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Clinical and Imaging Follow-up Practices after Transarterial Therapy for Primary and Secondary Hepatic Malignancies

Posted Nov 30, 2015 Updated Apr 10, 2023
By Ron C. Gaba MD , Mark O. Baerlocher MD , Boris Nikolic MD , Aradhana M. Venkatesan MD , Robert J. Lewowski MD
8 min read

Rationale and Objectives

To characterize practices and quantify variation in longitudinal follow-up approaches among interventional radiologists (IRs) after liver transarterial locoregional therapy (LRT) in contemporary Interventional Oncology practice.

Materials and Methods

In November/December 2014, Society of Interventional Radiology members were invited to participate in a survey regarding clinical and imaging follow-up of liver cancer patients treated with transarterial LRT. On survey closure, responses were compiled and analyzed.

Results

The 30-item survey response rate was 11% (361 of 3290). Respondents were predominantly American IRs (311 of 355, 88%) who perform 1–5 LRTs monthly (196 of 354, 55%). Most (305 of 336, 91%) IRs reported longitudinal follow-up, with patient encounters within 1-month (73%, 211 of 290) postprocedure and every 3 months (68%, 196 of 287) thereafter and involvement in imaging (up to 80%, 235 of 290) ordering and evaluation. Preferred timing of first follow-up imaging (1 month vs. 3 months) and response criteria used (mRECIST favored) varied.

Conclusions

Although IRs are actively involved in clinical and imaging follow-up of patients with liver malignancies treated with transarterial LRTs, there are differences in imaging frequency and response assessment. These data may serve as a starting point for standardization of LRT follow-up.

Longitudinal care of Interventional Oncology (IO) patients may have an important role for optimizing clinical outcomes and is critical for the acceptance of Interventional Radiologists (IRs) into the cancer care treatment paradigm. Although essential for patient and treatment response assessment, standardization of clinical and imaging follow-up protocols after transarterial locoregional therapy (LRT) of hepatic malignancies is hampered by a lack of supporting evidence in the IR literature to dictate suitable follow-up methods and limited guidance regarding posttreatment surveillance practices in current clinical practice guidelines . The development of standardized, evidence-based postprocedure surveillance practices after IO procedures is of paramount importance as these procedures have become integral to the care of the oncology patient. Although previous survey data have suggested variation in follow-up practices within the IR community , there remains a paucity of formally acquired information on the specific follow-up approaches used by IRs after IO therapies. This exploratory survey study thus aimed to characterize practices and quantify variation in follow-up approaches among IRs after liver transarterial LRTs in contemporary IO clinical practice to better understand currently used surveillance methods as a framework for future standardization of postprocedure care.

Materials and methods

Between November 24 and December 29, 2014, 3290 American and international Physician members of the Society of Interventional Radiology (SIR) (In-Training, Scientist, and Clinical Associate members excluded) were requested to participate in a survey ( Appendix ) designed by the SIR IO Service Line and disseminated through an online survey company (SurveyMonkey, Palo Alto, CA). Invitations were sent via electronic mail from the SIR on survey commencement and 3 weeks after survey outset as a reminder for participation. The order of survey questions was identical for all respondents. Two variant but structurally and substantively analogous parallel survey pathways were used, with the final five survey questions (21–25 vs. 26–30) differing for participants based on the individual response to question 20. Responses to the password-protected questionnaire were anonymous, and no compensation was provided for participation. Survey settings were structured to allow only one response per invited e-mail address to prevent duplicate responses. On survey closure, responses were compiled and analyzed.

Results

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Respondent Demographics

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Table 1

Demographics of Survey Respondents and Practice Settings

Member Characteristics SIR Members (n = 361) ∗ Years in practice <1 year 17 (5%) 1–5 years 92 (25%) 6–10 years 68 (19%) 11–15 years 56 (16%) >15 years 127 (35%) Practice location United States 311 (88%) Canada 8 (2%) Europe 14 (4%) South America 5 (1%) Asia 17 (5%) Practice type Community-based hospital 185 (54%) University-based (academic) hospital 153 (44%) Free-standing facility 8 (2%) Practice size Individual 17 (5%) 2 IRs 32 (9%) 3–5 IRs 182 (51%) 6–10 IRs 86 (24%) >10 IRs 41 (11%) Hospital size <200 beds 31 (9%) 201–400 beds 114 (32%) 401–600 beds 97 (27%) 601–800 beds 54 (15%) 801–1000 beds 35 (10%) >1000 beds 26 (7%) Liver transarterial therapies performed per month 1–5 196 (55%) 6–10 81 (23%) 11–15 31 (9%) >15 46 (13%)

SIR, Society of Interventional Radiology; IR, interventional radiologist.

