When is Y90 the right treatment for metastatic disease? Join Drs. Tyler Sandow, Zach Berman and host Kavi Krishnasamy in the conclusion of Dosimetry University where they discuss the complexities of treating different variations of metastatic disease and review how they’ve approached complicated cases with Y90.

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SYNPOSIS

The interventional oncologists first outline the types of metastases that they treat, including colorectal, lung, cholangiocarcinoma, breast, gastric, RCC, and melanoma. The doctors then discuss the potential for Y90 to provide palliative relief by reducing tumor-related pain. The conversation also covers key differences between treating liver-dominant and liver-only disease, along with their algorithm for patients not on systemic chemotherapy.
The episode then covers advanced concepts in Y90, such as sub-ablative dosing, the possibility of creating an abscopal effect, and how radiation thresholds change depending on treatment goals.

They outline their approach to partition dosimetry, using SPECT/CT to calculate tumor-to-normal ratios, and explain how they modify particle counts and microsphere activity, using flow augmentation based on tumor vascularity. Additional discussion includes the impact of mutation status, prior lines of chemotherapy, and tumor response criteria like RECIST 1.1 and mRECIST.

The experts conclude with a case series that illustrates decision-making around when to consider Y90, thermal ablation, TACE, or alternative approaches—even in complex cases like sphincter of Oddi dysfunction. The session underscores the nuanced nature of advanced dosimetric techniques and the evolving landscape of interventional oncology.

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TIMESTAMPS

00:00 - Introduction
01:30 - Types of Metastases Treated with Y90
02:50 - Liver-Dominant vs. Liver-Only Disease
07:20 - Sub-Ablative Dosing and the Abscopal Effect
09:55 - Tips for Partition Dosimetry
15:30 - Clinical Factors in Treatment Planning
23:50 - Choosing Ablation, Resection, or Y90 for mCRC
30:27 - Case Series: Colorectal Metastases, Biliary Complications, and more
46:00 - Final Thoughts: The Evolving Field

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RESOURCES

RECIST 1.1 and mRECIST Criteria:
https://pmc.ncbi.nlm.nih.gov/articles/PMC9161105/

COLLISION Trial:
https://ascopubs.org/doi/10.1200/JCO.2024.42.17_suppl.LBA3501

BackTable Episode on COLLISION Trial:
https://www.youtube.com/watch?v=NQLKcv1BRVM

FOXFIRE, SIRFLOX, FOXFIRE-Global:
https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(17)30457-6/fulltext

Symptomatic gallstones that can’t be treated with surgery? Interventional radiology can help. In this episode of BackTable, Dr. John Smirniotopoulos, IR at MedStar Health, joins Dr. Michael Barraza to share the latest advancements and techniques in biliary endoscopy.

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SYNPOSIS

Dr. Smirniotopoulos reflects on his early work with cholangioscopy at Cornell, highlighting ongoing innovation and evolving tools. The conversation covers the practical aspects of patient selection, procedural steps, and overcoming technical challenges. Dr. Smirniotopoulos shares his personal experiences managing small and large biliary stones, emphasizing the important role of selecting appropriate equipment to navigate procedural challenges.

Dr. Smirniotopoulos also highlights the collaborative role of surgeons and gastroenterologists throughout patient management. He also provides insights into the management of biliary strictures and emphasizes the importance of accurate billing and coding. The episode concludes with advice for clinicians seeking to integrate these techniques into their practice.

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TIMESTAMPS

00:00 - Introduction
01:09 - Early Experiences with Biliary Endoscopy
03:35 - Procedure Techniques and Tools
05:36 - Patient Selection and Case Studies
11:01 - Advanced Techniques and Equipment
14:02 - Patient Management and Follow-Up
18:21 - Technical Considerations and Best Practices
20:14 - Managing Stones in the Gallbladder
35:42 - Collaborating with Surgeons and GI Teams
37:59 - Advice for New Practitioners

The balance between targeting tumor and sparing healthy liver is delicate. How do the experts do it? In this case-based review, Drs. Zach Berman (UC San Diego) and Tyler Sandow (Ochsner Health) join host Dr. Kavi Krishnasamy to walk us through real-world scenarios and share how they approach Y90 dose optimization.

