What are the indications and contraindications for trans‑arterial chemo‑embolisation (TACE) in patients with unresectable liver‑dominant tumours such as hepatocellular carcinoma?

Indications for Transarterial Chemoembolization (TACE)

TACE is the first-line treatment for patients with intermediate-stage (BCLC B) hepatocellular carcinoma who have preserved liver function (Child-Pugh A or B7), good performance status (ECOG 0-1), large or multinodular tumors not amenable to resection/transplantation/ablation, and no macroscopic vascular invasion or extrahepatic spread. 1

Primary Indications

Standard Indication: BCLC Stage B (Intermediate)

• Large or multifocal HCC when surgical resection, liver transplantation, or percutaneous ablation are not viable options 1
• Asymptomatic patients with multinodular tumors confined to the liver 1
• Patients must have preserved liver function and no radiologic evidence of vascular invasion or extrahepatic spread 1

Extended Indications Beyond BCLC B

BCLC Stage A (Early Stage)

• Bridging to transplantation when waiting time exceeds 6 months to prevent tumor progression beyond Milan criteria 1, 2
• Downstaging to transplantation for patients initially outside Milan criteria 2, 3
• Alternative to curative therapy when resection or ablation cannot be performed due to tumor location, portal hypertension, poor tumor visibility on ultrasound, or patient comorbidities 1

Selected BCLC Stage C (Advanced Stage)

• Segmental or subsegmental portal vein thrombosis with preserved liver function when superselective TACE is technically feasible and hepatopedal collateral flow is present 1
• ECOG performance status 0-1 (not ≥2) with acceptable liver function, even with partial portal vein involvement 1
• Eastern guidelines support TACE for locally advanced HCC with vascular invasion in carefully selected patients 1

Patient Selection Criteria

Liver Function Requirements (Critical)

• Child-Pugh A: Optimal candidates 1, 2
• Child-Pugh B7: Acceptable if well-compensated without ascites 1, 2
• Serum bilirubin < 2 mg/dL required 2
• Even with good baseline function, consider functional reserve when treatment extent is large 1
• Superselective TACE may be considered in compromised liver function if tumors are small 1

Performance Status

• ECOG 0-1: Required for standard TACE 1, 2
• Good performance status ensures tolerance of procedure and post-embolization syndrome 1, 4

Tumor Characteristics

Size and Number

• Optimal: Up-to-seven criteria met (largest tumor diameter in cm + number of tumors ≤ 7) 2
• Acceptable: Multiple nodules if total tumor burden < 50% of liver volume 2
• Single tumors < 7 cm or fewer than 4 tumors are ideal 2, 3
• Large tumors (> 5-6 cm) may benefit more from transarterial radioembolization (TARE) 2, 3

Vascular Anatomy

• Superselective catheterization of tumor-feeding arteries must be technically feasible 1, 2
• Ability to spare normal parenchyma while targeting tumor vessels is essential 1

Laboratory Parameters

• Adequate coagulation for safe arterial puncture (no strict platelet or INR cutoff specified, but normal hemostasis implied) 2
• Creatinine clearance ≥ 30 mL/min 2

Absolute Contraindications

Liver Function

• Child-Pugh C cirrhosis 1, 2
• Child-Pugh B ≥ 8 points 2
• Decompensated cirrhosis with refractory ascites 2, 3
• Clinical hepatic encephalopathy 2

Vascular

• Main portal vein occlusion or complete thrombosis 1, 2
• Hepatofugal (reverse) portal flow 2
• Untreatable arteriovenous fistula 2

Performance and Renal

• ECOG performance status ≥ 2 1, 2
• Creatinine clearance < 30 mL/min 2

Biliary

• Biliary-enteric anastomosis or biliary stents due to high risk of hepatic abscess 1, 2
• Obstructive jaundice 1, 2

Tumor Extent

• Extensive tumor replacing both hepatic lobes (> 50% liver involvement) 2
• Massive chemo-embolic treatment planned for > 50% of liver in single session 1, 2

Relative Contraindications

Vascular Invasion

• Segmental/subsegmental portal vein thrombosis: May proceed if superselective approach feasible with hepatopedal collateral flow present 1, 2
• Branch portal vein invasion: Consider conventional TACE alone or combined with external beam radiation if liver function preserved 2

Extrahepatic Disease

• Limited extrahepatic metastases: May consider TACE if intrahepatic tumor bulk dominates and liver failure is the likely cause of death (case-specific decision) 1, 2
• Standard recommendation remains no extrahepatic spread 1

Prior Procedures

• Bile duct injury from previous surgery: Increases liver abscess risk; assess if patient can tolerate abscess if it develops 1

Critical Safety Considerations and Common Pitfalls

Risk Factors for Post-Procedural Liver Failure (Most Fatal Complication)

• Main portal vein occlusion 1
• Underlying liver function impairment 1
• Extensive TACE with massive chemo-embolic materials for > 50% of liver 1, 2
• Non-selective TACE 1
• Hepatic arterial occlusion from repetitive non-selective TACE 1

Technical Execution

• Always perform superselective catheterization using 1.5-2.0 F microcatheters when possible 1, 5
• Avoid treating > 50% of liver volume in a single session 2
• Do not perform TACE with complete main portal vein thrombosis—high risk of hepatic necrosis 2

Alternative Options When TACE is High-Risk

• Consider transarterial radioembolization (TARE) for portal vein thrombosis, large tumors > 6 cm, or after TACE failure 2, 3
• Consider external beam radiotherapy for vascular invasion 2
• Consider systemic therapy (sorafenib or other agents) 1
• Best supportive care when risks outweigh benefits 1

When to Discontinue TACE (Refractoriness Criteria)

• Lack of objective response after 2 consecutive TACE sessions within 6 months 2
• Development of new vascular invasion after TACE 2
• Development of extrahepatic metastasis after TACE 2
• Deterioration of liver function during treatment course 2

Multidisciplinary Communication

• 72.7% of hepatologists communicate with interventional radiologists for patient selection 1
• 65.6% use multidisciplinary team approaches 1
• Physicians requesting TACE must understand technical aspects; interventional radiologists must understand clinical situation 1
• Assess tumor size, location, distribution, vascular anatomy, and technical feasibility collaboratively 1