Skip to main content
SpringerLink
Log in

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

  • Clinical Investigation
  • Interventional Oncology
  • Published:
CardioVascular and Interventional Radiology Aims and scope Submit manuscript

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

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

References

  1. Torre LA, Siegel RL, Ward EM, Jemal A. Global cancer incidence and mortality rates and trends—an update. Cancer Epidemiol Prev Biomark. 2016;25(1):16–27.

    Article  Google Scholar 

  2. Lai CL, Lok ASF, Wu PC, Chan GCB, Lin HJ. Doxorubicin versus no antitumor therapy in inoperable hepatocellular carcinoma. A prospective randomized trial. Cancer. 1988;62(3):479–83.

    Article  CAS  PubMed  Google Scholar 

  3. Varela M, Real MI, Burrel M, et al. Chemoembolization of hepatocellular carcinoma with drug eluting beads: efficacy and doxorubicin pharmacokinetics. J Hepatol. 2007;46(3):474–81.

    Article  CAS  PubMed  Google Scholar 

  4. Hong K, Khwaja A, Liapi E, Torbenson MS, Georgiades CS, Geschwind J-FH. New intra-arterial drug delivery system for the treatment of liver cancer: preclinical assessment in a rabbit model of liver cancer. Clin Cancer Res. 2006;12(8):2563–7.

    Article  CAS  PubMed  Google Scholar 

  5. Kan Z, Sato M, Ivancev K, et al. Distribution and effect of iodized poppyseed oil in the liver after hepatic artery embolization: experimental study in several animal species. Radiology. 1993;186(3):861–6.

    Article  CAS  PubMed  Google Scholar 

  6. de Baere T, Arai Y, Lencioni R, et al. Treatment of liver tumors with lipiodol TACE: technical recommendations from experts opinion. Cardiovasc Intervent Radiol. 2016;39(3):334–43.

    Article  PubMed  Google Scholar 

  7. Gaba RC. Chemoembolization practice patterns and technical methods among interventional radiologists: results of an online survey. Am J Roentgenol. 2012;198(3):692–9.

    Article  Google Scholar 

  8. Bargellini I, Florio F, Golfieri R, Grosso M, Lauretti DL, Cioni R. Trends in utilization of transarterial treatments for hepatocellular carcinoma: results of a survey by the Italian Society of Interventional Radiology. Cardiovasc Intervent Radiol. 2014;37(2):438–44.

    Article  PubMed  Google Scholar 

  9. Gaba RC, Baerlocher MO, Nikolic B, Venkatesan AM, Lewandowski RJ. Clinical and imaging follow-up practices after transarterial therapy for primary and secondary hepatic malignancies: results of an online survey. Acad Radiol. 2015;22(12):1510–5.

    Article  PubMed  Google Scholar 

  10. Young S, Craig P, Golzarian J. Current trends in the treatment of hepatocellular carcinoma with transarterial embolization: a cross-sectional survey of techniques. J Eur Radiol. 2018;1:2. https://doi.org/10.1007/s00330-018-5782-7.

    Article  Google Scholar 

  11. Llovet JM, Real MI, Montaña X, et al. Arterial embolisation or chemoembolisation versus symptomatic treatment in patients with unresectable hepatocellular carcinoma: a randomised controlled trial. Lancet. 2002;359(9319):1734–9.

    Article  PubMed  Google Scholar 

  12. Lo CM, Ngan H, Tso WK, et al. Randomized controlled trial of transarterial lipiodol chemoembolization for unresectable hepatocellular carcinoma. Hepatology. 2002;35(5):1164–71.

    Article  CAS  PubMed  Google Scholar 

  13. Raoul J, Heresbach D, Bretagne J, et al. Chemoembolization of hepatocellular carcinomas a study of the biodistribution and pharmacokinetics of doxorubicin. Cancer. 1992;70(3):585–90.

    Article  CAS  PubMed  Google Scholar 

  14. Nakamura H, Hashimoto T, Oi H, Sawada S. Transcatheter oily chemoembolization of hepatocellular carcinoma. Radiology. 1989;170(3):783–6.

    Article  CAS  PubMed  Google Scholar 

  15. Kan Z, Wright K, Wallace S. Ethiodized oil emulsions in hepatic microcirculation: in vivo microscopy in animal models. Acad Radiol. 1997;4(4):275–82.

    Article  CAS  PubMed  Google Scholar 

  16. Lee K-H, Liapi E, Ventura VP, et al. Evaluation of different calibrated spherical polyvinyl alcohol microspheres in transcatheter arterial chemoembolization: VX2 tumor model in rabbit liver. J Vasc Interv Radiol. 2008;19(7):1065–9.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Koçyiğit A, Dicle O, Göktay Y, Astarcıoğlu İ. The effect of using different embolic agents on survival in transarterial chemoembolization of hepatocellular carcinoma: gelfoam versus polyvinyl alcohol. Diagn Interv Radiol. 2014;20(4):323.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Bonomo G, Pedicini V, Monfardini L, et al. Bland embolization in patients with unresectable hepatocellular carcinoma using precise, tightly size-calibrated, anti-inflammatory microparticles: first clinical experience and one-year follow-up. Cardiovasc Intervent Radiol. 2010;33(3):552–9.

    Article  PubMed  Google Scholar 

  19. Stampfl S, Bellemann N, Stampfl U, et al. Inflammation and recanalization of four different spherical embolization agents in the porcine kidney model. J Vasc Interv Radiol. 2008;19(4):577–86.

    Article  PubMed  Google Scholar 

  20. Malagari K, Pomoni M, Spyridopoulos TN, et al. Safety profile of sequential transcatheter chemoembolization with DC Bead™: results of 237 hepatocellular carcinoma (HCC) patients. Cardiovasc Intervent Radiol. 2011;34(4):774–85.

    Article  PubMed  Google Scholar 

  21. de Baere T, Plotkin S, Yu R, Sutter A, Wu Y, Cruise GM. An in vitro evaluation of four types of drug-eluting microspheres loaded with doxorubicin. J Vasc Interv Radiol. 2016;27(9):1425–31.

    Article  PubMed  Google Scholar 

  22. Martin R, Irurzun J, Munchart J, et al. Optimal technique and response of doxorubicin beads in hepatocellular cancer: bead size and dose. Korean J Hepatol. 2011;17(1):51.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Lee K-H, Liapi E, Vossen JA, et al. Distribution of iron oxide—containing Embosphere particles after transcatheter arterial embolization in an animal model of liver cancer: evaluation with MR imaging and implication for therapy. J Vasc Interv Radiol. 2008;19(10):1490–6.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Lencioni R, De Baere T, Burrel M, et al. Transcatheter treatment of hepatocellular carcinoma with Doxorubicin-loaded DC Bead (DEBDOX): technical recommendations. Cardiovasc Intervent Radiol. 2012;35(5):980–5.

    Article  PubMed  Google Scholar 

  25. Lewis AL, Taylor RR, Hall B, Gonzalez MV, Willis SL, Stratford PW. Pharmacokinetic and safety study of doxorubicin-eluting beads in a porcine model of hepatic arterial embolization. J Vasc Interv Radiol. 2006;17(8):1335–43.

    Article  PubMed  Google Scholar 

Download references

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.

Author information

Authors and Affiliations

  1. University of Minnesota, 420 Delaware Street SE, Minneapolis, MN, 55455, USA

    Paul Craig, Shamar Young & Jafar Golzarian

Authors
  1. Paul Craig
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Shamar Young
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Jafar Golzarian
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Paul Craig.

Ethics declarations

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.

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.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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).

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

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

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00270-019-02232-7

Keywords

Search

Navigation