Editor’s Note: The field of cancer treatment has made substantial progress, entering an era of multi-faceted, comprehensive approaches. With the government’s focus on major diseases, traditional cancer treatments like surgery, interventional therapy, radiotherapy, and chemotherapy have evolved into multidisciplinary approaches. Yttrium-90 (Y-90) selective internal radiation therapy (SIRT) is now emerging as a key treatment option for liver cancer. On October 12, the Radiotherapy and Immuno-Oncology Symposium successfully took place. Oncology Frontier invited Prof. Lin Zhang, the first certified Y-90 supervisor in mainland China and an expert from Beijing Tsinghua Changgung Hospital, to discuss the clinical applications and precision surgical principles guiding Y-90 therapy.

1. Can you describe the clinical characteristics of patients receiving Y-90 therapy at Beijing Tsinghua Changgung Hospital?

Prof. Lin Zhang: The Y-90 microsphere technology has been in China for three years. Under Academician Dong Jiahong’s leadership and through the dedicated work of our Y-90 team, we successfully introduced this technology domestically. Our team, in collaboration with partner institutions, completed the first mainland China Y-90 microsphere treatment on September 28, 2021, in Hainan. At our hospital, we successfully treated the first batch of patients on September 28, 2022.

Y-90 microsphere therapy offers hope for many hepatobiliary tumor patients. Currently, we mainly treat two types of patients: the first are those with malignant liver tumors who are unsuitable for other treatment methods or are at high surgical risk, including those who are ineligible for surgical resection, ablation, or other interventional treatments. For these patients, Y-90 microsphere therapy may be considered. The second group includes patients who experienced poor outcomes or treatment failure with other methods, such as recurrence after surgery, disease progression after transarterial chemoembolization (TACE) or hepatic arterial infusion chemotherapy (HAIC), or progression after targeted and immune therapy.

2. How do you and your team evaluate the safety and effectiveness of Y-90 therapy? What complications might arise, and how do you manage them?

Prof. Lin Zhang: As Academician Dong Jiahong described it, Y-90 therapy is the “nuclear missile” in hepatobiliary cancer treatment, with both high effectiveness and high risks. Therefore, our Y-90 team prioritizes thorough safety evaluations. Ensuring patient safety begins with meticulous patient assessment, including a comprehensive review of preoperative conditions, particularly liver function reserves and the status of the remaining liver, to establish a foundation for safe treatment.

When planning treatment, we conduct risk assessments and adopt pre-treatment strategies, especially addressing arteriovenous fistulas, to ensure the safety and effectiveness of the procedure. Additionally, our team has developed advanced techniques, such as fistula embolization, risk vessel pre-treatment, and optimized injection techniques for Y-90 microspheres, to handle complex cases safely.

3. How important is multidisciplinary collaboration in Y-90 therapy, and what does this collaboration entail?

Prof. Lin Zhang: Y-90 therapy exemplifies the value of a closely integrated multidisciplinary team. We position Y-90 as a minimally invasive and effective approach for treating malignant liver tumors. Its success hinges on the collaboration of diverse departments, including hepatobiliary surgery, interventional radiology, nuclear medicine, oncology, and radiotherapy. Our hospital’s seamless teamwork across these departments plays a vital role in the success of Y-90 therapy. While team coordination takes time to perfect, our shared goal is to prioritize patient outcomes and maximize therapeutic benefits.

4. How do you develop the expertise of medical staff in Y-90 therapy? What challenges do you foresee in promoting this therapy, and how can they be addressed?

Prof. Lin Zhang: Y-90 therapy requires a highly skilled surgical team. Internationally, there are stringent training standards for Y-90 therapy, including a formalized training regimen and qualification process. Trainees perform Y-90 procedures under a mentor’s supervision and can only operate independently after successfully completing three guided procedures and passing evaluations. In China, we follow this training model; however, due to the complexity of cases here, even after three supervised cases, doctors may still encounter challenges. Continuous learning, exchange, and skill enhancement are essential for Y-90 practitioners to improve their proficiency and address these challenges effectively.

5. Academician Dong Jiahong introduced the concept of “precision liver resection” in 2006, which evolved into the broader concept of precision surgery. How does the precision surgery philosophy benefit Y-90 therapy?

Prof. Lin Zhang: Academician Dong recently published an article in the Chinese Journal of Practical Surgery focusing on Y-90 therapy under the guidance of precision surgery principles. Y-90 therapy, involving close teamwork across multiple disciplines, demonstrates high efficacy and safety when applied correctly, though there are risks if misapplied.

The core of precision surgery rests on three principles: maximizing lesion removal, protecting organ function, and minimizing trauma. These principles align well with Y-90 therapy, where we strive for uniform distribution of Y-90 in tumor regions with an adequate dose, while protecting healthy liver, lungs, and gastrointestinal tissues and minimizing tissue damage. Guided by the precision surgery philosophy, we aim to optimize Y-90 therapy and open avenues for further innovation and exploration in the use of Y-90 technology.