Updated: May 3
Transarterial chemoembolization (TACE) and radioembolization (Y90) have individualized roles in the treatment of hepatocellular carcinoma. Dr. Justin Lee and Dr. Terence Gade discuss which patients are best suited for TACE versus Y90, as well as the advantages and disadvantages for each intervention.
The BackTable Brief
For HCC with unresectable tumor burden, TACE may be better suited for smaller lesions (<5 cm).
Dr. Justin Lee suggests using radioembolization over TACE when primary HCC is complicated by metastatic disease or in cases of portal vein invasion.
Treatment with Y90 may have a smaller side effect profile, yet may be cost prohibitive in certain patient populations, such as those with Medicaid.
Tumor susceptibility to certain treatments is dependent on molecular and vascular characteristics; some tumors may respond well with radioembolization whereas others are treated best with ischemia-driven interventions.
Disclaimer: The opinions expressed by the participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
When do I choose TACE versus Y90?
Dr. Lee recommends using TACE for cases of BCLC stage A HCC with lesion(s) less than 5 cm. He uses Y90, or radioembolization, on the other hand for treating metastatic disease. Radioembolization may also be preferred in the treatment of bilobar disease, large infiltrative lesions, and in cases of vascular invasion. [Michael Barraza] There has been a lot of buzz about some of the more recent data comparing chemoembolization to radioembolization for HCC. Do either of you anticipate any changes to your approach in the coming years?
[Justin Lee] If I have a small lesion, I will probably do TACE ablation if that person does not undergo resection. So we pretty much follow the BCLC, and we don't really amend it. So if they're BCLC-A, and they've got a small lesion or one lesion or maybe a few lesions, but they're all less than five centimeters or even less than three centimeters, then I'm going to TACE ablate that before I would apply Y90. For me, radioembolization is a tool for metastatic disease, and really in my practice at Georgetown that was the gateway for us to get into metastatic disease. By that I mean colorectal, pancreas … We apply it just about anything, anything that we think is radiosensitive or the patient would do better with a wider scope of embolization using a different model rather than vessel occlusion and a drug. Then we would apply radioembolization.
So for me, if somebody has HCC with portal vein invasion or their disease is behaving more as if they were a patient that had metastatic disease … And by that I mean bilobar disease, large infiltrative lesions, vascular invasion. That is, for me, a radioembolization patient. It's got a lot more nuances to it, and without a real demonstrable survival benefit except potentially for cases of portal vein invasion.
What are the advantages and disadvantages of TACE versus Y90 therapy?
Y90 is better tolerated with a smaller side effect profile when compared to TACE therapy. However, Y90 is an expensive treatment option, which isn’t feasible for certain patient populations, such as those on Medicaid. [Justin Lee] Y90 is a very well-tolerated procedure. Clearly, it's been shown that [between] TACE and Y90, TACE has more side effects. For me, I send people home oftentimes on the same day as a DEB TACE.
… The point you bring up about accessibility, I'd like to see Y90 more accessible in the community, but it is true. We did a little analysis: 25 to 30 percent of our population does not have Medicare and they’re on Medicaid. I already know before I see that patient that they're not a Y90 candidate. Whether I want them to be or not, I've got to be a little bit creative with how I'm going to treat those patients. I can get somebody scheduled for a TACE the next day, pretty much, versus a Y90. You can wait sometimes a long time still in that predetermination area, and if you're not fast in the community, your oncologist is going to move along. I think that's another point that people don't really think about.
When I was in academics, I was in that role where we were getting people that were [treatment] failures, or people didn't want to treat them in the community because HCC doesn't really have a whole lot of infusional therapies. Okay, then, you can start applying Y90. However, when you start to get out into the community you're not going to have that luxury. You're not going to be able to apply a therapy that the dose alone is $16,000, and you've got to map them once and then treat them again.
When you look at the nitty gritty of the program, I think TACE is just easy, it works, it's effective, patients do well from it, and it's been tried and true since the '90s. Individualizing the Treatment Plan
Choosing the correct endovascular therapy for HCC should be individualized to each patient. Identifying tumor characteristics such as vascularity, size, and degree of metastasis determines how the tumor should be treated. Some tumors are more susceptible to radiation whereas others respond to ischemia-driven interventions.
[Terence Gade] I would say that we're clearly, especially with the results of the PREMIERE trial, making significant strides with respect to characterizing the variety of different endovascular local regional therapies we can apply - we obviously, as Justin mentioned, have a lot of important progress to make. Specifically, I think we really need to use all the information at our disposal. This is how I think about it and I think a lot of my colleagues think about it too: [do] not assume that every tumor is alike or every HCC is alike and really consider the biology of the tumor and what data we have from our imaging to influence that. Our ultimate goal, with the Cancer Moonshot and a lot of these initiatives going on, is to apply a precision medicine approach. While that can mean a lot of different things to different people, I think we do have tools to generate a precision medicine approach in this regard [when] looking at the vascularity of the tumor and things of that nature … we know on a molecular level about the tumor itself and what that can mean for its susceptibility to radiation versus a more ischemic driven technology.
Podcast Participants: Dr. Justin Lee is a practicing interventional radiologist at Radiology Associates of Florida in Tampa, FL. Dr. Terence Gade is a practicing interventional radiologist with at the University of Pennsylvania. Dr. Michael Barraza Jr is a practicing interventional radiologist at Radiology Alliance in Nashville. Cite this podcast: BackTable, LLC (Producer). (2018, January). Ep 20 – Pressure-Directed Therapy in TACE [Audio podcast]. Retrieved from https://www.backtable.com/podcasts Medical Disclaimer: The Materials available on the BackTable Blog are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. Disclosures: The podcast referenced in this article was sponsored by Surefire Medical.