What is the indication for Transarterial Chemoembolization (TACE) in Hepatocellular Carcinoma (HCC) with unresectable tumor size?

From the Guidelines

TACE is the treatment of choice for some patients with intermediate-stage HCC and non-resectable HCC, and is associated with significantly improved overall survival rate, particularly for tumors larger than 2 cm but without a strict upper size limit, though tumors exceeding 10 cm may have less favorable outcomes. When considering TACE for unresectable HCC, it's crucial to assess the patient's liver function, as those with preserved liver function (Child-Pugh A or B) are more likely to benefit from the procedure 1. The size of the tumor is also an important factor, with TACE generally considered for unresectable HCCs that are larger than 2 cm, and some studies suggesting that tumors exceeding 10 cm may have less favorable outcomes 1. Some key points to consider when evaluating a patient for TACE include:

• The patient's performance status, with those having an ECOG PS of 2 or more being less likely to benefit from TACE 1
• The presence of severe hepatic decompensation, such as Child-Pugh C or decompensated Child-Pugh B, which may contraindicate TACE 1
• The absence of vascular invasion or extrahepatic spread, which are generally required for TACE to be effective 1
• The potential for down-staging before liver transplantation, which may be an option for some patients with HCC 1. The procedure involves delivering chemotherapeutic agents directly to the tumor via the hepatic artery, followed by embolization to trap the drugs within the tumor and induce ischemic necrosis, and has been shown to be effective in local tumor control, with potential survival benefits of 16-20 months in appropriate candidates 1. Contraindications for TACE include decompensated cirrhosis, portal vein thrombosis, biliary obstruction, and poor performance status, and the decision to proceed with TACE should be made on a case-by-case basis, taking into account the individual patient's characteristics and medical history 1.

From the Research

TACE in HCC Indication

• TACE is used as palliative and neoadjuvant treatment for patients with hepatocellular carcinoma (HCC) 2, 3.
• TACE should be offered as palliative treatment to patients with intermediate stage large or multinodular HCC if no curative treatment option is available by resection or thermoablation and if extrahepatic metastases and tumor infiltration of main portal and systemic veins has been excluded 3.
• TACE can be used for bridging and for downstaging prior to liver transplantation with the intention to maintain or reach limited intrahepatic tumor load defined by Milan criteria 4, 3.

Unresectable Size

• The size of the tumor is not the only factor in determining the suitability of TACE, but also the liver function, performance status, and vascularization pattern of the tumor 3.
• TACE can be used for patients with unresectable HCC, including those with large or multinodular tumors, as long as they have preserved liver function (Child-Pugh A-B, best up to 7 points) and good performance status (ECOG 0) 3.
• The goal of TACE is to achieve complete devascularization of the tumor tissue, and it can be performed as selectively as possible and repetitively if necessary 3.

TACE Techniques

• Conventional TACE (cTACE) and drug-eluting beads using TACE (DEB-TACE) are two techniques used for TACE, with similar anti-tumor effects but different risks and benefits 5.
• DEB-TACE carries a higher risk of hepatic artery and biliary injuries and a relatively lower risk of post-procedural pain than cTACE 5.
• The choice of TACE technique depends on the individual patient's characteristics and the vascularization pattern of the tumor 3.