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427

What microwave

ablation technique

is utilized for larger

tumors or those with

insufficient margins?

Synchronous ablation utilizing multiple

overlapping probes

How are ablation

patients typically

monitored post-

procedurally?

Monitored for pain and discharged with

pain medications.

If necessary, the patient may be admitted

overnight for pain control.

What medications

may be given prior to

TACE?

Variable. Some use a combination of

antiemetics, steroids, diphenhydramine,

and/or antibiotics.

When are

preprocedural

prophylactic

antibiotics indicated

for TACE?

Controversial. Some prescribe antibiotics

both 2–3days before and for 2–3weeks

following the procedure in patients

with increased risk of developing a liver

abscess (prior biliary interventions).

What vessel should

be interrogated

after aortography to

assess for accessory

or replaced hepatic

arteries?

SMA

What vessels

are commonly

interrogated, and

what are their

common injection

rates for hepatic

arterial interventions?

Aorta: 15–20mL/s for 30–40mL

SMA: 3–5mL/s for 12–30mL

Celiac: 3–4mL/s for 12–15mL

Common hepatic artery (CHA): 3mL/s

for 12mL

Gastroduodenal artery (GDA): 2mL/s

for 8mL

Proper hepatic: 3mL/s for 12mL

Left hepatic: 2mL/s for 8mL

Right hepatic: 2mL/s for 10–12mL

Phrenics: 1–2mL/s for 4–6mL

(continued)

Hepatic Interventional Oncology

https://t.me/med1917

428

Once the hepatic

tumoral supply is

identified, what

maneuver is necessary

prior to delivery

of chemoembolic

emulsion?

A microcatheter (2–2.8 Fr) should

be used to obtain selective access for

segmental/subsegmental treatment.

How should the

patient be managed

immediately following

TACE?

Aggressive IV hydration, pain control,

such as with patient-controlled analgesia

(PCA), and antiemetics

How is imaging

response to TACE

monitored?

Contrast-enhanced CT or MRI~4weeks

after the procedure.

If there is no residual viable disease,

follow-up imaging should be performed

every 2–3months.

Which medications

should be

administered for

TARE?

PPI or H2 blocker 1week prior and for

4weeks following procedure

Nausea medication such as ondansetron

day of procedure

+/− steroids for postembolization

syndrome

+/− empirical antibiotics for biliary tract

infection

+/− oral analgesics

What is the dose

of 99mTc-MAA

delivered during the

mapping study?

Approximately 4–5mCi

Why is it essential to

calculate “lung shunt

fraction?”

30Gy delivered per session or 50Gy

cumulatively to the lungs has been shown

to induce radiation pneumonitis.

S. I. Stein

https://t.me/med1917

429

What are the dose

reduction parameters

for patients with

lung shunting

demonstrated on

mapping study?

< 10% → no dose reduction.

10–15% → 20% dose reduction.

15–20% → 40% dose reduction.

> 20% → radioembolization is

contraindicated (with the caveat that it

may be performed in rare cases that total

absolute dose to the lung is less than

30Gy in a single session or 50Gy over

multiple sessions).

What imaging can

be performed to

document Y-90

deposition in tumoral

tissue?

Bremsstrahlung SPECT scan within 24h

of TARE

Newer modality time-of flight PET-CT

Complications

How are patients protected

from ablation of sensitive

nontarget tissue?

Hydrodissection with 5% dextrose

or sterile water can create a plane

between the ablation zone and

nontarget tissue.

What is the risk of tumor

seeding from RFA?

0.2–2.8% with risk factors including

high AFP, undifferentiated HCC,

subcapsular lesions, and multiple

needle insertions

Which patients are most

at risk for liver abscess

following liver-directed

therapy?

Prior biliary intervention

What is postembolization

syndrome?

Fever, abdominal pain, nausea, and

vomiting following an embolization

procedure

What is a commonly

utilized intraprocedural

practice to control pain

from visceral embolization?

Administer intra-arterial

lidocaine prior to delivery of

the chemoembolic emulsion and

between aliquots.

(continued)

Hepatic Interventional Oncology

https://t.me/med1917

430

What potential life-

threating complications

exist from administering

too much ethiodized oil in

TACE?

Pulmonary embolism from

hepatovenous shunting to the lungs

and liver failure

How does the side effect

profile of TARE compare

to TACE?

TARE patients also may develop

constitutional symptoms including

fatigue, abdominal pain, and nausea.

However, symptoms are usually not

as severe or immediate but can be

prolonged.

What are the complications

of TARE?

Radiation pneumonitis,

radioembolization-induced liver

disease (REILD), liver toxicity, GI

ulceration, gastritis, skin irritation,

and cholecystitis

Where should TARE be

performed relative to the

cystic artery?

Distal to the cystic artery

How does REILD present

and how is it managed?

