Transarterial chemoembolization (TACE) involves delivering chemotherapy drugs and embolic agents directly into liver cancers via catheters in the hepatic artery. TACE is generally used to treat hepatocellular carcinoma that cannot be surgically removed. During the procedure, a catheter is placed into the hepatic artery supplying the tumor and chemotherapy mixed with iodinated oil is injected, followed by embolization of the artery with gelatin sponges. TACE can reduce tumor size and symptoms but common side effects include abdominal pain and nausea. Response to treatment is evaluated after 3-4 weeks using imaging to assess the extent of tumor coverage by the oil and residual enhancement.

1. TACE
Dr. Yash Kumar Achantani
OSR

2. • Transarterial chemoembolisation (TACE) is a procedure
performed by interventional radiologists where chemotherapy
and embolic agents are delivered directly into primary or
secondary liver cancers via catheters placed in the hepatic
artery.
• TACE is generally indicated in the setting of unresectable
hepatocellular carcinoma. Where curative options for
hepatocellular carcinoma are not feasible; for example, with
advanced disease or multifocality, then patients may be treated
with TACE.

3. INDICATIONS
• Hepatocellular carcinoma (HCC)
• Selective metastatic disease (most commonly from colorectal
carcinoma)
• Cholangiocarcinoma
• As palliative treatment for a patient with unresectable HCC.
• Sometimes also be performed prior to radiofrequency tumor
ablation.

4. Contraindications
Absolute contraindications
• Extensive tumour infiltration throughout the liver
• Encephalopathy
• Large burden of extra-hepatic metastases
Relative contraindications
• Portal vein thrombosis
• Liver or renal failure
• Uncorrectable coagulopathy
• Significant arteriovenous shunting of blood through the
tumour

5. Procedure
• TACE is performed through the trans-femoral route.
• Superior mesenteric artery and celiac axis arteriogram is
obtained to begin with.
• Selective cannulation of the hepatic artery supplying the
tumour is performed using a 5F celiac catheter and a 0.035-
inch J-tip Terumo guidewire.
• Further, the catheter is placed as close as possible to the
tumour using either a 4F multipurpose slip catheter/glide
catheter or a 3F microcatheter.

6. • The chemotherapeutic drug emulsion is prepared. This consists
of doxorubicin 50 mg, cisplatin 100 mg , 10 ml of iodinated
non-ionic contrast media and 20ml of iodized oil (lipiodol).
• This amount of emulsion is ideal for lesions larger than 5cms
in size.
• The chemotherapeutic drug emulsion is then delivered through
this cannulated feeding hepatic artery.
• The amount of emulsion to be injected is decided during the
procedure. When the lesion shows complete coverage with
lipiodol or if there is reflux of emulsion into normal branches,
further injection of emulsion is stopped.

7. • Subsequent to the injection of the emulsion, this feeding artery
was embolized using gelatin sponge pledgets.
• Intra-arterial lidocaine (10 mg) is given between 10-ml
aliquots of chemoembolization material to reduce the pain
after embolization.
• Microcatheter coaxial system to access small and tortuous
feeders.

8. Post-procedural care
• Daily monitoring of liver and renal function
• Follow-up imaging (at 3-16 weeks)
• Patient’s groin site where the arterial sheath was placed should
be inspected for pseudoaneursyms

9. Outcomes
• TACE has been shown to have a survival benefit over current
treatments as well as reducing patient symptoms and
preventing tumor growth.
• CT is typically used for follow up imaging, with the oily based
embolic particles having a distinct high attenuation
appearance.
• One key advantage is the chemotherapy is targeted locally so
reducing the systemic side effects of intravenous
chemotherapy.

10. Response to treatment
• Imaging is generally advised after 3-4 weeks, either triple
phase CT, dynamic MRI or contrast enhanced USG.
• The accumulation pattern of the iodised oil and enhancement
pattern of the mass is to be observed to evaluate the response
to the treatment.
• The more the accumulation greater the necrosis and, thus, the
survival. Enhancing areas of tumour are considered as residual
viable tumour.

11. There are four types of patterns that have been described
(a) Complete response – when the tumour was fully covered
with lipiodol and had no enhancing viable tissue;
(b) Residual disease – when the tumour was partially covered
with lipiodol and enhancing viable tissue is seen;
(c) Recurrence – when the enhancement is seen at the previously
treated tumour site, indicating the presence of viable tissue;
(d) Fresh lesions – when new lesions are detected at different
sites in the liver and not at the site where the previously treated
tumours were located.

12. Adverse effects of TACE
• TACE is generally performed with an overnight stay in the
hospital or sometimes as a same day procedure.
• It is common to experience some post-procedural discomfort
in the region of where the catheters were placed (usually right
groin), as well as experiencing some generalised upper
abdominal discomfort for a few days.
• Patients may experience common post-chemotherapy side
effects as well, such as a low-grade fever, nausea and/or
malaise.

13. Immediate
• Immediately following the procedure, post-embolic symptoms
of generalised abdominal discomfort, a low-grade fever,
nausea and/or malaise are common.
• Minimal swelling and discomfort around the catheter site is
common.
Delayed
• Hepatic insufficiency or infarction.
• Abscess.
• Biliary necrosis.
• Tumour rupture.
• Cholecystitis.

14. Complete response following TACE in a patient of small HCC with chronic
hepatitis B. Pre-TACE arterial phase CT scan
(A)Shows a large enhancing surface tumor (arrow) in segment 6 of the liver.
TACE was done. Post-TACE CT scan at 1 month
(B)Shows Lipiodol completely involving the tumor (arrow), with no enhancing
residual viable tumor.

15. Follow-up CT scans at 1 year (C) and 3 years (D), respectively, show marked
tumor shrinkage, with retained Lipiodol and no residual or recurrent disease

16. Complete response in a patient with a large HCC, with cirrhosis due to hepatic vein
outlet tract obstruction.
Arterial phase CT scan shows a large, exophytic, vascular HCC (10 cm) in
segments 7 and 6 of the liver (arrow). TACE was done and a post-TACE CT scan at
1 year
(B) Shows reduction in tumor size; the tumor (arrow) is completely covered with
Lipiodol, with no viable residual disease

17. Residual disease following TACE in a patient with a large HCC and HBV cirrhosis.
Post-TACE non-contrast CT scan (A) shows scattered patchy areas of retained
Lipiodol (arrow) in the large HCC in segments 7/6 of the liver.
Arterial phase CT scan (B) shows multiple areas of enhancing viable tissue
(arrows) in the inferomedial aspect of the same mass, suggestive of residual disease

18. Disease progression following TACE depicting poor response in a patient of
mutifocal HCC with HBV cirrhosis. Post-TACE contrast-enhanced CT scans at 1
month (A,B) show multifocal HCC in the right and left lobes of the liver. Only a
few lesions are covered with Lipiodol (black arrow), while the remaining lesions
are devoid of Lipiodol (white arrow), suggesting inadequate response.
Additionally, multiple enhancing fresh lesions (small arrows in B) have also
appeared, indicating progression of disease.