Synoviorthesis (Radionuclide Synovectomy) with Yttrium -90 for Chronic Synovitis in Haemophilia : A Cost-Effective Therapy in Developing Countries.

Abstract

3497 Poster Board III-434 Recurrent joint bleeding continues to be a challenge in Hemophilia, thereby, resulting in a severe burden on family's economy, especially in a poor country like India, besides causing severe morbidity in one or more members of the family as a result of deblitating arthropathy. The weight-bearing joints and those on the patient's dominant side are more likely to be affected. Factor replacement is well established but costly therapeutic modality & almost always results in problems of inadequate dosage due to economic reasons & also to the development of inhibitors to factors. Synoviorthesis (Radionuclide Synovectomy) offers a minimally invasive, therapeutic option for early chronic synovitis in these patients. We performed 76 Synoviorthesis procedures in 49 children and young adults with severe hemophilia in armed forces hospitals at Pune & Delhi Cantt ( India) over last 6 years. We used Yttrium 90 (Y90) as a radio-synovectomy agent. In this study, we have evaluated long-term experience ranging from 6 months to 6 years (mean 38 months) for Knee joints ( n= 44 ), Elbows (n = 12) & ankles (n = 20 ) in total of 76 procedures for 49 patients. Their age ranged between 6-23 (mean: 15.5) years. The dose of Yttrium used was 5 mCi for knees & 2 mCi for other joints. After synoviorthesis there was significant reduction in bleeding events especially with grade 2 synovitis. The complete response ( 100% reduction in bleeding ) was seen in 67 % & 41% of patients at 6 & 12 months follow up. For elbow joint bleeding, these figures were 72 % and 55 %, whereas for ankles the reduction was 66% & 48% respectively. In grade 3 synovitis, complete response rates were 42 % & 35 % for knee joint bleeds, 60 % and 35 % for elbow joint bleeds and 65% and 48 % for ankle joint bleeds respectively. 12 patients required, repeated injections for acceptable control of hemarthrosis. The procedure also resulted in a significant reduction in Factor requirement for these patients over next two years ( 20% & 30% reduction for knee joints with Gr 3 & 2 synovitis respectively & 25 % reduction in overall usage of factors for all types of bleeds ). There were no serious adverse effects. There was no instance of radioisotope leakage or local inflamatory reaction. None of the cases had developed any malignancy during the follow up period of 6 months to 6 years. In conclusion, synoviorthesis appears to be a promising option for medium-sized joints, particularly in a developing countries, where factor replacement is always inadequate resulting in avoidable deforming complications besides the problems associated with inhibitor development. In our institutions this has significantly reduced the incidence of joint bleeds and there has been a significant reduction in the cost of maintaining these patients as well as a significant improvement in their quality of life. Disclosures: No relevant conflicts of interest to declare.

Radiosynovectomy in haemophilic synovitis and arthropathy of the knee: A scoping review

“…Reduction in factor consumption is reported in the region of 4740 units per month following P‐32 and a 25% reduction following Y‐90 RSV 5,43 . This may equate to savings of $190‐220,000 over 6 months per patient 17,26 …”

“…Forty‐three studies had sample sizes > 20 knees 5–47 . Sixty‐eight studies were defined as small and were not discussed further.…”

“…23 Y-90 cohorts with follow up durations up to 11 years have identified no incident cancer. 28,30,43 Additionally, no cancer cases were identified following P-32 RSV with a maximum follow up of 17 years in a small number of patients. 13,36 A large study using Canadian registry data of cancer rates following RSV in multiple joints (69% knees), found no significant increase in the hazards ratio of any type of cancer compared to the general population for either Y-90 or P-32.…”

“…Reduction in factor consumption is reported in the region of 4740 units per month following P-32 and a 25% reduction following Y-90 RSV. 5,43 This may equate to savings of $190-220,000 over 6 months per patient. 17,26 The dollar cost per injection of RSV in the USA is approximately $3000, whereas the cost for a surgical synovectomy is significantly higher at $61,000.…”

“…The risk of complications of knee RSV is low many cohorts reporting no complication with Y-90 or P32. 11,18,24,29,30,43,45 Local complications consist of bleeding and infection as well as radiation induced acute synovitis, skin burns and tract necrosis.…”