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Current trends in the treatment of hepatocellular carcinoma with transarterial embolization: a cross-sectional survey of techniques

  • Interventional
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Abstract

Purpose

Despite being accepted as a mainstay of treatment for hepatocellular carcinoma (HCC), technical aspects of transarterial chemoembolization (TACE) continue to vary by reporting author, leading to heterogeneity in the literature and making meaningful comparisons between treatments difficult. The goal of this survey was to report international chemoembolization practices for the treatment of HCC in an effort to understand current treatment strategies as a first step towards technique standardization.

Materials and methods

An anonymous 18-question online survey, evaluating technical aspects of their TACE practice, was distributed via email to practicing members of the five largest interventional radiology societies in Chinese and English. A total of 1160 responses were obtained from 62 countries. Responses were categorized according to region of practice and analyzed using Fisher’s exact test and chi-square test with Bonferroni correction as needed.

Results

There were significant statistical differences between regions for nearly all questions. Doxorubicin was more commonly used among respondents from North America, Europe, and South Korea than Japan and China (p = 0.0001). For single and multiple HCCs, drug-eluting bead TACE was most popular in North America and Europe (p = 0.0001), while conventional TACE was most popular in Japan, Korea, and China (p = 0.0001). CT was the most commonly used modality for follow-up among all respondents, although MR was used more commonly in North America and in academic centers (p = 0.0001).

Conclusion

This survey provides comprehensive information on and confirms the heterogeneous nature of current practice patterns in regard to TA(C)E for HCC.

Key Points

• There is a lack of information regarding current practice patterns in the area of technical considerations when performing transarterial chemoembolization.

• Type of transarterial chemoembolization utilized to treat hepatocellular carcinoma varies widely across geographical area.

• Chemotherapeutic agents and embolic agents used to perform transarterial chemoembolization for the treatment of hepatocellular carcinoma vary widely across geographical areas.

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Abbreviations

AASLD:

American Association for the Study of Liver Disease

BCLC:

Barcelona Clinic Liver Cancer

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

EASL:

European Association for the Study of the Liver

HCC:

Hepatocellular carcinoma

JSIR:

Japanese Society of Interventional Radiology

KSIR:

Korean Society of Interventional Radiology

LRTs:

Locoregional therapies

mRECIST:

modified Response Evaluation Criteria in Solid Tumors

RECIST:

Response Evaluation Criteria in Solid Tumors

SIR:

Society of Interventional Radiology

TACE:

Transarterial chemoembolization

TAE:

Transarterial embolization

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Acknowledgments

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.

Funding

The authors state that this work has not received any funding.

Author information

Authors and Affiliations

  1. Department of Radiology, Division of Interventional Radiology, University of Minnesota, 420 Delaware St SE, MMC 292, Minneapolis, MN, 55455, USA

    Shamar Young, Paul Craig & Jafar Golzarian

Authors
  1. Shamar Young
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  2. Paul Craig
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  3. Jafar Golzarian
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Corresponding author

Correspondence to Shamar Young.

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Guarantor

The scientific guarantor of this publication is Shamar Young.

Conflict of interest

The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article.

Statistics and biometry

Lei Zhang kindly provided statistical advice for this manuscript.

Informed consent

Informed consent was not required because this was a survey of practicing Interventional Radiologists.

Ethical approval

Institutional Review Board approval was not required because this was a survey of practicing Interventional Radiologists.

Methodology

• Cross-sectional survey study

• Multicenter study

Appendix 1

Appendix 1

Survey Text:

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

This short (one-page) survey should not take more than two minutes 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)

    6. 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

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

    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. 50mg Doxorubicin for every person). Please list dose below.

    2. b.

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

    3. c.

      Body surface area (e.g. 50mg/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.

      0-5ml

    3. c.

      5-7.5ml

    4. d.

      7.5-10ml

    5. e.

      >10ml

    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 endpoint?

    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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Young, S., Craig, P. & Golzarian, J. Current trends in the treatment of hepatocellular carcinoma with transarterial embolization: a cross-sectional survey of techniques. Eur Radiol 29, 3287–3295 (2019). https://doi.org/10.1007/s00330-018-5782-7

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  • DOI: https://doi.org/10.1007/s00330-018-5782-7

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