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The Future of Radiation Segmentectomy: New Tech, Tumor Markers & Indications
Jack Felkner • Updated Dec 31, 2024 • 38 hits
As the practice of radiation segmentectomy for HCC has become more prevalent, technological innovation and research have kept pace. The development of radiation dosimetry software like Simplicit90Y has allowed clinicians to optimize Y90 dosages to achieve optimal patient outcomes. Additionally, tumor marker research on albumin and AFP shows promise in classifying tumor behavior, while practitioners seek to apply radiation segmentectomy to other organs.
In this article, interventional radiologists and HCC specialists Dr. Juan Jimenez and Dr. Tyler Sandow explain how recent technological innovations and current research shape their practice. The interventional duo also comment on future developments that may continue to evolve Y90 and radiation segmentectomy practice. This article features transcripts for the BackTable Podcast. We’ve provided the highlight reel here, and you can listen to the full podcast below.
The BackTable Brief
• Simplicit90Y dosimetry software can improve clinicians’ ability to perform detailed voxel-based analysis (e.g., D70, D99), optimize Y-90 treatment for metastatic liver disease, and streamline the ordering process.
• Dr. Sandow and Dr. Gimenez are publishing research on tumor markers, identifying that multiple positive markers, including AFP, correlate with more aggressive liver cancer.
• Their research suggests that albumin levels can predict treatment success, finding that low albumin (<3.4) in ablation patients is linked to higher recurrence, prompting a shift toward Y90 treatment for those patients.
• The future of segmentectomy and Y90 may include use in metastatic disease and tumors of other organ systems, as well as augmented reality assistance in anatomical mapping.
Table of Contents
(1) Simplicit90Y in Dosimetry
(2) Research in Radiation Segmentectomy
(3) Future Directions in Radiation Segmentectomy: Metastases, Extrahepatic Indications & Augmented Reality
Simplicit90Y in Dosimetry
While methods like the TWI Excel spreadsheet and MIM were initially used to determine radiation dosage, Simplicit90Y, a tool developed by Boston Scientific, stands out for its simplicity and precision in handling complex cases, especially in multicompartment liver tumors. Clinicians can now achieve granular voxel-based dosimetry, which enhances the ability to assess doses to specific tumor areas (e.g., D70, D99) and normal tissue. The software's ease of use enables widespread adoption across different expertise levels, from novice to advanced users. Additionally, post-treatment imaging with SPECT/CT helps track radiation distribution, offering a more detailed view of sphere deposition and tumor response. This combination of detailed pre- and post-treatment dosimetry has contributed to optimizing treatment plans and improving patient outcomes.
[Dr. Chris Beck]
Now I do want to talk about dosimetry. Do you guys have some software that you like that's been helpful or been an unlock to how you treat these guys?
[Dr. Tyler Sandow]
We do.
[Dr. Juan Gimenez]
Yes. We're biased.
[Dr. Tyler Sandow]
A little. It was forced on me. I should say that dosimetry software was forced. I wasn't always this way, but I have come to be a believer. Before we used to use the TWI Excel spreadsheet that a lot of people use for TheraSphere. It worked well for us. We had no issues. I absolutely hated the way we had to draw volumes. We had a-- gosh, what was the name of the-- it was a vital product that we had to use.
[Dr. Juan Gimenez]
Vitria.
[Dr. Tyler Sandow]
Vitria. Yes. We had to use Vitria to map out our cone beam volumes, and it took forever. It was probably one of the most challenging products to use. Then we switched over to MIM. MIM is okay. I don't love it. I don't hate it, but it's just okay. Murata had – I think Juan has been working with them for quite some time. We had a lot of case volume and Juan had a lot of interest in dosimetry, and so he's been working to refine Simplicity for quite some time. He actually pushed me to start using it.
