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E1943. Liver-Directed Therapies for Transplant-Eligible and Near Eligible Patients With Hepatocellular Carcinoma: An Institutional Approach
Authors
  1. Ben McCafferty; University of Alabama at Birmingham School of Medicine
  2. Majd Habash; University of Alabama at Birmingham School of Medicine
  3. Junjian Huang; University of Alabama at Birmingham School of Medicine
  4. Robert Cannon; University of Alabama at Birmingham School of Medicine
  5. Andrew Gunn; University of Alabama at Birmingham School of Medicine
Background
For patients with hepatocellular carcinoma (HCC), interventional radiology can bridge transplant-eligible or downstage near transplant-eligible patients. In this exhibit, we will discuss our institution’s approach to liver-directed therapies in this patient population.

Educational Goals / Teaching Points
• Orient learners to liver transplant eligibility criteria and the importance of transplantation to patient survival • Discuss available therapeutic options for patients with HCC who are either transplant-eligible or near transplant-eligible • Describe our institution’s approach in selecting liver-directed therapies in this patient population (Table 1)

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
• Percutaneous ablation (PA): PA has oncologic outcomes similar to those of surgery for tumors up to 5 cm with greater preservation of hepatic function (1). Given a ~1% risk of tumor seeding after PA, the majority of our transplant-eligible and near transplant-eligible patients undergo intra-arterial therapies. • Conventional transarterial chemoembolization (cTACE): A randomized controlled trial supports cTACE for HCC (2) (Figure 1); although, it is being used less in our practice due to the emergence of drug-eluting bead transarterial chemoembolization (DEB-TACE). We primarily use cTACE in combination with PA or stereotactic body radiation therapy (SBRT) since the ethiodized oil retained within the tumor can act as a target under CT guidance. • DEB-TACE: DEB-TACE is the intra-arterial therapy of choice for multifocal HCC in our institution due to a reduction in liver toxicity and adverse effects when compared to cTACE (3). DEB-TACE can be performed with a variety of bead sizes and chemotherapy combinations. We use a single drug (doxorubicin 50-100mg) as there is no clear advantage to a triple-drug regimen. Smaller beads theoretically penetrate deeper into the tumor but can come at an increased risk of biliary necrosis. A study from our institution demonstrated the safety and efficacy of using beads as small as 75µm (4). Currently, our practice is to use 75µm beads for selective embolization while reserving larger beads (i.e., 100-300µm) for lobar therapies (Figure 2). • Transarterial radioembolization (TARE): TARE is most commonly used for tumors with main portal vein invasion since the radiolabeled spheres are not truly embolic within the hepatic artery. • cTACE + PA: Early studies have shown better outcomes with combination cTACE+PA than with either modality alone (5). Our institution employs combination cTACE+PA most frequently for tumors 3-5cm in size (Figure 3). • cTACE + SBRT: A retrospective study from our institution demonstrated a survival benefit from TACE+SBRT versus TACE alone in patients with tumors greater than 3cm in size (6). In our practice, cTACE+SBRT is most often used for tumors greater than or equal to 5cm (Figure 4).

Conclusion
Many liver-directed therapies exist for bridging transplant-eligible and downstaging near transplant-eligible patients with HCC. Without clear data to support one therapy over another, treatment selection is strongly driven by patient-specific factors and institutional experience.