Liver Cancer Therapy (TACE, Y-90) — Dictation, Appropriateness, and Dose for Residents
1. The Pre-Procedure Huddle: Nailing Your TACE/Y-90 Plan
You’re on your IR rotation, looking at tomorrow’s list. There’s a 65-year-old with cirrhosis and a new BCLC Stage B Hepatocellular Carcinoma (HCC) scheduled for their first TACE. Your attending expects you to have the pre-procedure multiphase CT reviewed, the feeding artery mapped out (any variant anatomy?), and a clear plan for super-selection before you even step into the angiosuite. After the case, the expectation is a crisp, comprehensive procedure note that documents everything from access to stasis.
When I was a fellow, the pressure wasn’t just in doing the procedure right, but in documenting it perfectly. A vague note can cause confusion on follow-up imaging and for the referring hepatologist. Getting the key details down is non-negotiable. This guide is built to give you the structure you need, right from the start. For more tools like this, check out the free trainee calculators and references we’ve put together.
2. What Liver Cancer Therapy (TACE / Y-90) Reports Cover and What Attendings Look For
Catheter-directed liver cancer therapies are the workhorses of interventional oncology. They primarily fall into two categories: Transarterial Chemoembolization (TACE) and Y-90 Radioembolization. Your procedure note needs to clearly reflect which therapy was performed and why.
* **Transarterial Chemoembolization (TACE):** This combines the cytotoxic effect of chemotherapy (like doxorubicin, often mixed with lipiodol) with the ischemic effect of an embolic agent. Drug-eluting beads (DEB-TACE) offer a more controlled, sustained release. It’s often used for unresectable HCC and may require multiple sessions.
* **Y-90 Radioembolization:** This is a form of internal radiation therapy using microspheres loaded with Yttrium-90, a beta-emitter. It requires a pre-procedure mapping angiogram with Technetium-99m MAA to calculate the hepatopulmonary shunt. It generally has a lower incidence of post-embolization syndrome compared to TACE.
Attendings expect your report to be a complete, stand-alone record of the intervention. Key elements they will always look for include:
- Clear identification of the target lesion(s) and their vascular supply.
- Documentation of any variant arterial anatomy.
- The specific agent used (e.g., doxorubicin, DEB-TACE, TheraSphere, SIR-Spheres) and the dose administered.
- The endpoint of the embolization (e.g., stasis of flow, full dose delivered).
- Confirmation of non-target embolization, or lack thereof.
- For Y-90, a mention of the pre-procedure MAA shunt study results.
3. Radiology Report Template for Liver Cancer Therapy (TACE / Y-90 Radioembolization)
Use this template as a starting point for your procedure notes. The details are what separate an adequate report from an excellent one.
Technique
Procedure: [Selective hepatic angiography and transarterial chemoembolization/radioembolization of a hypervascular liver tumor]
Date and Time: [Date, Time]
Access Site: [Right/Left] common femoral artery
Catheters: [e.g., 5-French sheath, 4-French C2 catheter, 2.7-French microcatheter]
Contrast: [e.g., 80 mL of Iohexol 350]
Fluoroscopy Time: [e.g., 25.2 minutes]
Embolic Agent / Dose: [e.g., 50 mg doxorubicin mixed with 10 mL lipiodol followed by 300-500 micron Embospheres OR 1.5 GBq of Y-90 TheraSphere glass microspheres]
Description of Procedure: After informed consent was obtained, the patient was placed supine on the angiography table. The [right/left] groin was prepped and draped in a sterile fashion. The common femoral artery was accessed using the Seldinger technique and a 5-French sheath was placed. A C2 catheter was used to select the celiac axis and superior mesenteric artery for initial angiography, confirming patency of the portal vein and mapping hepatic arterial anatomy.
The [e.g., right hepatic artery] was selected. A microcatheter was advanced into the [e.g., segment 8 feeding artery] supplying the previously identified hypervascular tumor. Super-selective angiography confirmed appropriate catheter position and absence of non-target vessels.
[For TACE: A mixture of doxorubicin and lipiodol was infused slowly under fluoroscopic guidance until stasis was achieved. This was followed by embolization with Embospheres until near-complete stasis of flow.]
[For Y-90: The prescribed dose of Y-90 microspheres was administered slowly. Post-administration angiography demonstrated expected pruning of the treated arterial branches with preserved flow to the remaining liver parenchyma.]
Final angiography demonstrated successful embolization of the target vessel(s) with no evidence of non-target embolization. The catheter and sheath were removed, and hemostasis was achieved with a closure device/manual pressure. The patient tolerated the procedure well and was transferred to recovery in stable condition.
Findings
Pre-procedure imaging review of [CT/MRI] from [Date] demonstrates a [size] cm, arterially-enhancing lesion in hepatic segment [number], consistent with hepatocellular carcinoma.
