Guideline Issued for Quality Improvement in TACE and Embolization of Hepatic Malignancy
The Society of Interventional Radiology (SIR) has published a quality improvement guideline for transarterial chemoembolization and embolization of hepatic malignancy.
The guideline was developed via a literature search, followed by critical review of peer-reviewed studies and level of evidence. In instances with unclear evidence, a Modified Delphi Consensus method was used to reach agreement on a parameter.
According to the authors, high-quality care in interventional radiology is driven by “quality assurance in case selection, procedure performance, and patient outcomes through establishment of threshold levels for therapy indication adherence, procedure success rates, and adverse event incidence.”
The document includes a diagnostic algorithm and treatment algorithm/decision tree that details general eligibility criteria as well as eligibility criteria in specific malignancies such as hepatocellular carcinoma, intrahepatic cholangiocarcinoma, metastatic NET, CRC liver metastases, metastatic uveal melanoma, and other liver metastases.
Preprocedural, procedural, and postprocedural considerations are covered in detail. Among the recommendations, the guideline states that:
* Antibiotics for gram-negative enteric organisms are often administered preprocedure, but not everyone follows this practice and the practice has not been prospectively proven as universally beneficial for patients.
* Patients with a disrupted sphincter of Oddi should receive antibiotic treatment for approximately 2 weeks.
* After transarterial chemoembolization, patients are often hospitalized overnight for observation, but same-day discharge may also be safe.
*Four weeks after treatment of all tumor-bearing areas, patients should undergo follow-up CT or MR imaging and response assessment should be performed with validated radiologic response criteria.
* Patients with no viable disease at the first follow-up should continually undergo follow-up surveillance every 3 to 6 months.
Quality Improvement considerations and thresholds include the following:
* The threshold for adherence to standard transarterial chemoembolization and embolization indications is 95%. When less than 95% of procedures are performed for this indication, operators may need to re-examine the patient selection process.
* The technical success threshold for transarterial chemoembolization and embolization is 95%, and success rates below this level may warrant review of institutional procedural methodology.
* Tumor response rates and clinical outcomes for individual operators should be similar to those in the published literature in at least 50% of cases.
* For serious adverse events, life-threatening or disabling adverse events, and patient deaths, the overall procedure threshold is 15%.
The authors affirmed the important role of transarterial chemoembolization and embolization in treating hepatic malignancies. “Although transarterial chemoembolization and embolization methodology may vary by practice, diligent periprocedure care, attentive interventional technique, and thorough clinical follow-up will optimize success rates and diminish adverse event incidence to ensure high quality oncologic care,” the authors concluded.
Gaba RC, Lokken RP, Hickey RM, et al. Quality improvement guidelines for transarterial chemoembolization and embolization of hepatic malignancy. J Vasc Interv Radiol. 2017;28(9):1210-1233.e3.