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This podcast is supported by:

Sirtex
https://www.sirtex.com/

Medtronic Emprint
https://www.medtronic.com/emprint

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SYNPOSIS

First, the doctors review a case of HCC and discuss key lab values, like albumin, and their role in planning. They also break down how they manipulate variables like microsphere activity, perfusion density, and total dose to deliver a tumor dose of around 1,100 Gy. The doctors also challenge the standard perfused dose of 400 Gy for large tumors and share when they feel comfortable pushing beyond it.
Next, they discuss nuances in treating portal vein tumor invasion and what decides which Vp classifications can be treated with Y90 or combination immunotherapy. A subsequent case involving a large central HCC tumor explores the risks of biliary stricture from high radiation and the challenge of missing tumor margins with overly selective catheterization. In the last case, the doctors discuss different scenarios in multifocal HCC liver lesions. Overall, the conversation explores different approaches based on tumor size, location, and patient liver function, and highlights the importance of multidisciplinary collaboration in optimizing patient outcomes.

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TIMESTAMPS

00:00 - Introduction and Case Overview
01:28 - Patient Case Study - Hep C and Alcoholic Cirrhosis
02:05 - Evaluating Liver Function and Treatment Approach
04:50 - Tumor Dose and Perfusion Density
15:49 - Portal Vein Tumor Invasion
21:42 - Case Study: Large Central HCC Tumor Treatment
22:19 - Challenges in Treating Large Central Tumors
22:48 - Dosimetry Considerations and Biliary Strictures
27:24 - Case Study: Assorted Multifocal HCC Lesions Scenarios

Are your current stroke interventions in line with the latest clinical data? Dr. Blaise Baxter, interventional radiologist at Sutter Health, and Dr. Jim Milburn, interventional neuroradiologist at the Ochsner Health, join host Dr. Michael Barraza to discuss the latest advancements in stroke interventions.

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This podcast is supported by:

Imperative Care
https://imperativecare.com/stroke/zoom-stroke-solution/

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SYNPOSIS

The episode begins with a discussion on the different pathways to becoming a neurointerventionalist, emphasizing why interventional radiologists are uniquely equipped for this transition. They dive into cutting-edge stroke interventions, sharing key takeaways from major trials on large core and medium vessel occlusions. Dr. Baxter and Dr. Milburn highlight the HERMES trial, which showed that endovascular thrombectomy led to beneficial effects on patients with anterior circulation occlusion. They then cover the BAOCHE trial, which showed better functional outcomes with thrombectomy over medical therapy.

Milburn and Baxter also share their perspectives on the shifting role of perfusion imaging and why the field may be moving beyond it. To close the discussion, the doctors underscore the powerful impact of rehabilitation in driving patient recovery, and stress the ongoing need for innovation and improved training in the field of neurointerventional radiology.

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TIMESTAMPS

00:00 - Introduction
06:18 - Training and Certification in Neurointervention
13:11- Large Core Trials and Their Impact
19:42 - CT Perfusion and Treatment Decisions
29:45 - Understanding Stroke Scale Scores and ICAD
30:31 - Thrombectomy Trials and Treatment Strategies
34:48 - Challenges in Randomizing Patients for Trials
44:25 - Advancements in Robotics and Stroke Treatment
51:37 - Future Directions in Stroke Rehabilitation
53:11 - Global Thrombectomy Adoption and Training

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RESOURCES

Hermes trial: Goyal M, Menon BK, van Zwam WH, et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. 2016;387(10029):1723-1731. doi:10.1016/S0140-6736(16)00163-X

BAOCH trial: Jovin TG, Li C, Wu L, et al. Trial of Thrombectomy 6 to 24 Hours after Stroke Due to Basilar-Artery Occlusion. N Engl J Med. 2022;387(15):1373-1384. doi:10.1056/NEJMoa2207576

How can interventional radiologists turn their unique capabilities into revenue? Dr. Matt Hawkins, interventional radiologist and Health Policy and Economics councilor at the Society of Interventional Radiology (SIR), joins host Dr. Ally Baheti to discuss how interventional radiologists can prove (and get paid for) the value that they bring to hospitals.

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This podcast is supported by:

Medtronic Emprint
https://www.medtronic.com/emprint

RADPAD® Radiation Protection
https://www.radpad.com/

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SYNPOSIS

The doctors discuss key physician reimbursement models, including the Hospital Outpatient Prospective Payment System (HOPPS) for hospital outpatient and Diagnosis-Related Groups (DRGs) for hospital inpatient, as well as strategies for negotiating subsidies. Dr. Hawkins covers key strategies for proving the value of IR to hospitals, emphasizing the importance of moving beyond work RVUs and focusing on the technical revenue generated for hospitals. The discussion underscores the critical role that IR plays in trauma, transplant, and cancer care. Lastly, Dr. Hawkins highlights SIR’s economic initiative emphasizing the importance of accurate documentation and coding in order to turn our clinical impact into measurable value.

