Transarterial Chemoembolization

(TACE) of Hepatocellular

Carcinoma (HCC)

Sreeja Sompalli

Jawaharlal Nehru Medical College, India

Advanced radiology clerkship

6/1/2013 to 6/30/2013

Gillian Lieberman, MD

Sreeja Sompalli,

Gillian Lieberman, MD

OVERVIEW:

Introduction to TACE

Indication and contraindications

Brief history of patient

Technique

Complications

Follow up

Outcomes

Future evolution of TACE

WHAT IS TACE?

A targeted therapy for HCC confined to the liver

Launched by Yamada as a palliative treatment in patients with non-operable HCC

Sedlinger technique

Catheter in Femoral artery Aorta Hepatic artery

Chemotherapeutic agent & embolising agent

Principles- two fold

Delivering high concentration of chemo

therapeutic agent to the tumor

Cutting off the blood supply and essentially

starving it to death

http://www.idahoarteryandvein.com/treatments/chemoembolization.php

Rationale for TACE:

In HCC, Hepatic artery supplies 90 to 100% of

blood

In non tumorous liver, Portal vein supplies 75 to 83

% of blood while Hepatic artery supplies 20 to 25%

only

Effects of TACE:

In TACE, high concentration of drug to HCC

but much less to non tumorous liver

lipoidal - slow release of drug from lipoid

drug emulsion--prolonged contact time of

tumor cells to drug

particle embolisation -Synergistic effect of

tumor necrosis due to ischemia and drug

effects

slows down blood flow - increases contact

time

Ischemia induces trans membrane pump -

greater absorption of drug

Candidates:

• Palliative treatment for unresectable HCC

Patients on transplant list

Prior to Radio frequency ablation

Residual tumors

Patients with metastatic neuroendocrine tumors in liver

Contra indications:

ABSOLUTE RELATIVE

◉Extensive liver

disease

◉Encephalopathy

◉Large burden

metastatic disease

outside the liver

◉Borderline Liver function

◉Total bilirubin >4mg/dl

◉Serum creatinine >2mg/dl

◉Portal vein thrombosis

◉Uncorrectable coagulopathy

◉Poor general health

◉Significant AV shunting

through tumor

◉Anaphylactic reaction to

chemotherapeutic drugs,

contrast

OUR PATIENT:

74 y.o. male with chronic Hep C infection

and liver cirrhosis

Dx with well differentiated HCC by Biopsy 5

months ago

On CT - HCC without evidence of

metastatic disease cirrhotic liver, mild

splenomegaly with mild gastro esophageal

varices, changes in lung consistent with

pulmonary fibrosis and emphysema and

aortic valve calcifications

enrolled himself in RFA trial

Post RFA: CT demonstrated successful ablation

with some residual tumor in segment VIII of the

liver

http://www.radiologyassistant.nl/en/p4375bb8dc241d

Post RFA: HCC in segment VIII of Liver

measuring 6.2cm TV * 6.4cm AP * 6cm

cc.

PACS BIDMC

Patient preparation:

• Clotting parameters should be checked and

corrected

Platelet count ideally >1,00,000cells/mm³

INR< 1.5

• NPO status for at least 8 hrs prior to

sedation/anesthesia

• Good iv hydration

• pre medication : antibiotics

anti emetics

• Informed consent

• Anesthesia:

Local anesthesia with lidocaine

moderate sedation- divided doses of

midazolam and fentanyl

• Total time - 1hr 25min

Technique

Access to the Right femoral

artery

PACS BIDMC

Diagnostic arteriograms: - SMA to exclude the aberrant supply to

the tumor

-to demonstrate the patency of portal

vein

PACS BIDMC

• Advanced to Celiac artery

PACS BIDMC

• Advanced further into Common Hepatic artery

• using micro catheter advanced into main

segment VIII artery

PACS BIDMC

• Delivery of chemo embolization mixture (lipoidal

and doxorubicin) under continuous fluoroscopic

visualization.

• Additional embolization to near stasis was

performed using 100 micron Embozene

particles.

PACS BIDMC

• Catheter/sheath removal and groin access

hemostasis

Post TACE CT

PACS BIDMC

Follow-up

CT FINDINGS

- after 24 hrs

- 1 month

- 2 months

- every 6 months there after

SEQUENCE OF CT SCANS FOLLOWING TACE, SHOWING THE

DEVELOPMENT OF INTRATUMORAL NECROSIS AND

DISAPPEARANCE OF THE TREATED LESION

ON DAY

1 MONTH

1 WEEK

6 MONTHS

http://emedicine.medscape.com/article/369936-overview

COMPLICATIONS:

Most common is Post embolization syndrome in 80% Triad of Abdominal pain, Nausea, Fever

Liver abscess

Non target embolization

Liver abscess

Septicemia

Irreversible liver failure

Hepatorenal syndrome

OUTCOMES:

The survival rates of TACE are appx.

