Procedure Guides
Oncology

Chemoembolization (TACE)

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Procedure Guide

Indications

  • Generally palliative for intermediate to advanced HCC (BCLC B-C) with worse liver function unable to tolerate radioembolization or in combination with radioembolization, e.g., TACE for few smaller lesions and TARE for the dominant tumor burden or TACE for small area of residual or recurrent disease after TARE. This can downstage some patients and serve as a bridge to curative transplant. See other lesion on liver cancer workup.

  • Earlier stage HCC in combination with ablation. TACE + ablation has been found to be superior to ablation alone for lesions 3-5 cm.

  • Promising data for TACE in other organs, e.g., lung via the pulmonary and bronchial arteries.

Contraindications

  • INR >1.5, Plts <50K, or other uncorrected coagulopathy

  • Decompensated cirrhosis w/ CP >=8, severely reduced portal venous flow, bili >4, MELD >20, but other data suggests it can be performed safely

  • Immediately life-threatening extrahepatic dx

  • AST/ALT 5xs upper limit

  • Pregnancy

  • (Relative) PV thrombosis, bilirubin >2mg/dl, xs nml, ECOG >2, biliary obstruction

Efficacy and alternatives

  • Ablation alone is ideal (and potentially curative) for lesions <3 cm. TACE + ablation helpful for intermediate to large HCC (3-5 cm, superior to TACE alone, should be done within 30d)

  • Bland embolization vs TACE: multiple trials have suggested no major difference in outcomes, e.g., Brown et al in 2016, but more pain and hospitalization after bland embo. Suggests embolic effect is more important than the chemo.

  • Systematic review of cTACE: OS 53%, TTP 3.1-13.5m, OS 1, 3, 5y 70, 40, 32%

  • DEE-TACE vs cTACE: DEE-TACE has shown higher intralesional chemo concentration, less systemic chemo levels, and less adverse events with similar TTP and OS (PRECISION V trial with subsequent RCTs confirming)

    • cTACE lipiodized oil preferentially targets larger tumor neovasculature, accumulates portal venules and sinusoids, facilitates endocytosis of chemo. Longer track record.

    • DEE-TACE embolizes terminal arterioles resulting in necrosis and prolonged drug elution into the tumor.

    • cTACE has less post-embolization syndrome but more systemic side effects of the chemotherapy used

  • TACE + sorafenib potentially superior to either alone across multiple studies but with increased adverse events.

  • TACE vs TARE: debated, some studies suggest better outcomes with TARE

  • Met uveal melanoma: (Immuno-TACE) promising… TBD

  • Can use the Assessment for Retreatment with TACE (ART) score to help predict benefit for repeat TACE, >2.5 suggests poor prognosis while 0.5-1.5 suggests potential benefit

  • TACE can also be used outside the liver, e.g., promising data in the lungs both via transvenous  pulmonary chemoembolization via the pulmonary artery and/or transarterial  via the bronchial arteries which more often are the dominant supply, mean OS for palliation 19.7 mo and paired with ablation 30.1 mo.

Pre-procedure care

  • MRI or triphasic CT to characterize anatomy and measure liver volumes

  • Obtain coags, CBC, AFP, CEA, serum Chem, LFTs

  • Premedicate with emend 150 mg IV, gabapentin 600 mg PO, Zofran 16 mg IV +/- dexamethasone 12 mg, pantoprazole 40 mg IV, Moxifloxacin if recent biliary work

    • Others use: cefazolin 1g IV (esp if h/o cholangitis or SOD), metronidazole 500 mg IV, Zofran 2-4 mg, dexamethasone 10 mg, Benadryl 50 mg

procedure

  • Access femoral or radial artery and check access

  • 5 Fr catheter to access celiac and SMA (often Sos or C2) -> DSA runs of celiac and SMA + DynaCT

  • Access for arterial supply of target lesions and potential for non-target embolization, for example:

    • Right inferior phrenic artery for subcapsular lesions

    • Left gastric and SMA for potential replaced/accessory hepatic arteries

    • Avoiding the cystic artery (often from RHA), right gastric (often from proper hepatic), falciform artery complex (often continuation of LHA), left inferior phrenic (can arise from LHA)

  • Selective catheterization with microcatheter and microwire, e.g., ProGreat catheter + Fathom wire 

  • Confirm positioning with DSA + DynaCT

  • Mix chemo with embolic. Note that lipiodol will destroy the plastic connections so work fast. Try to get as much air out as possible (Dan Sze: “air is a terrible embolic”).

    • Conventional TACE (cTACE) = 2:1 or 1:1 mixture of lipiodol w/ 25-50 mg doxorubicin +/- 100 mg cisplatin, and/or 10 mg mitomycin C *followed by particulate  embolization (100-300 um; not always done but that is the tested method).* Some literature suggests 2:1 emulsion is ideal but we tend to use 1:1 at Stanford. Ideally <15 mL lipiodol per session.

    • DEE-TACE = 1-2 vials 100-300 um beads loaded with 50-75 mg doxorubicin. Slow infusion (~10-20 min) mixed with contrast. Target near stasis (clearing after 2-5 beats). Better PFS may be achieved using smaller particles (75-150 um).

  • Deliver chemo. Can give aqueous lidocaine btwn chemo to decrease pain. Can give nitroglycerin if vasospasm occurs. Can cap with bland embolization (e.g. 100-300 micro Embospheres) if entire treatment delivered without stasis.

  • Remove sheath and obtain hemostasis

Complications

Post-embolization syndrome (ab pain, fever, nausea, ~50%)

Liver infarct/failure (2%), liver abscess (<1% with functional sphincter of Oddi, otherwise as high as 25%), HBV reactivation (may prevent with nucleoside analogs), gastritis/ulceration (<1%), pulmonary embolization (<1%), biloma or cholecystitis (<1%)

Hematoma, pseudoaneurysm, dissection

Post-procedure care & Follow Up

  • Can d/c same day or admit overnight 

  • Vigorous hydration

  • Methylprednisolone 4 mg PO taper, oxycodone 5 mg q6h PRN, Protonix 40 mg/d, Zofran 4 mg q6h PRN

  • Some people do 3-7d post-procedure antibiotics, e.g., Augmentin or Cipro. Should do for 2 weeks if disrupted sphincter of Oddi function

  • Repeat labs and CE-MRI or triphasic CT in 4-6wks, 3mo, 6mo, 1yr