When do you use TARE (Transarterial Radioembolization) and when to use TACE (Transarterial Chemoembolization) in HCC?

When to Use TARE vs TACE in Hepatocellular Carcinoma

TACE is the standard first-line treatment for intermediate-stage HCC (BCLC-B) with preserved liver function, while TARE should be selected when portal vein thrombosis is present, when TACE has failed after 2-3 sessions, or when treating large tumors (>6 cm) in patients who can tolerate the radiation dose. 1, 2, 3

Primary Decision Algorithm

Use TACE When:

• Intermediate-stage HCC (BCLC-B) with large or multifocal tumors, preserved liver function (Child-Pugh A or favorable B7), no vascular invasion, and ECOG performance status 0-1 4, 1
• Liver function is Child-Pugh A or B7 without ascites and there is no main portal vein occlusion 1, 3
• Tumor burden is limited (fewer than four tumors or solitary nodule <7 cm) without portal vein thrombosis 3
• Bridging or downstaging to liver transplantation is the goal in patients within or near Milan criteria 1, 3

Use TARE When:

• Portal vein thrombosis is present - TARE is safer than TACE in this setting, as TACE increases risk of liver failure with compromised portal flow 4, 2, 3
• Large tumors (>6 cm) - TARE achieves better tumor penetration and response in larger lesions compared to TACE 2, 3
• TACE refractoriness - after 2-3 unsuccessful TACE sessions showing no radiological response or progressive disease 1, 2
• Multifocal disease confined to the liver with Child-Pugh A liver function and adequate hepatic reserve (≥40% of liver volume receiving ≤30 Gy) 4, 2
• Child-Pugh A patients where preserved liver function after treatment is critical, as TARE may cause less acute hepatotoxicity than TACE 2, 3

Critical Contraindications

Absolute Contraindications for TACE:

• Decompensated cirrhosis (Child-Pugh C or decompensated Child-Pugh B) 4, 1
• Complete main portal vein occlusion 4, 1
• ECOG performance status ≥2 4, 1
• Obstructive jaundice or advanced liver dysfunction 4

Absolute Contraindications for TARE:

• Child-Pugh C or decompensated Child-Pugh B8-9 2
• Small liver volume (<1.5 L) with reduced functional hepatic volume 2
• Recent systemic therapy within 2 months 2
• Tumor involvement >50% of liver 2

Special Clinical Scenarios

Portal Vein Thrombosis:

TARE is the preferred arterial therapy when portal vein thrombosis exists, as TACE significantly increases the risk of post-procedural liver failure in this setting 2, 3. However, recent evidence suggests TACE may still provide survival benefit over conservative therapy when portal vein thrombus is present, though the benefit is less pronounced with advanced vascular invasion 3.

TACE Failure Definition:

Stop TACE and switch to TARE or systemic therapy after 2-3 unsuccessful sessions showing no radiological response, progressive disease, or when liver function deteriorates to Child-Pugh B8 or higher 1. The Korean Liver Cancer Association emphasizes that current definitions of TACE failure should differentiate between local versus systemic disease control failure 4.

Tumor Size Considerations:

• Tumors 3-5 cm: Consider combination therapy with ablation and arterial embolization 3
• Tumors >5 cm: Arterial embolic approaches (TACE or TARE) are recommended 3
• Tumors >6 cm: TARE may provide superior outcomes compared to TACE 2

Treatment Monitoring and Retreatment

TACE Retreatment Protocol:

• Repeat TACE "on-demand" with 1-2 month intervals between sessions 1
• Assess response at 4-6 weeks post-procedure using CT or MRI with mRECIST criteria 1, 5
• Cease TACE if no radiological response after 2-3 sessions or if liver function deteriorates 1

TARE Follow-up:

• Monitor for radioembolization-induced liver disease (REILD) at 4-8 weeks post-procedure, though late hepatotoxicity can occur up to 6 months after treatment 2
• Use ALBI grade to predict durable pathological response without hepatic decompensation 2

Common Pitfalls to Avoid

Do not perform extensive TACE with massive chemo-embolic materials for more than half of the liver, as this significantly increases risk of post-procedural liver failure 4. Always ensure superselective catheterization when treating patients with compromised liver function and small tumors 4.

Do not use TACE in patients with biliary obstruction, bile duct injury, bilioenteric anastomosis, or biliary stenting due to high risk of liver abscess; consider TARE, external beam radiotherapy, or systemic therapy instead 4.

For TARE, verify that non-target embolization to gastrointestinal organs is avoided, as yttrium-90 microspheres can cause severe complications including radiation pneumonitis and gastric ulceration 2.