Procedure Guide

Transarterial Chemoembolization (TACE) Procedure

Transarterial chemoembolization (TACE) procedure is a locoregional therapy primarly used for treatment of liver cancer, hepatocellular carcinoma (HCC) and cholangiocarcinoma vs selective metastatic tumors. Chemotherapeutic agents and mixture agents vary. Conventional TACE (cTACE) uses a mixture of chemotherapeutic and Lipiodol. Drug-eluting beads (DEB-TACE) loads chemotherapeutics onto vary sizing of drug-eluting beads as the name implies. TACE treatment can be used for HCC in different clinical settings such as bridge to transplant or palliative treatment. Understanding treatment paradigms for HCC is as important as the technical components to a successful TACE procedure. We lay out helpful information to explain this common interventional oncology TACE procedure below.

Step-by-step guidance on how to perform Transarterial Chemoembolization. Review tools, techniques, pearls, and pitfalls on the BackTable Web App.

Pre-Procedure Prep

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
• Allergies
• Medications

Labs:
• CMP
• Platelets/INR
• Tumor Markers: AFP, CEA

Transarterial Chemoembolization Podcasts

Ep. 92

Interventional Oncology in Private Practice (Part 2)

Interventional Radiologist Justin Lee tells us about his approach to treatment of Hepatocellular Carcinoma (HCC), including how this has changed over his years in private practice.

bt-app-icon-listens.png

Ep. 91

Interventional Oncology in Private Practice (Part 1)

Interventional Radiologist Justin Lee tells us how he started from scratch in growing a robust Interventional Oncology program in private practice, including pitfalls to avoid.

bt-app-icon-listens.png

Ep. 76

Targeting the Tumor Microenvironment in HCC

Interventional Radiologist Terence Gade tells us about emerging research and therapies targeting the tumor microenvironment in Hepatocellular carcinoma (HCC).

bt-app-icon-listens.png

Ep. 67

Locoregional Therapies for Bridging to Transplant in HCC

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

bt-app-icon-listens.png

TACE Procedure Steps

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 to Place 5-Fr 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

Transarterial Chemoembolization Articles

HCC Locoregional Therapies for Bridging to Transplant

Locoregional treatments for HCC, the UNOS 6-month wait period for liver transplantation, and methods and markers for HCC prognostication.

Hepatocellular carcinoma on CT

Patient Selection and Treatment of Hepatocellular Carcinoma

Evaluating HCC patients, multi-specialty collaboration, and locoregional therapies for both transplant and non-transplant candidates.

Hepatocellular carcinoma on angiography

Pressure-Directed Therapy for the Treatment of Hepatocellular Carcinoma (HCC)

Effective drug delivery systems attempt to maximize homogeneous distribution of the respective agent to the entire tumor to induce cytotoxicity and tumor necrosis. Dr. Justin Lee and Dr. Terence Gade discuss how pressure-directed therapy improves drug delivery to areas of tumor burden in cases of HCC.

Surefire infusion catheter for pressure directed therapy

Conventional TACE vs. DEB-TACE in the Treatment of HCC

Various treatment options exist for intermediate-stage HCC including lidiodal-based cTACE and DEB-TACE. Dr. Terence Gade discusses chemotherapeutic options, how tumor biology influences embolic delivery, and how these treatment modalities can be used to treat HCC.

3D image of hepatocellular carcinoma

Post-Procedure

Post-Procedural 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

Transarterial Chemoembolization Demos

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

Dr. Charles Nutting gives a presentation comparing Spheres vs. Chemoembolization vs Bland Embolization.

Transarterial Chemoembolization Tools

Child-Pugh Score Calculator

The Child-Pugh Score calculator can be used to quickly assess the severity of cirrhosis, life expectancy, and risk of perioperative abdominal surgery mortality in patients with liver disease. To use this tool, you will need bilirubin, albumin, prothrombin time (INR), ascites, and encephalopathy grade. Each of these measures have corresponding categories in the Child-Pugh Score calculator that give 1, 2, or 3 points. After inputting your values, the calculator will provide the severity of cirrhosis based on Child-Pugh class, life expectancy, and abdominal surgery perioperative mortality rate.

Child-Pugh Score Calculator on BackTable

LI-RADS Calculator

2017 version of the Liver Imaging Reporting and Data System (LI-RADS) for CT and MR Imaging.

LI-RADS Calculator on BackTable

DAVYR 3 Y90 Dosimetry

Mathematical modeling tool designed to provide the user with a more clear understanding of the relationship between activity (GBq) determination, and compartmental dose (liver, tumor, lung) as relating to Trans-Arterial Radioembolization (TARE) with Yttrium-90 microspheres.

DAVYR 3 Y90 Dosimetry on BackTable

Transarterial Chemoembolization Literature

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.

Related Content

No related content.

i-video.png

Podcast

Interventional Oncology in Private Practice (Part 2)

Interventional Oncology in Private Practice (Part 2) BackTable Podcast Guest Dr. Justin Lee
i-video.png

Podcast

Interventional Oncology in Private Practice (Part 1)

Interventional Oncology in Private Practice (Part 1) BackTable Podcast Guest Dr. Justin Lee
i-video.png

Article

HCC Locoregional Therapies for Bridging to Transplant

Hepatocellular carcinoma on CT
i-video.png

Practice Tool

DAVYR 3 Y90 Dosimetry

DAVYR 3 Y90 Dosimetry on BackTable

Join The Discussion

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.

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients.