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Trans-arterial Chemoembolization of Liver Tumors (TACE) & Radioembolization of Liver Tumors (Y90)

Transarterial-chemoembolization (TACE) has been a palliative treatment or bridging treatment for liver cancer, whether primary or metastatic. TACE is a combination of local delivery of chemotherapy and a procedure to block of the blood supply to the tumor and trap the chemotherapy in the tumor.

Here to discuss the latest advances in trans-arterial chemoembolization of liver tumors (TACE) & radioembolization of liver tumors (Y90) is Dr Ahmed M. Kamel, he is the Chief, Interventional Radiology Co-Medical Director, Heart and Vascular Center at UAB Medicine.
Trans-arterial Chemoembolization of Liver Tumors (TACE) & Radioembolization of Liver Tumors (Y90)
Featured Speaker:
Ahmed M. Kamel Abdel Aal, M.D., M.Sc., Ph.D.
Dr. Abdel Aal currently serves as Chief of Vascular and Interventional Radiology at UAB and Children’s Hospital of Alabama, Medical Director of the Heart & Vascular Center and Medical Director of the Vascular Access Service. His areas of clinical interest are oncologic interventions, arterial interventions, spine interventions, DVT management and varicoceles embolization.

Learn more about Dr. Abdel Aal 

Dr. Abdel Aal has the following financial relationships with commercial interests:

Boston Scientific, Sirtex, BTG - Grants/Research Support/Grants Pending
Boston Scientific, Sirtex - Honorarium

Dr. Abdel Aal does not intend to discuss the off-label use of a product. No other speakers, planners or content reviewers have any relevant financial relationships to disclose.

There is no commercial support for this activity.
Transcription:

Melanie Cole (Host): UAB Medcast is an ongoing medical education podcast. The UAB Division of Continuing Education designates that each episode of this enduring material is worth a maximum of 0.25 AMA PRA Category One credit. To collect credit, please visit uabmedicine.org/medcast and complete the episode’s posttest.

Melanie Cole (Host): Hepatic neoplasms, both primary and metastatic in origin, have traditionally been regarded as difficult tumors to treat, let alone cure. However, recent advances in radioembolization are starting to challenge these long-held beliefs. Here to discuss the latest advances in transarterial chemoembolization of liver tumors and radioembolization of liver tumors is Dr. Ahmed Kamel. He’s the Chief in Interventional Radiology and the Co-Medical Director in the Heart and Vascular Center at UAB Medicine. Welcome to the show, Dr. Kamel. So explain a little bit about the concept of radioembolization.

Dr. Ahmed M. Kamel Abdel Aal, MD (Guest): So, radioembolization is, basically, we access the femoral artery in the groin with a catheter, and we try to find our way to catheterize the hepatic artery using image guidance, and once we reach the arteries that supply the tumor, we inject fine little either glass or resin beads that are very, very small, and they are loaded with a beta emitter, a radio-emitting material, called yttrium-90 or Y90, and once that gets into the tumor, it sits there and starts to irradiate the tumor and kills it as well.

Melanie: So, while we’re talking about both TACE and radioembolization, how are they performed? Who is qualified to perform these procedures?

Dr. Kamel: Well, these two procedures, an interventional radiologist should perform – is the person that’s qualified to perform these two procedures.

Melanie: So what would be the difference with transarterial chemoembolization versus what you just described as radioembolization?

Dr. Kamel: In transarterial chemoembolization, we do exactly the same thing except that the difference is that we inject tiny particles that are loaded with chemotherapy. That’s the name chemoembolization. That’s where the name came from. For radioembolization, the particles are loaded with a radio-emitting material, which is the Y90, and both of them kill the tumor differently, but they are both actually effective in killing primary liver tumors which is hepatocellular carcinoma. One of them kills them by releasing the chemotherapy into the tumor and blocking the blood supply to the tumor – that’s the transarterial chemoembolization, and the other one kills the tumor by beta emission and also by embolization, which is the process of the radioembolization.

Melanie: And is the hepatic artery, or the blood vessel, is it blocked so that it can’t come back out again?

Dr. Kamel: There is some instances where the tumor finds some other blood supply, and it’ll probably be another artery other than the one that is blocked, and that’s why this is not a curative treatment. It's palliative, and the tumor is likely to maybe come again or another tumor can show up somewhere else because some of these patients also have the background of liver disease which is cirrhosis, in the case of hepatocellular carcinoma. So, in these cases, we are going to have to repeat either the TACE or repeat transarterial radioembolization, which is the theory. So, yes, there is a chance that, you know, the artery, not the same artery, but different arteries will start feeding the tumor again, and then we have to go in and block them as well and do either transarterial chemoembolization or transarterial radioembolization.

Melanie: So, evaluate, just a bit for us, the safety and the efficacy of TARE versus TACE. So, which one do you prefer to use more often? Is there a reason or a contraindication to using either one over the other?

