Ep. 561 Dosimetry University VI: Challenging Case Review with Dr. Tyler Sandow and Dr. Zach Berman

BackTable Vascular & Interventional

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