Transarterial Therapy Research Articles

Effect of transarterial chemoembolization prior to selective internal radiation therapy on yttrium-90 microsphere delivery in hepatocellular carcinoma patients.

458 Background: Transarterial chemoembolization (TACE) and selective internal radiation therapy (SIRT) are commonly used for treatment of liver tumors. The use of TACE, which is macroembolic, prior to SIRT may cause hemodynamic changes in tumor vasculature that impair yttrium-90 (90Y) microsphere delivery to the targeted lesions. This work aims to quantify dosimetric tumor coverage using positron emission tomography (PET) dosimetry after SIRT alone compared to TACE followed by SIRT. Methods: A total of 40 consecutive hepatocellular carcinoma (HCC) SIRT patients who had a post-SIRT PET scan were evaluated. Yttrium-90 PET scan was performed within 2 hours after completion of SIRT. 3D dose distribution of each patient was then reconstructed from the PET images. To quantify the quality of SIRT microsphere delivery, we evaluated the selectivity index (SI) defined as the ratio of the average dose inside the treated lesion(s) and the average dose of the normal liver. The SI values of patients were compared based on whether TACE was previously used. Results: Thirty patients had complete data for analysis. The average dose for a total of 125 targeted lesions was 106 Gy (range 0 Gy – 495 Gy). The average SI of the entire patient group was 3.0, indicating that the targeted lesion dose was three times higher than normal liver dose. The average SI was 1.7 for the 13 patients who had prior TACE and 3.8 for the 17 patients who did not have prior TACE (p = 0.01). Nearly 80% of the patients with prior TACE demonstrated poor 90Ymicrosphere delivery (SI < 2) while none demonstrated excellent microsphere delivery (SI > 4). On the other hand, the incidence of SI < 2 and SI > 4 among patients with no prior TACE was 24% and 40%, respectively. Conclusions: 3D dose evaluation using post-SIRT PET suggests that 90Y microsphere delivery to liver tumors is impaired among patients who received prior TACE compared to those who receive SIRT alone. These data warrant evaluation of clinical outcomes in SIRT patients based on prior use of TACE and may provide a rationale for the use of SIRT prior to TACE.

Radiological and Clinical Features of Vein of Galen Aneurysmal Malformation In Newborn, Endovascular Interventional Treatment Management: 10 Years Experience

Objective: To assess the clinical features, diagnosis, management strategies and results of newborns born between the years 2005-2015 with Vein of Galen Malformation (VGAM). Material and Method: Eight newborn patients with diagnosis of VGAM were assessed retrospectively in terms of clinical admission symptoms, diagnosis, treatment strategies and follow-up based on the information retrieved from patient files. Three of four patients who survived had neurological assessment while the information about the remaining patient whose family moved to another city were obtained via phone call. Results: Seven out of 8 patients (1 female, and 7 male patients) had antenatal diagnosis. In all cases severe heart failure and pulmonary hypertension were present from the first days of their life, later on development of hypotension, multiorgan failure, hydrocephalus and seizures was seen. VGAM and its feeder arteries were mapped by cranial magnetic resonance imaging and magnetic resonance angiography. Transarterial embolization therapy was performed successfully in four patients. Despite similar treatment modalities three of these patients died, and one patient was lost before initiation of embolization procedure. Conclusion: VGAM has high mortality and morbidity rates because of its complicated anatomy, pathophysiology leading to severe neurological sequelae. Prognosis in high risk neonates can be improved with aggressive medical support and early endovascular embolization therapy.

Treatments of Hepatocellular Carcinoma Patients with Hepatitis B Virus Infection: Treat HBV-related HCC

There have been major advances recently on the therapeutic approaches of hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC). Surgical treatments are the key curative treatments of HCC, whereas local ablative treatments may also achieve clinical remission in selected cases. Trans-arterial locoregional therapies are regarded as palliative but still lead to improved survival. There have been major breakthroughs in the systemic therapies for HCC. The first marketed targeted therapy, sorafenib, was shown to improve survival in patients with advanced HCC. Studies on other targeted therapies also showed promising results. Suppressing HBV with effective antiviral treatment would also benefit HCC patients by reducing recurrence and improving liver function.