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Transarterial LRT Procedures

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Figure 1, Preferred transarterial LRTs for different tumor types. HCC: c-TACE = 25%, DEB-TACE = 49%, bland particle embolization = 1%, 90 Y RE = 25%. mCRC: c-TACE = 9%, DEB-TACE = 28%, bland particle embolization = 1%, 90 Y RE = 62%. mNET: c-TACE = 16%, DEB-TACE = 19%, bland particle embolization = 22%, 90 Y RE = 43%. ICC: c-TACE = 14%, DEB-TACE = 28%, bland particle embolization = 7%, 90 Y RE = 51%. LRT, locoregional therapy; HCC, hepatocellular carcinoma; c-TACE, conventional transarterial chemoembolization; DEB-TACE, drug-eluting bead transarterial chemoembolization; 90 Y RE, yttrium-90 radioembolization; mCRC, metastatic colorectal carcinoma; mNET, metastatic neuroendocrine tumor; ICC, intrahepatic cholangiocarcinoma.

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Clinical Follow-up

Frequency and Duration

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Laboratory Assessment

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Imaging Follow-up

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Follow-up Imaging Based on Tumor Type Treated

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Table 2

Preferred Imaging Follow-up Modality Based on Tumor Type Treated ∗ , †

Tumor Type CT MR Imaging PET-CT Ultrasound HCC 129/190 (68%) 144/190 (76%) 11/190 (6%) 1/190 (0.5%) mCRC 135/184 (73%) 71/184 (39%) 106/184 (58%) 2/184 (1%) mNET 140/183 (77%) 88/183 (48%) 34/183 (19%) 0/183 (0%) ICC 125/181 (69%) 119/181 (66%) 26/181 (14%) 0/181 (0%)

CT, computed tomography; MR, magnetic resonance; PET, positron emission tomography; HCC, hepatocellular carcinoma; mCRC, metastatic colorectal carcinoma; mNET, metastatic neuroendocrine tumor; ICC, intrahepatic cholangiocarcinoma.

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Figure 2, Preferred response evaluation method for different tumor types. HCC: WHO = 2%, RECIST = 12%, mRECIST = 46%, EASL = 10%, no specific imaging response evaluation criteria = 27%. mCRC: c WHO = 3%, RECIST = 22%, mRECIST = 39%, EASL = 5%, no specific imaging response evaluation criteria = 28%. Other (e.g. mNET, ICC): WHO = 2%, RECIST = 18%, mRECIST = 36%, EASL = 4%, no specific imaging response evaluation criteria = 37%. HCC, hepatocellular carcinoma; WHO, World Health Organization; RECIST, Response Evaluation Criteria in Solid Tumors; mRECIST, modified Response Evaluation Criteria in Solid Tumors; EASL, European Association for the Study of the Liver; mCRC, metastatic colorectal carcinoma; mNET, metastatic neuroendocrine tumor; ICC, intrahepatic cholangiocarcinoma.

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Follow-up Imaging Based on Transarterial LRT Used

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Table 3

Preferred Imaging Follow-up Modality Based on Transarterial LRT Used ∗ , †

Tumor Type CT MR Imaging PET-CT Ultrasound c-TACE 50/86 (58%) 44/86 (51%) 10/86 (12%) 2/86 (2%) DEB-TACE 48/83 (58%) 46/83 (55%) 12/83 (15%) 1/83 (1%) Bland embolization 46/79 (58%) 39/79 (49%) 8/79 (10%) 2/79 (3%) 90 Y RE 42/78 (54%) 38/78 (49%) 24/78 (31%) 0/78 (0%)

CT, computed tomography; MR, magnetic resonance; PET, positron emission tomography; c-TACE, conventional transarterial chemoembolization; DEB-TACE, drug-eluting bead transarterial chemoembolization; 90 Y RE, yttrium-90 radioembolization.

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Figure 3, Preferred response evaluation method for different LRTs. c-TACE: WHO = 0%, RECIST = 11%, mRECIST = 55%, EASL = 11%, no specific imaging response evaluation criteria = 23%. DEB-TACE: c WHO = 0%, RECIST = 9%, mRECIST = 56%, EASL = 11%, no specific imaging response evaluation criteria = 24%. Bland particle embolization: WHO = 0%, RECIST = 10%, mRECIST = 60%, EASL = 9%, no specific imaging response evaluation criteria = 21%. 90 Y RE: WHO = 0%, RECIST = 11%, mRECIST = 54%, EASL = 10%, no specific imaging response evaluation criteria = 26%. LRT, locoregional therapy; c-TACE, conventional transarterial chemoembolization; WHO, World Health Organization; RECIST, Response Evaluation Criteria in Solid Tumors; mRECIST, modified Response Evaluation Criteria in Solid Tumors; EASL, European Association for the Study of the Liver; DEB-TACE, drug-eluting bead transarterial chemoembolization; 90 Y RE, yttrium-90 radioembolization.

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Discussion

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Acknowledgments

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Supplementary data

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Appendix

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References

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Academic Radiology, Volume 22, Issue 12
Journals General Radiology
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