TACE Eligibility and Proper Patient Selection Transarterial chemoembolization eligibility and proper patient selection

1. TACE Eligibility
& Proper Patient Selection
Mohamed M.A. Zaitoun, MD
Associate Professor of Interventional Radiology
Faculty of Medicine, Zagazig University, Egypt
FINR-Switzerland

2. Introduction
TACE Eligibility
Proper Patient Selection
Assessment for Retreatment
TACE Failure/Refractoriness
TACE-Impossible
TACE Unsuitability/Ineligibility
TACE outside Intermediate
Stage
Combined Treatments

3. Introduction
TACE Eligibility
Proper Patient Selection
Assessment for Retreatment
TACE Failure/Refractoriness
TACE-Impossible
TACE Unsuitability/Ineligibility
TACE outside Intermediate
Stage
Combined Treatments

4. Introduction
-Hepatocellular carcinoma (HCC) is the fifth-
most common type of cancer worldwide and
the second leading cause of cancer-related
death.
-In Egypt, liver and breast cancers are the most
common tumors in terms of incidence and
mortality.

7. Llovet JM, Fuster J, Bruix J; Barcelona-Clínic Liver Cancer Group. The Barcelona approach: diagnosis,
staging, and treatment of hepatocellular carcinoma. Liver Transpl. 2004;10(2 Suppl 1):S115-S120.

8. The majority of HCCs are unresectable at the time
of diagnosis because of:
Portal hypertension
Poor liver function
Multiplicity of tumors
Portal vein tumor invasion
Inability to secure sufficient resection margin
Old age
Severe comorbidities.

9. TACE is the most commonly used nonsurgical
treatment modality for these patients;
meanwhile, tumor necrosis can be achieved
by the combined effects of antitumor
chemotherapy and selective ischemia of
tumor tissue.

10. TACE can be classified as:
(a) Conventional TACE (cTACE) using Lipiodol.
(b) Drug-eluting bead TACE (DEB-TACE).
It is important to distinguish TACE from
transarterial embolization (Bland
Embolization), which uses only embolic
materials, and hepatic arterial infusion
chemotherapy (HAIC), which uses only
antitumor chemotherapeutic agents.

11. Introduction
TACE Eligibility
Proper Patient Selection
Assessment for Retreatment
TACE Failure/Refractoriness
TACE-Impossible
TACE Unsuitability/Ineligibility
TACE outside Intermediate
Stage
Combined Treatments

12. TACE Eligibility
TACE is recommended as the standard of care
for intermediate-stage HCC, asymptomatic
patients with limited unresectable
multinodular lesions, without vascular
invasion or extrahepatic spread and who have
well-preserved liver function.

15. 10,108 patients treated with Lipiodol TACE,
Objective response rate was 52.5%, Overall
survival (OS) was 70.3% at 1 year, 51.8% at 2
years, 40.4% at 3 years, and 32.4% at 5 years.
Median OS was 19.4 months.
HEPATOLOGY, VOL. 64, NO. 1, 2016

16. Introduction
TACE Eligibility
Proper Patient Selection
Assessment for Retreatment
TACE Failure/Refractoriness
TACE-Impossible
TACE Unsuitability/Ineligibility
TACE outside Intermediate
Stage
Combined Treatments

17. Proper Patient Selection
The Selection for TrAnsarterial
chemoembolization TrEatment (STATE) score,
the Hepatoma arterial-embolisation
prognostic (HAP) score and Chiba HCC in
intermediate-stage prognostic (CHIP) score
were developed to improve patient selection
for the first TACE treatment.

18. Selection for TrAnsarterial chemoembolisation TrEatment
(STATE) score.
The STATE score includes the serum albumin level, tumor load,
and C-reactive protein (CRP) level.
Serum albumin (g/L) - 12 (if up-to-7 out) - 12 (if CRP levels ≥ 1
mg/dl).
Differentiated 2 groups (<18, ≥18 points) with distinct prognosis
(median OS: 5.3 vs. 19.5 months, P<0.001) and a lower
STATE-score was associated with short-term harm and
increased mortality after TACE-1 (39% vs. 14%, P<0.001).
Journal of Hepatology 2014 vol. 61 j 1287–1296

19. Prognostic factor Points
Albumin <3.6 g/dL 1
AFP >400 ng/mL 1
Bilirubin >1 mg/dL 1
Max tumour size >7 cm 1
HAP classification Points
HAP A 0
HAP B 1
HAP C 2
HAP D >2
Hepatoma Arterial Embolization Prognostic score (HAP score)

20. 2015; 10(4): e0125244.
Chiba HCC in intermediate-stage prognostic
(CHIP) score.
An a 0-7-point prognostic score.
Five groups (0-2 points, 3 points, 4 points, 5
points, and 6-7 points) by the median
survival time (65.2, 29.2, 24.3, 13.1, and
8.4 months, respectively; p < 0.0001)

21. Introduction
TACE Eligibility
Proper Patient Selection
Assessment for
Retreatment
TACE Failure/Refractoriness
TACE-Impossible
TACE Unsuitability/Ineligibility
TACE outside Intermediate
Stage
Combined Treatments

22. Assessment for Retreatment
the Assessment for Retreatment with TACE
(ART) score and the ABCR (α-fetoprotein,
Barcelona Clinic Liver Cancer, Child-Pugh, and
Response) score were developed in order to
identify patients who may or who may not
benefit from repeated TACE.

