What are the indications for Transarterial Chemoembolization (TACE)?

From the Guidelines

Transarterial chemoembolization (TACE) is primarily indicated for the treatment of unresectable hepatocellular carcinoma (HCC) in patients with preserved liver function (Child-Pugh class A or B) and no vascular invasion or extrahepatic spread, as recommended by the most recent guidelines 1.

Indications for TACE

• Intermediate-stage HCC (Barcelona Clinic Liver Cancer stage B) with multinodular tumors confined to the liver
• Unresectable HCC with preserved liver function and no significant portal vein thrombosis
• Bridge therapy for patients awaiting liver transplantation to prevent tumor progression
• Downstaging procedure to reduce tumor size and enable surgical resection
• Selected cases of liver metastases from neuroendocrine tumors, colorectal cancer, and other hypervascular metastases when systemic therapy options are limited

Patient Selection

• Adequate liver function (bilirubin <3 mg/dL)
• No significant portal vein thrombosis
• No hepatic encephalopathy
• No significant ascites
• Tumor size and location should be considered, as well as the risk of post-procedural liver failure and liver abscess

Procedure

• TACE involves the combination of selective injection through the hepatic artery of antineoplastic agents and selective obstruction of tumoral feeding vessels
• The procedure works by delivering high concentrations of chemotherapeutic agents directly to the tumor while simultaneously blocking blood supply through embolization, causing tumor ischemia and necrosis
• TACE can be repeated every 1-3 months based on tumor response and patient tolerance, as recommended by the Korean Liver Cancer Association 1

Important Considerations

• TACE should not be used in patients with decompensated liver disease, advanced kidney dysfunction, macroscopic vascular invasion, or extrahepatic spread, as stated in the British Society of Gastroenterology guidelines 1
• The combination of TACE with systemic agents such as sorafenib or immune checkpoint inhibitors is not recommended, due to insufficient evidence and potential increased risk of adverse effects 1

From the Research

TACE Indications

• TACE is indicated for patients with large or multinodular hepatocellular carcinoma (HCC), preserved liver function, absence of cancer-related symptoms, and no evidence of vascular invasion or extrahepatic spread 2, 3, 4
• TACE can be used for early stage HCC if other curative treatments are not feasible or as a neoadjuvant treatment before liver transplantation 5, 4
• TACE can also be considered for selected patients with limited portal vein thrombosis and preserved liver function 2, 5
• TACE is recommended as first-line non-curative therapy for BCLC B/intermediate HCC (preserved liver function, multifocal, no cancer-related symptoms) in patients without vascular involvement 3

TACE Techniques

• Conventional TACE (cTACE) combines the transcatheter delivery of chemotherapy using Lipiodol-based emulsion plus an embolizing agent to achieve strong cytotoxic and ischemic effects 6, 4
• Drug-eluting beads TACE (DEB-TACE) uses beads that slowly release chemotherapeutic agents to increase ischemia intensity and duration 2, 5, 4
• Other types of TACE include TAE, c-TACE, DEB-TACE, and DSM-TACE, but there is insufficient evidence to recommend one technique over another 3

TACE Applications

• TACE can be used as a palliative treatment to control local tumor growth and improve survival rates 6
• TACE can be used as a neoadjuvant treatment before liver transplantation to downstage the tumor 6, 5
• TACE can be used as a bridging treatment before liver transplantation to control tumor growth while waiting for a transplant 6, 5
• TACE can be used to treat symptomatic patients with pain or bleeding caused by HCC 6