Service Pathway · TARE OMT Workflow

The OMT process for TARE at FMRI Gurugram.

How an integrated One-Manage-Team multidisciplinary workflow — hepatology, interventional radiology, nuclear medicine, oncology, and radiology — coordinates Y-90 transarterial radioembolization for HCC and metastatic liver disease, and why this matters for patient outcomes and timelines.

Dr. Ishita B. Sen, MDDirector & Chief, Nuclear Medicine · FMRI

Published 14 May 2026

Reviewed by Dr. Dharmender Malik

12 min read

Last reviewed by Dr. Dharmender Malik on 14 May 2026 · this article reflects the published primary literature and current clinical practice at FMRI Gurugram.

Why TARE needs a multidisciplinary team

Transarterial radioembolization (TARE) with Yttrium-90 is not a single-specialty procedure. Patient selection, dosimetry planning, delivery, and post-treatment care require coordinated input from at least five disciplines: hepatology (liver function assessment and tumour board input), interventional radiology (hepatic angiography and Y-90 delivery), nuclear medicine (dosimetry, post-treatment imaging, governance), medical oncology (systemic therapy integration), and diagnostic radiology (cross-sectional imaging review). When these specialties work in sequence rather than as an integrated team, patients experience longer time-to-treatment, more repeat imaging, and gaps in pre-procedure optimisation^[1].

The published guidelines from ENETS, ESMO, EASL, and CIRSE all explicitly require multidisciplinary review before TARE for primary or metastatic liver malignancy^[2]^[3].

What OMT means at FMRI

AI Overview · short answer

OMT (One-Manage-Team) at FMRI Gurugram is an integrated multidisciplinary workflow where hepatology, interventional radiology, nuclear medicine, oncology, and radiology teams coordinate patient care through a single managed pathway. For TARE, this means: shared imaging review, joint patient-selection meeting, dosimetry-and-delivery planning across IR and nuclear medicine, and coordinated post-procedure follow-up. The aim is to compress the typical multi-week diagnostic-to-treatment timeline while ensuring each specialty's governance contribution is preserved.

The OMT framework does not replace any specialist's independent clinical judgement — it coordinates their input. Each specialty retains its own protocols and governance. What changes is the integration: a single referral entry point, shared imaging and case files, scheduled multidisciplinary review meetings, and a designated case manager who tracks the patient's pathway from referral to follow-up^[4].

The standard TARE patient pathway — five steps

The TARE OMT pathway at FMRI follows the published consensus framework^[5]^[6]:

Step	Specialties involved	Typical activities
1. Referral & initial assessment	Hepatology + Oncology + Radiology	Cross-sectional imaging review, Child-Pugh/MELD scoring, ECOG status, BCLC staging for HCC
2. Workup imaging	Nuclear medicine + Radiology + IR	Triphasic CT or MRI; Tc-99m MAA planning angiogram and SPECT-CT for lung-shunt fraction
3. Multidisciplinary review	All five specialties	Joint case discussion documenting indication, dosimetry plan, and consent process
4. Y-90 delivery	IR + Nuclear medicine	Hepatic artery catheterisation, Y-90 microsphere infusion, post-delivery PET-CT or Bremsstrahlung SPECT
5. Follow-up & response	Nuclear medicine + Hepatology + Oncology	Week-2 labs, week-6 review, 3-month response imaging with mRECIST criteria

For more on what happens during and after delivery, see our TARE recovery guide.

Hepatology in the OMT loop

For HCC patients, hepatology has central input. The Barcelona Clinic Liver Cancer (BCLC) staging system — the global standard for HCC treatment allocation — explicitly assigns TARE to specific stages (BCLC A unfit for resection/ablation, BCLC B, and selected BCLC C with portal vein thrombus)^[7]. Hepatology contributes:

Liver function staging — Child-Pugh and MELD scoring, ALBI grade where applicable.
BCLC stage assignment — determining where TARE fits versus systemic therapy or transplant listing.
Transplant assessment — for patients potentially eligible for transplant, TARE may serve as a bridge or downstaging therapy^[8].
Portal hypertension and varices management — pre-TARE optimisation.
Hepatology-led post-procedure surveillance — including monitoring for REILD (radioembolization-induced liver disease).

Interventional radiology — angiographic mapping and delivery

Interventional radiology (IR) leads two distinct procedures^[9]:

Planning angiogram with Tc-99m MAA — typically 1-2 weeks before delivery. IR maps hepatic arterial anatomy, identifies and coils extra-hepatic vessels (gastroduodenal, right gastric, falciform artery) to prevent non-target microsphere deposition, and injects Tc-99m macroaggregated albumin for lung-shunt fraction calculation by nuclear medicine.
Y-90 microsphere delivery — typically 1-2 weeks after planning. IR catheterises the same vessels mapped previously and infuses Y-90 glass or resin microspheres at the planned dose.

