DEB TACE

Drug Eluting BeadsTranArterial ChemoEmbolization (DEB-TACE) for HCC

Drug-eluting beads (DEBs) are small, non-resorbable microspheres designed to carry cytotoxic agents, offering a combination of sustained drug release and embolization. These beads are composed of various hydrophilic ionic polymers that can bind anthracycline drugs through an ion exchange mechanism. The loading process allows up to 37.5 mg of doxorubicin per mL of microspheres in a relatively short time frame of 30 minutes to 2 hours.

Recently, a study revealed that doxorubicin loaded onto DC Bead® (100–300 μm) (BTG) was detected as far as 1.2 mm away from the occluded vessel in explanted HCC livers. Over time, the tissue concentration of doxorubicin decreased from 5 μmol/L at 8 hours after DEB-TACE to 0.65 μmol/L after 1 month, indicating a sustained drug delivery effect lasting for a month. Notably, the first phase II trial of DEB-TACE, assessing DC Bead® (500–700 μm) (BTG), showed that the DEB-TACE group exhibited lower plasma doxorubicin Cmax and Area Under the Curve (AUC) for up to 7 days compared to the cTACE group, suggesting a more controlled and sustained drug delivery profile with DEB-TACE.

Keypoints:

Steps	Recommendations
Patient Selection	Tumor Burden and Staging, Liver Function and Performance Status are assessed. Scoring system like STATE score and HAP score can be used (Predicting Response to First TACE).
Pre-Procedure Imaging	Triple Phase Computed Tomography or Dynamic Contrast Enhanced Magnetic Resonance Imaging is performed prior to treatment allocation
Patient Preparation	Discuss Antiemetic treatment, Intravenous hydration, Analgesic management, and Antibiotic Management.
Role of Cone Beam CT	Cone Beam CT can be performed for tumor visualization, targeting, and assessment of treatment completion
Assessment of Extrahepatic vascular supply to HCC (- Tumor size > 5cm, - Tumor Location near bare area of liver, - Exophytic tumor, - Prior intervention like TACE/surgery)	Arranged from most common to least common: 1. Right and Left inferior phrenic artery 2. Omental branch: from gastroepiploic artery 3. Adrenal artery 4. Intercostal and subcostal artery: common levels of the intercostal arteries that supply HCCs are T9, T10, and T11. 5. Cystic artery: divided into superficial and deep branch. Superficial branch feds peritoneal surface of the gallbladder, and the deep branch (potential for tumor supply) supplies the gallbladder bed and portion of liver parenchyma . 6. Right and Left internal mammary artery: segment VIII and IV HCCs can have supply from the right internal mammary artery, and HCCs located in the left lateral segment can have supply from the left internal mammary artery 7. Renal or renal capsular artery 8. Branch of superior mesenteric artery 9. Right and Left gastric artery 10. Lumbar artery
Various Chemotherapy agents	1. Anthracycline: Doxorubicin, Epirubicin, Adriamycin, Pirarubicin 2. Raltitrexed: Raltitrexed 3. Pyrimidine: Fluorouracil Gemcitabine 4. Mitomycin: Mitomycin 5. Platinum: Cisplatin, Miriplatin, Lobaplatin 6. Ethanol: Ethanol
Most common single Chemotherapy regimen	Doxorubicin = 50-75 mg/m² body surface area, to a maximum of 150 mg Cisplatin = 50-100 mg/m² body surface area Epirubicin = 75 mg/m2 body surface area
Most common combination of chemotherapy agents used	1. Anthracycline + Mitomycin 2. Anthracycline + Mitomycin + Pyrimidine: Doxorubicin + Mitomycin + Gemcitabine) 3. Anthracycline + Mitomycin + Platinum: Epirubicin + Lobaplatin + Mitomycin 4. Anthracycline + Mitomycin: Doxorubicin + Mitomycin 5. Anthracycline + Platinum + Mitomycin + Pyrimidine: Epirubicin + Cisplatin + Mitomycin + Furuorouracil
TACE type	cTACE (conventional TACE), DEB-TACE (Drug Eluting Beads TACE)
Other Embolic Agents	Link
Super Selective TACE	Super-Selective TACE using a microcatheter and Cone-beam CT is recommended.
Response Evaluation	Tumor response to TACE can be assessed using objective radiologic response like mRECIST criteria for HCC, EASL etc
Re TACE regimen	Decision for Re TACE can be taken after patient assessment and using various scores like ART, ABCR, SNACOR. Atleast two TACE procedures performed 2-8 weeks apart are recommended prior to stopping due to lack of response.
Some Important Publication and studies	Link

Contraindications for TACE:

Different Staging systems for HCC have slightly different exclusion criterias.

Factors	Absolute Contraindication
Liver Cirrhosis Related	1. Decompensated cirrhosis - Child-Pugh C, - Jaundice (T. Bilirubin > 2-3mg/dl), - Albumin < 3 g/dl, - Uncorrectable coagulopathy, - Poor patient performance status ECOG > 3, - Hepatic encephalopathy, - Refractory ascites, - Hepatorenal syndrome. 2. Impaired portal blood flow - Portal vein thrombus, - Hepatofugal blood flow
HCC Related	1. Extensive tumor involving the entirety of both lobes of liver 2. Malignant Portal Vein Thrombosis
Others	1. Untreatable arteriovenous Fistula 2. Acute Infection
Renal Related	1. S. Creatinine ≥ 2 mg/dl 2. Creatinine Clearance <30 ml/min

Factors	Relative Contraindication
Liver Cirrhosis Related	Untreatable esophageal varices with high risk of bleeding
HCC Related	Large Tumor > 10 cm
Others	1. Severe Comorbidities 2. Incompetent papilla with pneumobilia (owing to biliary stenting or surgery) 3. Biliary dilatation

Method of Preparation:

Complications:

Post Embolization Syndrome (Most common) – Presents as pain, fever, nausea, and vomiting. Managed using analgesic, antipyretic, antiemetic, and antibiotics depending upon patient’s symptoms post TACE
Entry site complications (2-3%) – Hematoma, AV fistula, Pseudoaneurysm
Vascular Complications (Rare) – Arterial dissection, thrombosis, Vasospasm
Non-target embolization (Rare) – Chemical cholecystitis, Chemical pneumonitis
Others (Rare)– Biloma, Abscess

References