JVIR November: Articles on Downstaging HCC with DEB-TACE and Y-90 - What's Your Practice?

Jul 9, 2013
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Two articles in the latest issue of JVIR address downstaging HCC with drug-eluting bead chemoembolization and selective internal radiotherapy with Y-90. Downstaging is often used in regions where transplantation lists are extensive. The following are abstract summaries of the two articles. Questions for discussion: Do you perform downstaging at your institution? What technique do you tend to use and why?



Article 1:

Downstaging Disease in Patients with Hepatocellular Carcinoma Outside of Milan Criteria: Strategies Using Drug-eluting Bead Chemoembolization

Green TJ, Rochon PJ, Chang S, et al.

22 patients remained in a retrospective single-center analysis, 17 of whom experienced downstaging to Milan criteria (7 went to transplant, 1 remained on the transplant list, 6 had disease progression, 2 underwent conventional chemoembolization and 1 radiofrequency ablation. The patients who were downstaged and those who weren't had similar age, MELD. They did not find an association with ECOG, tumor burden, presence of multiple tumors, or hepatitis C infection (p > 0.05 for all of them). Baseline AFP did differ btw those who survived and those who didn't (p=0.02), however, this did not persist with progression free survival (p = 0.62).



Article 2:

Yttrium-90 Radioembolization as a Bridge to Liver Transplantation: A Single-Institution Experience

Tohme S, Sukato D, Chen HW, et al.

22 Y-90's performed in 20 patients before transplantation. 3.5 months median time from first therapy to transplant. 14 pts met Milan criteria at first treatment and 6 did not (number of patients for downstaging low, especially in comparison with the first article). All 14 under Milan criteria remained before transplant and 2 of the 6 were downstaged. 9 patients meeting mRECIST criteria who had complete or partial response. 5 of the 14 patients who met Milan criteria had no evidence of tumor on path.



At our institution, we use conventional TACE, DEB-TACE and Y-90, depending on specific features. Interestingly, we've had several cases of patients with portal vein tumor thrombus who were downstaged with Y-90. We've also had several Y-90 cases where the pathologists reported absence of viable tumor on path.
 
Dec 9, 2011
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At the five hospitals that we cover, Y-90 is not done at all.
TACE is done at a very low volume sometime for metastatic colon cancer.

We are a relatively large group in the middle of a large metropolitan area covering multiple medium sized hospitals.

Interventional oncology procedures are done in places with active transplant service and also active surgical oncology service. Each state has 1-2 transplant centers which is almost always the big regional medical center. Outside that, nobody ablate HCC.
 

omarsaleh66

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Jul 10, 2003
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I'm in a private group and I mainly cover 1 400 bed hospital and offer partial coverage at another 400 bed hospital. I have started tace with deb at the main hospital I cover. I am using 100mg doxurubicin loaded beads and will treat a patient to downstage or bridge to transplant and then refer to the nearby transplant program when there has been adequate treatment. I have not started y90 yet. Starting a y90 program will be a pain in the butt.