What chemotherapeutic drugs can cause complications with Transarterial Chemoembolization (TACE) or Transarterial Radioembolization (TARE)?

Chemotherapeutic Drugs That Can Cause Complications with TACE or TARE

Systemic therapy within 2 months prior to TARE is a significant risk factor for radioembolization-induced liver disease (REILD), which can lead to increased morbidity and mortality in patients undergoing transarterial radioembolization. 1

Risk Factors for Complications

For TARE (Transarterial Radioembolization):

1. Prior Systemic Chemotherapy:

   • Systemic therapy administered within 2 months before TARE significantly increases the risk of REILD 1
   • This risk is particularly important in patients with:
     • Small liver volume (<1.5 L)
     • Limited functional liver reserve due to cirrhosis
     • Extensive tumor burden (>50% liver involvement)

2. Specific Drug Considerations:

   • Multi-kinase inhibitors (MKIs) such as sorafenib may have interactions with TARE 1
   • Immune checkpoint inhibitors require special consideration as they can potentially upregulate antiviral immunity against HBV, necessitating prophylactic antiviral treatment before TARE in HBV-positive patients 1

For TACE (Transarterial Chemoembolization):

1. Chemotherapeutic Agents Used in TACE:

   • Doxorubicin, cisplatin, and mitomycin C are commonly used in conventional TACE 2
   • These agents themselves can cause hepatotoxicity, which may be exacerbated when combined with certain systemic therapies

2. Combination Therapies:

   • Concurrent administration of sorafenib with TACE has not shown significant survival benefits and may increase toxicity 1
   • The NCCN guidelines note that trials combining TACE with systemic therapies (sorafenib, brivanib, orantinib) have not demonstrated clinically meaningful benefits compared to TACE alone 1

Special Considerations

Hepatitis B Virus (HBV) Reactivation:

• HBV reactivation is a significant concern with both TACE (4-40% of patients) and TARE 1
• Risk factors for HBV reactivation include:
  • Lack of prophylactic antiviral therapy
  • Combination treatment (TACE + external beam radiation therapy has twice the risk compared to TACE alone) 1
  • Systemic therapy with immune checkpoint inhibitors 1

Liver Function:

• Pre-existing liver dysfunction increases the risk of complications with both procedures
• Child-Pugh class B or C cirrhosis patients are at higher risk for complications 1
• Portal vein invasion is a relative contraindication for TACE due to increased risk of liver failure 1

Management Recommendations

1. Pre-procedure Assessment:

   • Evaluate recent history of systemic chemotherapy (especially within 2 months)
   • Assess liver function and volume
   • Screen for HBV status and initiate prophylactic antivirals if positive

2. Drug-Specific Precautions:

   • Consider delaying TARE if patient has received systemic therapy within 2 months
   • Avoid concurrent administration of sorafenib with TACE 1
   • Initiate prophylactic antiviral therapy in HBV-positive patients before either procedure 1

3. Monitoring:

   • Close monitoring for signs of liver dysfunction post-procedure
   • Extended follow-up (up to 6 months) for delayed REILD in TARE patients 1
   • Monitor for HBV reactivation in at-risk patients

Conclusion

When planning TACE or TARE, careful consideration must be given to the patient's history of systemic chemotherapy, particularly within the preceding 2 months. The risk of complications, especially REILD with TARE, is significantly increased when systemic therapy has been recently administered. Prophylactic antiviral therapy is essential for HBV-positive patients to prevent reactivation. The decision between TACE and TARE should consider these factors along with the patient's underlying liver function and tumor characteristics.