Transarterial Chemoembolization

Transarterial Chemoembolization

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Pre-Procedure

Indications:
• Hepatocellular carcinoma
• Metastatic neuroendocrine tumor (mNET)
• Metastatic colorectal adenocarcinoma (mCRC)
• Cholangiocarcinoma
Other liver metastases
• Breast cancer
• Melanoma
• Renal cell carcinoma

Contraindications:
• ECOG Performance Status Scale > 2
• Poor baseline liver function/decompensated cirrhosis
• Child-Pugh Class C
• Hyperbilirubinemia
• Extensive tumor with massive replacement throughout liver
• Portal vein occlusion
• Arteriovenous fistula not amenable to treatment
• Extensive extrahepatic metastasis

Preprocedural evaluation:
• ECOG Performance Status
• Prior surgeries or liver directed therapies
• Biliary-enteric anastomosis - pre and post operative antibiotic regimen recommended
Prior imaging - CT/MRI
Labs:
• CMP
• Platelets/INR
• Tumor Markers: AFP, CEA
Allergies
Medications

Procedure

Antibiotics: many regimens that cover skin flora and gram negative enterics
• Ceftriaxone 1g
• Ampicillin/sulbactam (Unasyn) 1.5g
• Vancomycin (15mg/kg) and Gentamicin (5mg/kg) for penicillin allergy
• Multiple regimens for patients without intact sphincter of Oddi - moxifloxacin PO 400 mg Qday x 20 days. Begin regimen 3 days before procedure.
Antiemetics
• Zofran 8-16 mg IV
• Scopolamine patch 1.5 mg
• Dexamethasone 10 mg IV

Transfemoral vs transradial access - place 5 or 6-Fr sheath
Catheterize SMA and perform DSA
• evaluate for replaced or parasitized vasculature
• option to carry run out to portal phase to document patency of portal vasculature

Catheterize celiac and perform DSA to define anatomy
Catheterize common hepatic, proper hepatic and right/left hepatic arteries as needed
• evaluate for all potential feeding vessels to tumor
• evaluate for potential non-target embolization
Cone-beam CT optional: helpful to perform from more proximal location to identify all feeder vessels to the tumor

Embolize from most selective position as possible and embolize all feeding vessels
• Minimizes collateral damage to non-involved liver
• Ensure that all portions of the liver tumor are being treated
• Appropriate collimation during embolic administration to watch for reflux and non-target embolization
Cone-beam CT optional: helpful to identify potential sites of untreated tumor

Embolization administration
cTACE with Lipiodol
DEB-TACE: many options
• Oncozene 100 μm loaded with 50-75 mg Doxorubicin
• Consider irinotecan with DEBs for mCRC

Endpoint:
• Near stasis - contrast clears within 2-5 heartbeats.
• Pruned tree appearance
If endpoint not reached with amount of drug-eluted beads.
• Options to further embolize during same session with conventional microspheres or gelfoam
• Repeat DEB-TACE during second treatment session

Post-Procedure

Postprocedural care:
• Overnight admission vs. same-day discharge
• IV hydration
• Pain control: dilaudid 0.4 mg IV Q2 until tolerating PO
• Antiemetics
• Can continue antibiotics until discharge: Ancef 1 mg IV Q8 and Flagyl 500 mg IV Q12
• Monitor closely for fever, chills, worsening pain or jaundice.

Follow up:
• Repeat labs in 3 weeks
• Re-image in 4 weeks
• IR clinic visit after imaging and labs
• Subsequent cross sectional imaging Q3 months for first 2 years, then 6 months thereafter
• Response assessment by modified RECIST
• If undergoing 2nd treatment, retreat 4-8 weeks after first chemoembolization

Complications:
Post embolization syndrome - most common
• Symptoms: fever, abdominal pain, nausea, vomiting, leukocytosis and elevated LFTs
• Lysed tumor cells release toxins into systemic circulation
• Typically self-limiting within 3 days
Liver failure - higher risk with more advanced cirrhosis and more extensive treatment area
Infection/hepatic abscess
• 10-14 days after procedure
• Associated pain, fever and leukocytosis
• Pitfall: treated tumors can have intra-lesional gas related to embolization
• Treatment should include percutaneous drainage if size permits and broad spectrum antibiotics
• Consider ceftriaxone and vancomycin
• Tailor antibiotic coverage based on sensitivities
Renal dysfunction
Cholecystitis related to non-target embolization
• Can be managed conservatively. Occasionally cholecystostomy tube or cholecystectomy required
• Consider ciprofloxacin and flagyl for antibiotic regimen
Biloma