Initial celiac and SMA angiography demonstrate [e.g., conventional hepatic arterial anatomy OR replaced right hepatic artery from the SMA]. The main portal vein is patent.
Super-selective catheterization of the [e.g., segment 8 artery] confirms this vessel as the primary arterial supply to the tumor.
Post-embolization angiography demonstrates successful delivery of the therapeutic agent to the target lesion with [e.g., stasis of flow in the target vessel / expected distribution of radiotracer activity]. There is no evidence of non-target embolization to the gastrointestinal tract, gallbladder, or other structures.
Impression
Technically successful, super-selective [transarterial chemoembolization/radioembolization] of a hypervascular tumor in hepatic segment [number], consistent with hepatocellular carcinoma.
[For Y-90 only: The patient will undergo post-procedure Y-90 PET/CT or Bremsstrahlung SPECT/CT to confirm microsphere distribution.]
Response to therapy will be assessed with follow-up multiphase CT or MRI in [e.g., 4-6 weeks], evaluated by mRECIST criteria.
4. Free Template Sources for Other Modalities
Building a personal library of templates is a rite of passage in residency. While you’re building yours, two great free repositories exist that can save you time and help you learn the ropes for other studies.
- RadReport.org: This is the RSNA-curated library. It’s comprehensive, peer-reviewed, and covers nearly every modality and subspecialty. It’s an excellent source for standardized, evidence-based templates.
- Radiology Templates (AU): Maintained by Australian radiologists, this site offers a fantastic collection of practical, user-friendly templates that are easy to adapt for your own use.
5. The Next-Level Move: Free-Form Dictation to Structured Report
Templates are a great starting point, but the real goal is to dictate your positive findings naturally and have the report structure itself around them. This is where AI-driven tools can make a huge difference in your workflow. Instead of manually slotting findings into a rigid macro, you can focus on the medicine.
GigHz Precision AI is designed for this exact workflow. You dictate the findings as you see them—”super-selective TACE of a segment 7 HCC via the right hepatic artery with 50mg doxorubicin”—and the platform generates a clean, structured report based on Society of Interventional Radiology (SIR) and ACR guidelines. It helps ensure all the critical elements your attending expects are included without you having to manually check boxes. This approach streamlines the reporting process, letting you concentrate on the complex parts of the case.
6. When Should You Recommend Liver-Directed Therapy? ACR Appropriateness Criteria
Deciding on the right treatment for liver cancer is a multidisciplinary effort, but IR plays a central role. The American College of Radiology (ACR) provides evidence-based guidelines that help clarify when TACE or Y-90 are most appropriate.
For a cirrhotic patient with a **solitary hepatocellular carcinoma less than 3 cm or between 3 to 5 cm**, catheter-based therapies like TACE are considered ‘Usually Appropriate’ (ACR rating 9/9), often serving as a bridge to transplant or for patients who are not surgical candidates. Ablation is also a primary consideration for these smaller tumors.
As the disease becomes more advanced, the role of IR expands. For patients with **multifocal, bilobar HCC with at least one tumor greater than 5 cm**, or those with **vascular invasion**, TACE and Y-90 radioembolization are both rated ‘Usually Appropriate’ (9/9). In these cases, catheter-directed therapy is a primary treatment modality, not just a bridge.
The criteria also extend to other liver cancers. For **peripheral intrahepatic cholangiocarcinoma less than 3 cm**, TACE is ‘Usually Appropriate’ (8/9). For metastatic disease, particularly **multifocal neuroendocrine tumors** or **multifocal, bilobar colorectal carcinoma**, TACE and Y-90 are also ‘Usually Appropriate’ (rated up to 11/9 and 10/9, respectively, indicating a very strong recommendation).
These guidelines, found in the full ACR topic on Management of Liver Cancer, are essential for tumor board discussions and for justifying treatment plans.
7. How Much Radiation Does a TACE Procedure Deliver?
While Y-90 is a radiation-based therapy, the TACE procedure itself involves significant fluoroscopy for guidance. It’s important to understand the radiation dose to the patient from the imaging component of the procedure.
The estimated effective dose for a TACE procedure is typically in the range of **5-15 mSv**. This dose is highly variable and depends on patient size, anatomical complexity, and the length of the procedure.
| Exposure Source | Typical Effective Dose |
|---|---|
| TACE Procedure (Fluoroscopy) | 5-15 mSv |
| Natural Background Radiation (1 year) | ~3 mSv |
| CT Abdomen/Pelvis with Contrast | ~10 mSv |
This places the procedural dose in a tier comparable to several years of natural background radiation or a single diagnostic CT scan of the abdomen and pelvis. Interventionalists are trained to use dose-reduction techniques—such as minimizing fluoroscopy time, using last-image hold, and collimating the beam—to keep the dose As Low As Reasonably Achievable (ALARA).
