SIRT (Selective Internal Radiation Therapy) – A guide for patients

Introduction

This leaflet is for patients booked to have a SIRT (Selective Internal Radiation Therapy).

What is SIRT?

• SIRT (also known as radio-embolisation) is a special type of internal radiotherapy that targets liver tumours inside the body with high doses of radiation.
• It involves injecting millions of tiny radioactive ‘beads’ called microspheres into the main blood vessel of the liver.
• The microspheres travel to the liver where they lodge themselves in the very small blood vessels in and around the liver tumours where they give off high doses of radiation.
• As the microspheres only give off radiation to a small area, they target the liver tumour while doing little damage to the surrounding healthy liver tissue.
• The action of the radiation destroys the liver tumour cells causing the tumours to shrink. The radiation has a useful effect on the tumour for about two weeks.

Why do I need this procedure?

The doctors looking after you have decided that best way to treat your type of liver cancer (cancer arising from the liver cells themselves (hepatocellular carcinoma) or spread to your liver from another cancer (typically bowel cancer)) is to have SIRT treatment.

Who has made the decision for me to have this procedure?

• The consultant in charge of your case and the radiologist performing the procedure will have discussed your case and come to the conclusion that this is the best way of treating your condition.
• You will have the opportunity for your opinion to be taken into account, and if after discussion with your doctors, you do not want the procedure carried out, you can decide against it.

Who will be performing the procedure and other staff you are likely to meet?

• A specially trained doctor called an Interventional Radiologist will be performing your procedure.
• Radiologists have special expertise in using x-ray equipment and in interpreting the images produced, as well as performing minimally invasive procedures.
• They will look at these images whilst carrying out the procedure to guide treatment.
• The radiologist will be assisted by a radiographer and nurses and/or other Radiology doctors or trainees.

Where will the procedure take place?

You will be taken to the Interventional Radiology Department.

What happens before my procedure?

• You may be admitted to hospital on the day of, or the night before the procedure.
• A doctor will take a medical history from you.
• You may have a small needle put into a vein in your arm for painkillers to be given if necessary.
• Standard blood tests may be carried out.
• You may eat a light meal and drink as normal unless otherwise informed – in which case, you may be fasting for 4-6 hours prior.
• You may be given antibiotics or other pre-medication on the morning of the procedure if required.
• If you have any allergies, you must let your doctor know and a red allergy band will be attached to your wrist.
• If you take any medications to thin the blood (anticoagulants or antiplatelets) please let us know beforehand, as these will need to be stopped a certain length of time before the procedure.
  • Examples include: warfarin, dalteparin, enoxaparin, tinzaparin, dabigatran, rivaroxaban, apixaban, clopidogrel, ticagrelor.
  • Low dose aspirin (75mg) is safe to continue.
  • Please discuss with a doctor before stopping any medicines, as sometimes other treatment will need to be given.
• If you have previously reacted to intravenous contrast medium (the dye used for CT scans), you must also tell your doctor about this.

What happens during the procedure?

• The procedure is performed in 2 stages on 2 different days.
• Stage 1, known as the ‘SIRT work-up’ is usually performed as a day case procedure.
• Stage 2, known as the ‘SIRT treatment’, requires an overnight stay in hospital the day after the procedure.
• You will get dressed into a hospital gown.
• You will lie on the x-ray table, generally flat on your back.
• You will have a monitoring device attached to your finger and will have a blood pressure cuff placed around your arm.
• The procedure is performed under sterile conditions, and the radiologist and scrub nurse will wear sterile theatre gowns and operating gloves.
• Your skin will be cleaned and local anaesthetic given to numb the area and prevent any pain.
• Local anaesthetic will be injected in the skin in your groin, and a needle will be inserted into the artery.
• Sometimes the procedure will be performed using the artery in the wrist instead of the groin.
• Small catheters (plastic tubes) will then be guided into the arteries that are being treated.
• When pictures need to be taken some iodine dye will be injected; you will be asked to hold your breath for a short time at these points. You may feel a hot feeling from the dye, and it can make your bladder feel full.
• During Stage 1 (SIRT work-up) a test dose of a radioactive material called Technetium-99 is injected.
• During Stage 2 (SIRT treatment) the radioactive material Yttrium-90 will be injected to treat the targeted area.
• Once the procedure is completed you will be moved back onto your hospital bed.
• The tube in the artery will then be removed, and pressure applied on the site for several minutes.

Will the procedure hurt?

• Some discomfort may be felt in the skin and deeper tissues during the injection of the local anaesthetic.
• You may feel a warm sensation for a few seconds when the x-ray dye is injected, and some people report a metallic taste in the mouth. You may also feel like you are passing urine; this is normal.
• During the procedure you may develop abdominal pain which can be treated with painkillers.
• There will be a nurse, or another member of the clinical staff, in the room looking after you.

How long does the procedure take?

Every patient’s situation is different, and it is not always easy to predict how complex or straightforward the procedure will be. Generally, the procedure will last approximately 2 hours.

What happens after the procedure?

• You will be taken back to your ward for observations and a period of bed rest. You may also stay for further treatment or investigations.
• Nursing staff will carry out routine observations including taking your pulse and blood pressure readings and will also check the treatment site.
• If you experience pain, sickness, abnormal swellings or are generally feeling unwell, please let the nursing staff know.
• After Stage 1 (SIRT work-up) a nuclear medicine scan is performed on the same day to check whether the radioactivity has reached the intended tumour.
• If the scan’ after Stage 1 (SIRT work-up)’ is satisfactory then Stage 2 (SIRT treatment) will be scheduled.
• After Stage 2 (SIRT treatment) another nuclear medicine scan will be performed (normally the next day) to check the radioactive material has reached the intended tumour.
• You will need to stay in bed for a few hours, until you have recovered and are ready to be sent home (Stage 1, SIRT work-up).
• You will need to stay in hospital overnight (Stage 2, SIRT treatment).
• Stage 1 (SIRT work-up)
  • You should refrain from strenuous exercise for 48 hours.
  • 48 hours off work is advised.
• Stage 2 (SIRT treatment)
  • You should refrain from strenuous exercise for approximately a week.
  • One to two weeks off work is advised.