Catheter-based transarterial therapies for hepatocellular cancer.

As the prevalence of liver cancer increases, so does the demand for nonsurgical, minimally invasive alternatives to surgery, since many patients have tumors that cannot be surgically resected. Catheter-based hepatic arterial procedures may be an option in patients with primary and metastatic liver cancer. The authors describe four catheter-based hepatic arterial procedures and outline the management of potential complications during the immediate postprocedural period.

Effects of combining transarterial chemoembolization with percutaneous microwave coagulation therapy for hepatocellular carcinoma abutting the diaphragm

Objective: This study aims to explore the clinical effectiveness of a combination therapy of transarterial chemoembolization (TACE) and percutaneous microwave coagulation therapy (PMCT) in treating hepatocellular carcinoma (HCC) abutting the diaphragm. Material and methods: Six cases with HCC were treated with TACE followed by PMCT one month later with the aid of artificial pneumothorax. Results: CT/MRI revealed complete necrosis in the tumor lesions and the treated tumor margins (≥5 mm). Serum alpha-fetoprotein (AFP) levels markedly declined in patients who originally had higher serum AFP levels. Postoperative complications such as fever, mild hepatic dysfunction and pleural effusion were alleviated within a short period of time. All patients were closely monitored through follow-up; all patients survived, except for one patient who received a liver transplantation. Conclusions: As lesions are either invisible or poorly visible in sonography, determining an effective treatment for HCC abutting the diaphragm remains a particular challenge. TACE and PMCT combined therapy with the aid of artificial pneumothorax proved to be an available treatment option.

Navigational Tools for Interventional Radiology and Interventional Oncology Applications

The interventional radiologist is increasingly called upon to successfully access challenging biopsy and ablation targets, which may be difficult based on poor visualization, small size, or the proximity of vulnerable regional anatomy. Complex therapeutic procedures, including tumor ablation and transarterial oncologic therapies, can be associated with procedural risk, significant procedure time, and measurable radiation time. Navigation tools, including electromagnetic, optical, laser, and robotic guidance systems, as well as image fusion platforms, have the potential to facilitate these complex interventions with the potential to improve lesion targeting, reduce procedure time, and radiation dose, and thus potentially improve patient outcomes. This review will provide an overview of currently available navigational tools and their application to interventional radiology and oncology. A summary of the pertinent literature on the use of these tools to improve safety and efficacy of interventional procedures compared with conventional techniques will be presented.

Intermediate hepatocellular carcinoma: the role of transarterial therapy.

According to Barcelona Clinic Liver Cancer, the recommended first-line treatment for patients with intermediate stage of hepatocellular carcinoma (HCC) is transarterial chemoembolization. Patients with intermediate stage of HCC represent 20% with a 2-year survival of approximately 50%. Nowadays, transarterial therapies have proved precious in the treatment of hepatic malignancies. During the last years, there were important developments in practiced transarterial therapies and their efficacy is still controversial. The purpose of this review is to discuss in further details these transarterial therapies that have been used to treat cases of HCC.

Clinical and Imaging Follow-up Practices after Transarterial Therapy for Primary and Secondary Hepatic Malignancies: Results of an Online Survey

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. 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. 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. 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.

Efficacy of combined adjuvant transarterial chemoembolization and antiviral therapy in patients with HBV-related hepatocellular carcinoma after surgery.

Efficacy of combined adjuvant transarterial chemoembolization and antiviral therapy in patients with HBV-related hepatocellular carcinoma after surgery.

Imaging findings and transarterial therapy of primacy hepatic carcinoma fed by right renal capsular artery

