <5 percent) and the details of the neoplasm were described with an MRI. The results were sent for evaluation by BTG and to approval to continue the treatment phase.
On Feb. 15, 2018, we performed our first radioembolization treatment using TheraSphere®, at 10 a.m. at the Angeles Mocel Hospital (Grupo Angeles) in Mexico City. Following the established protocols, the procedure was carried out successfully by a multidisciplinary team of nursing staff and technicians of the IR service, anesthesia staff, nuclear medicine and senior residents of the radiology department, headed by Dr. Ríos-Reina.
I was a member of this multidisciplinary team as a medical assistant in IR procedures and research under Dr. Ríos-Reina’s supervision. We were very proud of having initiated this radioembolization program in Mexico, offering an alternative that has fewer co-morbidities/complications than other more-invasive procedures and that, in certain contexts, is more effective. We hope that sharing our team’s experience in Mexico will open the array of therapeutic possibilities for patients in other countries and will motivate experienced as well as young interventional radiologists to include this advanced image guided solution in their clinical practices. It is also very important that this treatment be recognized by oncology, internal medicine, hepatology and other groups, and that they take into consideration the work done by interventional radiologists in relation to oncology.
There is still much to be done, but this first step is groundbreaking for the multidisciplinary management of HCC in Mexico and Latin America.
Radioembolization for the treatment of liver malignancy is being introduced throughout Latin America. In addition to this new program in Mexico, doctors in Brazil, Argentina and Chile have also started programs and are currently treating patients with radioactive microspheres.