TACE Procedure - Transarterial Chemoembolization

TACE is generally done for procedures wherein surgery is not feasible. Most procedures are done to keep the tumour under control and prevent tumour progression. They are predominantly done with an intent to increase patient life span and are not done with a curative intent. However, in certain specific conditions, TACE may also be done with a curative intent. These include: Focal tumours where in no other treatment is possible (patient not fit for resection or surgery). TACE can then be combined with other treatment modalities like tumour thermal ablation (either MWA or RFA). This is done for tumours between 3 and 5 cm in size. Here using both TACE and thermal ablation, curative intent can be achieved. TACE can also be done as a bridge to transplant. The final treatment for HCC is either resection or liver transplant. While the patient is awaiting transplant, TACE can be done to keep it under control. Here, it is used as bridge therapy.

With newer techniques and devices, it is possible to enter the smallest arteries of the tumours, thus depositing the drug only to the tumour and not affecting the liver. This is variable – depends on the operator and case to case.

Ideal treatment for liver tumour is either resection or transplant, because that is curative. Like said earlier, TACE is generally for preventing disease progression and improving life span. Rarely it is curative (as discussed above). When the option of surgery is out, TACE is your best bet. For extremely progressed tumours involving both the liver lobes and/or portal vein, even TACE may not be possible. In those circumstances only systemic palliative chemotherapy may be an option then. You need to be assessed by your doctor to see whether you are the candidate for TACE. This involves

• Assessment of your CT/MRI to know if TACE is feasible
• A surgical opinion to assess for feasibility of surgery
• Liver function tests (particularly to look for bilirubin levels, albumin levels, AST and ALT)
• Complete blood count
• Coagulation profile
• An ultrasound and doppler assessment to look for fluid/ascites and rule out portal vein thrombosis
• AFP levels
• Rarely a biopsy may be required prior to the procedure for confirmation. Generally, a biopsy is not required in HCC (diagnosis is based only on imaging)

Based on these parameters specially to see the liver status an make sure that the liver is functioning fine, you may be advised for or against TACE. A special doctor called an interventional radiologist (IR) performs TACE.

Contraindications for TACE Procedure

Patients in which the liver functions are grossly deranged, in cases with portal vein thrombosis and with poor liver profile (subjectively measured with the MELD, Child Pugh score) are not good candidates for TACE.

• TACE involves the deposition of chemotherapeutic drug inside the HCC.
• TARE involves radionucleotide/radioactive beads inside the tumour therefore called trans-arterial radioembolization (TARE).
• TARE is generally done for more advanced tumours including those with portal vein thrombosis or more spread tumours.
• However, the choice between TACE and TARE varies from patient to patient.
• A lot of new advanced literature is in favour of TARE showing excellent data for even locally controlled tumours.
• In certain cases, radiation (TARE) can be given to the entire segment called radiation segmentectomy.
• The issues with TARE are: it is more costly and requires a special AERB approved centre for the radiation drugs to be given.
• The choice of procedure – TACE versus TARE – varies from patient to patient, case to case.
• Your treatment options shall be discussed with you and joint decision shall be taken what is best for you.

What is the chemoembolization drug and agent given?

Generally doxorubicin is given mixed with a special agent called lipiodol to deliver the drug. This is inserted through a special tube called a microcatheter inside the small arteries of the liver. Following this, the artery is blocked with small beads called polyvinyl alcohol (PVA) particels or gelfoam slurry.

• Pain and fever may be experienced for a few days (3-4 days) associated with nausea and vomiting. This is called post embolization syndrome. This is generally self limiting with medication.
• Rarely, more severe complications like a liver abscess may form.
• Bleeding at the groin site at the point of entry into the femoral artery is a possibility.
• Post procedure, you shall be asked to remain immobile for 6 hours to reduce the chances of bleeding in your groin.
• Due to supply of chemotherapeutic drugs to the normal liver, sometimes, liver functions may be deranged – leading to liver failure/liver decompensation.

• Your reports and images will be reviewed.
• It shall be made sure you are the right content for TACE.
• Admission will be required for the procedure.
• Shaving of your groin shall be done.
• You will be asked to remain fasting for 6 hours prior.
• Procedure shall be done under local anesthesia. Mild sedation or pain killers may be given.
• Your groin shall be anesthetized.
• A small needle prick will be given in your femoral artery. A sheath will be placed.
• Using a tube, the hepatic artery will be accesses. Blood supply to the tumour shall be documented.
• Selective cannulation of all small arteries shall be done. After entering these small arteries, the drug shall be delivered.
• Following this, the PVA particles will be given to block the blood supply.
• Following supply of the drug and all the agents, the catheter and tube shall all be removed.
• You shall be asked to lie immobile for 6 hours after the procedure.
• It takes 1-2 hours depending on the complexity of the case.
• Generally, you would be admitted for 24-48 hours after the procedure for monitoring.
• Few blood tests may be required on the second/third post procedure day and then you shall be discharged if all is fine.