Complications Related to Transarterial Treatment of Hepatocellular Carcinoma: A Comprehensive Review

Lee Hyoung Nam,Hyun Dongho 대한영상의학회 2023 Korean Journal of Radiology Vol.24 No.3

Currently, various types of transarterial treatments are performed for hepatocellular carcinoma from the early to advanced stages. Its indications and efficacy have been widely investigated. However, procedure-related complications have not been updated in the literature, although new types of transarterial treatments, such as drug-eluting bead transarterial chemoembolization and transarterial radioembolization, are common in daily practice. Herein, a comprehensive literature review was carried out, and complications were organized according to the organs affected and treatment modalities.

조기 간암에서의 동맥치료: 완화법에서 완치법으로

오정석 ( Jung Suk Oh ),천호종 ( Ho Jong Chun ) 대한간암학회 2012 대한간암학회지 Vol.12 No.2

Early stage hepatocellular carcinoma (HCC) based on BCLC staging system can be curatively treated by liver transplantation, surgical resection or percutaneous ablation. However, transarterial approaches, including transarterial chemoembolization (TACE) or transarterial radioembolization (TARE), are standard of care for intermediate stage HCC and can be an alternative treatment in the patients with early stage HCC which are unresectable, unsuitable for percutaneous ablation, or not eligible for liver transplantation. Many previous TACE studies in early stage HCC revealed that the overall survival rate was competitive with those of curative therapies considering their operation risks, but recurrence-free survival rate was significantly lower than curative therapies. Moreover, the histopathologic reports about TACE in early stage HCC demonstrated that only 38% of the HCC nodules were completely necrotic after TACE and only 81% of the nodules with complete response by EASL criteria showed complete necrosis. Although there is no long-term survival data about TARE in early stage HCC, a histopathologic report about TARE showed that 73% of the HCC nodules were completely necrotic after TARE and 100% of the nodules with complete response by EASL criteria showed complete necrosis. In conclusion, TACE is now limited to be categorized into a curative therapy in early stage HCC, according to the previous data about TACE. However, new recent technologies including C-arm CT, superselective embolization technique, drug-eluting bead (DEB) may sufficiently improve the survival data of TACE to prove its curative role. Considering its RFA-comparable histopathologic tumor response, TARE may prove to be a potential curative therapeutic for early stage HCC.

Radioembolization for hepatocellular carcinoma: what clinicians need to know

( Jin Woo Choi ),( Hyo-cheol Kim ) 대한간암학회 2022 대한간암학회지 Vol.22 No.1

Transarterial radioembolization (TARE) with yttrium 90 (⁹⁰Y) has been used in the management of hepatocellular carcinoma (HCC) for more than 10 years in Korea. There are two types of ⁹⁰Y radioactive microspheres available, namely, glass and resin microspheres, with comparable clinical outcomes. In general, TARE outperforms transarterial chemoembolization regarding post-embolization syndrome, time to progression, tumor downsizing for liver transplantation, and hospitalization stay. Although TARE is commonly recommended for patients with unresectable large HCCs, it can be an alternative to or performed in combination with ablation, surgical resection, and systemic treatment. This review aimed to address ⁹⁰Y radioactive microspheres, patient selection, clinical outcomes, simulation tests, radioembolization procedures, follow-up imaging, and complications. (J Liver Cancer 2022;22:4-13)

A Prognostic Prediction Model of Transarterial Radioembolization in Hepatocellular Carcinoma: SNAP-HCC

( Joon Yeul Nam ),( Yun Bin Lee ),( Jeong-hoon Lee ),( Su Jong Yu ),( Hyo-cheol Kim ),( Jin Wook Chung ),( Jung-hwan Yoon ),( Yoon Jun Kim ) 대한간학회 2020 춘·추계 학술대회 (KASL) Vol.2020 No.1