60% to 80% at 1 year

30% to 60% at 2 years

18% to 50% at 3 years

Studies have shown that TACE

combined with RFA improved the

overall survival compared with that of

TACE alone.

WHO criteria for Tumor

assessment COMPLETE RESPONSE - The disappearance of all

known disease, determined by 2 observations not less than 4 weeks apart

PARTIAL RESPONSE - 50% or more decrease in total tumor size of the lesions which have been measured to determine the effect of therapy by 2 observations not less than 4 weeks apart and there can be no appearance of new lesion

NO CHANGE - 50% decrease in total tumor size cannot be established nor has a 25% increase in size of one or more measurable lesions been demonstrated

PROGRESSIVE DISEASE - 25% increase in size of one or more measurable lesions, or the appearance of new lesions

Future evolution of TACE:

Anti-VEGF antibodies in combination

with TACE

Ultra selective catheterization of tumor

feeding arteries

TACE in combination with p53 gene

therapy.

REFERENCES: • Antoine Bouchard-Fortier, Réal Lapointe, Pierre Perreault, Louis Bouchard,

and Gilles Pomier-Layrargues, “Transcatheter Arterial Chemoembolization of

Hepatocellular Carcinoma as a Bridge to Liver Transplantation: A

Retrospective Study,” International Journal of Hepatology, vol. 2011, Article

ID 974514, 7 pages, 2011. doi:10.4061/2011/974514

• Lance C, McLennan G, Obuchowski N, Cheah G, Levitin A, Sands M, Spain

J, Srinivas S, Shrikanthan S, Aucejo FN, Kim R, Menon KV., "Comparative

analysis of the safety and efficacy of transcatheter arterial

chemoembolization and yttrium-90 radioembolization in patients with

unresectable hepatocellular carcinoma ",J Vasc Interv Radiol. 2011

Dec;22(12):1697-705. doi: 10.1016/j.jvir.2011.08.013. Epub 2011 Oct 8.

• Bruls S, Joskin J, Chauveau R, Delwaide J, Meunier P.,"Ruptured

hepatocellular carcinoma following transcatheter arterial chemoembolization

",JBR-BTR. 2011 Mar-Apr;94(2):68-70

• Amit G. Singal, Jorge A. Marrero.,"Recent Advances in the Treatment of

Hepatocellular Carcinoma", Curr Opin Gastroenterol. 2010;26(3):189-

195.

• T. U. Haq.,"Transcatheter Chemo-Embolization for Hepatocellular

Carcinoma and certain Hepatic Metastasis",JPMA. 2004 Mar: vol.54,

No.3

• Sung Wook Shin.,"The Current Practice of Transarterial

Chemoembolization for the Treatment of Hepatocellular

Carcinoma',Korean J Radiol. 2009 Sep-Oct; 10(5): 425–434.

• Published online 2009 August 25. doi: 10.3348/kjr.2009.10.5.425

• Geschwind J F, Ramsey D E, Choti M A, Thuluvath P J, Huncharek M S.

Chemoembolization of hepatocellular carcinoma: results of a

metaanalysis. American Journal of Clinical Oncology 2003; 26(4): 344-

349.

• Wang."Transarterial chemoembolization in combination with

percutaneous ablation therapy in unresectable hepatocellular carcinoma:

a meta-analysis" Liver International Volume: 30 Issue: 5 (2010-05-01) p.

741-749. ISSN: 1478-3223

• Peter Huppert."Current concepts in transarterial chemoembolization of

hepatocellular carcinoma",Department of Diagnostic and Interventional

Radiology, Klinikum Darmstadt GmbH, Grafenstrasse 9,64283 Darmstadt,

Germany Published online 2009 August 25. doi: 10.3348/kjr.2009.10.5.425

• doi: 10.1634/theoncologist.8-5-425 The Oncologist October 2003 vol. 8 no. 5

425-437

Acknowledgements:

• Gillian Lieberman, MD

• Neda Sedora Roman, MD

• Dr. Rashmi Jayadevan, MD

• My radiology colleagues

THANK YOU!