To evaluate the characteristics of primary hepatic carcinoma (PHC) teed by the right renal capsular artery(RRCA) and to assess the technical success rate,tumor response and complications in patients treated with transcatheter arterial chemoembolization (TACE) via the RRCA with or without other extrahepatic arteries and/or intrahepatic arteries. From July 2010 to February 2014,23 patients were treated by TACE via the RRCA. We evaluate the characteristics of tumor, the blood supply situation of RRCA and the technical success rate, complications and tumor response of TACE via the RRCA. Tumor size was 90.60+/-48.23 mm. Of the 23 rumors,3 were located in segment V, 11 in segment VI and 9 in segment VII.8 cases were found to have RRCA supply at the first TACE session. The technical success rate was 100%.No severe complication occurred in 23 patients. Among the 23 patients, CR, PR, SD and PD were achieved in 3(13.0%), 10(43.5%), 2(8.7%), 8(34.8%) respectively. The objective response rate was 56.5%. The overall cumulative 6 month, 1-3-and 5-year survival rates and the median survival time were 82.6%, 52.2%,21.7%, 17.4% and 16.8 months, respectively. RRCA can participate in tumor blood supply when it located in the right hepatic lobe and with a larger diameter, or it was small but located in the bare area.Superselective intubation of RRCA with microcatheter and precise TACE via right renal capsular artery is safe ,effective and feasible.

Transarterial chemoembolization (TACE) for colorectal liver metastases--current status and critical review.

Transarterial liver-directed therapies are currently not recommended as a standard treatment for colorectal liver metastases. Transarterial chemoembolization (TACE), however, is increasingly used for patients with liver-dominant colorectal metastases after failure of surgery or systemic chemotherapy. The limited available data potentially reveals TACE as a valuable option for pre- and post-operative downsizing, minimizing time-to-surgery, and prolongation of overall survival after surgery in patients with colorectal liver only metastases. In this overview, the current status of TACE for the treatment of liver-dominant colorectal liver metastases is presented. Critical comments on its rationale, technical success, complications, toxicity, and side effects as well as oncologic outcomes are discussed. The role of TACE as a valuable adjunct to surgery is addressed regarding pre- and post-operative downsizing, conversion to resectability as well as improvement of the recurrence rate after potentially curative liver resection. Additionally, the concept of TACE for liver-dominant metastatic disease with a focus on new embolization technologies is outlined. There is encouraging data with regard to technical success, safety, and oncologic efficacy of TACE for colorectal liver metastases. The majority of studies are non-randomized single-center series mostly after failure of systemic therapies in the 2nd line and beyond. Emerging techniques including embolization with calibrated microspheres, with or without additional cytotoxic drugs, degradable starch microspheres, and technical innovations, e.g., cone-beam computed tomography (CT) allow a new highly standardized TACE procedure. The real efficacy of TACE for colorectal liver metastases in a neoadjuvant, adjuvant, and palliative setting has now to be evaluated in prospective randomized controlled trials.

Reproducibility of mRECIST in assessing response to transarterial radioembolization therapy in hepatocellular carcinoma.

The purpose of our study was to evaluate the reproducibility of Modified Response Evaluation Criteria in Solid Tumors (mRECIST) in hepatocellular carcinoma (HCC) lesions undergoing transarterial radioembolization (TARE) therapy and to determine whether mRECIST reproducibility is affected by the enhancement pattern of HCC. One hundred and three HCC lesions from 103 patients treated with TARE were evaluated. The single longest diameter of viable tumor tissue was measured by two radiologists at baseline; response to therapy was evaluated according to mRECIST. The enhancement pattern of HCC lesions was correlated with their mRECIST response. The response rate between mRECIST and RECIST 1.1 was compared. Wilcoxon signed-rank test, paired t test, Lin's concordance correlation coefficient (ρc ), Bland-Altman plot, kappa statistics, and Fisher's exact test were used to assess intra- and interobserver reproducibilities and to compare response rates. There were better intra- than interobserver agreements in the measurement of single longest diameter of viable tumor tissue (bias = 0 cm intraobserver versus bias = 0.3 cm interobserver). For mRECIST, good intraobserver (ĸ = 0.70) and moderate interobserver (ĸ = 0.56) agreements were noted. The mRECIST response for HCC lesions with homogeneous enhancement at both baseline and follow-up imaging showed better intra- and interobserver agreements (ĸ = 0.77 and 0.60, respectively) than lesions with heterogeneous enhancement at both scans (ĸ = 0.54 and 0.40, respectively). In the early follow-up period mRECIST showed a significantly higher response rate than RECIST (40.8% versus 3.9%; P = 0.025). In HCC patients treated with TARE, mRECIST captures a significantly higher response rate compared with RECIST; it also demonstrates acceptable intra- and interobserver reproducibilities for HCC lesions treated with TARE, and mRECIST reproducibility may be lower for HCC lesions with heterogeneous distribution of the viable tumor tissue.

