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BackTable / VI / Article
TACE vs Y90 in the Treatment of Hepatocellular Carcinoma
Alexander Aslesen • Updated Sep 19, 2025 • 5.2k hits
Transarterial chemoembolization (TACE procedure) and radioembolization (Y90 procedure) are two commonly used liver-directed therapies that play distinct roles in the treatment of hepatocellular carcinoma (HCC). Physicians often face the decision of choosing TACE vs Y90 depending on tumor characteristics, patient comorbidities, and treatment goals. While both therapies are minimally invasive and delivered through the hepatic artery, they differ in mechanism and clinical application.
Dr. Justin Lee and Dr. Terence Gade explain how the choice between TACE vs Y90 depends on factors such as tumor size, vascular involvement, liver function, and overall patient health. The TACE procedure is often preferred in patients with smaller lesions or those at an earlier stage of disease, while the Y90 procedure may be more effective in cases of large, diffuse, or bilobar tumors, or when portal vein thrombosis is present. By comparing outcomes, side effects, and patient selection criteria, they provide a clearer understanding of the benefits and drawbacks of each approach.
We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable Brief
• For HCC with unresectable tumor burden, the TACE procedure is often preferred for smaller lesions (less than 5 cm) when comparing TACE vs Y90.
• Dr. Justin Lee suggests using the Y90 procedure instead of the TACE procedure when primary HCC is complicated by metastatic disease or in cases of portal vein invasion.
• Treatment with the Y90 procedure generally has a smaller side effect profile, but it may be cost-prohibitive for certain patient populations, including those with Medicaid.
• Tumor susceptibility to treatment depends on molecular and vascular characteristics; some tumors may respond more effectively to radioembolization with Y90, whereas others are treated best with ischemia-driven interventions such as the TACE procedure.
Table of Contents
(1) When do I choose TACE vs Y90?
(2) TACE vs Y90: Advantages and Disadvantages
(3) Individualizing the Treatment Plan: TACE vs Y90
When do I choose TACE vs Y90?
Dr. Lee recommends using the TACE procedure for patients with BCLC stage A hepatocellular carcinoma (HCC) who present with one or more lesions measuring less than 5 cm. In these cases, ischemia-driven therapy through chemoembolization is often more effective and can provide good local control of disease. The TACE procedure allows for the delivery of chemotherapy directly to the tumor while simultaneously blocking its blood supply, which makes it particularly suitable for smaller, well-defined lesions.
On the other hand, Dr. Lee explains that the Y90 procedure is often the better option for treating metastatic disease, where the disease burden is more diffuse and not easily targeted with embolization alone. Radioembolization may also be preferred when treating bilobar disease, large infiltrative lesions, or cases of vascular invasion, since these tumors are more responsive to targeted radiation therapy than to ischemia. When comparing tace vs y90, patient selection is key, as the Y90 procedure can offer more favorable outcomes in complex presentations where TACE may be less effective.
[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.
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TACE vs Y90: Advantages and Disadvantages
The Y90 procedure is generally better tolerated by patients, with a smaller side effect profile when compared to the TACE procedure. Many patients experience fewer post-procedural symptoms such as pain, nausea, or fatigue, which makes Y90 an attractive option when evaluating TACE vs Y90 for hepatocellular carcinoma treatment. This improved tolerability can allow for faster recovery and better quality of life following therapy, especially in patients who may already have compromised liver function.
However, the Y90 procedure is also significantly more expensive than TACE therapy, and this financial factor plays a critical role in treatment decisions. For certain patient populations, including those insured through Medicaid or with limited financial resources, access to radioembolization may be restricted. In these situations, the TACE procedure may remain the more feasible choice despite its higher rate of side effects. As a result, cost considerations, insurance coverage, and overall accessibility often influence whether clinicians recommend TACE vs Y90 for a given patient.
[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, vs 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: TACE vs Y90
Choosing the correct endovascular therapy for hepatocellular carcinoma (HCC) should always be individualized to each patient rather than approached with a single standard protocol. Careful assessment of tumor characteristics such as vascularity, size, location, and degree of metastasis is essential in determining whether the TACE procedure or the Y90 procedure will offer the best outcome. These clinical details help guide physicians in making the most appropriate choice when weighing TACE vs Y90.
Some tumors are more susceptible to radiation therapy, making them better candidates for radioembolization with Y90, particularly in cases of vascular invasion or bilobar disease. In contrast, other tumors respond more effectively to ischemia-driven interventions, where the TACE procedure is used to block the blood supply and deliver localized chemotherapy. By aligning the treatment with both tumor biology and patient-specific factors, physicians can maximize effectiveness and minimize risks in the management of HCC.
[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 vs a more ischemic driven technology.
Additional resources:
Procedure Prep: Transarterial Chemoembolization (TACE)
https://www.backtable.com/shows/vi/topics/procedure/transarterial-chemoembolization-tace
Podcast Contributors
Cite This Podcast
BackTable, LLC (Producer). (2018, January 18). Ep. 20 – Pressure-Directed Therapy in TACE [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com 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. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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