What is the indication and protocol for Transarterial Chemoembolization (TACE) procedure in patients with liver cancer?

From the Guidelines

Transarterial Chemoembolization (TACE) is indicated for patients with intermediate-stage hepatocellular carcinoma (HCC) who have preserved liver function (Child-Pugh A or B), good performance status, and unresectable tumors without vascular invasion or extrahepatic spread. The procedure involves a two-step protocol: first, selective catheterization of tumor-feeding arteries followed by injection of chemotherapeutic agents (typically doxorubicin 50-75 mg/m², cisplatin 50-100 mg/m², or mitomycin C 10-20 mg/m²) mixed with lipiodol; second, embolization of these vessels using gelfoam particles, polyvinyl alcohol, or drug-eluting beads.

Key Points

• Pre-procedure preparation includes laboratory tests (complete blood count, liver function, coagulation profile), imaging studies (CT or MRI with contrast), and temporary discontinuation of anticoagulants.
• Patients typically require overnight hospitalization for pain management and hydration.
• Post-procedure, patients may experience post-embolization syndrome (pain, fever, nausea) for 3-7 days, managed with analgesics and antiemetics.
• Follow-up imaging is performed at 4-6 weeks to assess tumor response, with repeat TACE sessions scheduled every 2-3 months as needed.
• TACE works by delivering high concentrations of chemotherapy directly to the tumor while blocking its blood supply, causing ischemic necrosis while sparing surrounding liver tissue, as supported by recent guidelines and expert consensus-based practical recommendations 1.

Protocol Details

• The choice of chemotherapeutic agents and embolization materials may vary depending on the patient's specific condition and the institution's protocol.
• Drug-eluting bead TACE (DEB-TACE) can be considered as an alternative treatment to conventional TACE (cTACE) in HCCs ≥3 cm, as it may reduce systemic side effects and improve tolerability 1.
• The combination of TACE with systemic agents such as sorafenib is not recommended outside clinical trials, as it has not shown a significant benefit in overall survival or progression-free survival 1.

Patient Selection

• Patient selection is crucial for the success of TACE, and patients with decompensated cirrhosis, extensive tumor, or severely reduced portal vein flow are not ideal candidates for TACE.
• Close communication between the interventional radiologist, hepatologist, and oncologist is essential to ensure proper patient selection and treatment planning, as emphasized in recent clinical practice guidelines 1.

Recent Guidelines

• Recent guidelines and expert consensus-based practical recommendations support the use of TACE as a first-line treatment for patients with intermediate-stage HCC, as it has been shown to improve overall survival and quality of life compared to supportive care alone 1.
• The guidelines also emphasize the importance of proper patient selection, pre-procedure preparation, and post-procedure management to minimize complications and optimize outcomes.

From the Research

Indications for TACE Procedure

• The TACE procedure is indicated for patients with liver cancer, specifically those with hepatocellular carcinoma (HCC) 2, 3, 4.
• The procedure is suitable for patients with large or multinodular HCC, preserved liver function, absence of cancer-related symptoms, and no evidence of vascular invasion or extrahepatic spread 3.
• TACE can be used as a palliative, neoadjuvant, bridging, and symptomatic therapy option for local and diffuse HCC 2.

Protocol for TACE Procedure

• The TACE procedure involves the intra-arterial injection of chemotherapeutic drugs, such as doxorubicin, cisplatin, and mitomycin, into the hepatic artery, followed by lipiodol injection, Gelfoam for vessel occlusion, and degradable microspheres 2.
• The procedure can be performed using conventional TACE (cTACE) or TACE with drug-eluting beads (DEB-TACE) 4.
• The choice of TACE technique and chemotherapeutic agents may vary depending on the patient's condition and tumor characteristics 3, 5.

Efficacy and Safety of TACE Procedure

• TACE has been shown to improve local tumor control and survival rates in patients with unresectable HCC 2, 6.
• The procedure can achieve partial response rates of up to 32% and stable disease rates of up to 29.8% 5.
• However, TACE can also cause side effects and complications, such as fever, upper abdominal pain, vomiting, and liver cell failure 2.
• The overall survival benefits of TACE and systemic chemotherapy are similar for patients with unresectable HCC, but TACE may offer better local tumor control and palliative effects 6.