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Radioimmunotherapy with 90Y-ibritumomab tiuxetan


Medical editor Trond Bogsrud MD
Specialist in Nuclear Medicine
Radiumhospitalet
Oslo University Hospital

General

Radiation therapy is undergoing final approval and will soon be available.

Radioimmunotherapy has been used in Norway since 2004 when 90Y-ibritumomab tiuxetan (Zevalin®) was approved in Europe. Experimental treatment has been underway since the beginning of the 1990's. 

Zevalin® is a very effective drug that will likely gain an important place in treatment of less aggressive lymphomas. Seventy-four percent of patients have good effect from treatment.

90 Y-ibritumomab tiuxetan has in a series of studies also shown to have positive effects on follicular lymphomas. The radioactive istope yttrium-90 is added to the murine monoclonal antibody which then binds to the CD20 antibody. The preparation takes place at each spesific treatment centre. Results can be compared with those achieved by chemotherapy and side effects are most likely less. The entire treatment is completed in one week and can be done on an outpatient basis. 

Radioimmunotherapy with Zevalin® can now be carried out at larger oncology departments in Norway. Treatment is approved for patients with recurrence after, or, with no reponse to rituximab. This treatment is very costly and there is currently no reimbursement scheme. 

Indications

  • Follicular non-Hodgkin lymphomas
  • Recurrence or resistance to the monoclonal antibody rituximab

Contraindications are allergic reaction to the drug or additives, or other mouse proteins. 

Goal 

  • Palliative or curative

Drugs

  • 90 Y-ibritumomab tiuxetan (Zevalin®) consists of a targeted monoclonal antibody (ibritumomab) bound to a radioactive isotope (Yttrium-90, 90Y). The antibody binds to cancer cells thereby exposing the tumor to a crossfire of cell-killing beta rays. 
  • Tiuxetan is approved for treatment of adult patients with low-grade lymphomas. These lymphomas almost always bear the CD20 molecule on the surface to which Zevalin® binds.
  • Rituximab (MabThera®) is an antineoplastic drug. Rituximab binds to the normal B cells thereby the radioactive antibody  90Y-ibritumomab tiuxetan can more effectively bind to cancer cells.

Preparation

  • Height and weight. Calculate body surface for dosage.
  • Blood tests. Thrombocytes ≥ 75.000 x 109/L, neutrophile granulocytes ≥ 1.5 x 109/L
  • The patient is given two doses of rituximab; one dose is given the week before and the other dose the same day Zevalin ® is given. 

Implementation

  • 90 Y-ibritumomab tiuxetan is prepared at a nuclear medicine department
  • After infusion of rituximab (MabThera®), the patient is is given the dose of Zevalin® at the nuclear medicine department. 
  • The dose is injected during 10 minutes.

Observations

  • The patient should be observed for 20 minutes for a possible allergic reaction.
  • The drug causes very little side effects. The most common side effect is reduction of platelets.

Suppression of bone marrow in patients with significant lymphoma involvement of bone marrow may occur. 


Follow-up

The main disadvantage of treatment is bone marrow suppression that occurs 4-8 weeks after treatment, but this is temporary. Weekly blood tests are therefore important. 

In 10–20%, the fall will be significant and require treatment.

  • A small number of patients will need transfusions with platelets.
  • Febrile neutropenia may occur.

Body fluid may contain small amounts of radioactivity in the first week after Zevalin® is injected.
The patient must be attentive to:

  • Good hand hygiene
  • Flushing twice after each toilet visit
  • Condoms are recommended to avoid transfter of bodily fluid.

The patient must use effective birth control during the first year after treatment is finished. 


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