Aims: Transarterial radioembolization (TARE) has been one of the treatment options for hepatocellular carcinoma (HCC). However, the indication of TARE was not well-established and prognosis after TARE still remains difficult to predict among individual patients. The aim of this study was to develop a prognostic scoring model to guide TARE initiation. Methods: A total of 174 consecutive patients who underwent TARE for HCC as an initial treatment in Korea were included. The primary outcome was overall survival (OS) from the date which TARE was performed. We developed a prediction model using independent risk factors for OS and conducted a validation with bootstrap. Results: Median maximal tumors size was 8.15 cm (interquartile range (IQR), 5.8-12.0) and median tumor number was 2 (IQR, 1-3). Median albumin level was 4.0 g/dl (IQR, 3.6-4.2). Portal vein invasion was found in 80 patients [46%, Vp1-3 (39.7%) and Vp4 (6.3%)]. Using four independent risk factors associated with OS (maximal tumor Size, tumor Number, serum Albumin, and Portal vein invasion), a scoring system (SNAP-HCC) was developed. Harrell C-index values for OS were 0.756 (95% confidence interval: 0.729-0.783) in validation using bootstrap. The patient group according to SNAP-HCC score (0-5) were well-discriminated and showed significantly different OS among each group (all P<0.001). Patients with SNAP-HCC<3 showed significantly longer OS than patients with SNAP-HCC≥3 (P<0.001) (Figure). The expected survival probabilities at years 1, and 3 were 0.81 and 0.73 in the low-risk group (SNAP<3); and 0.32 and 0.14 in the high-risk group (SNAP≥3), respectively. Conclusions: SNAP-HCC score system could predict a prognosis of HCC patients who underwent TARE as an initial treatment. This model could be helpful for making a decision for selecting HCC treatment.

Recent advances in transarterial embolotherapies in the treatment of hepatocellular carcinoma

( Edward Wolfgang Lee ),( Sarah Khan ) 대한간학회 2017 Clinical and Molecular Hepatology(대한간학회지) Vol.23 No.4

Management of hepatocellular carcinoma (HCC) can be maximized with the utilization of multiple treatment modalities including transplant, surgical resection and locoregional therapies including ablative therapies and transarterial embolotherapies. Although transplant and surgical resection offer the best clinical outcomes, a limited number of patients are amenable to these surgical treatment options due to the advanced disease at presentation. Transarterial embolotherapies including conventional transarterial chemoembolization (cTACE), bland transarterial embolization (TAE), drug-eluting beads transarterial chemoembolization (DEB-TACE) and selective internal radiation therapy (SIRT) with Yttrium 90 (⁹⁰Y) have played an increasingly important role for these patients with unresectable HCC. With a better understanding of different transarterial embolotherapies, more personalized and precise treatment should be implemented for these patients with unresectable HCC. In this review, the updated evidence on the current role of each embolotherapy in the treatment of HCC is summarized. (Clin Mol Hepatol 2017;23:265-272)

Transarterial radioembolization versus tyrosine kinase inhibitor in hepatocellular carcinoma with portal vein thrombosis

Moon Haeng Hur,Yuri Cho,Do Young Kim,Jae Seung Lee,Gyoung Min Kim,Hyo-Cheol Kim,Dong Hyun Sinn,Dongho Hyun,Han Ah Lee,Yeon Seok Seo,In Joon Lee,Joong-Won Park,Yoon Jun Kim 대한간학회 2023 Clinical and Molecular Hepatology(대한간학회지) Vol.29 No.3

Background/Aims: Transarterial radioembolization (TARE) has shown promising results in treating advanced hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT). However, whether TARE can provide superior or comparable outcomes to tyrosine kinase inhibitor (TKI) in patients with HCC and PVTT remains unclear. We compared the outcomes of TARE and TKI therapy in treatment-naïve patients with locally advanced HCC and segmental or lobar PVTT. Methods: This multicenter study included 216 patients initially treated with TARE (n=124) or TKI (sorafenib or lenvatinib; n=92) between 2011 and 2021. Baseline characteristics were balanced using propensity score matching (PSM) or inverse probability of treatment weighting (IPTW). The primary outcome was overall survival (OS). The secondary outcomes included progression-free survival (PFS) and objective response rate (ORR). Results: In the unmatched cohort, the median OS of the TARE and TKI groups were 28.2 and 7.2 months, respectively (P<0.001), and the TARE group experienced significantly and independently longer OS compared to the TKI group (adjusted hazard ratio=0.41, 95% confidence interval=0.28–0.60, P<0.001). Similar results were observed in the study cohorts balanced with IPTW (P=0.003) or PSM (P=0.004). Although PFS was comparable between the two groups, the TARE group showed a trend of prolonged PFS in a subpopulation of patients with Vp1 or Vp2 PVTT (P=0.052). In the matched cohorts, the ORR of the TARE group was 53.0–56.7%, whereas that of the TKI group was 12.3–15.0%. Conclusions: For patients with advanced HCC with segmental or lobar PVTT and well-preserved liver function, TARE may provide superior OS compared to sorafenib or lenvatinib.

