“This work highlights how central interventional radiology [IR] has become in the multidisciplinary care of patients with hepatocellular carcinoma [HCC]. What is particularly meaningful is that IR is not simply contributing procedures, it is involved throughout the patient journey, from first-line treatment to downstaging, bridging to transplantation and management of recurrent disease. From my perspective as a recent president of the Society of Interventional Radiology [SIR], this study reflects the broader evolution of our specialty from a procedural service to an integral clinical partner in longitudinal cancer care. As systemic and locoregional therapies continue to advance, our opportunity is to integrate these approaches thoughtfully to provide the right treatment, or combination of treatments, for each patient.”
These were the reflections of Robert Lewandowski (Northwestern University Feinberg School of Medicine, Chicago, USA), speaking to Interventional News following the publication of a 25-year single-centre multidisciplinary analysis of IR utilisation for the treatment of HCC at a high-volume academic transplant centre in the Journal of Vascular and Interventional Radiology (JVIR).
Between 2000 and 2025, 2,520 patients (72.6%) with HCC were treated by IR, which performed 4,313 procedures, with IR accounting for 68.3% of first-line treatments across all specialities. This finding, the authors write, demonstrates IR’s central role in HCC management. Following the 2020 US Food and Drug Administration (FDA) approval of atezolizumab plus bevacizumab as first-line systemic therapy for HCC, IR utilisation declined from 75.7% to 64.6%, yet remained the most utilised specialty, while absolute IR procedural volume was stable.
The results showed that IR procedures were comprised of transarterial radioembolization (TARE; 72.6%), transarterial chemoembolization (TACE; 18.7%), and ablation (7.9%). Surgery treated 1,350 (38.9%), medical oncology 746 (21.5%), and radiation oncology 96 (2.8%). Of 939 liver transplant patients, 510 (54.3%) received IR treatments pre-transplant at a median of 201 days, primarily TARE (67.0%).
The authors report that the procedural composition of IR “shifted remarkably”, with TARE rising to 86.8% of post-approval IR procedures, TACE declining from 24.7% to 2.3%, while microwave ablation (MWA) emerged as the second most common IR modality in the post-approval era at 10.8%.
The marked decline of TACE occurred alongside an expanding evidence base favouring TARE in selected patients, including prospective randomised data, evolving explant pathology and quality-of-life metrics. The authors reference findings from the PREMIERE and TRACE trials, which demonstrated superior median time to progression and overall survival for TARE, respectively.
According to the authors, the concurrent increase in MWA may reflect the emergence of thermal ablation as a curative conversion strategy in patients achieving tumour downsizing with systemic therapy, alongside advances in ablation device technology which have enabled more precise targeting and verification of ablation margins.
Findings also showed that surgical utilisation declined markedly with age, from 55% in patients under 50 to 8.8% in patients 75 years and older, while IR utilisation across the same age groups rose from 56.2% to 82.3%. The investigators note that systemic therapy and radiation utilisation remained consistent across all age groups.
“This inverse pattern between IR and surgery may reflect perceived tolerability, comorbidity considerations, and multidisciplinary treatment selection in older patients with greater comorbidity burden and reduced physiologic reserve, consistent with IR’s frequent use across the full age spectrum including in patients who are not surgical candidates,” write the authors.
Of note, the investigators highlight the “near-symmetric” distribution of IR before and after hepatic resection (24.6% vs. 26.5%), which contrasts with its predominantly pre-operative role before transplantation (54.3% vs. 3.1% after), which demonstrates IR’s “functionally distinct” purpose in these two surgical pathways.
Pre-resection IR treatments commonly include radiation lobectomy for future liver remnant hypertrophy induction. “[This treatment] serves a dual therapeutic and preparatory role and cannot be distinguished from purely therapeutic TARE using billing codes,” state the authors, “while post-resection IR reflects locoregional management of recurrent disease in the remnant liver.”
The pattern of specialty transitions further elucidates the frequent use of IR before surgical therapy, say the investigators, with 22.6% of treatment transitions originating from IR leading to surgery, compared with 3.9% of transitions originating from systemic therapy. The authors acknowledge that, while this difference may reflect the use of IR in treatment pathways intended to facilitate surgical candidacy through tumour control and/or liver remnant augmentation, it may also reflect underlying differences in disease stage, liver function and tumour burden.
Regarding limitations of their analysis, the study authors highlight its single-centre design which may limit generalisability, “particularly given early TARE expertise, IR utilisation and modality composition”, they note, which may differ across centres.
In summary, the investigators state: “These findings define the central and evolving role of IR in multidisciplinary HCC management and provide an institutional benchmark for evaluating the impact of future therapeutic advances.”