Dr. Kamel: It really depends on the type of the tumor. So, in the case of hepatocellular carcinoma, which is the primary tumor of the liver, we usually use TACE or TARE. Both of them are equally efficacious because TACE is, you know, more readily available, and it requires one session only. We usually use it more frequently. There are some instances in hepatocellular carcinoma where the portal vein, which is the vein that supplies blood also to the liver, when the vein is thrombosed because of tumor invasion. In these cases, we usually use radioembolization or transarterial radioembolization, which is the third. In case of metastatic disease to the liver, we usually use transarterial radioembolization. This is actually the best treatment for colorectal cancer metastasis to the liver or metastatic melanoma, or any other metastasis in which control of the liver metastasis is required because it affects the outcome and the survival of patients with these tumors.

Melanie: So, I stated in my intro, Dr. Kamel, that this has been palliative. Has it progressed now from being palliative in nature to curative with the introduction of ablative therapies and combination therapies? What are you seeing?

Dr. Kamel: Well, TACE and TARE are sometimes used in combination with other therapies, like you mentioned ablative therapy. This gives an outcome, or survival outcome, as equivalent to surgery with a transplant or segmentectomy. For example, if you do TACE followed by ablation, of course, you know, the patient has to meet certain criteria, and the tumor has to meet certain criteria, but if you do TACE and ablation, studies have shown that this is equivalent to segmentectomy, and there's also good results or improved results that happen if we do TARE in a certain way that makes it equivalent to what we call radiation segmentectomy. So, if we go very selectively into the artery that supplies the tumor and inject the high dose of radiation, it will probably produce segmentectomy field, which is, you know, in terms of survival outcomes might be equivalent to surgical segmentectomy.

Melanie: Then speak a little bit about patient selection criteria and pre-procedure management and clinical contraindications for the institution?

Dr. Kamel: Yeah. So, for both TACE and TARE, the criteria is the patient has to meet certain size criteria and also the portal vein invasion by the cancer is also important for us to decide between TACE versus TARE, but in both cases, you know, the patient should have a bilirubin that is less than 2. If we are doing very selective TACE or TARE, we can go a little bit above 2, but up to 3. The patient also has to be not very advanced in terms of the Child score. So, we prefer to do these on patients with Child score of A or B and not C, except again, in certain situations where we can get to the tumor only and not damage the surrounding liver. In these cases, we can also do Child C. Also, the performance status of the patient, which is what we call ECOG status of the patient. So, we usually try to do ECOG zero or one, and these are the patients that we have seen that will have better survival and better outcomes with these kind of procedures.

Melanie: So, what are some current issues in medical or surgical management, possible complications after embolization?

Dr. Kamel: There is something called post-embolization syndrome, which is basically pain that occurs at the site of embolization, and this can range from a general discomfort in the right upper quadrant where the liver is up to severe pain that really might require the use of narcotics for this, and it also, you know, some fevers and chills and things like that. It’s like flu-like symptoms or a flu-like disease. You know, it's always treated conservatively. Usually it goes away within seven to ten days, no longer than this, and that’s the beauty of using minimally-invasive procedures is there is usually a very fast recovery of these patients and there are very good survival outcomes for these patients, and like I said, you know, we are moving into combined therapy right now which gives, you know, survival outcomes that is equivalent to surgery.

Melanie: So expand just a minute about some current research. What does it indicate for future developments in these targeted treatments?

Dr. Kamel: Right now, you know, the medical community, especially the interventional community is looking at the value of using maybe a smaller size of the beads. Maybe looking also for loading these beads with different types of chemotherapy than what's available right now. So, all these are, you know, still under development, and it’s not yet FDA approved for usage. So, but this probably would be coming very soon to be used to improve the survival of patients either with HCC or metastasis to the liver.

Melanie: So, in summary Dr. Kamel, tell other physicians what you'd like them to know about TACE and TARE and when to refer to a specialist?

Dr. Kamel: So, if there is a patient who has hepatocellular carcinoma, definitely TACE is a very, very good treatment option for these patients, and this is a minimally-invasive procedure that can be done for these patients, and we would be happy definitely to see these patients and treat them. If the patients have metastasis from colorectal cancer or any other primary disease elsewhere in the body, and you feel that controlling the liver metastasis will affect the outcome of these patients, then definitely we would be happy to see these patients and treat them with the transarterial radioembolization which is also known as Y90.

Melanie: And tell us about your team, Dr.Kamel. Why is UAB so great to work with?

Dr. Kamel: UAB has a great team which starts from the nurses preparing the patient for the procedure up to the techs and nurses inside the room who will take care of the patient, and also we have physicians here, interventional radiologists, who are very specialized in interventional oncology, which includes TACE and TARE. The range of experience here ranges from five to thirty years of experience. Collectively, the experience of all the team members might reach up to 70 years of experience. So, we do a lot of these cases every year, and we have a lot of, you know, experience in how to manage even difficult cases and difficult tumors, and the patients are always very satisfied with the outcomes and the physicians as well.

Melanie: Thank you so much Dr. Kamel for being with us today, and a community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That’s 1-800-822-6478. You're listening to UAB Medcast. For more information on resources available at UAB Medicine, you can go to uabmedicine.org/physician. That’s uabmedicine.org/physician. This is Melanie Cole. Thanks so much for listening.