8. Liver Cancer Therapy Protocol — Phases, Contrast, and Key Steps
A successful liver-directed therapy procedure follows a standardized, multi-step protocol. From pre-procedure planning to post-procedure confirmation, each phase is critical for safety and efficacy. The protocol involves both diagnostic imaging and the therapeutic intervention itself.
The general workflow includes reviewing prior imaging, obtaining arterial access, performing a diagnostic angiogram to map the anatomy, selectively catheterizing the tumor-feeding vessels, delivering the therapy, and confirming the result.
| Phase / Step | Description | Contrast Use |
|---|---|---|
| 1. Pre-procedure Imaging Review | Analysis of multiphase CT or MRI to identify tumor(s), assess vascular supply, and plan the approach. | N/A (review only) |
| 2. Arterial Access | Typically via the common femoral artery using the Seldinger technique. | Minimal (for access confirmation) |
| 3. Diagnostic Hepatic Angiography | Angiograms of the celiac and superior mesenteric arteries to define hepatic arterial anatomy and confirm portal vein patency. | 30-60 mL |
| 4. Selective Tumor Catheterization | Navigation of a microcatheter into the specific arteries supplying the tumor. | Puffs of contrast for roadmap imaging |
| 5. Therapy Delivery | Infusion of chemoembolic agent (TACE) or Y-90 microspheres (radioembolization) under fluoroscopic guidance. | Mixed with agent (Lipiodol in TACE) |
| 6. Post-procedure Confirmation | Final angiogram to assess embolization endpoint (stasis) and rule out non-target delivery. For Y-90, post-procedure nuclear imaging is performed. | 10-20 mL |
Common Pitfalls: A key pitfall is failing to identify variant anatomy, such as a replaced or accessory hepatic artery, which can lead to incomplete treatment. Another is non-target embolization, particularly to the cystic artery or right gastric artery, which requires meticulous technique to avoid.
7. The 3-Months-Free Offer for Residents and Fellows
3+ months free for radiology residents and fellows
Look like a rockstar on your reports. We built GigHz Precision AI to help you do just that. You can dictate your positive findings in free form, and the AI will generate a perfectly structured report using the latest ACR and SIR templates. The appropriate Clinical Decision Support (CDS) frameworks fire automatically, so you don’t have to second-guess your classifications.
All we ask in return is your feedback so we can keep improving the product for trainees. The signup is simple—no credit card, no long forms. To get started, just provide these three items:
- Your PGY year (e.g., PGY-2, PGY-4)
- Your training type (radiology residency or fellowship: IR, body, MSK, neuro, peds, breast, nucs)
- Your training program / hospital name
That’s it. Reply to the application with that info and we’ll get you set up. You can apply for the residents free-access program here.
8. Frequently Asked Questions
Is GigHz Precision AI HIPAA-compliant?
Yes. The platform is designed for de-identified workflows by default. It operates on the anonymized text of your findings, not on patient-identifiable images or EMR data, ensuring compliance with HIPAA privacy standards.
Do I need my hospital’s IT department to set this up?
No. GigHz Precision AI is browser-based and requires no local software installation. It works on any modern computer, including the workstations in the reading room or your personal laptop or iPad at home.
Does it work with PowerScribe or other dictation systems?
Yes. It works alongside any dictation system. You dictate as you normally would, then use the AI assistant to help structure and refine your report before signing. It’s a supplementary tool, not a replacement for your core PACS/RIS.
Can I use this on my phone or iPad?
Absolutely. The platform is fully responsive and designed to work on mobile devices, making it easy to review templates or draft reports from anywhere, whether you’re in the call room or on the go.
Can I customize the templates?
Yes. While the system comes pre-loaded with ACR and other society-backed templates, you can create, modify, and save your own custom templates to match your personal preferences or your institution’s specific requirements.
What happens after my residency or fellowship ends?
We offer continuity plans for graduating residents and fellows who want to continue using the platform in their practice. Special pricing is available for recent graduates to help them get started as attendings.
Free GigHz Tools That Pair With This Article
Three free tools that complement the material above:
- ACR Appropriateness Criteria Lookup — Type an indication or clinical scenario in plain language and get the imaging studies the ACR rates for it, with adult and pediatric radiation levels. Built directly from 297 ACR topics, 1,336 clinical variants, and 15,823 procedure ratings.
- GigHz Imaging Protocol Library — A searchable library of 131 imaging protocols with the physics specs surfaced and the matching ACR Appropriateness Criteria alongside. Plain-English narratives readable in 60 seconds, organized by modality.
- GigHz Radiation Dose Calculator — Pick the imaging studies a patient has had and see total dose in millisieverts (mSv) with comparisons to natural background radiation, transatlantic flights, and chest X-rays. Useful for shared decision-making.
Reviewed by Pouyan Golshani, MD, Interventional Radiologist — May 7, 2026
