TranArterial ChemoEmbolization (TACE) for HCC

Transarterial chemoembolization (TACE) is a minimally invasive medical procedure used in the treatment of certain types of liver cancer. It involves the injection of a chemotherapy drug directly into the blood vessels that supply the tumor, followed by the injection of embolic agents to block the blood flow to the tumor. This dual approach aims to deliver high concentrations of chemotherapy directly to the tumor site while simultaneously depriving it of its blood supply.

Keypoints:

StepsRecommendations
Patient SelectionTumor 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 ImagingTriple Phase Computed Tomography or Dynamic Contrast Enhanced Magnetic Resonance Imaging is performed prior to treatment allocation
Patient PreparationDiscuss Antiemetic treatment, Intravenous hydration, Analgesic management, and Antibiotic Management.
Role of Cone Beam CTCone 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 agents1. 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 regimenDoxorubicin = 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 used1. 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 typecTACE (conventional TACE), DEB-TACE (Drug Eluting Beads TACE)
Other Embolic AgentsLink
Super Selective TACESuper-Selective TACE using a microcatheter and Cone-beam CT is recommended.
Response EvaluationTumor response to TACE can be assessed using objective radiologic response like mRECIST criteria for HCC, EASL etc
Re TACE regimenDecision 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 studiesLink

Contraindications:

Each Staging system has slight variation of exclusion list. 

FactorsAbsolute Contraindication
Liver Cirrhosis Related1. 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 Related1. Extensive tumor involving the entirety of both lobes of liver
2. Malignant Portal Vein Thrombosis
Others1. Untreatable arteriovenous Fistula
2. Acute Infection
Renal Related1. S. Creatinine ≥ 2 mg/dl
2. Creatinine Clearance <30 ml/min
FactorsRelative Contraindication
Liver Cirrhosis RelatedUntreatable esophageal varices with high risk of bleeding
HCC RelatedLarge Tumor > 10 cm
Others1. Severe Comorbidities
2. Incompetent papilla with pneumobilia (owing to biliary stenting or surgery)
3. Biliary dilatation

Complications:

  1. 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
  2. Entry site complications (2-3%) – Hematoma, AV fistula, Pseudoaneurysm
  3. Vascular Complications (Rare) – Arterial dissection, thrombosis, Vasospasm
  4. Non-target embolization (Rare) – Chemical cholecystitis, Chemical pneumonitis
  5. Others –Liver failure, Death from any cause, Biloma, Abscess, Tumor rupture, Cholecystitis
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