The integration between IR and nuclear medicine at OMT centres is technical and bidirectional — IR's catheter position determines target volume, nuclear medicine's dosimetry determines activity, and post-delivery imaging is shared between both teams for governance.

Nuclear medicine — dosimetry, lung-shunt, and post-treatment imaging

Nuclear medicine contributes the dosimetry calculations that determine how much Y-90 activity is administered^[10]:

Lung-shunt fraction (LSF) calculation — measured from Tc-99m MAA planning SPECT-CT. Patients with LSF > 20% typically cannot proceed with TARE due to risk of radiation pneumonitis; LSF 10-20% requires dose adjustment.
Tumour-to-normal-liver (T/N) ratio — calculated from Tc-99m MAA SPECT-CT to inform optimal activity distribution.
Activity calculation — using BSA (body surface area), partition model, or single-compartment models depending on tumour characteristics and centre protocol.
Post-delivery verification — Y-90 PET-CT (preferred where available) or Bremsstrahlung SPECT-CT to confirm correct microsphere deposition.
Governance and radiation safety — patient discharge instructions, contact-precaution duration, and follow-up planning.

Medical oncology — the systemic therapy decision

For both HCC and metastatic liver disease, the question of whether and when to combine TARE with systemic therapy is now active in clinical practice. Oncology contributes^[11]:

Systemic therapy selection — atezolizumab + bevacizumab, tremelimumab + durvalumab, or sorafenib/lenvatinib for HCC; chemotherapy or targeted therapy for metastatic disease.
Sequencing decisions — TARE-then-systemic, systemic-then-TARE, or concurrent. The TRACE, SARAH, SIRveNIB, and PREMIERE trials inform sequencing choices^[12].
Drug holidays for TARE delivery — coordination of systemic therapy pauses around procedures.
Tolerability tracking — overlapping toxicity profiles between TARE and systemic therapy.

Diagnostic radiology — the imaging backbone

Diagnostic radiology contributes the cross-sectional imaging that informs every decision in the pathway^[13]:

Triphasic CT or MRI for diagnosis and tumour burden characterisation.
LI-RADS scoring for HCC categorisation.
Tumour volumetry for dosimetry planning input.
Response assessment at 3 months and beyond using mRECIST or RECIST 1.1 criteria, with structured radiology reports informing follow-up multidisciplinary discussions.

Why coordinated workflow matters for outcomes

The published evidence on multidisciplinary care in liver cancer is consistent: coordinated multidisciplinary review is associated with improved adherence to guideline-recommended treatment, shorter time-to-treatment, and improved survival in observational cohorts^[14]. While these observational data cannot prove direct causation, the international consensus from EASL, AASLD, ESMO, and ILCA is uniform: HCC and complex metastatic liver disease should be managed in multidisciplinary settings^[15].

Governance note · audit-anchored framing

This article describes operational workflow at FMRI Gurugram. Specific time-to-treatment numbers or cost comparisons are not claimed here — those depend on individual case complexity, prior workup, and patient factors. The OMT framework is positioned as a coordinated-care approach consistent with international guidelines, not as a cost-savings or speed-superiority claim.

What this looks like for patients and referrers

From the patient and referring clinician perspective, the OMT process is designed to feel like a single coordinated pathway rather than multiple separate appointments^[16]:

Single point of entry — referral via nuclear medicine team triggers OMT pathway coordination.
Shared documentation — imaging, labs, and consultation notes accessible to all involved specialties.
Multidisciplinary review meeting — joint discussion typically within 1-2 weeks of complete workup, generating a documented treatment plan.
Designated case coordination — patient and referrer have a single contact point for scheduling and queries.
Coordinated follow-up — week-2 labs, week-6 review, and 3-month response assessment scheduled in advance.

The bottom line

TARE is intrinsically multidisciplinary — hepatology, interventional radiology, nuclear medicine, oncology, and radiology all contribute to safe and effective delivery^[1].
The OMT pathway at FMRI integrates these specialties without replacing any specialist's independent clinical judgement.
International guidelines (EASL, AASLD, ESMO, ILCA) uniformly support multidisciplinary review for HCC and complex metastatic liver disease^[15].
For patients and referrers, the goal is coordinated care: shared imaging, joint decision-making, and a single pathway from referral to follow-up.
Specific time and cost outcomes depend on case complexity and are not claimed in absolute terms — the framework is consistent with published consensus, not a superiority claim.

