This document provides an overview of transarterial chemoembolization (TACE) for the treatment of hepatocellular carcinoma (HCC). It discusses patient selection criteria for TACE, the mechanism by which it works, details of the procedure, potential adverse effects and treatment schedules. TACE selectively cuts off the arterial blood supply to tumors while preserving liver function. The document also reviews experiences with TACE at hospitals in Bangladesh and combinations of TACE with other therapies. Proper patient selection and further study of combination approaches are emphasized as important areas for improving HCC management.

1. D Dr. Most. Rokshana Begum
Assistant Professor, Hepatology

2. Contents..
 Preamble
 Patient selection for TACE: Indication &
Contraindication
 Mechanism
 TACE Procedure
 TACE adverse effects
 Treatment Schedule
 TACE with other combinations
 Our Experiences
 Conclusion

3. Preamble
 Hepatocellular carcinoma (HCC) is one of the most
common cancers worldwide.
 Even with the breakthrough in preventive strategies,
and new diagnostic and treatment modalities,
incidence and fatality rates of HCC is climbing.
 Despite improved surveillance programs,
approximately 80% of patients with HCC have
intermediate- or advanced-stage disease at the time of
diagnosis where curative surgery is not possible.

4. Preamble cont..
 Transarterial Chemoembolization (TACE) is a
locoregional therapy regarded as a first-line treatment
in patients with intermediate-stage HCC.
 In real-world clinical practice, TACE also plays an
important role in early- and advanced-stage HCC.
 TACE is recommended as first line non-curative
therapy for non-surgical patients.

5. Patient selection for TACE
BCLC stage B (Intermediate stage) patients,
supported by EASL, AASLD, APASL, and JSH for
intermediate-stage HCC.
The BCLC staging system defines intermediate HCC as
 Presence of multifocal nodules
 >3 nodules or a maximum nodule diameter of >3 cm
 Preserved liver function
 No cancer related symptoms, i.e. ECOG 0.
 No macrovascular invasion or extrahepatic spread.
Zhong B.Y. et al: TACE for HCC

6. Treatment as per BCLC
Kung et al. Hepatoma Res 2022;8:17

7. BCLC staging and treatment strategy
in 2022
Journal of Hepatology 2022 vol. 76 j 681–693

8. Patient selection for TACE cont..
 TACE is also used in patients with early-stage HCC as a
bridge to liver transplantation, Neoadjuvant
chemoembolization
 When liver transplantation, hepatic resection, and
image-guided ablation are not possible, in keeping
with the stage migration strategy
Journal of Hepatology 2018 vol. 69 j 182–236

9. Patient selection for TACE cont..
 The majority of guidelines do not recommend the use
of TACE in advanced HCC patients; the only exception
is the CNLC which recommends TACE as the first-line
choice for patients with macrovascular invasion.
 In combination with other therapies
 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.
 Secondaries at liver

10. Variation at different guidelines
Zhong B.Y. et al: TACE for HCC

11. TACE contraindication
 Decompensated liver (Child-Pugh B) with tumor-
related symptoms.
 Macrovascular invasion of the main portal branches or
the main portal vein, impaired portal blood flow.
 Extensive tumor (>10 cm)
 Creatinine >2 mg/dl
 Co-morbidities
 Biliary dilation
 Untreated esophageal varices with a high risk of
bleeding. 2022 Manjunatha et al. Cureus 14(8): e28439. DOI 10.7759/cureus.28439 2

12. Mechanism of TACE

13. Mechanism of TACE ..
 The primary notion of TACE relies upon the concept of
the liver's dual blood supply
 Normal hepatocytes receive dual blood supply
predominantly from the portal vein
 The objective of transarterial embolization is to
selectively deprive arterial inflow to the tumour, which
causes ischaemic necrosis.
 Hepatocyte perfusion is then maintained by patent
portal vein.
2022 Manjunatha et al. Cureus 14(8): e28439. DOI 10.7759/cureus.28439 2

14. Mechanism of TACE cont..
 Mori et al. in 1966 were the first to perform hepatic
artery ligation to create ischemic necrosis of the tumor
leading to regression.
 Tumor embolization using embolic agents injected via
a percutaneous injection, was used by angiographers
in the early 1970s.
 Later in 1974, Doyon et al. were the first to perform and
describe TACE
2022 Manjunatha et al. Cureus 14(8): e28439. DOI 10.7759/cureus.28439 2