Can present up to several months

following TARE

Laboratory: elevated bilirubin and

decreased albumin

Clinical: ascites

Imaging: hepatic perfusion

abnormalities (veno-occlusive

disease)

Treatment: depends on severity,

may include diuretics, high-dose

steroids, sustained low-dose

heparin, ursodeoxycholic acid, and

pentoxifylline

What measures are taken

to avoid REILD when

performing bilobar whole

liver TARE or when

prescribed activity is high?

Dose reduction strategies or

sequential sessions/fractionation

to each lobe separated by 1-month

dosing to single lobe

S. I. Stein

https://t.me/med1917

431

How are patients

protected from “nontarget

embolization” in TARE?

Prophylactic coiling or gel foam

embolization of potential nontarget

arterial branches

Landmark Research

Ablation

Chen M-S, Li J-Q, Zheng Y, etal. A prospective randomized

trial comparing percutaneous local ablative therapy and par-

tial hepatectomy for small hepatocellular carcinoma. Ann

Surg. 2006;243(3):321–8.

• RCT comparing percutaneous RFA with partial hepatec-

tomy for early solitary HCC≤5cm.

• Ablation and resection for early HCC had similar 1-, 2-, 3-,

and 4-year survival rates.

• Resection had statistically significant increase in complica-

tions related to surgery, longer hospital stay, and increased

postoperative stay.

Loriaud A, Denys A, Seror O, etal. Hepatocellular carci-

noma abutting large vessels: comparison of four percutane-

ous ablation systems. Int J Hyperthermia. 2018;34(8):1171–8.

• RCT in patients with BCLC stage 0 and A with perivascu-

lar HCC comparing monopolar RFA, cluster RFA, multi-

bipolar RFA, and microwave ablation.

• Primary endpoint: overall long-term progression.

• Multi-bipolar RFA and cluster RFA provided better local

tumor control than microwave ablation or monopolar

RFA.

Conventional TACE

Lo C-M, Ngan H, Tso W-K, Liu C-L, Lam C-M, Poon RT-P,

et al. Randomized controlled trial of transarterial lipiodol

33 Hepatic Interventional Oncology

https://t.me/med1917

432

chemoembolization for unresectable hepatocellular carci-

noma. Hepatology. 2002;35(5):1164–71.

• TACE vs. symptomatic treatment for unresectable HCC in

Asian patients

• TACE with improved overall survival at 1, 2, and 3years

Llovet JM, Real MI, Montaña X, etal. Arterial embolisa-

tion or chemoembolisation versus symptomatic treatment in

patients with unresectable hepatocellular carcinoma: a ran-

domised controlled trial. Lancet. 2002;359(9319):1734–9.

• TACE vs. bland embolization vs. symptomatic treatment

for unresectable intermediate stage HCC in Caucasian

patients.

• The study was stopped due to consistent results showing

improved 1-, 2-, and 3-year survival of chemoembolization

patients.

• TACE group showed lower rates of vascular invasion and

lowest rate of death due to tumor progression, but the

study stopped prior to establishing improved effectiveness

compared to bland embolization.

DEB-TACE

Lammer J, Malagari K, Vogl T, etal. Prospective randomized

study of doxorubicin-eluting-bead embolization in the treat-

ment of hepatocellular carcinoma: results of the PRECISION

V study. Cardiovasc Intervent Radiol. 2010;33(1):41–52.

• Multicenter RCT with 1200 patients randomized to con-

ventional TACE vs. drug-eluting bead treatment of HCC,

with primary outcome of tumor response at 6months.

• Demonstrated safety of DEB-TACE, unable to demon-

strate superiority of DEB-TACE to conventional TACE.

• Subgroup analysis showed DEB-TACE with improved

response in more advanced disease (CP B, ECOG 1) com-

pared to conventional TACE.

S. I. Stein

https://t.me/med1917

433

• DEB-TACE with improved tolerability and decreased

serious liver toxicity overall.

Lencioni R, Llovet JM, Han G, Tak WY, Yang J, Guglielmi

A, etal. Sorafenib or placebo plus TACE with doxorubicin-

eluting beads for intermediate stage HCC: the SPACE trial. J

Hepatol. 2016;64(5):1090–8.

• RCT comparing DEB-TACE alone vs. DEB-TACE +

sorafenib for intermediate stage HCC.

• Did not establish significant improvements in clinical out-

comes for combination group as opposed to DEB-TACE

alone.

Bland Embolization

Brown KT, Do RK, Gonen M, et al. Randomized trial of

hepatic artery embolization for hepatocellular carcinoma

using doxorubicin-eluting microspheres compared with

embolization with microspheres alone. J Clin Oncol.

2016;34(17):2046–53.

• Single-center RCT comparing bland embolization to

DEB-TACE for the treatment of HCC.

• Included BCLC A, B, and C patients in both groups

• No difference in imaging response, progression-free sur-

vival, or overall survival between the two groups

Transarterial Radioembolization

Salem R, Gordon AC, Mouli S, etal. Y90 radioembolization

significantly prolongs time to progression compared with

chemoembolization in patients with hepatocellular carci-

noma. Gastroenterology. 2016;151(6):1155–63.

