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Transarterial Chemoembolization (TACE)

Transarterial chemoembolization (TACE) procedure is a locoregional therapy primarly used for treatment of liver cancer, hepatocellular carcinoma (HCC) and cholangiocarcinoma vs selective metastatic tumors. Chemotherapeutic agents and mixture agents vary. Conventional TACE (cTACE) uses a mixture of chemotherapeutic and Lipiodol. Drug-eluting beads (DEB-TACE) loads chemotherapeutics onto vary sizing of drug-eluting beads as the name implies. TACE treatment can be used for HCC in different clinical settings such as bridge to transplant or palliative treatment. Understanding treatment paradigms for HCC is as important as the technical components to a successful TACE procedure. We lay out helpful information to explain this common interventional oncology TACE procedure below.

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BackTable is a knowledge resource for physicians by physicians. Get practical advice on Transarterial Chemoembolization (TACE) and how to build your practice by listening to the BackTable VI Podcast, reading exclusing BackTable Articles, and following the work of our Contributors.

Ep 402 Immunotherapy in HCC: Evolving Treatment Paradigms with Dr. Tyler Sandow, Dr. Edward Kim and Dr. Terence Gade

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Pre-Procedure Prep

Indications

• Hepatocellular carcinoma
• Metastatic neuroendocrine tumor (mNET)
• Metastatic colorectal adenocarcinoma (mCRC)
• Cholangiocarcinoma

Other liver metastases
• Breast cancer
• Melanoma
• Renal cell carcinoma

Contraindications

• ECOG Performance Status Scale > 2
• Poor baseline liver function/decompensated cirrhosis
• Child-Pugh Class C
• Hyperbilirubinemia
• Extensive tumor with massive replacement throughout liver
• Portal vein occlusion
• Arteriovenous fistula not amenable to treatment
• Extensive extrahepatic metastasis

Preprocedural Evaluation

• ECOG Performance Status
• Prior surgeries or liver directed therapies
• Biliary-enteric anastomosis - pre and post operative antibiotic regimen recommended
• Prior imaging - CT/MRI
• Allergies
• Medications

Labs:
• CMP
• Platelets/INR
• Tumor Markers: AFP, CEA

Transarterial Chemoembolization (TACE) Podcasts

Listen to leading physicians discuss transarterial chemoembolization (tace) on the BackTable VI Podcast. Get tips, tricks, and expert guidance from your peers and level up your practice.

Episode #402

Immunotherapy in HCC: Evolving Treatment Paradigms

In this episode, Dr. Tyler Sandow (Ochsner Health) interviews interventional radiologists Dr. Edward Kim (Mount Sinai) and Dr. Terence Gade (University of Pennsylvania) about the future directions of hepatocellular carcinoma (HCC) treatments, specifically focusing on the adoption of precision medicine and multidisciplinary approaches.

Episode #379

Management of HCC: Focus on Radiation Segmentectomy Part 2

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Management of HCC: Focus on Radiation Segmentectomy Part 1

In this episode, host Dr. Chris Beck interviews Dr. Juan Gimenez and Dr. Tyler Sandow. Juan and Tyler are both interventional radiologists in New Orleans, Louisiana who practice at Ochsner Health System - one of the United States’ leading transplant centers. As a result, both doctors have significant experience in Y-90 radiation segmentectomy and other complex procedures for treatment of hepatocellular carcinoma (HCC).

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Episode #256

Origins of TACE

In this episode, guest host Dr. Nicholas Fidelman interviews Dr. Michael Soulen, a key player in the development and widespread adoption of transarterial chemoembolization (TACE). The doctors discuss how TACE became a major therapeutic option for liver tumors, his preferred method of TACE dosage and management, and exciting new frontiers in chemoembolization.

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Interventional Radiologist Terence Gade from Penn Medicine, University of Pennsylvania Health System tells us about emerging research and therapies targeting the tumor microenvironment in Hepatocellular carcinoma (HCC).

