Current Trends in the Treatment of Hepatocellular Carcinoma with Transarterial Embolization: Variability in Technical Aspects

Abstract

Purpose

While transarterial chemoembolization (TACE) is a mainstay of treatment for unresectable hepatocellular carcinomas (HCCs), technical aspects have varied considerably in the literature. These variations lead to heterogeneity and make meaningful comparisons between articles difficult. The goal of this survey was to report international embolization practices for the treatment of HCC in an effort to understand current treatment strategies as a first step toward technique standardization.

Materials and Methods

An anonymous 18 question online survey, evaluating technical aspects of TACE, was distributed via e-mail to practicing members of the five largest interventional radiology societies in Chinese and English. A total of 1160 responses were obtained from 62 countries.

Results

Between regions, there were significant statistical differences in nearly all responses, including the amount of ethiodol oil used for cTACE (p = < 0.001). Practitioners most commonly used greater than 7.5 ml of ethiodol oil (240/506, 47.4%) and most did not utilize a specific mixing method (249/505, 49.3%). Particles utilized varied by geographical region (p = < 0.001), spherical embolic particles were slightly favored (363/757, 47.9%), followed closely by gelatin-based or sponge particles (279/680, 36.8%). Gelfoam was used almost exclusively in Japan and Korea (79/82 responses). LC/DC beads were the most commonly used drug-eluting bead (DEB) (450/742, 60.6%), with the most common size of DEB being 100–300 μm (354/690, 51.3%, p = 0.07).

Conclusion

Technical aspects of transarterial embolization for HCC vary significantly by geographical location.

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Fig. 1

Abbreviations

CIRSE:

Cardiovascular and Interventional Radiology Society of Europe

CSIR:

Chinese Society of Interventional Radiology

cTACE:

Conventional transarterial chemoembolization

DEB-TACE:

Drug-eluting bead transarterial chemoembolization

HCC:

Hepatocellular carcinoma

JSIR:

Japanese Society of Interventional Radiology

KSIR:

Korean Society of Interventional Radiology

TACE:

Transarterial chemoembolization

TAE:

Transarterial embolization

SIR:

Society of Interventional Radiology

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Acknowledgements

The authors would like to acknowledge Dr. Yasuaki Arai, Dr. Gaojun Teng, Dr. Young Soo Do, Dr. Hyun-Ki Yoon, Dr. Daniel Brown, and Dr. Charles Ray for their feedback and comments in the preparation of the survey. Guarantor: The scientific guarantor of this publication is Paul Craig. Statistics and biometry: Scott Lunos kindly provided statistical advice for this manuscript.

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Correspondence to Paul Craig.

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Informed consent was not required because this was a survey of practicing interventional radiologists.

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Institutional Review Board approval was not required because this was a survey of practicing interventional radiologists.

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Appendix: Survey Text

Appendix: Survey Text

Transcatheter Arterial (Chemo)embolization (TA(C)E) Survey

This short (one-page) survey should not take more than 2 min of your time. This survey was designed to obtain a general idea of the type of TA(C)E procedures that you typically perform. It is important to answer at least one answer per question, as follow-up questions may drop down. Thank you very much for your participation.

  1. 1.

    What country do you practice in?

    1. a.

      (Answer field blank)

  2. 2.

    What type of practice are you in?

    1. a.

      Academic

    2. b.

      Private practice – community hospital

    3. c.

      Private practice – secondary or tertiary referral center

    4. d.

      Government hospital

    5. e.

      Other (please specify)

      1. i.

        (Answer field blank)

  3. 3.

    For TA(C)E procedures at your institution, what is the common cytotoxic agent used for the treatment of hepatocellular carcinoma (HCC)?

    1. a.

      Doxorubicin

    2. b.

      Epirubicin

    3. c.

      Cisplatin

    4. d.

      Mitoxantrone

    5. e.

      Mitomycin C

    6. f.

      SMANCS

    7. g.

      Pirarubicin

    8. h.

      Nemorubicin

    9. i.

      Miriplatin

    10. j.

      Idarubicin

    11. k.

      Irinotecan

    12. l.

      Anthracycline (e.g., Doxorubicin, Epirubicin) and Mitomycin C

    13. m.

      Anthracycline and Cisplatin

    14. n.

      Anthracycline, Mitomycin C, and Cisplatin

    15. o.

      None of the above (bland transarterial embolization (TAE))

    16. p.

      Other (please specify)

  4. 4.

    For TA(C)E procedures at your institution, how is the dose of cytotoxin agent determined?

    1. a.

      Fixed dose (e.g., 50 mg Doxorubicin for every person). Please list dose below.

