Molecular Radiotherapy Information Series 3 Information for adults having Lutetium (Lu-177) treatment

This page has been written for patients who are having Lutetium (Lu-177) treatment. It explains what the treatment involves, how to prepare for it and what you can expect afterwards.

We understand this may be a worrying time for patients and their families, and we hope this page can help to answer any questions you have. If you have any questions about the treatment or the information below, please speak to the team looking after you.
 

We want to involve you in all the decisions about your care and treatment. If you decide to go ahead with treatment, by law, we must ask for your consent and will ask you to sign a consent form. This confirms that you agree to having the procedure and understand what it involves.

Staff will explain all of the risks, benefits and possible alternatives before they ask you to sign a consent form. If you are unsure about any aspect of your proposed treatment, please do not hesitate to speak to speak to the team looking after you.
 

Lutetium (LU-177) treatment is a form of radiotherapy treatment called molecular radiotherapy (MRT). You may also hear this being referred to as peptide receptor radionuclide therapy (PRRT). The treatment targets specific tumours called neuroendocrine tumours. These tumours are a group of rare cancers that develop in the neuroendocrine system, a system made up of nerve and gland cells that produce hormones.
Dotatate is a chemical that is taken up by certain neuroendocrine tumours. Dotatate is attached to Lu-177, which is radioactive. The dotatate carries the radioactive
Lu-177 in the bloodstream to the neuroendocrine tumour where it is absorbed. The Lu-177 delivers radiation to the cancer cells and kills them.

We aim to give patients a course of LU-177 treatment every eight to twelve weeks, for a maximum of four courses. However, this will depend on patients’ blood count recovery. Please see the schedule below for Lu-177 treatment:

At the first visit you will meet the consultant clinical oncologist who will talk to you about the plan for treatment and explain what you can expect. You will have a chance to ask any questions you may have at this appointment.

We will take you to the ward to meet some of the nurses who will be looking after you. We will show you the protected rooms in which you will be staying for the duration of your treatment. You will also meet the molecular radiotherapy team who will coordinate your care and treatment. Visiting the ward and treatment rooms, and meeting the staff involved in your care, will help you to know what to expect. It will also help to ensure you are comfortable and familiar with what is happening.

Please be aware of the following changes within the service due to the outbreak of coronavirus (COVID-19) within the community.

• We advise that you attend all appointments alone. Visitors are not permitted within the hospital.
• Currently your appointment can be a phone call or a video call. Please let the clinical team know if you feel that you need a face-to-face appointment.
• Attend Anywhere is a UCLH approved, secure online tool for video calls between patients and clinicians. If you need more information on this, please let the team looking after you know.

Before coming into hospital, you will have diagnostic scans in the nuclear medicine department. These scans will help the medical team to plan your treatment. They will be able to measure how well the Lu-177 is absorbed by the neuroendocrine tumour cells, and therefore how suitable Lu-177 treatment is for you. Other scans may also be needed and we will advise you if this is the case. These scans may be done at your local hospital, or here at University College Hospital (UCH).

We also need to make sure you are fit and well enough to have treatment, and that you have no other health issues. A wide range of specialists will be involved in making this decision prior to treatment. You will have a range of test and scans to check that you meet all the criteria. These will be organised by the radioisotope team.

It is important that the medical team are told of all medications you are taking or have been prescribed. Some medications may affect the uptake of Lu-177 by the tumour cells and may need to be stopped one or two weeks before treatment. For example, you may be on a monthly injection of somatostatin (sandostatin, LAR/lanreotide). Your last injection must be at least 4 weeks before starting Lu-177 treatment. There are shorter acting drugs such as octreotide injections which may need to be stopped the day before.

You should not have Lu-177 treatment if you are pregnant or breastfeeding. You must tell the staff if there is any chance of you being pregnant. If you are of child-bearing age, you will need to have a pregnancy test prior to treatment. Treatment will only be given if you are not pregnant.

All individuals with internal reproductive organs (a uterus) of child-bearing ability (12-55 years) will have a urine pregnancy test before treatment starts. Individuals should not become pregnant for at least six months after Lu-177 treatment.

Individuals with external reproductive organs (testes) should not conceive a child for at least four months after Lu-177 treatment. All patients should use reliable contraception throughout this period.

If you will be having multiple Lu-177 treatments, there may be a small risk your fertility is affected in the future. Your medical team will discuss egg preservation or sperm banking with you, if it is appropriate. The MRT radiographers will discuss any issues around sex, contraception and intimacy with you.

You will be admitted to hospital a day before your Lu-177 treatment is due to start, so that we can check you are well enough to undergo treatment. You will be admitted to T14 ward on the 14th floor of the main UCH building. You will stay in a protected side room with en-suite shower and toilet.

The nursing team will do some blood tests, to check your blood levels, and do any other investigations needed before treatment.

