In a patient with hepatocellular carcinoma, what specific disease stage, liver function (Child‑Pugh class), performance status (ECOG), tumor size/number, portal‑vein involvement, extra‑hepatic spread, hepatic arterial anatomy, platelet count and INR criteria define the indications for transarterial chemo‑embolisation (TACE)?

TACE Indications for Hepatocellular Carcinoma

Primary Indication: Intermediate-Stage Disease

TACE is the standard first-line treatment for intermediate-stage HCC (BCLC B) in patients with preserved liver function, good performance status, multinodular asymptomatic tumors without macroscopic vascular invasion or extrahepatic spread. 1

Specific Patient Selection Criteria

Disease Stage Requirements

• BCLC Stage B (intermediate): Large or multifocal tumors not amenable to resection, transplantation, or ablation 1
• BCLC Stage A: May be considered when patients are excluded from transplantation or unfit for surgery/ablation due to tumor location 1, 2
• Selected BCLC Stage C: Patients with ECOG 0-1 and only segmental/subsegmental portal vein thrombosis (not main portal vein) may be considered with superselective technique 1

Liver Function (Child-Pugh Class)

• Child-Pugh A: Optimal candidates 1
• Child-Pugh B7: Acceptable if well-compensated without ascites 1
• Child-Pugh B ≥8: Absolute contraindication 1
• Child-Pugh C: Absolute contraindication 1
• Bilirubin: Must be <2 mg/dL 1

Performance Status

• ECOG 0-1: Required for TACE 1
• ECOG ≥2: Absolute contraindication 1

Tumor Characteristics

Tumor Size and Number

• Optimal: Uni- or pauci-nodular disease, tumors ≤7 cm 1, 2
• Acceptable: Multiple nodules if tumor burden <50% of total liver volume 1
• Poor candidates: Extensive tumor with massive replacement of both lobes 1
• Best survival outcomes: Patients meeting "up-to-seven" criteria (sum of largest tumor diameter in cm plus number of tumors ≤7) 1

Portal Vein Involvement

• Main portal vein occlusion: Absolute contraindication 1
• Hepatofugal blood flow: Absolute contraindication 1
• Segmental/subsegmental portal vein thrombosis: Relative contraindication; TACE may be performed if superselective approach is feasible and hepatopedal collateral flow is present 1
• Branch portal vein invasion with preserved liver function: cTACE alone or combined with external beam radiation therapy may be considered 1

Extrahepatic Spread

• No extrahepatic metastases: Required for standard TACE indication 1
• Limited extrahepatic disease: Relative contraindication; may consider TACE if bulk of disease is intrahepatic and patient likely to die from liver disease rather than metastatic disease 1

Hepatic Arterial Anatomy

• Superselective catheterization must be technically feasible to target tumor-feeding arteries while preserving non-tumoral tissue 1
• Untreatable arteriovenous fistula: Absolute contraindication 1

Laboratory Parameters

Platelet Count and Coagulation

• Platelet count: No specific threshold defined in guidelines, but adequate hemostasis required for arterial puncture 1
• INR: No specific cutoff stated, but normal coagulation parameters implied for safe arterial access 1

Renal Function

• Creatinine clearance <30 mL/min: Absolute contraindication 1

Additional Laboratory Contraindications

• Clinical encephalopathy: Absolute contraindication 1
• Refractory ascites: Absolute contraindication 1
• Obstructive jaundice: Absolute contraindication 2

Special Anatomical Considerations

• Biliary-enteric anastomosis or biliary stents: Contraindication due to high risk of hepatic abscess 1

Additional Clinical Scenarios for TACE

Bridging to Transplantation

• Waiting time >6 months: TACE may be offered to minimize tumor progression and maintain patients within transplant criteria 1, 2
• Response to TACE: Can serve as predictor of tumor biology in transplant candidates 1

Downstaging for Transplantation

• Beyond Milan criteria: TACE may reduce tumor burden to meet eligibility criteria if sufficient radiologic response achieved 3, 2

Treatment Response and Retreatment Criteria

When to Repeat TACE

• On-demand approach: Repeat at 1-2 month intervals based on tumor response assessment 2, 4
• Imaging follow-up: CT or MRI at 4-6 weeks post-procedure using mRECIST criteria 2, 4
• Complete or partial response: Continue TACE on-demand 4
• Stable disease after one TACE: Repeat once more 4

TACE Refractoriness (When to Stop)

• No objective response after 2 consecutive TACE sessions within 6 months 1
• New vascular invasion or extrahepatic metastasis 1
• Progressive disease or stable disease after 2 TACE sessions: Switch to systemic immunotherapy 4
• Liver function deterioration to Child-Pugh B8 or higher 2
• ECOG performance status worsens to ≥2 2

Common Pitfalls to Avoid

• Avoid treating >50% of liver volume in single session: Significantly increases risk of post-procedural liver failure 1, 4
• Do not combine TACE with systemic TKIs in intermediate-stage HCC: No survival benefit demonstrated and increases risk of hepatic decompensation 4
• Do not perform TACE in patients with complete main portal vein thrombosis: High risk of hepatic necrosis and liver failure 1
• Ensure superselective catheterization in compromised liver function: Non-selective TACE causes excessive parenchymal injury 2, 4