Ep. 655 Managing Large Liver Tumors: Strategies and Challenges with Dr. Beau Toskich, Dr. Chris Malone, and Dr. Tyler Sandow

How is Y90 radioembolization rewriting the rules for managing large HCC tumors and creating new curative-intent therapeutic pathways where palliation was once deemed the only option? In this episode of the 2026 HCC Creator Weekend™, interventional radiologists Dr. Chris Malone (WashU), Dr. Tyler Sandow (Ochsner Health), and Dr. Beau Toskich (Mayo Clinic Florida) join host Dr. Zach Berman for a case-based discussion on advanced dosimetric strategies and embolization approaches for large and complex HCC lesions. --- Get the BackTable apphttps://www.backtable.com/app --- This podcast is supported by an educational grant from Boston Scientific. --- Timestamps 00:00 - Introduction01:59 - Case 1: Ablative Dosing to Solitary Tumor04:38 - Post-Treatment Residual Arterial Enhancement07:35 - Case 2: Tumor with Multiple Feeding Arteries10:02 - Role of Combination with Immunotherapy13:01 - Case 3: Large Caudate Tumor16:03 - Approach to Extrahepatic Arterial Supply19:14 - Case 4: Tumor Adjacent to Viscera21:32 - Does Microsphere Count Matter?24:10 - Case 5: Radioembolization in HCC Downstaging28:18 - Dosing Paradigms for Large Tumors33:06 - Case 6: Pressure-Augmented Delivery35:16 - Case 7: Multifocal Disease and Satellite Lesions37:47 - Palliative Dosimetry vs. Radiation Lobectomy40:11 - Significance of Complete Pathonecrosis43:25 - Closing Remarks --- More about this episodeThe physicians discuss systematic approaches to patient selection, the nuances of MIRD single-compartment versus multi-compartment dosing, and the critical role of precise mapping and particle dynamics in optimizing treatment for heterogeneous tumors. The panel also examines how to navigate the risks and situational challenges of delivering high radiation doses to large central and multifocal tumors. They address practical concerns such as responding to post-treatment imaging changes, managing long-term risks like biliary strictures, and ensuring the safety of treating disease near mobile viscera. The specialists highlight the power of Y90 in successful downstaging, citing evidence of its superior potential to achieve complete pathological necrosis (CPN) at explant when compared with other modalities. Ultimately, they advocate for a bold, collaborative approach within the multidisciplinary tumor board, encouraging providers to employ combination therapies and advanced technologies to optimize patient outcomes and expand the boundaries of curable HCC. --- Resources Yttrium-90 Radioembolization for the Treatment of Solitary, Unresectable HCC: The LEGACY Studyhttps://doi.org/10.1002/hep.31819 A US Study to Evaluate Transarterial Radioembolization (TARE) in Combination With Durvalumab and Bevacizumab Therapy in People With Unresectable Hepatocellular Carcinoma Amenable to TARE (EMERALD-Y90)https://clinicaltrials.gov/study/NCT06040099 TheraSphere With Durvalumab and Tremelimumab for HCC (ROWAN)https://clinicaltrials.gov/study/NCT05063565 Personalized versus standard dosimetry approach of selective internal radiation therapy in patients with locally advanced hepatocellular carcinoma (DOSISPHERE-01): a randomised, multicentre, open-label phase 2 trialhttps://doi.org/10.1016/S2468-1253(20)30290-9 Downstaging Outcomes for Hepatocellular Carcinoma: Results From the Multicenter Evaluation of Reduction in Tumor Size before Liver Transplantation (MERITS-LT) Consortiumhttps://doi.org/10.1053/j.gastro.2021.07.033 --- BackTable Vascular & Interventional (VI) is the go-to podcast for interventional radiologists, vascular surgeons, and interventional cardiologists. Download the free BackTable app to get early access to new episodes, cases, and courses curated by physicians in your specialty. ► https://www.backtable.com/app