Transarterial Chemoembolisation (TACE)

Authors: Dr Gerald Goh*
                            Dr Timothy Joseph *

What is a transarterial chemoembolisation?

Transarterial chemoembolisation (TACE) is a procedure performed by interventional radiologists where chemotherapy and embolic agents are delivered directly into primary or secondary liver cancers via catheters placed in the hepatic artery. TACE is generally indicated in the setting of unresectable hepatocellular carcinoma. Where curative options for hepatocellular carcinoma (such as resection, liver transplant, or percutaneous or open ablation) are not feasible; for example, with advanced disease or multifocality, then patients may be treated with TACE.

What are the generally accepted indications for a transarterial chemoembolisation?

• Unresectable hepatocellular carcinoma. A patient’s eligibility for TACE should be discussed in a multidisciplinary team setting. Oncologists, hepatologists/gastroenterologists, upper gastrointestinal surgeons and interventional radiologists should have input to the overall suitability of a patient for the procedure.
• Multiple factors are considered, including:

• • • reasonable liver function as indicated by serum biochemistry;
    • the patient’s daily activity performance capabilities (ECOG score);
    • lack of microvascular invasion;
    • limited extrahepatic disease.
    • The diagnosis of hepatocellular carcinoma has to be confirmed radiologically (primarily multiphase computed tomography (CT) of the liver or magnetic resonance imaging), biochemically (raised alpha fetoprotein) or pathologically.

• In less common circumstances, TACE has been performed in the setting of isolated or hepatic dominant metastatic deposits.

What are the prerequisites for having a transarterial chemoembolisation performed?

A recent CT scan of the liver and blood tests, such as a full blood examination (FBE), electrolytes, liver function tests (LFT) and coagulation profile are required.

What are the adbsolute contraindications for a transarterial chemoembolisation?

Absolute contraindication to treatment is acute decompensation of baseline liver function (severe encephalopathy, for example). Chemoembolisation risks further impairment of hepatic function. Other absolute contraindications include severe (i.e. anaphylaxis) iodinated contrast allergies and portal vein thrombosis.

Other contraindications to TACE will depend on the patient’s general health. Patients with borderline liver function should be considered carefully regarding their eligibility, recognising the risks of further liver failure versus success of treatment.

What are the relative contraindications for a transarterial chemoembolisation?

General contraindications to angiographic procedures include previous contrast allergy, renal impairment or coagulopathy. General relative contraindications to chemotherapy include severe cytopenia, renal impairment or cardiac dysfunction.
Patients with a generally poor prognosis (widespread metastatic disease, class C Child Pugh, ECOG 3–4) and/or decompensation may not benefit from tumour embolization. Selective or super-selective chemoembolisation may remain a consideration for such patients.

What are the adverse effects of a transarterial chemoembolisation?

TACE is generally performed with an overnight stay in the hospital or sometimes as a same day procedure. It is common to experience some post-procedural discomfort in the region of where the catheters were placed (usually right groin), as well as experiencing some generalised upper abdominal discomfort for a few days. Patients may experience common post-chemotherapy side effects as well, such as a low-grade fever, nausea and/or malaise.

Immediate:

Immediately following the procedure, post-embolic symptoms of generalised abdominal discomfort, a low-grade fever, nausea and/or malaise are common. Minimal swelling and discomfort around the catheter site is common.

Delayed:

Four percent of patients sustain more significant and delayed effects of TACE. Major complications include hepatic insufficiency or infarction, abscess, biliary necrosis, tumour rupture, or cholecystitis. Non-target embolisation (where embolization occurs in non-intended parts of the body) occurs infrequently. Symptoms of inflammation and pain at the site of inadvertent embolization occur infrequently, and are rarely associated with important side effects. Cardiac damage toxicity and anaemia occur in less than 1% of patients undergoing TACE. The 30-day mortality of the procedure is 1%.

Is there any specific post-procedural care required following a transarterial chemoembolisation?

Daily monitoring of liver and renal function is required for between one and three days following the procedure. Follow-up imaging, such at CT scanning, is usually performed at 3-16 weeks. This will generally be arranged by the treating radiologists or gastroenterology unit. The patient’s groin site where the arterial sheath was placed should be inspected for pseudoaneursyms. Referring clinicians may be asked to assist in this regard if local imaging and lab testing is more convenient.

Are there alternative imaging tests, interventions of surgical procedures to a transarterial chemoembolisation?

Surgical resection, liver transplantation and percutaneous ablative techniques, if appropriate, could be an option. Systemic chemotherapy (such as sorafenib or other) may be offered if the patient was not suitable for transarterial chemoembolisation.

References

Llovet,JM. Burroughs, A. Bruix, J. Hepatocellular Carcinoma. Lancet 362:1907-1917, 2003
Llovet JM, Bruix J. Systematic review of randomized trials for unresectable hepatocellular carcinoma: Chemoembolization improves survival. Hepatology. 2003 Feb;37(2):429-42

*The author has no conflict of interest with this topic.

Page last modified on 31/8/2017.