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Hepatic Chemoembolization
Mandeep S. Dagli, MD
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KEY FACTS

  • Terminology

    • Procedure

      • Post Procedure

        • Outcomes

          TERMINOLOGY

          • Definitions

            • Transcatheter liver-directed therapy
              • Targeted treatment of primary and secondary hepatic malignancies by injecting therapeutic agent via catheter advanced into hepatic artery
              • Includes bland embolization, chemoembolization [conventional and drug-eluting bead (DEB)], and radioembolization
              • Takes advantage of fact that hepatic cancers receive blood supply primarily from hepatic artery, whereas liver parenchyma has dual supply from hepatic artery and portal vein, making it less susceptible to injected therapeutic
            • Transcatheter arterial chemoembolization (TACE)
              • a.k.a. hepatic arterial chemoembolization
              • Treatment of hepatic tumor by injection of chemotherapeutic agent with or followed by embolic particles
              • 2 subtypes of TACE, conventional TACE (cTACE) and DEB chemoembolization (DEB-TACE), differ primarily in carrier agent for chemotherapeutic
              • Primary antitumor effect is via ischemic necrosis; however, also causes high, prolonged concentration of chemotherapeutic drug within hepatic tumor, which is thought to provide additional antitumor effect
            • cTACE
              • Uses Lipiodol (iodized fatty acids of poppy seed oil) as carrier agent for chemotherapeutic
              • Aqueous chemotherapeutic solution is emulsified with hydrophobic Lipiodol to create water-in-oil emulsion
                • Chemolipiodol mixture is injected directly into hepatic artery via catheter; it is preferentially retained within abnormal tumor microvasculature relative to that of surrounding liver
                • Chemolipiodol is selectively taken up and retained by tumor cells
                • Chemolipiodol mixture is followed by or mixed with particulate embolic agent to produce tumor ischemia and decrease washout of chemotherapeutic from tumor
            • DEB-TACE
              • Embolization using beads impregnated with chemotherapeutic agent, such as doxorubicin or irinotecan
              • Embolic beads designed for controlled local delivery of chemotherapeutic drugs with decreased washout into systemic circulation compared with chemolipiodol
                • Beads act as occlusive embolic agents: Ischemic effect
                • Chemotherapy slowly released from beads delivers local, sustained dose of drug: Chemotherapeutic effect
                • Decreased systemic release of drug compared with chemolipiodol appears to cause fewer systemic side effects from chemotherapeutic
            • Bland embolization
              • Transcatheter arterial embolization using only embolic material without chemotherapy
              • Proponents argue that efficacy of TACE, particularly when treating hypervascular tumors, such as hepatocellular carcinoma (HCC), or neuroendocrine tumor, comes from embolization not chemotherapeutic agent
              • Much less commonly used than TACE as 1st-line therapy for treatment of most primary and metastatic hepatic malignancies
              • Often used as 1st-line therapy in actively bleeding hepatic tumors
              • Often used as 1st-line therapy for benign hepatic lesions, such as unresectable hepatic adenomas

          PREPROCEDURE

          • Indications

            • Contraindications

              • Preprocedure Imaging

                • Getting Started

                  • Chemotherapy/Embolization Agents

                    PROCEDURE

                    • Patient Position/Location

                      • Equipment Preparation

                        • Procedure Steps

                          • Alternative Procedures/Therapies

                            POST PROCEDURE

                            • Things to Do

                              • Post Procedure Imaging and Clinical Assessment

                                OUTCOMES

                                • Complications

                                  • Controversies

                                    • Expected Outcomes

                                      Selected References

                                      1. Ahmed S et al: Quality of life in hepatocellular carcinoma patients treated with transarterial chemoembolization. HPB Surg. 2016:6120143, 2016
                                      2. Gaba RC et al: Transcatheter therapy for hepatic malignancy: standardization of terminology and reporting criteria. J Vasc Interv Radiol. 27(4):457-73, 2016
                                      3. Kouri BE et al: ACR appropriateness criteria radiologic management of hepatic malignancy. J Am Coll Radiol. 13(3):265-73, 2016
                                      4. Fiorentini G et al: Intra-arterial infusion of irinotecan-loaded drug-eluting beads (DEBIRI) versus intravenous therapy (FOLFIRI) for hepatic metastases from colorectal cancer: final results of a phase III study. Anticancer Res. 32(4):1387-95, 2012
                                      5. Khan W et al: Moxifloxacin prophylaxis for chemoembolization or embolization in patients with previous biliary interventions: a pilot study. AJR Am J Roentgenol. 197(2):W343-5, 2011
                                      6. Lammer J et al: Prospective randomized study of doxorubicin-eluting-bead embolization in the treatment of hepatocellular carcinoma: results of the PRECISION V study. Cardiovasc Intervent Radiol. 33(1):41-52, 2010
                                      7. Wible BC et al: Longitudinal quality of life assessment of patients with hepatocellular carcinoma after primary transarterial chemoembolization. J Vasc Interv Radiol. 21(7):1024-30, 2010
                                      8. Moreno Planas JM et al: Efficacy of hepatocellular carcinoma locoregional therapies on patients waiting for liver transplantation. Transplant Proc. 37(3):1484-5, 2005
                                      9. Llovet JM et al: The Barcelona approach: diagnosis, staging, and treatment of hepatocellular carcinoma. Liver Transpl. 10(2 Suppl 1):S115-20, 2004
                                      10. Llovet JM et al: Systematic review of randomized trials for unresectable hepatocellular carcinoma: Chemoembolization improves survival. Hepatology. 37(2):429-42, 2003
                                      11. Lo CM et al: Randomized controlled trial of transarterial lipiodol chemoembolization for unresectable hepatocellular carcinoma. Hepatology. 35(5):1164-71, 2002
                                      Related Anatomy
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                                      Related Differential Diagnoses
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                                      References
                                      Tables