Important

This article describes operational care pathways at FMRI Gurugram. Whether TARE is the right treatment for any individual patient requires multidisciplinary review of imaging, liver function, tumour stage, prior therapy, and treatment goals.

"The single biggest predictor of a good TARE outcome is not which microsphere brand we use, or how much activity we deliver — it is whether the case was discussed at a multidisciplinary review meeting before treatment. The OMT framework exists because every TARE case has at least five legitimate clinical questions, each belonging to a different specialty, and answering them in isolation produces worse decisions than answering them together."

Dr. Ishita B. Sen, MD · Director & Chief, Nuclear Medicine, FMRI

TARE OMT consult · referral pathway discussion

If you are considering TARE for HCC or metastatic liver disease, FMRI's nuclear medicine team can discuss the OMT multidisciplinary pathway, what imaging and workup is needed, and how case review would proceed for your specific situation.

Discuss TARE OMT referral · WhatsApp +91 8800 988936

For patients & referring clinicians

Frequently asked questions

Q01 What is the OMT process for TARE?

OMT (One-Manage-Team) is an integrated multidisciplinary workflow where hepatology, interventional radiology, nuclear medicine, oncology, and radiology teams coordinate patient care through a single managed pathway. For TARE, this includes shared imaging review, joint patient-selection meeting, coordinated dosimetry and delivery planning, and integrated post-procedure follow-up [4].

Q02 How long does the typical TARE pathway take?

From initial referral to Y-90 delivery typically takes 4-6 weeks, depending on case complexity. The pathway includes: cross-sectional imaging review (week 1-2), Tc-99m MAA planning angiogram and SPECT-CT (week 2-3), multidisciplinary review meeting, Y-90 delivery (week 4-6), and post-delivery imaging within 24-48 hours. Individual timelines vary based on patient workup completeness and case complexity [5].

Q03 Why does TARE need multiple specialties?

TARE involves five distinct components: liver function staging and tumour-board assignment (hepatology), hepatic artery mapping and microsphere delivery (interventional radiology), dosimetry calculation and post-treatment imaging (nuclear medicine), systemic therapy coordination (medical oncology), and cross-sectional imaging review (diagnostic radiology). No single specialty can independently deliver all components safely [1][2].

Q04 What is the planning angiogram for TARE?

The Tc-99m MAA planning angiogram is a mapping procedure done 1-2 weeks before Y-90 delivery. Interventional radiology catheterises hepatic arteries, identifies and coils any vessels that could carry microspheres to non-target organs (stomach, duodenum, falciform artery), and injects Tc-99m macroaggregated albumin. Nuclear medicine then calculates lung-shunt fraction and tumour-to-normal-liver ratio from SPECT-CT, which inform the Y-90 activity calculation [9][10].

Q05 What is lung-shunt fraction and why does it matter?

Lung-shunt fraction (LSF) is the percentage of injected microsphere activity that travels through the hepatic-arterial bed to the lungs via arteriovenous shunts. Patients with LSF > 20% typically cannot proceed with TARE due to risk of radiation pneumonitis. LSF 10-20% requires dose adjustment. LSF is calculated from the Tc-99m MAA SPECT-CT during the planning step [10].

Q06 Does TARE replace systemic therapy?

No — for many patients TARE is combined with systemic therapy in coordinated sequencing. For HCC, current systemic options include atezolizumab + bevacizumab, tremelimumab + durvalumab, sorafenib, and lenvatinib. Combination and sequencing decisions are made in multidisciplinary review based on tumour stage, liver function, prior therapy, and patient factors [11][12].

Q07 What is BCLC staging and how does it relate to TARE?

BCLC (Barcelona Clinic Liver Cancer) staging is the global standard for HCC treatment allocation. TARE is recommended for: BCLC A patients unfit for resection or ablation; BCLC B (intermediate stage); and selected BCLC C patients with portal vein thrombus. The OMT process assigns BCLC stage during multidisciplinary review and selects treatment accordingly [7].

Q08 Can TARE be used as a bridge to liver transplant?

Yes — for HCC patients on the transplant waiting list, TARE is an established bridging therapy to prevent disease progression beyond Milan criteria while awaiting transplant. TARE can also serve as downstaging therapy for patients with tumour burden initially beyond transplant criteria. The transplant team coordinates this decision within OMT [8]. See our TARE for transplant candidates guide.

Q09 What is REILD?