23. Prognostic factor Points
Absence of radiologic tumor response 1
AST increase ≥25% 4
Child-Pugh score increase:
1 point
≥2 points
1.5
3
Patients who gained 2.5 or more points after
the first TACE had an OS of about 7 months
while patients with less than 2.5 points in
the ART score had a good prognosis with a
median OS of 28 months.
Patients with 2.5 or more points in the ART
score prior the second TACE may not profit
from further TACE sessions.
These patients should rather receive other
evidence-based treatments like, e.g.,
Sorafenib therapy.
The ART (Assessment for Retreatment
with Transarterial chemoembolization)

24. The START strategy
The START strategy combines the STATE score and the ART score and aims
to improve both patient selection for the initial treatment and patient
suitability for retreatment.
The vast majority of patients with a high STATE-score ≥ 18 points had either
only one TACE with subsequent excellent prognosis or achieved an ART-
score of 0-1.5 points, which would have recommended retreatment
with TACE.
In contrast, patients with a low STATE-score (< 18 points) prior to TACE-1
had a two-thirds risk to receive either only 1 TACE or to be in the dismal
ART-score prognostic group prior TACE-2 with subsequent dismal
prognosis in case of re-TACE.
Although one-third of patients with low STATE-score but beneficial ART-
score (0-1.5 points) may still gain some benefit from re-TACE, we
believe, that with a number needed to harm of 4 it is inacceptable to
recommend TACE in this patient population.

25. The ABCR score associates two parameters observed
at baseline and usually linked with OS (BCLC and
AFP level) and two treatment-related parameters,
one associated with efficacy (tumor response) and
the other with toxicity (increase by more than 1
point in the Child-Pugh score).
Ranging from -3 to +6
ABCR score
-3 >> median OS of 37.5 months
0 >> 25.4 months
3 >> 12.2 months
A score ranging from 4 to 6 >> median OS 5.1 months.
An ABCR score >4 prior to the second TACE identified
patients with dismal prognosis who may not
benefit from further TACE sessions.
Journal of Hepatology 2015 vol. 62 j 855–862

26. These scores have shown limited predictive value
and cannot be used to make clear-cut clinical
decisions.
Because the predictive value of these scores has
not been demonstrated, they can only serve as
one component in the decision-making process.
To date, tumor burden, BCLC stage at baseline,
Child-Pugh score, and radiologic response are
considered the most predictive factors for TACE
retreatment decision-making and for
consideration of alternative therapy after two
TACE treatments.

27. In practice, TACE should not be repeated
when substantial necrosis is not achieved
after two TACE treatments or when there
is progression or liver function
impairment, worsening of performance
status (PS), or the appearance of portal
vein tumor thrombosis or extrahepatic
metastases.

28. Introduction
TACE Eligibility
Proper Patient Selection
Assessment for Retreatment
TACE
Failure/Refractoriness
TACE-Impossible
TACE Unsuitability/Ineligibility
TACE outside Intermediate
Stage
Combined Treatments

29. TACE Failure/Refractoriness
The definition of TACE failure/refractoriness
itself differs from country to country.
The major criteria currently available include:
(1) The JSH TACE failure/refractoriness criteria
(2) The criteria proposed by Raoul et al.
(3) The Taiwan criteria
(4) The International Expert Panel (EPOI HCC)
criteria.

30. (1) The JSH (Japan Society of Hepatology) TACE
failure/refractoriness criteria:

31. (2) The criteria proposed by Raoul et al.:
Recommend switching to the next treatment if there is
no response after 2 TACE sessions.

32. (3) The Taiwan criteria & (4) The International
Expert Panel (EPOI HCC) criteria:
State that patients who need 2 or 3 TACE
sessions within 6-12 months should be
considered TACE failure/refractory, at which
point they should be switched to systemic
therapy.
Taiwan, this is also a criterion for eligibility for
insurance reimbursement.

33. Repeated TACE in a patient who has become
refractory to TACE leads to impaired liver
function and consequently poor prognosis.
However, switching to Sorafenib after
refractoriness to TACE is more likely to preserve
liver function and reduce the incidence of
events associated with disease progression,
such as extrahepatic or vascular invasion.
Unfortunately, 20-26% of patients who were
considered to have progressed to TACE
failure/refractoriness had already progressed to
Child-Pugh class B or C.