Trans-arterial embolisation therapies for unresectable intrahepatic cholangiocarcinoma: a systematic review.

Unresectable intrahepatic cholangiocarcinoma (ICC) portends a poor prognosis despite standard systemic treatments which confer minimal survival benefits and significant adverse effects. This study aimed to assess clinical outcomes, complications and prognostic factors of TAE therapies using chemotherapeutic agents or radiation. A literature search and article acquisition was conducted on PubMed (MEDLINE), OVID (MEDLINE) and EBSCOhost (EMBASE). Original articles published after January 2000 on trans-arterial therapies for unresectable ICC were selected using strict eligibility criteria. Radiological response, overall survival, progression-free survival, safety profile, and prognostic factors for overall survival were assessed. Quality appraisal and data tabulation were performed using pre-determined forms. Results were synthesized by narrative review and quantitative analysis. Twenty articles were included (n=929 patients). Thirty three percent of patients presented with extrahepatic metastases. After treatment, the average rate of complete and partial radiological response was 10% and 22.2%, respectively. Overall median survival time was 12.4 months with a median 30-day mortality and 1-year survival rate of 0.6% and 53%, respectively. Acute treatment toxicity (within 30 days) was reported in 34.9% of patients, of which 64.3% were mild to moderate in severity. The most common clinical toxicities were abdominal pain, nausea and vomiting, and fatigue. Multiplicity, localization and vascularity of the tumor may predict worse overall survival. Trans-arterial therapies are safe and effective treatment options which should be considered routinely for unresectable ICC. Consistent and standardized methodology and data collection is required to facilitate a meta-analysis. Randomized controlled trials will be valuable in the future.

Interventional Oncology: Adding Options to the Care of Patients with Cancer.

Last spring, the husband of a patient I treated in 2004 unexpectedly contacted me. I initially met with him and his wife to discuss salvage treatment options for her metastatic colorectal cancer (CRC). After a right hepatectomy to treat metachronous metastases from her colon cancer, she had developed a new 3-cm focus deep in segment 4. The tumor had progressed on oxaliplatin and irinotecan. The hepatobiliary surgeon was hesitant about repeat surgery, out of concern that her short disease-free interval might portend rapid development of widespread metastatic disease. Her medical oncologist and surgeon inquired whether any percutaneous options were available for the new metastasis. During the clinic visit, the anxiety felt by the patient and her husband was palpable. Young and previously healthy, she had exhausted standard therapeutic options. Fortunately, my group was able to successfully perform radiofrequency ablation on the metastasis. We followed up with her in our clinic, and a year later she developed a new retroperitoneal focus that we also ablated. Over time, I moved to a new institution and was no longer directly involved in her care. The most recent communication was a heartfelt thank you from her husband for helping to provide her with a cancer-free decade because she remained not only alive but also disease-free 10 years after treatment. Anecdotal outcomes surpassing expectations are one of the strongest positive reinforcements clinicians receive, but this patient’s clinical course also provides relevant insights into the current status of interventional oncology, particularly as it relates to treatment options for liver metastases from CRC. Minimally invasive imageguided treatments, such as chemoembolization, radioembolization with yttrium-90 (90Y) microspheres, and thermal ablation, are increasingly being used in the United States. Current indications for these treatments are part of several NCCN Guidelines. Ablation is the preferred treatment modality in renal cell carcinoma for surgical candidates with suboptimal health, and outcomes appear similar to those of partial nephrectomy for patients with T1a tumors. Transarterial therapies are recommended for progressive liver metastases in many patients with neuroendocrine tumors. Transarterial therapies and ablation are also the preferred treatments for patients with unresectable hepatocellular carcinoma. Complete resection of hepatic metastases from CRC that has spread to the liver can be curative; this option is the gold standard and will remain so. However, given that only 10% to 20% of patients are candidates for resection, the overwhelming majority of patients with liver-dominant metastatic disease survive only as allowed by systemic or biologic agents. This bleak prognosis has led to more aggressive measures for patients with unresectable disease, including maximal operative debulking supplemented by ablation of remaining disease. Given the expansion of potential surgical strategies for cure, it is worth reevaluating palliative options, including whether 90Y provides benefit within the first 2 lines of systemic therapy. Enthusiasm in the oncology community regarding the benefit of 90Y for CRC metastases remains mixed at best. These reservations are understandable, because much of the literature contains anecdotal reports, and, similar to my patient, are from single-center retrospective experiences with limited sample size. The issue of prospective data is being addressed: multiple large-scale prospective randomized trials comparing firstand secondline therapy with and without 90Y are in progress. An additional randomized prospective trial is evaluating 90Y plus chemotherapy as part of maintenance therapy after first-line FOLFOX/bevacizumab versus maintenance therapy alone. Daniel B. Brown, MD