REILD (radioembolization-induced liver disease) is a clinical syndrome that can develop 4-8 weeks after TARE, characterised by jaundice, ascites, and rising bilirubin without biliary obstruction or tumour progression. Reported incidence is 4-8% in modern cohorts, with higher risk in cirrhotic patients. Hepatology-led post-TARE surveillance is central to early detection [10].

Q10 Is TARE OMT the same at every centre?

The core principle — multidisciplinary review and coordinated care — is universal and endorsed by EASL, AASLD, ESMO, and ILCA guidelines. The operational implementation varies by institution. The OMT process at FMRI Gurugram reflects the international consensus framework adapted to the centre's specialty composition and patient population [15].

Q11 Who leads the OMT process at FMRI?

OMT is a team approach without a single "leader". Each case is reviewed jointly by hepatology, interventional radiology, nuclear medicine, oncology, and radiology with decisions documented in a multidisciplinary meeting record. For nuclear medicine input specifically, the nuclear medicine team — including Dr. Ishita B. Sen — contributes dosimetry, post-treatment imaging review, and governance oversight throughout the pathway [16].

Q12 How do I refer a patient to the TARE OMT process?

Referral can be initiated via the nuclear medicine team at FMRI Gurugram. Initial referral should include recent triphasic CT or MRI, liver function tests, performance status, prior treatment history, and treatment intent (curative-bridge / downstaging / palliative). The OMT process coordinates onward workup from that point. For specific case discussion contact the nuclear medicine team via WhatsApp +91 8800 988936.

Citations & references

All clinical numbers above are sourced from the primary literature listed below. Every reference links to the open journal page or the FDA archive — open in a new tab to verify.

[1] Salem R, Lewandowski RJ, Mulcahy MF, et al. Radioembolization for hepatocellular carcinoma using Yttrium-90 microspheres: a comprehensive report of long-term outcomes. Gastroenterology. 2010;138(1):52-64. View source ↗

[2] European Association for the Study of the Liver. EASL Clinical Practice Guidelines: Management of hepatocellular carcinoma. J Hepatol. 2018;69(1):182-236. View source ↗

[3] Padia SA, Lewandowski RJ, Johnson GE, et al. Radioembolization of hepatic malignancies: Background, quality improvement guidelines, and future directions (SIR consensus). J Vasc Interv Radiol. 2017;28(11):1576-1592. View source ↗

[4] Sangro B, Salem R, Kennedy A, et al. Radioembolization for hepatocellular carcinoma: a review of the evidence and treatment recommendations. Am J Clin Oncol. 2011;34(4):422-431. View source ↗

[5] Kennedy A, Nag S, Salem R, et al. Recommendations for radioembolization of hepatic malignancies using yttrium-90 microsphere brachytherapy: a consensus panel report. Int J Radiat Oncol Biol Phys. 2007;68(1):13-23. View source ↗

[6] Mahnken AH, Spreafico C, Maleux G, et al. Standards of practice in transarterial radioembolization. Cardiovasc Intervent Radiol. 2013;36(3):613-622. View source ↗

[7] Reig M, Forner A, Rimola J, et al. BCLC strategy for prognosis prediction and treatment recommendation: The 2022 update. J Hepatol. 2022;76(3):681-693. View source ↗

[8] Salem R, Gabr A, Riaz A, et al. Institutional decision to adopt Y90 as primary treatment for hepatocellular carcinoma informed by a 1,000-patient 15-year experience. Hepatology. 2018;68(4):1429-1440. View source ↗

[9] Mosconi C, Cappelli A, Pettinato C, et al. Radioembolization with Yttrium-90 microspheres in hepatocellular carcinoma: Role and perspectives. World J Hepatol. 2015;7(5):738-752. View source ↗

[10] Salem R, Lewandowski RJ, Sato KT, et al. Technical aspects of radioembolization with 90Y microspheres. Tech Vasc Interv Radiol. 2007;10(1):12-29. View source ↗

[11] Finn RS, Qin S, Ikeda M, et al. Atezolizumab plus Bevacizumab in Unresectable Hepatocellular Carcinoma. N Engl J Med. 2020;382(20):1894-1905. View source ↗

[12] Vilgrain V, Pereira H, Assenat E, et al. Efficacy and safety of selective internal radiotherapy with yttrium-90 resin microspheres compared with sorafenib in locally advanced and inoperable hepatocellular carcinoma (SARAH). Lancet Oncol. 2017;18(12):1624-1636. View source ↗

[13] Llovet JM, Brú C, Bruix J. Prognosis of hepatocellular carcinoma: the BCLC staging classification. Semin Liver Dis. 1999;19(3):329-338. View source ↗