On the day of treatment, the nursing team will insert a cannula in your arm. You will be given anti-sickness drugs which will reduce the risk of feeling sick or being sick.

You will also be given intravenous fluids before the treatment. These fluids will normally last twenty-four hours. The fluids will help flush the Lu-177 through your body and reduce any radiation dose to your bladder.

You will be given an infusion of amino acids before your Lu-177 treatment, to protect your kidneys. After the amino acid infusion has been running, it will be stopped to allow the Lu-177 to be given. The Lu-177 infusion takes thirty minutes.

You may experience discomfort at the site of the tumour whilst the treatment is being given. You may have some brief periods of flushing where you become very warm and your face may go red. This typically lasts for only a few minutes.

After the Lu-177 infusion has finished, the infusion of amino acids will be restarted. If you notice that your arm is sore, red or burning please tell the staff straight away

During your stay, you will have a whole-body scan, or a series of scans in the nuclear medicine department. The scans produce a map to see where the Lu-177 has been absorbed in your body. You will be given the appointment times by the MRT radiographers.

The Lu-177 will enter your bloodstream and be absorbed by the neuroendocrine tumour cells. Most of the remaining Lu-177 will be excreted through your urine over the following days. The Lu-177 can also be excreted in other bodily substances such as saliva, vomit, faeces, sweat and oils secreted by your skin.

The radiation from Lu-177 is treating your cancer but it could be a risk to other people. You will therefore stay in a protected room to reduce any radiation exposure to other people.

Strict regulations state that patients receiving radioactive drugs must stay in hospital until most of it has been excreted. Other rules are:

• You must not leave the room.
• You must only use the shower and toilet in the en-suite.
• The en-suite shower and toilet cannot be used by anyone else.
• You must only wash and dry your hands using the paper towels in the room and throw them in the yellow bin bags.
• One of the two doors to the suite must always be closed.
• All medical and nursing staff and visitors entering the room must wear protective shoe covers, aprons and gloves.
• Anyone entering the room must wear a radiation monitor and record their measurements.
• If you feel sick, please tell the nursing staff immediately. You can use the toilet in the en-suite to be sick in. The nurses can also provide a disposable bowl.
• All patients are encouraged to sit rather than stand whilst urinating, to minimise the risk of contamination in the bathroom.
• Please double flush the toilet.

Please tell us if you have any accidents with bodily fluids while in hospital. It may be harmful to yourself and others if you fail to tell us.

You will stay in hospital for a week in order to reduce the radiation exposure to other people. You will stay in the protected room most of the time during treatment.
Exceptions include going to the nuclear medicine department for scans or in a medical emergency.

You can wear hospital nightclothes and a dressing gown during your stay. If you wish to wear your own clothes, old and comfortable clothes are best to wear while you are admitted to hospital.

You should only bring items you will not need to take home immediately. This is because any personal possessions brought in will become contaminated with radiation. You may need to leave some things behind if they carry traces of radioactivity. The radiotherapy physics team will monitor the radiation levels of your belongings and let you know if there are any items they need to store.
These items may need to be kept for up to three months. If you would like them back, please let us know and we can contact you when they are ready to be collected

Meals will be brought to you three times a day. Meals will be served on paper plates with plastic cutlery for easy disposal. If you do not get a meal, please let a nurse know. Please let us know if you have any special dietary needs.

There is a smart TV, books, mood lighting, a kettle, fridge and an X-box in the room. If you are uncertain on what things you can bring in due to the risk of radiation contamination, please ask the MRT radiographers.

Adult visitors, who are not pregnant, are allowed to visit 24hrs after radioactive lutetium (Lu-177) administration. Adults may visit for up to one hour and sit outside the protected room behind a lead screen. All visitors must report to the nurse’s station on arrival.

People under 18, pregnant or breastfeeding cannot visit under any circumstances.
 

During your stay on the ward, you may gather lots of different waste in the room. We would like you to separate the waste into different bins to ensure that we can reduce the volume of radioactive waste. The categories of waste are:

Non-clinical waste that has been in the mouth

Examples include:

• Disposable cutlery
• Empty cans/cups
• Food contaminated waste

The items that have been in your mouth and have had saliva on them are more contaminated than waste that has not been in your mouth.

Non-clinical waste that has not been in the mouth

Examples include:

• Sweet and crisp wrappers
• Fruit peels
• Newspapers/ magazines
• Teabags

Clinical waste

Examples include:

• Waste with bodily fluids
• Dressing and plasters
• Gloves and Aprons
• Non-sharp syringes

If you wear incontinence pads, please talk to the radioisotope radiographers who will tell you how to dispose of them during treatment.

Clothes, Towels and Linen

We try to limit the amount of times we change your bed linen during treatment. If you have an accident, the nurses will change the linen.

You should plan to be in hospital for two to three days. The radiotherapy physics team will give you a yellow card. The card has details of your treatment, any restrictions in place at the time of your discharge, the time the restrictions are applied until and the contact details for the radiotherapy physics department.