• RCT conventional TACE vs. TARE for BCLC A and B

patients.

• Primary outcome: time to progression.

33 Hepatic Interventional Oncology

https://t.me/med1917

434

• TARE had a significantly longer time to progression

(>26 months) than conventional TACE (6.8 months).

Longer time to progression did not translate to increased

overall survival.

Lewandowski RJ, Gabr A, Abouchaleh N, etal. Radiation

segmentectomy: potential curative therapy for early hepato-

cellular carcinoma. Radiology. 2018;287(3):1050–8.

• Retrospective cohort study of BCLC stage 0 and A

patients at single center with solitary HCC≤5cm treated

with radiation segmentectomy (>190Gy ablative dose).

• Median overall survival, 6.7 years; time to progression,

2.4years.

• Response rates, tumor control, and survival comparable to

other “curative” therapies such as thermal ablation, partial

hepatectomy, and transplantation in early stage HCC.

Wasan HS, Gibbs P, Sharma NK, et al. First-line selective

internal radiotherapy plus chemotherapy versus chemother-

apy alone in patients with liver metastases from colorectal

cancer (FOXFIRE, SIRFLOX, and FOXFIRE-Global): a

combined analysis of three multicentre, randomised, phase 3

trials. Lancet Oncol. 2017;18(9):1159–71.

• Analyzed data from three trials to assess chemotherapy

alone vs. chemotherapy + TARE with resin microspheres

as first-line therapy for patients with liver-only colorectal

cancer metastases

• Found that adding TARE improved liver-specific progres-

sion and radiological response, but did not improve overall

or progression-free survival

Vilgrain V, Pereira H, Assenat E, etal. Efficacy and safety

of selective internal radiotherapy with yttrium-90 resin

microspheres compared with sorafenib inlocally advanced

and inoperable hepatocellular carcinoma (SARAH): an

open-label randomised controlled phase 3 trial. Lancet

Oncol. 2017;18(12):1624–36.

• Multicenter RCT in France comparing the use of sorafenib

vs. TARE for patients with locally advanced stage (BCLC

S. I. Stein

https://t.me/med1917

435

stage C) or intermediate stage (BCLC stage B failing

TACE) HCC.

• Primary endpoint: overall survival, which did not differ

between the two groups.

• TARE patients had improved QOL, improved tumor

response, and decreased adverse events (sorafenib can

have many toxic side effects).

Chow PKH, Gandhi M, Tan S-B, etal. SIRveNIB: selective

internal radiation therapy versus sorafenib in Asia-Pacific

patients with hepatocellular carcinoma. J Clin Oncol.

2018;36(19):1913–21.

• Multicenter RCT in comparing the use of sorafenib vs.

TARE for patients with locally advanced (BCLC stage B

or C) HCC.

• Primary endpoint: overall survival, which did not differ

between groups.

• TARE patients had fewer grade ≥ 3 adverse events than

sorafenib; TARE patients had better tumor response rate.

• Key differences from SARAH trial (above): Single TARE

(vs. SARAH with repeat TARE allowed), lower bilirubin

level threshold (32 mmol/L vs. <=50 SARAH), lower

proportion of BCLC C disease, and better survival in

patients with BCLC C disease treated with TARE in

SIRveNIB vs. SARAH.

Common Questions

What is the goal temperature of

RFA?

60–100°C (above 100°C

is less effective due to

charring).

What is the primary model utilized

to calculate activity for delivery of

Y-90 resin microspheres?

Body surface area (BSA)

model

(continued)

Hepatic Interventional Oncology

https://t.me/med1917

436

What is the primary model utilized

to calculate activity for delivery of

Y-90 glass microspheres?

Medical internal radiation

dose (MIRD)

How long is the patient “radioactive”

after TARE and what measures

should be taken?

Y-90 has a 64-h half-life.

Patients should avoid close

contact with pregnant

women and children for

3days.

What is the typical surface radiation

dose from the patient after TARE?

< 1 mrem/h.

What is the goal future liver remnant

(FLR) before surgical resection in

patients with cirrhosis or chronic

hepatitis?

≥ 40% of the preoperative

liver volume

What is portal vein embolization

(PVE)?

Technique utilized to cause

compensatory hypertrophy

in the FLR.

PVE may increase FLR

by 30%.

Takes 3–4weeks to induce

hypertrophy.

What is radiation lobectomy? Delivery of Y-90in a lobar

fashion

Similar to PVE, causes

compensatory hypertrophy

to the contralateral lobe

prior to resection

Can take longer than PVE

to induce hypertrophy,

but has the advantage of

controlling the tumor(s)

What liver-directed therapies can be

used to target early HCC?

Depending on liver

transplantation candidacy

and location, thermal

ablation and radiation

segmentectomy can be

considered.

S. I. Stein

https://t.me/med1917

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