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References

[1] Llovet JM, Real MI, Montaña X, et al. Arterial embolisation or chemoembolisation versus symptomatic treatment in patients with unresectable hepatocellular carcinoma: a randomised controlled trial. Lancet. 2002;359(9319):1734-9.
[2] Lo CM, Ngan H, Tso WK, et al. Randomized controlled trial of transarterial lipiodol chemoembolization for unresectable hepatocellular carcinoma. Hepatology. 2002;35(5):1164-71.
[3] Georgiades C, Geschwind JF, Harrison N, et al. Lack of response after initial chemoembolization for hepatocellular carcinoma: does it predict failure of subsequent treatment?. Radiology. 2012;265(1):115-23.
[4] Prajapati HJ, Xing M, Spivey JR, et al. Survival, efficacy, and safety of small versus large doxorubicin drug-eluting beads TACE chemoembolization in patients with unresectable HCC. AJR Am J Roentgenol. 2014;203(6):W706-14.
[5] Poliektov N, Johnson DT. Treatment of Liver Tumors with Transarterial Chemoembolization. Semin Intervent Radiol. 2018;35(4):350-355.
[6] Chehab MA, Thakor AS, Tulin-Silver S, et al. Adult and Pediatric Antibiotic Prophylaxis during Vascular and IR Procedures: A Society of Interventional Radiology Practice Parameter Update Endorsed by the Cardiovascular and Interventional Radiological Society of Europe and the Canadian Association for Interventional Radiology. J Vasc Interv Radiol. 2018;29(11):1483-1501.e2. doi:10.1016/j.jvir.2018.06.007
[7] Dinorcia J, Florman SS, Haydel B, et al. Pathologic Response to Pretransplant Locoregional Therapy is Predictive of Patient Outcome After Liver Transplantation for Hepatocellular Carcinoma: Analysis From the US Multicenter HCC Transplant Consortium. Ann Surg. 2020;271(4):616-624.

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Demos

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Reflux Control Microcatheter Designed Using Flow Dynamic Principals, Creating a Fluid Barrier

The fluid dynamics of Guerbet's SEQURE® microcatheter for reflux control when injecting embolic beads achieved by a fluid barrier to help reduce the reflux of embolic material.

Drug-Eluting Bead Chemoembolization (DEB-TACE) for Liver Cancer

At Mount Sinai Hospital in New York City, interventional radiologists Dr. Edward Kim and Dr. Scott Nowakowski perform DEB (Drug Eluting Bead) chemoembolzation of hepatocellular liver carcinoma.

Spheres vs. Chemoembolization vs. Bland embolization by Dr. Charles Nutting

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Tools

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Child-Pugh Score Calculator

Child-Pugh Score Calculator on BackTable

Estimate cirrhosis severity with this quick Child-Pugh Score calculator.

 

Literature

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American Journal of Roentgenology (Dec 2014)

Survival Efficacy and Safety of Small Versus Large Doxorubicin Drug-Eluting Beads TACE Chemoembolization in Patients with Unresectable HCC

The purpose of this study was to investigate the overall survival, efficacy, and safety of small (100–300 μm) versus large (300–500 and 500–700 μm) doxorubicin drugeluting beads transarterial chemoembolization (DEB TACE) in patients with unresectable hepatocellular carcinoma (HCC).

CardioVascular and Interventional Radiology (Feb 2010)

Prospective Randomized Study of Doxorubicin-Eluting-Bead Embolization in the Treatment of Hepatocellular Carcinoma: Results of the PRECISION V Study.

This article description is not yet available.

 

Podcasts

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Locoregional Therapies for Bridging to Transplant in HCC BackTable Podcast Guest Dr. Alex Kim

Dr. Alex Kim

Dr. Christopher Beck

Interventional Radiologist Dr. Alex Kim and Dr. Christopher Beck discuss the utility of different locoregional liver therapies in bridging HCC patients to transplant.

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Pressure-Directed Therapy in TACE Podcast Guest Dr. Justin Lee

Dr. Justin Lee

Dr. Terence Gade

Discussion of experiences and utility of pressure-directed, antireflux infusion for TACE treatments.

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Pressure-Directed Therapy in Y90 Podcast Guest Dr. Nainesh Parikh

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Dr. Nainesh Parikh

The docs discuss pressure-directed, antireflux infusion for Y90 Radioembolization, including the SureFire Infusion system.

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HCC Bridge to Liver Transplant Podcast Guest Dr. Jennifer Berumen

Dr. Jennifer Berumen

Dr. Isabel Newton

Transplant Surgeon Dr. Jennifer Berumen and Interventional Radiologist Dr. Isabel Newton discuss the treatment of HCC and bridging patients to successful liver transplantation.

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Blog Articles

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TACE Versus Radioablation in the Treatment of Hepatocellular Carcinoma (HCC)

Transarterial chemoembolization (TACE) and radioembolization (Y90) have individualized roles in the treatment of hepatocellular carcinoma. Dr. Justin Lee and...