IR Prep and Y90 Phase 1

Roy had a video call with his Interventional Radiologist on Tuesday in preparation for his Phase 1 Y-90 treatment on Monday March 16. Dr. Taylor reviewed Roy’s history and explained that the HCC becomes more common with End Stage Liver Disease and Cirrhosis and that the Y-90 treatment is meant to be a “bridge to transplant.” He believes that the main tumor can be eradicated because it has positioned itself on the periphery of Roy’s liver; the other two are just to be “watched” because they are classified as Li-Rads 3. Most of the blood flowing through the liver is moving through the portal vein so it is possible to target the tumor using the arteries without harming the liver unnecessarily. He showed Roy some of the imaging; the largest “slice” of the image is 4.2 cm. Dr. Taylor reviewed the procedure process, discussed how Roy would feel, and covered the risks.

Remember we were not clear on the “staging” of the liver cancer and had guessed this HCC might be at a B stage based on the tumor size we had been told. When asked, Dr. Taylor clarified that Roy is still within the transplant criteria so he said he believed that the cancer would be staged as stage A-to-B but more A than B in the Barcelona Clinic Liver Cancer (BCLC) system that combines the size of the tumor with the Child-Pugh scores for liver function. With the cirrhosis, we’ve always been watching the MELD-Na score but Child-Pugh Score is something we’ve encountered before (it just doesn’t come up in conversation as much).

The Barcelona Clinic Liver Cancer system is often used when determining which treatments to use for a patient whose cancer starts in the liver (not moves there from another starting point). It sounds a bit different to what we normally hear about cancer – we’re used to hearing Stage 1 up to Stage 4 and we know colloquially that 4 means it is a bigger challenge for the patient. We are always hoping someone says Stage 1, right? In the BCLC, the range starts at 0 and then amps up alphabetically:

• Stage 0 aka “Very Early”- this stage means there is one small HCC tumor on the liver (< 2 cm), the liver is performing normally, and the patient feels mostly well and able to do normal life.
• Stage A aka “Early” – this stage means there are three or fewer HCC tumors less than 3 cm in size, the liver is working, and the patient feels okay.
• Stage B aka “Intermediate” – this stage means that the liver has more than 3 HCC tumors and the patient still feels fine and the liver seems to be working anyway.
• Stage C aka “Advanced” – this stage indicates that the HCC has spread into the blood vessels or other organs. The patient does not feel well and is less active (not doing heavy lifting or working), but the liver is still functioning.
• Stage D aka “End-Stage” – this stage is for severe liver damage, with tumors of any size, and the patient does not feel well and needs help with daily life.

I am guessing that the alphabet has been used in the BCLC because the Child-Pugh Score also uses an alphabetical system. The Child-Pugh Score for Cirrhosis Mortality combines the lab results for Bilirubin, Albumin, and INR with the presence of Ascites and Encephalopathy. The resulting score can be an A, B or C. First developed in the 1960s to prioritize patients for surgical interventions or transplants, the Child-Pugh has been adjusted over time to use more finely tuned laboratory results and a grading system to apply to cirrhosis. Currently, A means the liver is still working well, while in B it is “moderately impaired” and in C, the liver has great dysfunction. When I run Roy’s most recent lab numbers in the calculator, he scores a Child-Pugh B.

Dr. Taylor explained that the Y-90 Phase 1 next week will be focused on mapping the route in Roy’s body while he is under mild sedation but breathing on his own. After a small incision into an artery, they will give him some dye and a test dose of radiation. They are mostly making sure that the tumor and liver have not created any shunts into the lungs. Some radiation will likely get to his lungs but if it is too much when they do the imaging afterward, they will have to adjust the treatment. They will keep him for several hours after the mapping to do some imaging and we have to watch for some swelling where the cut is placed, but he should just be a little sore for a few days. He will feel more impact when they insert a full load of radiation in Phase 2 (March 27); he will feel icky for about two weeks. Risks range from some slight bleeding at the incision site up through the radiation beads going on holiday into other parts of his body.

We did learn that Roy will not be as radioactive as our previous reading had led us to believe; the cats will be safe! They won’t be putting in so much Y-90 that it will escape outside of Roy’s body. We won’t know if this treatment works, although Dr. Taylor was quite confident that this tumor would be eradicated, until they take a peek at it again 3 months after Phase 2. If the HCC hasn’t decided to leave at that point, they might do a second round of Y-90 or choose to attack it another way. The doctor did say that 85-90% of patients who receive this treatment see success.

The reason this is a “bridge to transplant” treatment is that those two other tumors are still lurking. They might be nothing or they might decide to grow. And patients who have HCC can develop more tumors even if this first one dies. So, the goal is to knock this one down and keep the HCC contained until a transplant is possible. The hard part is going to continue to be all the waiting.

We go to Houston on Monday.