What is the procedure for liver tumors that involves inserting a catheter through the groin?

Transarterial Chemoembolization (TACE): The Procedure for Liver Tumors via Groin Catheter

Transarterial chemoembolization (TACE) is the procedure for liver tumors that involves inserting a catheter through the groin to deliver chemotherapeutic agents and embolic materials directly to the tumor-feeding blood vessels, causing tumor necrosis through both cytotoxic effects and selective ischemia. 1

Procedure Overview

• TACE is performed by interventional radiologists who selectively catheterize the arterial branch of the hepatic artery feeding the tumor through a femoral artery access in the groin 1
• The procedure exploits the dual blood supply to the liver - while normal liver tissue receives most blood from the portal vein, liver tumors are primarily supplied by the hepatic artery 1, 2
• The hypervascular nature of hepatocellular carcinoma (HCC) results in increased blood flow to the tumor relative to normal liver tissue, making selective arterial delivery highly effective 1, 2

Types of TACE

• Conventional TACE (cTACE): Uses a mixture of Lipiodol (an oil-based contrast agent) and chemotherapeutic agents (typically doxorubicin, cisplatin, or mitomycin), followed by embolization with gelfoam particles 1, 3
• Drug-eluting bead TACE (DEB-TACE): Uses microspheres loaded with chemotherapeutic agents that simultaneously deliver the drug and cause embolization, potentially reducing systemic drug exposure 4, 1
• Bland embolization (TAE): Similar procedure without chemotherapeutic agents, though less commonly recommended 1

Procedural Steps

1. Pre-procedure evaluation: Assessment of liver function, tumor characteristics, and vascular anatomy through CT or MRI imaging 1
2. Groin access: Catheter insertion through the femoral artery in the groin under local anesthesia 1, 2
3. Angiography: Careful evaluation of the arterial anatomy of the liver to identify tumor-feeding vessels 1
4. Selective catheterization: Navigation of the catheter to the specific arterial branches supplying the tumor 1, 2
5. Drug delivery: Injection of chemotherapeutic agents (in cTACE) or drug-eluting beads (in DEB-TACE) 1, 4
6. Embolization: Introduction of embolic materials to block blood flow to the tumor, enhancing drug retention and causing ischemic necrosis 1
7. Confirmation angiography: Final imaging to verify successful embolization 5

Patient Selection

• TACE is recommended for patients with preserved liver function, good performance status, and no radiologic evidence of vascular invasion or extrahepatic spread when surgical resection, transplantation, or ablation are not viable options 1
• It is the standard first-line treatment for intermediate-stage HCC according to the Barcelona Clinic Liver Cancer (BCLC) staging system 1, 6
• TACE can be considered for patients with early-stage HCC when curative treatments cannot be performed due to factors like tumor location, portal hypertension, or poor visibility on ultrasonography 1

Contraindications and Cautions

• Absolute contraindications: Decompensated liver disease, advanced liver dysfunction, main portal vein occlusion, and obstructive jaundice 1
• Relative contraindications: Biliary obstruction, bile duct injury, bilioenteric anastomosis, and biliary stenting (increased risk of liver abscess) 1, 7
• Technical limitations: Tumors in certain locations may be difficult to access or treat safely 1

Complications

• Post-embolization syndrome: Occurs in approximately 20% of patients, characterized by fever, abdominal pain, and nausea/vomiting 7, 3
• Serious complications: Liver failure (especially with compromised liver function), acute cholecystitis, hepatic abscess, bile duct injury, and rarely liver rupture or acute pancreatitis 7, 1
• Mortality risk: Treatment-related deaths occur in less than 2% of cases with proper patient selection 1, 7

Effectiveness and Outcomes

• TACE has been proven to delay tumor progression, prevent macrovascular invasion, and provide survival benefits compared to supportive care 1, 2
• Median survival for intermediate HCC cases is extended from approximately 16 months to about 20 months with TACE 1, 6
• Partial responses are achieved in 15-55% of patients, with local tumor control rates of 15-60% in palliative settings 3, 2
• When used as a bridging therapy before liver transplantation, 5-year survival rates can reach 59-93% 3

Follow-up and Assessment

• Post-procedure imaging (CT or MRI) is essential to evaluate tumor response using modified Response Evaluation Criteria in Solid Tumors (mRECIST) 1
• Repeated TACE sessions may be necessary for optimal tumor control, with intervals typically determined by tumor response and liver function 1

TACE represents a critical intervention for patients with unresectable HCC, offering meaningful survival benefits and tumor control when performed by experienced interventional radiologists with careful patient selection.