Which Interventional Oncology Tool Is Best?
For those of us who more than dabble in interventional oncology we are aware of the myriad procedures available for unresectable hepatocellular carcinoma. I call this the interventional oncology menu. When HCC is unresectable, we can ablate with percutaneous ethanol injection, radiofrequency ablation, microwave ablation, irreversible electroporation, cryotherapy, or high-intensity focused ultrasound. If not appropriate, there is transarterial therapy and beyond that even combinations of transarterial therapy plus one of the above.
Transarterial therapy also has many camps, with disciples in each lauding their success. These include bland embolization, traditional transarterial chemoembolization, drug-eluting beads, and Y90. Having used all modalities, I try to tailor the treatment to the patient’s disease and accept that a different approach can lead to similar results. In fact, while preparing a lecture on “how I do it” to be given in hostile territory, I gladly reviewed the recent and less current data of all intra-arterial approaches. Trying to get a handle on the numbers, I realized that regardless of the intra-arterial treatment, the survival was pretty much the same in the recent studies done by dedicated individuals.
Each of these valuable studies described the method by which their results were obtained. It again became apparent that it might not be the type of therapy employed but how it is performed. There is a range of variables that play into the successful evaluation and treatment of patients with HCC and underlying liver disease. Is there appropriate 3- or 4-phase imaging? What is the ECOG and Child-Pugh status of the patient? How about the liver enzymes? Have the vessels been appropriately interrogated with selective and subselective microcatheters? Is the lesion apparent angiographically and if not is dyna computed tomography employed? Were extrahepatic vessels evaluated? What was the dose and type of drug or drugs administered? Was the dose diluted and by how much? At what rate was it delivered, slow or fast? Was the embolization taken to stasis or embo lite? And then of course there is the question of postembolization follow-up and the appropriate pre-, intra- and postprocedure medications.
These are some of the necessary variables that require meticulous attention. Failing to give these the proper consideration can lead to a less-than-desirable outcome that is unrelated to the mode of treatment. It appears from the literature that if appropriate, fastidious attention is paid to these many variables, each treatment modality will generate similar survivals with less untoward events. Again, “It is not the tool but the tool who is using it.” Better yet, don’t blame the dish if you forget the garlic! Jim Caridi MD FSIR