    2. b.

      Body weight (e.g., 1 mg Doxorubicin for every kg). Please list amount per kg below.

    3. c.

      Body surface area (e.g., 50 mg/meter2). Please list amount per meter2 below.

    4. d.

      Tumor size

    5. e.

      Liver function (AFP, etc.)

    6. f.

      Other (please specify)

  5. 5.

    What is your typical procedure for a single HCC?

    1. a.

      Ethiodized oil TACE (cTACE)

    2. b.

      Drug-Eluting Beads TACE

    3. c.

      Bland Transarterial Embolization (TAE)

    4. d.

      Technique depends on the extension and location of the tumor

    5. e.

      Other (please specify)

  6. 6.

    (What amount of ethiodized oil is typically used?

    1. a.

      Not applicable

    2. b.

      0–5 ml

    3. c.

      5–7.5 ml

    4. d.

      7.5–10 ml

    5. e.

      > 10 ml

    6. f.

      Other

  7. 7.

    What is the ratio (volume:volume) of ethiodized oil to cytotoxic agent used in your procedure?

  8. 8.

    How is the ethiodized oil mixed with the cytotoxic agent?

    1. a.

      Not applicable

    2. b.

      Pump between stop cock (to and fro)—ethiodized oil tube injected into cytotoxin tube

    3. c.

      Pump between stop cock (to and fro)—cytotoxin tube injected into ethiodized oil

    4. d.

      Pump between stop cock (to and fro)—no preference in order mixed

    5. e.

      Mixed with a machine

    6. f.

      No specific method

    7. g.

      Other (please specify)

  9. 9.

    What type of drug-eluting beads do you use?

    1. a.

      Not applicable

    2. b.

      Tandem

    3. c.

      Pearl

    4. d.

      QuadraSpheres

    5. e.

      LC/DC

    6. f.

      Other (please specify)

  10. 10.

    What size of drug-eluting beads do you use (please specify)?

    1. a.

      (Answer field blank)

  11. 11.

    What is your procedural end point?

    1. a.

      Administration of fixed dose

    2. b.

      Flow reduction in the feeding vessel(s)

    3. c.

      Complete stasis in the feeding vessel(s)

    4. d.

      Oil uptake by tumor

    5. e.

      A combination of B and D or C and D

    6. f.

      Other (please specify)

  12. 12.

    Are embolic agents used in your procedure?

    1. a.

      No

    2. b.

      Yes—Gelatin (specify product below)

    3. c.

      Yes—Non-spherical polyvinyl alcohol (specify product below)

    4. d.

      Yes—Spherical (specify product below)

  13. 13.

    What is your typical procedure for multiple HCCs?

    1. a.

      Ethiodized oil TACE (cTACE)

    2. b.

      Drug-Eluting Beads TACE

    3. c.

      Bland Transarterial Embolization (TAE)

    4. d.

      Technique depends on the extension and location of the tumor

    5. e.

      Other (please specify)

  14. 14.

    Are additives used with the primary cytotoxic agent (water-soluble contrast, solubility agents, etc.)?

    1. a.

      No

    2. b.

      Yes (please specify)

  15. 15.

    Do you routinely use antibiotics with TA(C)E procedures?

    1. a.

      No

    2. b.

      Yes, before

    3. c.

      Yes, during

    4. d.

      Yes, after

    5. e.

      A combination of the factors listed above

  16. 16.

    When is your typical clinical follow-up for TA(C)E procedures?

    1. a.

      Less than 2 weeks

    2. b.

      2 weeks–1 month

    3. c.

      > 1 month–< 2 months

    4. d.

      > 2 months

  17. 17.

    What type of imaging follow-up do you perform?

    1. a.

      CT (specify interval below)

    2. b.

      MR (specify interval below)

    3. c.

      Other (please specify below)

  18. 18.

    What criteria do you use to determine tumor response?

    1. a.

      European Association of the Study of Liver (EASL)

    2. b.

      World Health Organization (WHO)

    3. c.

      Response Evaluation Criteria in Solid Tumors (RECIST)

    4. d.

      Modified Response Evaluation Criteria in Solid Tumors (mRECIST)

    5. e.

      Other (please specify).

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Craig, P., Young, S. & Golzarian, J. Current Trends in the Treatment of Hepatocellular Carcinoma with Transarterial Embolization: Variability in Technical Aspects. Cardiovasc Intervent Radiol 42, 1322–1328 (2019). https://doi.org/10.1007/s00270-019-02232-7

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Keywords

  • Chemoembolization
  • Hepatocellular carcinoma (HCC)
  • Survey