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
HCC: (TACE) TTP 3.1-13.5 mo, OS 19.4 mo; (TARE) better for tumor in vein because it’s less obstructive
ICC: (TACE) median OS 15.7 mo, 1yr OS 58%, 18.9% complication rate
Met NET: (TACE) OS 17-82 mo > (TARE) 14-67 mo
Met CRC: (DEBIRI vs FOLFIRI) median survival 22 vs 15 mo; PFS 7 vs 4 mo ; (TARE + mFOLFOX6 vs mFOLFOX6) PFS liver 20.5 vs 12.6 mo; PFS all 10.7 vs 10.2 mo
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).
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