What are the benefits and possible risks of the procedure?

Benefits

• SIRT targets liver tumours directly with radiation while minimising damage to the surrounding healthy liver.
• SIRT delivers much higher doses of radiation over much longer periods of time than would be possible with external beam radiation.
• SIRT delivers a radiation dose that is well below the limit the healthy liver tissue can tolerate without serious damage.

Risks

• With any medical procedure there are some risks and complications that can arise.
• The side effects of SIRT are generally mild.
• The most common side effects following a SIRT procedure are:
  • Tiredness: This is one of the most common effects and can last for up to six weeks. Tiredness usually subsides after a few weeks.
  • Loss of appetite: This can last for about six weeks.
  • Mild fever: This may last for up to a week.
  • Abdominal pain: You may feel some pain or tightness in your abdomen.
  • Sickness: This may last for one to two days.
  • Soreness: You may experience some bruising or a small lump where the catheter went into your groin.
  • Diarrhoea: This is usually mild and does not usually require treatment.

Please contact your referring team or GP if any of the symptoms persist or worsen. They will be able to provide advice and medication if required.

• Rare to uncommon side effects:
  • A small number of the radioactive microspheres may inadvertently reach other organs in the body, such as the gallbladder, stomach, intestine, or pancreas causing inflammation or ulceration that can be troublesome and difficult to treat.
  • If this occurs it will require additional medical treatment.
  • In extremely rare cases, as with any other treatment options used to extend the survival of patients with cancer, the side effects from the treatment can lead to death.
  • You will be treated by a doctor who is specially trained in SIRT to minimise the risk of these side effects from happening.

Radiation

• You have been referred for an Interventional Radiology procedure to help deliver your treatment. A specialist in radiology agrees that this is the best procedure to treat your clinical condition and that the benefit of the examination is greater than the risk.
• The x-ray involves a dose of ionising radiation equivalent to a few months or years of natural background radiation which we are all exposed to every day.
• Ionising radiation can cause cell damage that may turn cancerous, however the risk of this happening from your examination is considered low.
• Depending on the length of the procedure there may also be a small risk of an excess radiation dose to the skin leading to short term and long-term effects (e.g. reddening of the skin and burns).
• If this happens as a result of this procedure, you will receive further advice following the procedure. The dose delivered will be kept as low as is practicable.
• For further information please see the information on our webpage.

Accessibility requirements

If you require support for your appointment, e.g. if you find it hard to hear, see or be understood by others, please let the receptionist or healthcare professional know on arrival or:

• contact us by email

or

• telephone: 01223 256998.

Pregnancy status

We have a legal responsibility to enquire if you are pregnant. Any patient aged between 12-55 years will be asked if there is a possibility they could be pregnant. This is important for us to know before you have your examination involving ionising radiation.

You can discuss this with a healthcare professional in private if you wish.

Medication

Bring all of your medicines (including inhalers, injections, creams, eye drops or patches) and a current repeat prescription from your GP.

Can I bring someone with me?

Those accompanying you may be required to stay out of the examination room during the procedure and remain in the waiting area.

Childcare whilst in the department

Staff are unable to look after or supervise children whilst your procedure is taking place. Please make alternative arrangements for the care of your children whilst you attend for your procedure. If you attend an appointment with children with no one to look after them whilst you have your procedure, then your appointment will unfortunately have to be cancelled and rescheduled.

Personal belongings

Patients are advised to bring minimal belongings and not to bring valuable items. Any valuable belongings (mobile phone, wallet etc.) will go with the patient while having their procedure and can be secured in a locked box/safe.

How, when and by whom will my results be communicated?

Imaging examinations are reported in order of clinical priority to ensure those with the highest urgency are reported first.

Your referring team or clinician will be responsible for communicating reports back to you.

Test results are made available via MyChart but there is 3-week delay from when an examination has been reported to when it is available on MyChart, in order to allow time for your clinical team to be able to see and action the results prior to them being released to the individual patient.

Contacts/Further information

Please call the Radiology Day Unit and speak to the Imaging Nurses, on telephone number 01223 254639 if you have any questions or concerns about this procedure.

Some of your questions about the procedure should have been answered by this leaflet, but remember this is only a starting point for discussion about your treatment with the doctors looking after you and you will be able to discuss any questions you have with them.

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Question, concern or complaint?

Firstly, speak to your nurse, doctor or other staff member as soon as you can so they can do their best to put things right straightaway.

If you don’t feel able to speak directly to the people caring for you, contact the patient advice and liaison service (PALS). Please call 01223 216756 9am to 4pm Monday to Friday, via email, or via a form available via link on the CUH PALS webpage.

PALS is open every weekday, and you can leave a message in the evenings and weekends.

MyChart

We would encourage you to sign up for MyChart. This is the electronic patient portal at Cambridge University Hospitals that enables patients to securely access parts of their health record held within the hospital’s electronic patient record system (Epic). It is available via your home computer or mobile device.

More information is available on our website: MyChart

This document has been adapted from one prepared by the British Society of Interventional Radiology (BSIR).