Transarterial approaches to primary and secondary hepatic malignancies.

Transarterial therapies in the setting of primary and secondary liver malignancies are becoming an essential part of the oncology landscape. Most patients with hepatic malignancies are not candidates for curative surgical intervention, thereby warranting exploration of alternative means of treatment that preserves quality of life while providing clinical benefit. Herein, the data for intra-arterial chemoinfusion, transarterial chemoembolization, drug-eluting beads, and radioembolization are discussed in the setting of malignancies within the liver; outcome data relating to survival, time-to-progression, time-to-recurrence, and adverse events are presented. Further data regarding different treatment paradigms for hepatocellular carcinoma, metastatic colorectal carcinoma, neuroendocrine tumours, and intrahepatic cholangiocarcinoma are also provided. In light of these and forthcoming data, transarterial therapies seem to offer a viable treatment pathway for select populations of patients.

Multimodal treatment of unresectable hepatocellular carcinoma to achieve complete response results in improved survival

IntroductionWith technological advances, questions arise regarding how to best fit newer treatment modalities, such as transarterial therapies, into the treatment algorithm for patients with hepatocellular carcinoma (HCC). MethodsBetween 2005 and 2011, 128 patients initially treated with transarterial radioembolization or chemoembolization using drugeluting beads were identified. The response was graded retrospectively. Toxicity was measured 1, 3, and 6 months after the first and last treatments. ResultsSixtyfive patients (53%) were advanced stage. Twenty patients (16%) had an initial complete response, but with additional treatments, this was increased to 46 (36%). Patients with a complete response as their best response to treatment had a median survival [95% confidence interval (CI)] of 5.77 (2.58, upper limit not yet reached) years, significantly longer than those whose best response was a partial response, 1.22 (0.84, 2.06) years and those with stable disease as their best response, 0.34 (0.29, 0.67) years. Repeated treatments did not increase toxicity. DiscussionThis retrospective review of patients treated for intermediate and advanced stage HCC revealed a significant survival advantage in patients who achieved a complete response. These data support use of a multimodality approach to intermediate and advanced stage HCC, combining liverdirected treatments as necessary to achieve a complete response.

Inpatient Treatment Patterns and Health Care Expenditures for Hepatocellular Carcinoma among the Population with Urban Basic Health Insurance in China

ObjectiveTo identify inpatient treatment patterns and health care expenditures for hepatocellular carcinoma (HCC) among the population with urban basic health insurance (BHI) in China. MethodsHospitalizations for patients 18 years or older with discharge diagnosis of HCC from 2008 to 2011 and enrolled in the Chinese BHI plan were identified from the Chinese Health Insurance Research Association database. Treatment approaches and hospital expenditures were assessed for the full sample, and according to city level and hospital tier. Analyses were extrapolated to the national urban BHI population. ResultsA total of 3679 HCC hospitalizations were identified in the period 2008 to 2011, representing 615,359 hospitalizations among the urban BHI population. More than two-thirds of the patients received active treatment during hospitalization (68%, N = 418,394), most commonly with traditional Chinese medicine (51%) and/or transarterial intervention therapy (21%). Cases from larger level 1 cities and larger tier 3 hospitals reported greater use of active treatments (81% and 83%, respectively) than did those from smaller level 3 cities (46%) or tier 1 hospitals (56%). Hospital expenditures were higher in level 1 cities (mean [95% confidence interval] Chinese currency renminbi [¥] 17,119 [¥16,292–¥17,946]; US $2,506 [$2,385–$2,628]) than in level 3 cities (mean [95% confidence interval] ¥7,870 [¥5,775–¥9,964]; $1,152 [$846–$1,459]). ConclusionsMost patients with HCC received active treatment during hospitalization in China. There were substantial disparities, however, in the use of HCC treatments across different economic regions, and nearly a third received only palliative care. With the recent launch of health care reform, this study provides valuable insights into current resource use and costs for HCC in China to help prioritize areas of improvement.