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TIMESTAMPS

00:00 - Introduction
01:58 - Understanding Professional and Technical Reimbursement
04:49 - Hospital Reimbursement Structures
07:59 - Quantifying Value and Negotiating Contracts
15:55 - Economic Arguments for IR in Trauma, Transplant, and Cancer
23:01 - The Importance of IR Leadership in Mixed IRDR Groups
25:13 - Challenges and Strategies for Independent IR Practices
28:41 - Maximizing Revenue Through Evaluation and Management (E&M)
36:40 - Navigating Coding and Documentation for Better Negotiation
38:54 - Financial Literacy and Business Strategies

Radiation segmentectomy: who, when, how? Interventional oncologists Dr. Nima Kokabi, Dr. Tyler Sandow, and Dr. Kavi Krishnasamy continue their in-studio discussion on all things Y90 in Part 4 of Dosimetry University, focusing on specific applications of radiation segmentectomy.

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This podcast is supported by:

Sirtex
https://www.sirtex.com/

Medtronic Emprint
https://www.medtronic.com/emprint

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SYNPOSIS

This session kicks off with a discussion on the curative potential of Y90, comparing it to other curative modalities like resection. The doctors discuss the importance of achieving a complete pathological necrosis (CPN) with Y90 for better survival outcomes, especially in the context of liver transplantation. The conversation also covers personalized approaches for treating liver-dominant metastatic cancers using Y90, and strategic considerations when choosing between techniques like radiation lobectomy, thermal ablation, and chemoembolization.

The interventional oncologists explore the viability of radiation segmentectomy in treating small lesions and discuss data supporting its efficacy. Real-world clinical cases are examined to highlight the practical application of these therapies, their impact on overall survival, and the intricacies of dosimetry and patient selection.

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TIMESTAMPS

00:00 - Introduction
01:07 - Ablative Y90 Curative Outcomes and Survival Rates
02:16 - Radiation Segmentectomy vs. Ablation
09:22 - Case Study: Metastatic Colorectal Cancer
18:06 - Tumor Distinction on Cone Beam CT
19:58 - Case Study: 77-Year-Old Female with Breast and Colorectal Cancer
21:09 - Challenges and Techniques in Selective Radiation Segmentectomy
24:28 - Avastin and Y90
28:16 - Case Study: 53-Year-Old Male with Metastatic Colorectal Cancer
29:40 - Radiation Lobectomy and Hypertrophy Strategies
32:37 - Approaches for Metastatic and HCC Patients

Will single session Y90 become the standard of care for HCC and oligo-metastatic disease? Tune in to our third installment of Dosimetry University with interventional oncologists Drs. Tyler Sandow, Nima Kokabi, and Kavi Krishnasamy as they share their experiences and best practices in single session Y90 treatment.

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This podcast is supported by:

Sirtex
https://www.sirtex.com/

Medtronic Emprint
https://www.medtronic.com/emprint

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SYNPOSIS

The doctors discuss the application and workflow of single session Y90 therapy for primary and oligo-metastatic liver tumors. They discuss the latest data from various institutions, emphasizing reduced lung dose, lower time to treatment, improved cost-efficiency, and the advantageous safety profile associated with single session treatment. The discussion also covers ideal patient selection based on tumor location and vascular characteristics, the importance of cone beam CT, and how to identify red-flag features of vascular enhancement.

Our panel then reviews key technical considerations for single session success, including the use of flow-modifying microcatheters, gelfoam, and strategies for flow redirection. The episode concludes with a case discussion to explore the best strategy for a large liver tumor, detailing the specifics of each treatment and the potential role of combined therapies to achieve better long-term outcomes.

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TIMESTAMPS

00:00 - Introduction
00:47 - Single Session Y90: Workflow and Benefits
03:52 - Patient Selection
04:31 - Tumor Location and Preferred Techniques
14:31 - Reperfusion and Redirection Techniques
26:16 - Case Study: Large Tumor Treatment
37:01 - Long-Term Outcomes and Surgical Considerations

So you’re going to be an IR resident–what exactly did you sign up for? Find out with Dr. Neil Jain, an integrated IR resident at Georgetown as he hosts a discussion on optimizing integrated IR residency programs with Dr. Nicole Lamparello, an Assistant Professor of Clinical Radiology at Weill Cornell Medicine, and Dr. Gregg Khodorov, a PGY-5 resident at Thomas Jefferson University Hospital. The conversation covers a comprehensive range of topics, including optimal rotation schedules, early IR exposure, consult services, and the benefits of structured clinics.