I will say that I didn't really like switching from what I'm used to with the Excel spreadsheet, which is working fine, but I do believe in the Simplicit90Y. It has allowed us to up our game when it comes to multicompartment, when it comes to looking at post-treatment spec and making sure you can do voxel-based dosimetry so we know what our D70 looks like, the dose to 70% of the tumor or D99. A lot of the stuff that we've been able to do with Simplicit90Y has been great. It's made ordering smoother. I think I should also plug Juan too. Juan is actually setting up a course. He's got a Simplicit90Y course coming up.
[Dr. Juan Gimenez]
I saw it on the SIR forum.
[Dr. Tyler Sandow]
Did you see it? Yes.
[Dr. Juan Gimenez]
You're making me blush, Tyler.
[Dr. Tyler Sandow]
I know. Juan is going places. I don't know if you realize this, but you better get on board now. Juan is there, man.
[Dr. Chris Beck]
I feel like a rocket ship.
[Dr. Tyler Sandow]
Exactly.
[Dr. Juan Gimenez]
Because of Tyler.
[Dr. Chris Beck]
All right. Simplicit90Y, that's the Boston side product?
[Dr. Juan Gimenez]
Yes.
[Dr. Chris Beck]
The software? When did you guys start using it? What do you like about it, Juan?
[Dr. Juan Gimenez]
We started using it around COVID. To Tyler’'s point, we had been working with Boston, and they had this new product. I think Boston understood that the whole ordering process was, and the dosimetry process was cumbersome. Nobody was really doing it. Even MIM didn't have a dedicated software for Y-90 at that point. We had a lot of headaches. We were switching packs. With the switch of the packs, our volume software went away. We needed to do it. We brought it in.
Like its name implies, it's simple to use. At the same time, it allows you to get as granular as you want. You can, to Tyler's point, draw all your tumors, look at how much radiation went to each of them and get as granular as you want. It's something that, we have-- some of the guys in our group have difficulty using computers, and some are very advanced. This catered to pretty much everybody. I could just show and they can just do it themselves. It was very easy.
It allowed everybody to keep their ordering on time because otherwise, people would just procrastinate. It helps us keep a huge database of all our patients. They're all saved. We can go and literally open any of them. It's been key to look at our outcomes, and research, and a lot of the things that we've been doing – with what Tyler's been doing, I should say. I just ride his coattails when it comes to all of the research stuff. Yes, it's simple.
We have four or five vial cases routinely. I would say if we get one patient with one vial, that's unheard of. When you're ordering multiple vials to be able to understand how much you're going to send to the lungs, how much you're putting into the liver, the percentage of the liver that you're treating, that makes it very simple. To Tyler's point, MIM works. It's just that, I don't know, there's this thing about MIM that they like to make it a little bit of complex and it's unintuitive in my opinion. I was not able to figure it out. I know all the nuclear medicine guys love MIM, so more power to them.
[Dr. Chris Beck]
What do you guys use Simplicit90Y for as far as Tyler, you mentioned you guys do specs on the back end after treatments to look at dose and where it's going?
[Dr. Tyler Sandow]
Yes. We so specs after map, SPECT/CT after mapping, and after delivery. That's the one protocol. He has made sure that where we do Y-90, we do SPECT/CT. I think that's a good thing to do. Not everybody has access to SPECT/CT, but we do. We're going to make sure that we do it that way. if we're going to do multicompartment, we'll use the mapping SPECT/CT if it can help give us an idea about dose to tumor, dose to normal and we can tailor our dose that way.
Then we'll also use Simplicit90Y, the actual dosimetry aspect of Simplicit90Y to track what the dose to tumor was and actually look at-- you can take even more granular, do voxel-based dosimetry. They call it D70, or D50, or D99. You can see what the dose to 70% of the tumor, or 90% of the tumor, or what your dose to normal was. We'll use that. That detailed information has allowed us to figure out how spheres were deposited in tumors. Because if we know what the dose was in those areas based on the SPECT/CT, we know how many spheres went there if we know when we delivered the spheres. We've been able to figure out sphere concentrations in normal tissue and tumor tissue and optimize how we choose what day to deliver particles.