A Step Closer to Individualization of Hepatocellular Carcinoma Therapy

In an ideal medical setting, treatment selection for a specific patient’s disease should be individualized and unique to avoid side effects and to achieve the best possible outcome. Gaba et al (1) explore gene expression profiling in a small subset of hepatocellular carcinoma (HCC) tissues obtained from patients before transarterial chemoembolization therapy with the aim to associate those gene profiles with response to treatment. Despite the small sample size, lack of tissue quality control analysis, and inadequacy to assess outcomes after treatment in this pilot study (1), the idea offered by the authors is innovative and clinically significant: the intent to move the daily clinical care of patients with HCC to “individualization of medicine” through the prediction of response to therapy. The advent of new technology, including microarrays and next-generation sequencing, has enabled scientists to investigate the simultaneous expression of thousands of genes, and has become a powerful tool to predict disease recurrence and response to different treatments and gain new insights into various oncogenic pathways and the process of metastasis and tumor progression. Several therapies for HCC have been introduced. Among them, liver transplantation has emerged as the optimal treatment for early-stage HCC, achieving 5-year survival rates of 75% (2). However, the incidence of HCC recurrence after liver transplantation remains a clinically significant issue, affecting approximately 10%– 20% of transplant recipients (3). Unfortunately, an important rate of discrepancy between pretransplantation imaging and histopathologic staging of liver explants has been reported (4). Because of the scarcity of

The celiac axis revisited: anatomic variants, pathologic features, and implications for modern endovascular management.

The celiac axis (CA) and its branches are critically important arteries that supply blood to the vital solid and hollow abdominal viscera of the foregut. There are many potential anatomic configurations, with up to half the population having a variation from the classic pattern of the CA bifurcating into the hepatosplenic trunk and left gastric artery. These configurations result from permutations in the fusion of the paired dorsal aortas during the first trimester. Despite the short length of the CA, it is affected by a wide range of pathologic conditions, including mesenteric ischemia due to intrinsic occlusion (secondary to causes such as atherosclerosis or thromboembolic events) and extrinsic compression from masses or the median arcuate ligament. Symptoms of mesenteric ischemia are nonspecific and include postprandial abdominal pain and weight loss; thus, the underlying pathologic condition may be found only when being sought specifically. More unusual pathologic conditions include dissection, aneurysms, and vascular malformations. Awareness of the pathologic conditions that affect the CA is important for both diagnostic and interventional radiologists. Early recognition and treatment of CA disease may prevent catastrophic hemorrhage and bowel infarction. Both endovascular and surgical approaches to treatment are greatly enhanced by correct identification of arterial anatomic variants; catheter angiography, computed tomographic angiography, and magnetic resonance angiography can facilitate detection of these variants. Knowledge of the different anatomic permutations is essential to guide endovascular procedures, such as hemorrhage control, transarterial interventional oncologic therapy, and treatment of visceral artery aneurysms. Online supplemental material is available for this article.

Tumor lysis syndrome and primary hepatic malignancy: case presentation and review of the literature.

Tumor lysis syndrome (TLS) represents a constellation of laboratory and clinical derangements that can occur following treatment of malignancies with high cellular turnover. Most commonly noted in hematologic malignancies, TLS has been reported to occur following liver-directed therapy in the form of both ablative therapies and transarterial therapies. Classification schemes exist, as do established diagnostic criteria, to aid in the definitive diagnosis of TLS. In addition, treatment algorithms are reported for patients with the diagnosis of TLS. This manuscript will review the risk factors associated with the development of TLS, the diagnostic criteria used, and treatment and preventative strategies employed. In addition, an algorithm for the diagnosis and treatment of TLS will be provided.