Extrahepatic 90 Y Complication; Gastric Ulcer Secondary to 90 Y Therapy for Liver Metastasis Despite Negative Preprocedural Imaging

Connor Shea 대한핵의학회 2024 핵의학 분자영상 Vol.58 No.2

Transarterial radioembolization using yttrium-90 (90Y) therapy has become a standard modality of treatment for primary andmetastatic liver malignancies due to its high efficacy rate and relatively low risk of adverse effects compared to other formsof locoregional and systemic therapies. Non-target distribution of radio embolic beads and adjacent structure radiation arethe two most common adverse effects. However, these are rarely encountered due to thorough imaging and mapping studiesprior to 90Y therapy. We present the case of a 66-year-old male who developed a radiation-induced gastric ulcer following90Y therapy with negative pre-procedural imaging and mapping who was retrospectively found to have an accessory arteryfrom the left hepatic artery to the gastric antrum.

Radioembolization for the treatment of hepatocellular carcinoma

( Hyo-cheol Kim ) 대한간학회 2017 Clinical and Molecular Hepatology(대한간학회지) Vol.23 No.2

Transarterial radioembolization (TARE) with yttrium 90 (⁹⁰Y), an intra-arterial procedure performed by interventional radiologists, has begun being utilized in managing hepatocellular carcinoma (HCC) in Korea. There are two available TARE products: glass and resin microspheres with different physical characteristics. All patients undergoing TARE must be assessed with clinical examination and laboratory tests as well as a thorough angiographic evaluation. TARE is safe and effective in the treatment of unresectable HCC, as it has longer time-to-progression, greater ability to downsize tumors for liver transplantation, less post-embolization syndrome, and shorter hospitalization compared with chemoembolization. TARE can also serve as an alternative to ablation, surgical resection, portal vein embolization, and sorafenib. The utility of TARE continues to expand with new insights in interventional oncology. (Clin Mol Hepatol 2017;23:109-114)

The Radiation Dose Absorbed by Healthy Parenchyma Is a Predictor for the Rate of Contralateral Hypertrophy After Unilobar Radioembolization of the Right Liver

Nazim Coskun 대한핵의학회 2022 핵의학 분자영상 Vol.56 No.6

Purpose To investigate the predictors of contralateral hypertrophy in patients treated with unilobar transarterial radioembolization(TARE) with yttrium-90-loaded resin microspheres due to unresectable right-liver tumors. Methods Patients who underwent right unilobar TARE with resin microspheres between May 2019 and September 2021were screened retrospectively. Contralateral hypertrophy was evaluated by calculating the kinetic growth rate (KGR) in 8–10weeks after TARE. The predictors of increased KGR were determined with linear regression analysis. Results A total of 24 patients (16 with primary and 8 with metastatic liver tumors) were included in the study. After right unilobarTARE, mean volume of the left lobe increased from 368.26 to 436.16 mL, while the mean volume of the right lobe decreased from1576.22 to 1477.89 mL. The median KGR of the left lobe was 0.28% per week. The radiation dose absorbed by the healthy parenchymaof the right lobe was significantly higher in patients with increased KGR (31.62 vs. 18.78 Gy, p = 0.037). Linear regression analysisshowed that the dose absorbed by healthy parenchyma was significantly associated with increased KGR (b = 0.014, p = 0.043). Conclusion Patients who received right unilobar TARE for liver malignancies could develop a substantial contralateralhypertrophy, and the radiation dose absorbed by the healthy parenchyma of the right lobe was significantly associated withincreased KGR in the left lobe. TARE could have a role for inducing contralateral hypertrophy as it offers the advantage ofconcurrent local tumor control along with its hypertrophic effect.

Transarterial Radioembolization Agents: a Review of the Radionuclide Agents and the Carriers

Alrfooh Aysheh,Patel Aditi,Laroia Sandeep 대한핵의학회 2021 핵의학 분자영상 Vol.55 No.4

Liver tumors, both primary and secondary to metastatic disease, remain a major challenge, with an increasing incidence. In this context, taking advantage of the dual blood supply of the liver, and the fact that liver tumors derive majority of their blood supply from the hepatic artery, intraarterial therapies are gaining popularity. Intraarterial liver-directed therapy (IALDT) is the option when the surgery is not feasible due to the number of metastases or for other reasons. Transarterial radioembolization (TARE) is a specific type of IALDT, where a carrier particle/microsphere is labeled with a radioactive substance and then is injected into hepatic artery for therapeutic purposes. As this field is rapidly evolving, with multiple agents being investigated and being introduced into clinical practice, it is hard for the practitioners and researchers to encompass all the available information concisely. This article aims to present a comprehensive review of the prominent TARE technologies.