15. Mechanism of TACE cont..
 There are four main types of transarterial therapies:
 Transarterial embolization (or “bland” embolization,
TAE),
 Transarterial chemoembolization (TACE),
 TACE using drug-eluting beads (DEB-TACE)
 Transarterial radioembolization (TARE).
Kung et al. Hepatoma Res 2022;8:17

16. Procedure:
 An interventional radiologist or a hepatologist
usually performs TACE through a percutaneous
transarterial approach.
 Femoral artery on the right is punctured, and
under local anesthesia, an arterial sheath is placed
into the artery by Selinger's method
 A catheter is then introduced through the sheath;
a wire often aids the catheter into the arterial
system under imagining guidelines.
2022 Manjunatha et al. Cureus 14(8): e28439. DOI 10.7759/cureus.28439 2

17. Procedure cont..
 To reach the target branches that supply the tumor, a
micro catheter is then inserted through the common
hepatic artery and then the proper hepatic artery;
 After locating the feeding vessel, an iodized oil along
with cytotoxic drug, followed by embolization particles
is injected.

18. Procedure cont..

19. Procedure cont…
 Commonly used cytotoxic drugs in TACE are:
doxorubicin, cisplatin, epirubicin or miriplatin.
Idarubicin is under clinical trial.
 Carrier: Lipiodol
 Embolic agents: gel foam, micro particles
 At DEB-TACE, microspheres charged with cytotoxic
drugs are administered.

20. Procedure cont…
Adverse effects: 03 types
1. Intraoperative complications
2. Post Operative complications
3. Tumour lysis syndrome
Intraoperative complications:
 Allergic reactions
 Intraoperative bleeding
 Biliary cardiac reflex

21. Procedure cont..
Post operative complications:
 Postembolization syndrome (PES): 47.7% suffered from this.
Results in fever (17.2%), vomiting, liver enzyme abnormalities
(18.1%), abdominal pain(11%) , and nausea, vomiting (6%).
 Liver abscess,
 Acute cholecystitis, pancreatitis
 Upper gastrointestinal bleeding
 Liver and renal failure
 Myelosuppression
 Ectopic embolism
 Bile duct damage

22. Procedure cont..
Tumour lysis syndrome: Results from rapid destruction
of tumour cells, lead to-
 Renal insufficiency
 Metabolic disturbance
 Arrhythmias
 Seizures
 30-day mortality of 1%
 Overall mortality 0.6%
Kung et al. Hepatoma Res 2022;8:17

23. Treatment Schedule
Scheduled TACE & On demand TACE
 Aggressive Schedule like TACE every two months may
result liver failure and at present repeat TACE is
usually done if CT images Suggest viable tumour.
 TACE should not be repeated if substantial necrosis is
not achieved after two rounds or if there are
untreatable progression.
 If patient gets multiple session of TACE,
echcardiogram should be done and cumulative dose
should not exceed 450 mg/m2
Journal of Hepatology 2018 vol. 69 j 182–236

25. TACE Sorafenib Combination
307 patients with
intermediate-stage HCC at 85
centers in 13 countries
(2016)
Conclusion: Sorafenib plus DEB-TACE was technically
feasible, but the combination did not improve TTP in
a clinically meaningful manner compared with DEB-
TACE alone.

26. TACE and RFA combination
The combination of TACE and RFA can treat some
patients with HCC more effectively when offered to
patients with HCC over 3 cm .
But, ASLDB- At this time, the combination of RFA with
TACE requires further study

27. TACE with other combinations

28. Our Experience on TACE
In Bangladesh, First TACE in April 1 2016
As of now,
338 cases

31. Baseline Data
Male,
80.2%
Female,
19.8%
Total Patients 283
64%
15%
10%
6%
1%
4%
ETIOLOGY OF HCC
HBV HCV Cryptogenic
NASH Occult HBV Hepatic Mets

32. initiated in 150 patients,
77 completed an initial target of 3-
months follow-up.
The study was designed to assess the
impacts of the combined therapy with
TACE and sorafenib on advanced HCC at
Bangladesh.
The primary end point was the survival
for 3 months after start of therapy
Out of 77 patients, 33 patients (43%)
died within 3 m
A total of 44 patients (57%) have
been surviving for more than 3
months
All patients with diffuse HCC died within
3 months

33. Concluding Remarks
 Being the 5th most common cancer and second most
common cancer related death globally, management of
HCC is getting utmost attention world wide.
 Proper selection of patients is of paramount
importance
 Important area to pay attention is-
 Combination therapies
 To increase coverage
Miles to go yet…..