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Research in Radiation Segmentectomy
Tumor markers and albumin levels may soon play a role in treatment decisions for hepatocellular carcinoma, particularly in patients undergoing Y90 radiation segmentectomy. Dr. Giminez and Dr. Sandow’s research, currently being prepared for publication, highlights the predictive value of certain tumor markers, including AFP, which can indicate aggressive tumor behavior, especially when other markers are also positive.
This information may influence how clinicians approach therapy, especially when deciding between Y90 and ablation. Notably, albumin levels emerged as a key prognostic factor—patients with low albumin levels (≤ 3.4 g/dL) who undergo ablation exhibit higher recurrence rates, suggesting the potential benefit of Y90 therapy in such cases. The research team has also observed a strong correlation between good immune function (indicated by higher albumin levels) and better treatment outcomes, further supporting the clinical importance of nutritional and immune status in managing HCC.
[Dr. Chris Beck]
The research you guys are doing. Are you all publishing any of this?
[Dr. Juan Gimenez]
That's on Tyler.
[Dr. Chris Beck]
Is this Ochsner secrets?
[Dr. Tyler Sandow]
We like to keep it. We hold our cards close. No, I have zero academic time. Basically, if anyone from Ochsner administration hears this maybe they'll give me some. No. We work with some of the most brilliant research. We have a research team that works with transplant and has agreed to partner with us. Paul Theibinaeux, Kelly Nunes they have built-in protocols and algorithms for tracking these patients. That has gained the interest of a lot of companies even outside of the local regional spectrum but just in the HCC spectrum as a whole.
One of the coolest things is that – and we're in the process of publishing a lot of this stuff. In the last several years we put out about three, or four, or five papers a year with our group. The coolest stuff that we have coming down the pipeline is we're looking at tumor markers, and tumor markers that aren't readily available in the US. They are available in China. they've been used for a while but they're not really pushed in the US.
What we've identified is there's three tumor markers, one of them being AFP but the other two are not routinely ordered. What we found is that if you have multiple biomarkers that are positive, your tumor tends to behave incredibly aggressive. If you have biomarkers that are negative you basically could flick the tumor and it's going to die. If you have three that are positive you got to throw the kitchen sink at it.
Even if you throw the kitchen sink at it, you rarely get on top of it and get control. We have Kaplan-Meier curves showing how that lays out., and I have never seen Kaplan-Meier curves look as beautiful as this. It literally follows how you–
[Dr. Chris Beck]
It's a nice Kaplan-Meier curve.
[Dr. Tyler Sandow]
Yes, I was shocked. Tumor markers is a big thing. Another thing that we're looking at and that we mentioned earlier how we deviate off the BCLC spectrum is albumin. We use albumin as a marker for tumor response. We can get on the nitty-gritty but albumin is a marker of nutrition, nutrition is a marker of immune function. All those key concepts tie into tumor response. If you have good immune function the body can help compensate and take some of that tumor down.
We've looked at maybe 500 patients and ideal patients if you stack apples to apples or even apples to oranges. What we found is that there was an unusual situation with our ablation patients. Our ablation patients when they had low albumin, so an albumin 3.4 or less, they tended to have higher rates of recurrence at one year and at two years compared to any other modality, intra-arterial, taste, or Y-90.
We did a deep dive on it. We're like, "Oh, so the first question you would ask is maybe Veejay left and you guys just became bad ablationists?" That would be the first thing you would say. He gets involved in this data too. Ironically if you have an albumin greater than 3.4 you almost have no progression after for ablation. With our Y-90 population, we have almost no progression at two years or any intra-arterial therapy, no progression. We're going to study that a little closer now. For patients that would otherwise be candidates for ablation, if you have an albumin less than 3.4, we're actually choosing to treat those patients with Y-90 because of the results that we've seen over the last several years with the ablation patients.
