Trans-Arterial Embolization for Liver Hemangiomas: It's a New Dawn; It's a New Day; It's a New Life?
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COMMENTARY
COMMENTARY
Trans-Arterial Embolization for Liver Hemangiomas: It’s a New Dawn; It’s a New Day; It’s a New Life? Tiago Bilhim1
•
Jafar Golzarian2 • Otto M. van Delden3
Received: 21 October 2020 / Accepted: 31 October 2020 Springer Science+Business Media, LLC, part of Springer Nature and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2020
If you ask a room full of hepatic surgeons and interventional radiologists (IRs) how we should treat symptomatic liver hemangiomas, most will likely say: surgery, surgery, surgery. Of course, symptoms, the performance status, comorbidities and age of the patient, lesion size and location will be essential aspects to consider before surgery. However, many IRs and hepatic surgeons feel that trans-arterial embolization (TAE) has no role when treating liver hemangiomas. Recently, two systematic reviews and metaanalyses have raised awareness on the potential role of TAE for liver hemangiomas [1, 2]. Is this the new dawn for TAE? These studies reviewed the data from 12 to 21 cohort studies including 1284–1450 patients. Major adverse events were reported in less than 3% due to pain, fever, biloma and liver abscesses. Minor adverse events including post-embolization syndrome and transient liver enzyme elevation were reported in 33%–37% of treated patients. Both reviews [1, 2] conclude that TAE is effective, reducing the size of hemangiomas in approximately 90% of treated patients, with a 4–6 cm reduction of the largest tumor diameter and a volume reduction of 45%–80%. Most patients (91.1%) will have a partial symptomatic relief, with 1.5% of patients presenting with persistent or
& Tiago Bilhim [email protected] 1
Interventional Radiology Unit, Centro Hospitalar Universita´rio de Lisboa Central (CHULC), Nova Medical School, Lisbon, Portugal
2
Department of Radiology, University of Minnesota, Minneapolis, USA
3
Department of Interventional Radiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
recurrent symptoms. Complete resolution of symptoms is rarely reported (7.4%). If TAE is safe and effective for reducing size and volume of liver hemangiomas and to relieve symptoms, why do many IRs feel that it does not work? This may be partially explained by the most recent meta-analysis [1] that also compared outcomes with different embolization techniques. Bland TAE with polyvinyl alcohol (PVA) particles, gelfoam and/or coils induces a reduction in size \ 1 cm, frequently insufficient for symptomatic improvement, with many patients experiencing increase in size and persisting symptoms. This has been the traditional approach for many IRs in the past. On the other hand, embolization with lipiodol mixed with bleomycin, pingyangmycin or ethanol was shown to induce a significantly greater size reduction of the liver hemangiomas; roughly 4–5 cm. Seems as it is not a matter of questioning if we should perform TAE for liver hemangiomas, but rather, how should we do it. For Western countries, lipiodol mixed with bleomycin
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