Episode #67

Locoregional Therapies for Bridging to Transplant in HCC

Interventional Radiologist Dr. Alex Kim and Dr. Christopher Beck discuss the utility of different locoregional liver therapies in bridging HCC patients to transplant.

Episode #64

Bridging to Transplant for HCC

Transplant Surgeon Dr. Jennifer Berumen and Interventional Radiologist Dr. Isabel Newton discuss the treatment of HCC and the importance of multi-specialty collaboration in bridging these patients to successful liver transplantation. Special discussion was given around this HCC consortium article in Annals of Surgery: https://pubmed.ncbi.nlm.nih.gov/30870180/

Episode #32

Building an Interventional Oncology Program

Interventional Radiologist Dr. Julie Zaetta and Oncologist Dr. Natalie Stanton discuss the essentials of building a successful Interventional Oncology program, including the importance of a multidisciplinary approach.

Episode #20

Pressure-Directed Therapy in TACE

Our 20th BackTable podcast episode featuring special guests Dr. Justin Lee of Florida Interventional Specialists, and Dr. Terence Gade of Hospital of University of Pennsylvania. They discuss experiences and utility of pressure-directed, antireflux infusion for TACE treatments.

Episode #16

Pressure-Directed Therapy in Y90

Dr. Charles Nutting FSIR of RIA Endovascular and Dr. Nainesh Parikh of Moffitt Cancer Center. They discuss pressure-directed, antireflux infusion for Y90 Radioembolization, including the SureFire Infusion system.

TACE Procedure Steps

Antibiotics

Many regimens that cover skin flora and gram negative enterics
• Ceftriaxone 1g
• Ampicillin/sulbactam (Unasyn) 1.5g
• Vancomycin (15mg/kg) and Gentamicin (5mg/kg) for penicillin allergy
• Multiple regimens for patients without intact sphincter of Oddi - moxifloxacin PO 400 mg Qday x 20 days. Begin regimen 3 days before procedure.

Antiemetics
• Zofran 8-16 mg IV
• Scopolamine patch 1.5 mg
• Dexamethasone 10 mg IV

Transfemoral vs Transradial Access to Place 5-Fr or 6-Fr Sheath

Catheterize SMA and perform DSA
• evaluate for replaced or parasitized vasculature
• option to carry run out to portal phase to document patency of portal vasculature

Catheterize celiac and perform DSA to define anatomy
• Catheterize common hepatic, proper hepatic and right/left hepatic arteries as needed
• evaluate for all potential feeding vessels to tumor
• evaluate for potential non-target embolization
• Cone-beam CT optional: helpful to perform from more proximal location to identify all feeder vessels to the tumor

Embolize from most selective position as possible and embolize all feeding vessels
• Minimizes collateral damage to non-involved liver
• Ensure that all portions of the liver tumor are being treated
• Appropriate collimation during embolic administration to watch for reflux and non-target embolization
• Cone-beam CT optional: helpful to identify potential sites of untreated tumor

Embolization Administration

cTACE with Lipiodol
DEB-TACE: many options
• Oncozene 100 μm loaded with 50-75 mg Doxorubicin
• Consider irinotecan with DEBs for mCRC

Endpoint

• Near stasis - contrast clears within 2-5 heartbeats.
• Pruned tree appearance

If endpoint not reached with amount of drug-eluted beads.
• Options to further embolize during same session with conventional microspheres or gelfoam
• Repeat DEB-TACE during second treatment session

Transarterial Chemoembolization (TACE) Articles

Read our exclusive BackTable VI Articles for quick insights on transarterial chemoembolization (tace), provided by physicians for physicians.

Current Practices In Combination Therapy for Hepatocellular Carcinoma

Numerous systemic therapies, such as immunotherapy, can be utilized either with or without local therapy to treat hepatocellular carcinoma (HCC). Learn more about combination therapies and current practices.

An Introduction to Systemic Therapies for Hepatocellular Carcinoma

Interventional radiologists Dr. Edward Kim and Dr. Terence Gade explain the numerous systemic therapies, such as immunotherapy, used to treat hepatocellular carcinoma (HCC) with or without local regional therapy.

Post-Procedure

Post-Procedural Care

• Overnight admission vs. same-day discharge
• IV hydration
• Pain control: dilaudid 0.4 mg IV Q2 until tolerating PO
• Antiemetics
• Can continue antibiotics until discharge: Ancef 1 mg IV Q8 and Flagyl 500 mg IV Q12
• Monitor closely for fever, chills, worsening pain or jaundice.

Follow-Up

• Repeat labs in 3 weeks
• Re-image in 4 weeks
• IR clinic visit after imaging and labs
• Subsequent cross sectional imaging Q3 months for first 2 years, then 6 months thereafter
• Response assessment by modified RECIST
• If undergoing 2nd treatment, retreat 4-8 weeks after first chemoembolization

Complications

Post embolization syndrome - most common
• Symptoms: fever, abdominal pain, nausea, vomiting, leukocytosis and elevated LFTs
• Lysed tumor cells release toxins into systemic circulation
• Typically self-limiting within 3 days

Liver failure - higher risk with more advanced cirrhosis and more extensive treatment area
Infection/hepatic abscess
• 10-14 days after procedure
• Associated pain, fever and leukocytosis
• Pitfall: treated tumors can have intra-lesional gas related to embolization
• Treatment should include percutaneous drainage if size permits and broad spectrum antibiotics
• Consider ceftriaxone and vancomycin
• Tailor antibiotic coverage based on sensitivities

Renal dysfunction

Cholecystitis related to non-target embolization
• Can be managed conservatively. Occasionally cholecystostomy tube or cholecystectomy required
• Consider ciprofloxacin and flagyl for antibiotic regimen

Biloma

Transarterial Chemoembolization (TACE) Tools

Check out transarterial chemoembolization (tace) apps, calculators, and decision aids to assist you in your day to day practice.

Child-Pugh Score Calculator

Backtable's Child-Pugh score calculator is a comprehensive tool for medical professionals and patients. Assess liver function and determine the severity of liver cirrhosis with ease and accuracy.

MELD Calculator

BackTable's MELD score calculator is a reliable and easy-to-use tool for assessing liver disease severity. Improve diagnostic accuracy today.

References

[1] Llovet JM, Real MI, Montaña X, et al. Arterial embolisation or chemoembolisation versus symptomatic treatment in patients with unresectable hepatocellular carcinoma: a randomised controlled trial. Lancet. 2002;359(9319):1734-9.
[2] Lo CM, Ngan H, Tso WK, et al. Randomized controlled trial of transarterial lipiodol chemoembolization for unresectable hepatocellular carcinoma. Hepatology. 2002;35(5):1164-71.
[3] Georgiades C, Geschwind JF, Harrison N, et al. Lack of response after initial chemoembolization for hepatocellular carcinoma: does it predict failure of subsequent treatment?. Radiology. 2012;265(1):115-23.
[4] Prajapati HJ, Xing M, Spivey JR, et al. Survival, efficacy, and safety of small versus large doxorubicin drug-eluting beads TACE chemoembolization in patients with unresectable HCC. AJR Am J Roentgenol. 2014;203(6):W706-14.
[5] Poliektov N, Johnson DT. Treatment of Liver Tumors with Transarterial Chemoembolization. Semin Intervent Radiol. 2018;35(4):350-355.
[6] Chehab MA, Thakor AS, Tulin-Silver S, et al. Adult and Pediatric Antibiotic Prophylaxis during Vascular and IR Procedures: A Society of Interventional Radiology Practice Parameter Update Endorsed by the Cardiovascular and Interventional Radiological Society of Europe and the Canadian Association for Interventional Radiology. J Vasc Interv Radiol. 2018;29(11):1483-1501.e2. doi:10.1016/j.jvir.2018.06.007
[7] Dinorcia J, Florman SS, Haydel B, et al. Pathologic Response to Pretransplant Locoregional Therapy is Predictive of Patient Outcome After Liver Transplantation for Hepatocellular Carcinoma: Analysis From the US Multicenter HCC Transplant Consortium. Ann Surg. 2020;271(4):616-624.

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