Hepatic Tumor Chemoembolization

Background and indications

Transarterial chemoembolization (TACE) is a locoregional treatment for hepatocellular carcinoma (HCC) combining intra-arterial chemotherapy injection with embolization of tumor feeding arteries. It is the reference treatment for intermediate-stage HCC (BCLC B: multinodular, preserved liver function, no vascular invasion).

TACE can be conventional (cTACE: chemotherapy mixed with Lipiodol + gelatin particles) or drug-eluting bead (DEB-TACE: microspheres progressively releasing chemotherapy). It is also used as bridge/downstaging therapy before liver transplantation.

Pre-procedure assessment

Assessment includes liver MRI (tumor mapping), thoraco-abdomino-pelvic CT, complete hepatic blood panel (Child-Pugh A-B7 required), AFP measurement, and tumor board discussion. TACE is contraindicated in Child-Pugh C, main portal vein thrombosis, or significant arterioportal shunt.

Procedure

Under local anesthesia and sedation, a catheter is introduced through the femoral artery. Under fluoroscopic guidance, hepatic arteries feeding the tumor are catheterized selectively or super-selectively. For cTACE, a doxorubicin (or cisplatin) and Lipiodol mixture is injected, followed by gelatin particles for embolization. For DEB-TACE, doxorubicin-loaded microspheres (100-300 or 300-500 µm) are injected. The procedure takes 1 to 2 hours and may require multiple sessions 4-8 weeks apart.

Results and scientific evidence

Two randomized trials (Llovet et al., The Lancet, 2002; DOI: 10.1016/S0140-6736(02)07906-1; Lo et al., Hepatology, 2002; DOI: 10.1053/jhep.2002.33156) demonstrated significant survival benefit of TACE over symptomatic treatment for unresectable HCC: median survival 20-28 months vs 16 months. Objective response rate (mRECIST) is 50-70%. DEB-TACE offers lower systemic toxicity than cTACE with similar efficacy.

Risks and complications

Post-embolization syndrome (abdominal pain, nausea, fever: 60-80%, resolving in 3-7 days), transient hepatic decompensation (10-15%), severe liver failure (< 3%, mainly in advanced Child-Pugh B), liver abscess (< 2%), ischemic cholecystitis (< 1%). 30-day mortality is 1-3%.

Recovery

2-3 night hospitalization for post-embolization syndrome management. Control MRI at 4-6 weeks to evaluate response (mRECIST criteria). Sessions are repeated based on tumor response ("on demand" concept).

Practical information

The procedure is performed as a short inpatient stay. It is performed by an interventional oncology radiologist, in coordination with the hepatologist and oncologist.