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This podcast is supported by:
Medtronic Emprint
https://www.medtronic.com/emprint

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SYNPOSIS

The doctors first discuss the nuances of choosing a surgical, medicine, or transitional intern year, and the electives that best prepare junior trainees for a career in IR. They then discuss the optimal balance between diagnostic and interventional training in DR years, and the best way to keep junior trainees involved in IR throughout their residency.

The conversation moves on to the different structures of the consult service at each of the speakers’ programs and what this means for training quality and patient care. The doctors then break down what the last year of IR residency looks like, and the residents detail what they would like to see in order to prepare best for attending life. They explore exposure to private practice, subspecialty clinic, and elective time; sharing innovative practices from their own institutions and emphasizing the importance of mentorship, integration, and resident retention. The episode also addresses the challenges and potential solutions for resident attrition within the integrated IR residency track.

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TIMESTAMPS

0:00 - Host Introductions
3:34 - PGY1: Medicine, Surgery or Transitional Intern Year?
15:41 - PGY2-PGY4: Diagnostic Radiology Years
24:46 - IR Clinic Training Throughout IR/DR Curriculum
27:49 - IR Consult Service Structure
38:23 - PGY5: Credentialing in Nuclear Medicine and Mammography
43:58 - PGY6: Preparing for Attending Life
53:00 - Minimizing Attrition Rate

BSA, MIRD, or voxel-based dosimetry? Join us for part 2 of Dosimetry University where interventional oncologists Dr. Tyler Sandow, Dr. Nima Kokabi, and Dr. Kavi Krishnasamy explore and debate the critical nuances of a successful Y90 procedure, covering dosing methods, lung shunt management, and when to incorporate other therapeutic approaches.

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This podcast is supported by:

Sirtex
https://www.sirtex.com/

Medtronic Emprint
https://www.medtronic.com/emprint

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SYNPOSIS

The episode begins with a discussion on methodologies for calculating lung shunt fractions using planar imaging versus SPECT CT. The physicians highlight the implications of various dosimetry models, including BSA (Body Surface Area), MIRD (Medical Internal Radiation Dose), and voxel-based dosimetry for determining prescribed activity. Drawing on their clinical experience, they address the management of high lung shunt fraction cases and the application of therapeutic strategies like TACE (Transarterial Chemoembolization) and SBRT (Stereotactic Body Radiotherapy). The conversation also covers the roles of cryoablation and microwave ablation in treating centrally located lesions. The episode concludes with a case study emphasizing the importance of individualized dosimetry planning.

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TIMESTAMPS

00:00 - Introduction
01:05 - Lung Shunt Calculation Methods
06:42 - BSA, MIRD, and Voxel-Based Dosimetry
16:03 - High Lung Shunt Management
30:02 - Case Study: Liver Tumor Treatment
34:10 - Cryo vs Microwave: A Safer Option?
35:42 - Y-90 Procedure: Imaging and Techniques
43:35 - Dosimetry and Dose Calculations
51:10 - Post-Treatment Analysis and Outcomes
57:51 - Transplant Considerations and Aggressive Treatments
58:18 - Conclusion and Final Thoughts

Dosimetry University is now in session! First up—how do you plan your Y90 treatments and what can you do in the planning phase to maximize efficacy? Find out in Part I of BackTable’s Dosimetry University series featuring interventional oncologists Dr. Nima Kokabi from the University of North Carolina Chapel Hill and Dr. Tyler Sandow from Ochsner Health. This episode is hosted by Dr. Kavi Krishnasamy and recorded live in the BackTable studio.

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This podcast is supported by:

Sirtex
https://www.sirtex.com/

Sponsor

This podcast is supported by:

Medtronic Emprint
https://www.medtronic.com/emprint

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SYNPOSIS

The doctors first discuss the structure of their Y90 service lines, including the impact of multidisciplinary tumor boards and clinics on time to treatment for liver cancer patients. They then talk through their technical preferences—whether to use glass or resin, preferred dosimetry guidelines and apps, and the dosimetry softwares that they use in treatment planning. The doctors also discuss the utility of the T2N ratio, advanced imaging like cone beam CT, and angiographic targeting software—emphasizing how these tools can help achieve the delicate balance of preserving normal tissue while treating as much tumor as possible. This episode also highlights the importance of collaboration between academic and private practices to optimize patient care and treatment outcomes.

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TIMESTAMPS

00:00 - Introduction and Overview
02:21 - Multidisciplinary Clinics and Tumor Boards
13:12 - Dosimetry Guidelines and Practices
27:46 - Nuances in Tumor Dosage and Segmentectomy
32:00 - Angiographic Targeting Software
33:18 - Cone Beam CT Techniques
48:33 - Anesthesia, Access, and Catheters