.png){kind=small}
.png){kind=small}
BackTable / VI / Article
Transarterial Chemoembolization (TACE)
Dr. Chris Beck • Updated Sep 16, 2021 • 2.8k hits
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.
Table of Contents
(1) Pre-Procedure Prep
(2) TACE Procedure Steps
(3) Post-Procedure
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
Listen to the Full Podcast
Stay Up To Date
Follow:
Subscribe:
Sign Up:
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
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
Additional resources:
[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.
Podcast Contributors
Cite This Podcast
BackTable, LLC (Producer). (2025, August 12). Ep. 564 – Pressure-Enabled Drug Delivery in HCC & Metastatic Liver Lesions [Audio podcast]. Retrieved from https://www.backtable.com
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. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
Podcasts
Articles
The Future of Radiation Segmentectomy: New Tech, Tumor Markers & Indications
Planning for HCC Radiation Segmentectomy: Mapping, Margins & Dosage
Hepatocellular Carcinoma in Practice: Optimizing Workflows & Treatment Decisions
Current Practices In Combination Therapy for Hepatocellular Carcinoma
Topics
