TACE- Transarterial Chemoembolisation

Basics of TACE

1. TACE Dr. Yash Kumar Achantani OSR

2. 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 are not feasible; for example, with advanced disease or multifocality , then patients may be treated with TACE.

3. INDICATIONS Hepatocellular carcinoma (HCC) Selective metastatic disease (most commonly from colorectal carcinoma) Cholangiocarcinoma As palliative treatment for a patient with unresectable HCC. Sometimes also be performed prior to radiofrequency tumor ablation.

4. Contraindications Absolute contraindications Extensive tumour infiltration throughout the liver  Encephalopathy Large burden of extra-hepatic metastases Relative contraindications Portal vein thrombosis Liver or renal failure Uncorrectable coagulopathy Significant arteriovenous shunting of blood through the tumour

5. Procedure TACE is performed through the trans-femoral route. Superior mesenteric artery and celiac axis arteriogram is obtained to begin with. Selective cannulation of the hepatic artery supplying the tumour is performed using a 5F celiac catheter and a 0.035-inch J-tip Terumo guidewire. Further, the catheter is placed as close as possible to the tumour using either a 4F multipurpose slip catheter/glide catheter or a 3F microcatheter .

6. The chemotherapeutic drug emulsion is prepared. This consists of doxorubicin 50 mg, cisplatin 100 mg , 10 ml of iodinated non-ionic contrast media and 20ml of iodized oil ( lipiodol ). This amount of emulsion is ideal for lesions larger than 5cms in size. The chemotherapeutic drug emulsion is then delivered through this cannulated feeding hepatic artery. The amount of emulsion to be injected is decided during the procedure. When the lesion shows complete coverage with lipiodol or if there is reflux of emulsion into normal branches, further injection of emulsion is stopped.

7. Subsequent to the injection of the emulsion, this feeding artery was embolized using gelatin sponge pledgets . Intra-arterial lidocaine (10 mg) is given between 10-ml aliquots of chemoembolization material to reduce the pain after embolization. Microcatheter coaxial system to access small and tortuous feeders.

8. Post-procedural care Daily monitoring of liver and renal function Follow-up imaging (at 3-16 weeks) Patient’s groin site where the arterial sheath was placed should be inspected for pseudoaneursyms

9. Outcomes TACE has been shown to have a survival benefit over current treatments as well as reducing patient symptoms and preventing tumor growth. CT is typically used for follow up imaging, with the oily based embolic particles having a distinct high attenuation appearance. One key advantage is the chemotherapy is targeted locally so reducing the systemic side effects of intravenous chemotherapy.

10. Response to treatment Imaging is generally advised after 3-4 weeks, either triple phase CT, dynamic MRI or contrast enhanced USG. The accumulation pattern of the iodised oil and enhancement pattern of the mass is to be observed to evaluate the response to the treatment. The more the accumulation greater the necrosis and, thus, the survival. Enhancing areas of tumour are considered as residual viable tumour.

11. There are four types of patterns that have been described Complete response – when the tumour was fully covered with lipiodol and had no enhancing viable tissue; (b) Residual disease – when the tumour was partially covered with lipiodol and enhancing viable tissue is seen; (c) Recurrence – when the enhancement is seen at the previously treated tumour site, indicating the presence of viable tissue; (d) Fresh lesions – when new lesions are detected at different sites in the liver and not at the site where the previously treated tumours were located.

12. Adverse effects of TACE 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.

13. 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 Hepatic insufficiency or infarction. Abscess. Biliary necrosis. Tumour rupture. Cholecystitis.

14. Complete response following TACE in a patient of small HCC with chronic hepatitis B. Pre-TACE arterial phase CT scan Shows a large enhancing surface tumor (arrow) in segment 6 of the liver. TACE was done. Post-TACE CT scan at 1 month Shows Lipiodol completely involving the tumor (arrow), with no enhancing residual viable tumor .

15. Follow-up CT scans at 1 year (C) and 3 years (D), respectively, show marked tumor shrinkage, with retained Lipiodol and no residual or recurrent disease

16. Complete response in a patient with a large HCC, with cirrhosis due to hepatic vein outlet tract obstruction. Arterial phase CT scan shows a large, exophytic , vascular HCC (10 cm) in segments 7 and 6 of the liver (arrow). TACE was done and a post-TACE CT scan at 1 year (B) Shows reduction in tumor size; the tumor (arrow) is completely covered with Lipiodol , with no viable residual disease

17. Residual disease following TACE in a patient with a large HCC and HBV cirrhosis. Post-TACE non-contrast CT scan (A) shows scattered patchy areas of retained Lipiodol (arrow) in the large HCC in segments 7/6 of the liver. Arterial phase CT scan (B) shows multiple areas of enhancing viable tissue (arrows) in the inferomedial aspect of the same mass, suggestive of residual disease

18. Disease progression following TACE depicting poor response in a patient of mutifocal HCC with HBV cirrhosis. Post-TACE contrast-enhanced CT scans at 1 month (A,B) show multifocal HCC in the right and left lobes of the liver. Only a few lesions are covered with Lipiodol (black arrow), while the remaining lesions are devoid of Lipiodol (white arrow), suggesting inadequate response. Additionally, multiple enhancing fresh lesions (small arrows in B) have also appeared, indicating progression of disease.