Future Directions in Radiation Segmentectomy: Metastases, Extrahepatic Indications & Augmented Reality
While traditionally used for liver-targeted therapy, Y90 is now being considered as an ablative modality for metastatic tumors in other parts of the body, similar to microwave or radiofrequency ablation. Operators are beginning to perform multiple subsegmentectomies for metastatic tumors, allowing for more aggressive tumor control. Additionally, advancements in augmented reality are gaining attention, with the potential to enhance intraoperative navigation and image interpretation, improving the precision of procedures. Trials exploring Y90 for non-liver tumors, such as glioblastoma and potentially soft tissue sarcomas or lung cancers, signal exciting new possibilities for this therapy. As technologies and indications evolve, Y90 could play a broader role in treating a variety of malignancies, expanding its application far beyond the liver.
[Dr. Chris Beck]
Anything you guys are excited about as far as things that are coming down the pipeline or things that are y'all are doing with your practice, whether it's HCC or something else that you want to talk about? Final thoughts.
[Dr. Juan Gimenez]
You didn't put that one on the outline. Now I got to think about it. [laughs]
[Dr. Chris Beck]
No, I didn't, man. There's got to be some kind of spontaneity.
[Dr. Tyler Sandow]
I think we're starting to see segmentectomy play a role as an ablative modality for metastatic disease. I think we always used to think of Y-90 as a lobar-only treatment for metastatic disease, whether it be trying to control multifocal or microscopic diseases that you couldn't see. At least what I'm seeing is that the paradigm seems to be shifting. There seems to be more of a push for us, surgeons, anyone to be more aggressive in controlling tumor burden, especially inside the liver.
We're using the segmentectomy game to our advantage. We'll do multiple subsegmentectomies for multiple metastatic tumors applying the same concept among the sphere conundrum thing to our practice. I think we're going to start to see Y-90 re-emerge as a treatment for metastatic disease but it's going to be Y-90 as a ablative modality similar to what you see with microwave ablation or RFA when it comes to treating metastatic tumors.
[Dr. Juan Gimenez]
I'm a little bit more of a geek so I'm more into technology and things like that. What I would like to see or I'm excited about is how augmented reality AR are going to play a role not after the fact or before fact, but as you're mapping this patient. All the opportunities and I just look at Apple's new headset that Vision Pro, I think of all of the things you can do with that while you are in the suite and all the processing power and analyzing all these images.
It can help not just us out but it can also help level out the field amongst people that may not necessarily do as many of us. If you have something guiding you as you go through helping you understand the images as you acquire them I think that could be huge. I would just say that's what I would like to see. That's what I'm getting excited about.
[Dr. Chris Beck]
Have you guys been seeing anything or talking to anyone who's doing Y-90 for organs outside of the liver? Is that the horizon for you guys by any chance?
[Dr. Juan Gimenez]
Yes. Not necessarily for Tyler or I, but as you know they have a trial going on for GBM or one of our partners Paul Glada who does mainly neuro IR is getting involved with that. I think some of the preliminary results for that have been very promising. I think that would be great. I know there's another trial looking at up prostate I'm not very familiar with that and there could be other applications. I think this is what we should borrow.
A lot of times people see what we're doing and they try to apply that techniques to what we do. This is what we should mainly radiation oncology we should do the same. Everything that they radiate we should be able to go after. I think if you look at it that way soft tissue sarcomas, a bunch of other things. Lung, I think there's an interesting-- lung that I think we should be applying it the same way.
Podcast Contributors
Dr. Juan Gimenez
Dr. Juan Gimenez is an interventional and diagnostic radiologist with Ochsner Health in New Orleans, Louisiana.
Dr. Tyler Sandow
Dr. Tyler Sandow is an interventional radiologist with Ochsner Health in New Orleans, Louisiana.
Dr. Christopher Beck
Dr. Chris Beck is a practicing interventional radiologist with Regional Radiology Group in New Orleans.
Cite This Podcast
BackTable, LLC (Producer). (2023, October 27). Ep. 379 – Management of HCC: Focus on Radiation Segmentectomy Part 2 [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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