You should carry this card with you at all times after leaving hospital, until the date indicated on the card. If you are attending another healthcare setting during the restriction period, the yellow card must be shown to staff. The card will not prevent you from receiving treatment in an emergency, but it will allow the team to request information and advice from UCH.

Depending on your radiation levels, you may need to avoid being in close contact with people for prolonged periods, particularly children and pregnant individuals.

You should not fly until you reached a low radiation level which is determined by the radiotherapy medical physics team.

If you wish for your restrictions to be lifted earlier, we may recommend that you return to the hospital to be re-monitored. The radiotherapy physics team will discuss this with you before you are discharged from the ward. If you live some distance from UCH, it may be possible for re-monitoring to take place at a local hospital, with nuclear medicine facilities, with prior arrangement.

Lu-177 treatment can cause:

• Low red blood cells (anaemia). If your red blood cells are low, you may feel tired, and experience shortness of breath, heart palpitations and pale skin.
• Low white blood cells, especially neutrophils which fight infection (neutropenia). If your neutrophils are low, you may experience signs of an infection. You may experience a fever, a high temperature of 38c or above, flu-like symptoms and tiredness.
• Low platelets which clot blood (thrombocytopenia). Low platelets can cause tiredness, lack of appetite, developing bruises easily and bleeding in the mouth, nose and gums.

These effects may take up to four to six weeks to happen. They are usually temporary and after a period of time the blood count recovers. The doctors will talk to you more about all these symptoms.

Due to the breakdown in cells by the Lu-177 treatment, you may experience an excessive release of hormones. This can cause a temporary increase in the intensity of symptoms such as flushing, sweating, palpitations and increased frequency of diarrhoea. This is usually limited to 24 hours after treatment. Please let the team know if you experience any side effects.

You may experience an increase in pain due to inflammation of the tumour, especially if it is in your bones, liver or pancreas. This is usually limited to 72 hours following treatment. A low dose of steroids may be prescribed to help reduce this, but you may need to take your usual pain medication more regularly.

Your kidney function may be reduced over several courses of Lu-177 treatment. This will be monitored closely, and an infusion of amino acid solution will be given before each treatment to protect your kidneys.

Late side effects can develop months or years after Lu-177. This includes secondary malignancy and an increased risk of leukaemia. However, the risk is very low, affecting around 0-5% of patients. Your consultant clinical oncologist will discuss this with you.

We will ask you to have a blood test at twice weekly intervals for eight to twelve weeks after treatment. The blood tests can be done at your local hospital or GP practice. The results will be monitored by the UCH team. This is to check the effect the treatment has had on your blood cells. The UCH team will contact you when they have blood test results to discuss them, answer questions you may have and offer support.

The results of the nuclear medicine scan will be discussed with you after treatment in a follow-up clinic appointment.

The treatment works slowly over a period of months. Usually, you will have multiple treatments that are given eight to twelve weeks apart depending on the effect the treatment has on your blood cells and kidney function.

The scans and blood tests after treatment are used to decide how effective each treatment has been, and if you need any more treatment. When treatment is completed, further scans and tests will be organised as part of your follow up. Your clinical oncologist will discuss this with you in more detail.

Radiation – The shortened term for ‘ionising radiation’. It is used to describe the wave or particle emitted by a substance.

Radioactive – A term used to describe a substance that emits radiation. Radioiodine (I-131) is radioactive.

Radioisotope – A radioactive substance. For example, Iodine-131 is a radioisotope.

Half-life – As radioisotopes emit radiation they decay and become weaker. The half-life is the amount of time it takes for a radioisotope to decay to a state in which it emits only half as much radiation. The half-life for radioiodine is eight days.

µSv (microsievert) – A unit of radiation dose.

Bq (Bequerel) – A unit which describes how much radioactivity is present.

Dosemeter – A small device that is worn to measure radiation dose.

Radiation meter – An electronic device used to detect the presence of radiation and measure radiation levels.

Contamination – The presence of a radioisotope in an area it is not planned for it to be in. For example, the presence of a radioactive substance anywhere but in your child’s body or in the toilet.

Lead shield – Used to stop radiation. Since lead shields are very thick and lead is a very dense material, it stops or “absorbs” almost all of the radiation.

Molecular Radiotherapy Team
t: 020 3447 4286
t: 020 3456 7890 bleep 1089 or 1097
e: uclh.RadiotherapyIsotopes@nhs.net

Molecular Radiotherapy Pathway Coordinator
t: 020 3447 7283

T14 North Ward
t: 020 3447 1489/ 020 3447 1402

Radiotherapy Medical Physics
t: 020 3456 7890 Bleep 2173.

If you have any concerns that you would like to discuss in confidence, please contact our PALS (Patient Advice and Liaison Service) for information and advice.
t: 020 3447 3042
e: uclh.pals@nhs.net