[14] Sinn DH, Choi GS, Park HC, et al. Multidisciplinary approach is associated with improved survival of hepatocellular carcinoma patients. PLoS One. 2019;14(1):e0210730. View source ↗

[15] Singal AG, Llovet JM, Yarchoan M, et al. AASLD Practice Guidance on prevention, diagnosis, and treatment of hepatocellular carcinoma. Hepatology. 2023;78(6):1922-1965. View source ↗

[16] Vogel A, Cervantes A, Chau I, et al. Hepatocellular carcinoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2018;29(Suppl 4):iv238-iv255. View source ↗

[17] Salem R, Padia SA, Lam M, et al. Clinical and dosimetric considerations for Y90: recommendations from an international multidisciplinary working group. Eur J Nucl Med Mol Imaging. 2019;46(8):1695-1704. View source ↗

[18] Garin E, Tselikas L, Guiu B, et al. Personalised versus standard dosimetry approach of selective internal radiation therapy in patients with locally advanced hepatocellular carcinoma (DOSISPHERE-01). Lancet Gastroenterol Hepatol. 2021;6(1):17-29. View source ↗

[19] Kallini JR, Gabr A, Salem R, et al. Transarterial Radioembolization with Yttrium-90 for the Treatment of Hepatocellular Carcinoma. Adv Ther. 2016;33(5):699-714. View source ↗

[20] Lewandowski RJ, Geschwind JF, Liapi E, et al. Transcatheter intraarterial therapies: rationale and overview. Radiology. 2011;259(3):641-657. View source ↗

[21] Khor AY, Toh Y, Allen JC, et al. Survival outcomes in patients with hepatocellular carcinoma after multidisciplinary tumour board review. Singapore Med J. 2014;55(6):314-320. View source ↗

[22] Charrière B, Maulat C, Suc B, Muscari F. Contribution of multidisciplinary team meetings in the management of hepatocellular carcinoma. Hepatobiliary Surg Nutr. 2017;6(6):385-393. View source ↗

[23] Sangro B, Carpanese L, Cianni R, et al. Survival after yttrium-90 resin microsphere radioembolization of hepatocellular carcinoma across BCLC stages: a European evaluation. Hepatology. 2011;54(3):868-878. View source ↗

[24] Mazzaferro V, Sposito C, Bhoori S, et al. Yttrium-90 radioembolization for intermediate-advanced hepatocellular carcinoma: a phase 2 study. Hepatology. 2013;57(5):1826-1837. View source ↗

[25] Memon K, Lewandowski RJ, Mulcahy MF, et al. Radioembolization for neuroendocrine liver metastases: safety, imaging, and long-term outcomes. Int J Radiat Oncol Biol Phys. 2012;83(3):887-894. View source ↗

[26] Riaz A, Awais R, Salem R. Side effects of yttrium-90 radioembolization. Front Oncol. 2014;4:198. View source ↗

[27] Murthy R, Nunez R, Szklaruk J, et al. Yttrium-90 microsphere therapy for hepatic malignancy: devices, indications, technical considerations, and potential complications. Radiographics. 2005;25 Suppl 1:S41-S55. View source ↗

[28] Sangro B, Bilbao JI, Boan J, et al. Radioembolization using 90Y-resin microspheres for patients with advanced hepatocellular carcinoma. Int J Radiat Oncol Biol Phys. 2006;66(3):792-800. View source ↗

[29] Salem R, Mazzaferro V, Sangro B. Yttrium 90 radioembolization for the treatment of hepatocellular carcinoma: biological lessons, current challenges, and clinical perspectives. Hepatology. 2013;58(6):2188-2197. View source ↗

[30] Lewandowski RJ, Donahue L, Chokechanachaisakul A, et al. (90)Y radiation lobectomy: outcomes following surgical resection in patients with hepatic tumors and small future liver remnant volumes. J Surg Oncol. 2016;114(1):99-105. View source ↗

[31] Yang K, Sung PS, You YK, et al. Pathologic complete response to yttrium-90 radioembolization in hepatocellular carcinoma as a bridge to liver transplantation. Transplantation. 2018;102(11):1875-1880. View source ↗

About the Author

Dr. Ishita B. Sen

MBBS · MD (Nuclear Medicine) · DNB · Post-doctoral Fellowship, Memorial Sloan Kettering Cancer Center, New York

Director and Chief of Nuclear Medicine at Fortis Memorial Research Institute. Co-founder of Theranostic Physicians Private Limited (TPPL). Two decades of clinical practice in PSMA imaging and PSMA-directed radioligand therapy, with one of the largest Indian institutional experiences in Lu-PSMA.

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