34. Introduction
TACE Eligibility
Proper Patient Selection
Assessment for Retreatment
TACE Failure/Refractoriness
TACE-Impossible
TACE Unsuitability/Ineligibility
TACE outside Intermediate
Stage
Combined Treatments

35. Concept of TACE-Impossible
1-Patients are considered TACE-impossible upon:
disappearance/ devastation of the feeding artery
due to repeated TACE and/or the development of
a parasitic feeding artery, which preclude
selective catheterization.
2-Patients whose liver function has worsened to
Child-Pugh class C after repeated TACE.
3-Patients with large A-P shunts or major vascular
invasion such as Vp3 or Vp4 disease because of
the risk of liver failure caused by TACE.

36. In TACE-impossible cases related to the
disappearance/devastation of the feeding artery,
transarterial therapy cannot be performed;
therefore, systemic therapy should be used if liver
function is Child-Pugh class A.
In Child-Pugh class C cases, BSC is usually
recommended.
systemic therapy should be considered for patients
with large A-P shunts or patients with Vp3 and
Vp4 lesions.

37. Introduction
TACE Eligibility
Proper Patient Selection
Assessment for Retreatment
TACE Failure/Refractoriness
TACE-Impossible
TACE
Unsuitability/Ineligibility
TACE outside Intermediate
Stage
Combined Treatments

38. Concept of TACE Unsuitability/Ineligibility

39. Introduction
TACE Eligibility
Proper Patient Selection
Assessment for Retreatment
TACE Failure/Refractoriness
TACE-Impossible
TACE Unsuitability/Ineligibility
TACE outside
Intermediate Stage
Combined Treatments

40. TACE: Outside of Intermediate Stage
Early stage disease
Advanced stage disease

41. Early stage disease

42. Patients with earlier stage disease who cannot
benefit from the recommended option can
receive TACE according to the treatment stage
migration concept.
The role of TACE as neoadjuvant therapy prior to
liver transplantation (LT) is widely accepted,
either as a bridge between treatments while the
patient is on the waiting list or to downstage
tumor burden to accepted criteria for
transplantation.

43. TACE is also used in patients with early-stage HCC as a
bridge to liver transplantation or when liver
transplantation, hepatic resection, and image-guided
ablation are not possible, in keeping with the stage
migration strategy.
Although TACE is the first-line treatment option for
intermediate-stage HCC, in real life approximately
40% of TACEs are performed in either early or, more
rarely, advanced stages.

46. Advanced stage disease

47. Both the EASL (European Association for the Study
of the Liver) and AASLD (American Association for
the Study of Liver Diseases) Guidelines stand
against the use of TACE in patients with portal
vein tumor thrombosis (PVTT).
Some authors have proposed expanding the scope
of indications for TACE beyond BCLC-B in some
patients with advanced HCC due to PVTT.

48. The rationale is that the formation of collateral
vessels around the portal vein along with good
liver function may allow TACE to be tolerated
in selected cases, with this so-called Quasi-C
subgroup population being defined by
segmental or sub-segmental PVTT.

50. The survival benefits for the different degrees of PVTT were
reported as follows for cTACE and BSC, respectively:
Type I: 19 months vs. 4 months (P = 0.001)
Type II: 11 months vs. 1.4 months (P = 0.001)
Type III: 7.1 months vs. 1.3 months (P = 0.001)
Type IV: 4 months vs. 1 month (P = 0.005)
TACE is an effective treatment mode compared with
conservative treatment for HCC and PVTT and may provide a
significantly better survival benefit for different extent of
PVTT.

51. RCTs comparing TACE to Sorafenib as first-line
treatment are still needed to assess the
potential role of this technique for patients
with advanced disease who are intolerant of
or unsuitable for systemic therapy.

52. Introduction
TACE Eligibility
Proper Patient Selection
Assessment for Retreatment
TACE Failure/Refractoriness
TACE-Impossible
TACE Unsuitability/Ineligibility
TACE outside Intermediate
Stage
Combined Treatments

53. Combined Treatments
Combining TACE with local ablation
Combining TACE with systemic therapy

54. Combining TACE with Local Ablation
Surgical resection (SR) and LT are considered
standard curative therapies for HCC.
When surgery is not possible, percutaneous
ablation (radiofrequency ablation, RFA, or
microwave ablation, MWA) is usually
considered to be a suitable alternative.

55. A lot of studies showed that patients with single
HCC 3-7 cm or with a maximum of 3 lesions
that were less than 3 cm undergoing
combined cTACE + RFA treatment had
significantly better overall survival and
recurrence-free survival than patients treated
with RFA alone.

56. Volume 262: Number 2—February 2012

57. No significant differences in long-term therapeutic
outcomes between combined
chemoembolization/RF ablation and SR groups.
Therefore, combined chemoembolization/RF
ablation therapy may be an alternative treatment
for single 2-3 cm HCCs.

58. Combining TACE with Systemic Therapy
TACE can cause acute hypoxia, leading to the
upregulation of VEGF, which might contribute
to tumor revascularization and local
recurrence.
Thus, the rationale for combining TACE with
systemic therapy was that combining TACE
with tyrosine kinase inhibitors would inhibit
both revascularization and tumor
(re)proliferation.

59. The combination of TACE plus anti-angiogenic
drugs was expected to extend the period
during which TACE controls tumor progression
and improves the survival of patients with
intermediate stage disease.