                                      Tables

                                      KEY FACTS

                                      • Terminology

                                        • Procedure

                                          • Post Procedure

                                            • Outcomes

                                              TERMINOLOGY

                                              • Definitions

                                                • Transcatheter liver-directed therapy
                                                  • Targeted treatment of primary and secondary hepatic malignancies by injecting therapeutic agent via catheter advanced into hepatic artery
                                                  • Includes bland embolization, chemoembolization [conventional and drug-eluting bead (DEB)], and radioembolization
                                                  • Takes advantage of fact that hepatic cancers receive blood supply primarily from hepatic artery, whereas liver parenchyma has dual supply from hepatic artery and portal vein, making it less susceptible to injected therapeutic
                                                • Transcatheter arterial chemoembolization (TACE)
                                                  • a.k.a. hepatic arterial chemoembolization
                                                  • Treatment of hepatic tumor by injection of chemotherapeutic agent with or followed by embolic particles
                                                  • 2 subtypes of TACE, conventional TACE (cTACE) and DEB chemoembolization (DEB-TACE), differ primarily in carrier agent for chemotherapeutic
                                                  • Primary antitumor effect is via ischemic necrosis; however, also causes high, prolonged concentration of chemotherapeutic drug within hepatic tumor, which is thought to provide additional antitumor effect
                                                • cTACE
                                                  • Uses Lipiodol (iodized fatty acids of poppy seed oil) as carrier agent for chemotherapeutic
                                                  • Aqueous chemotherapeutic solution is emulsified with hydrophobic Lipiodol to create water-in-oil emulsion
                                                    • Chemolipiodol mixture is injected directly into hepatic artery via catheter; it is preferentially retained within abnormal tumor microvasculature relative to that of surrounding liver
                                                    • Chemolipiodol is selectively taken up and retained by tumor cells
                                                    • Chemolipiodol mixture is followed by or mixed with particulate embolic agent to produce tumor ischemia and decrease washout of chemotherapeutic from tumor
                                                • DEB-TACE
                                                  • Embolization using beads impregnated with chemotherapeutic agent, such as doxorubicin or irinotecan
                                                  • Embolic beads designed for controlled local delivery of chemotherapeutic drugs with decreased washout into systemic circulation compared with chemolipiodol
                                                    • Beads act as occlusive embolic agents: Ischemic effect
                                                    • Chemotherapy slowly released from beads delivers local, sustained dose of drug: Chemotherapeutic effect
                                                    • Decreased systemic release of drug compared with chemolipiodol appears to cause fewer systemic side effects from chemotherapeutic
                                                • Bland embolization
                                                  • Transcatheter arterial embolization using only embolic material without chemotherapy
                                                  • Proponents argue that efficacy of TACE, particularly when treating hypervascular tumors, such as hepatocellular carcinoma (HCC), or neuroendocrine tumor, comes from embolization not chemotherapeutic agent
                                                  • Much less commonly used than TACE as 1st-line therapy for treatment of most primary and metastatic hepatic malignancies
                                                  • Often used as 1st-line therapy in actively bleeding hepatic tumors
                                                  • Often used as 1st-line therapy for benign hepatic lesions, such as unresectable hepatic adenomas

                                              PREPROCEDURE

                                              • Indications

                                                • Contraindications

                                                  • Preprocedure Imaging

                                                    • Getting Started

                                                      • Chemotherapy/Embolization Agents

                                                        PROCEDURE

                                                        • Patient Position/Location

                                                          • Equipment Preparation

                                                            • Procedure Steps

                                                              • Alternative Procedures/Therapies

                                                                POST PROCEDURE

                                                                • Things to Do

                                                                  • Post Procedure Imaging and Clinical Assessment

                                                                    OUTCOMES

                                                                    • Complications

                                                                      • Controversies

                                                                        • Expected Outcomes

                                                                          Selected References

                                                                          1. Ahmed S et al: Quality of life in hepatocellular carcinoma patients treated with transarterial chemoembolization. HPB Surg. 2016:6120143, 2016
                                                                          2. Gaba RC et al: Transcatheter therapy for hepatic malignancy: standardization of terminology and reporting criteria. J Vasc Interv Radiol. 27(4):457-73, 2016
                                                                          3. Kouri BE et al: ACR appropriateness criteria radiologic management of hepatic malignancy. J Am Coll Radiol. 13(3):265-73, 2016
                                                                          4. Fiorentini G et al: Intra-arterial infusion of irinotecan-loaded drug-eluting beads (DEBIRI) versus intravenous therapy (FOLFIRI) for hepatic metastases from colorectal cancer: final results of a phase III study. Anticancer Res. 32(4):1387-95, 2012
                                                                          5. Khan W et al: Moxifloxacin prophylaxis for chemoembolization or embolization in patients with previous biliary interventions: a pilot study. AJR Am J Roentgenol. 197(2):W343-5, 2011
                                                                          6. Lammer J et al: Prospective randomized study of doxorubicin-eluting-bead embolization in the treatment of hepatocellular carcinoma: results of the PRECISION V study. Cardiovasc Intervent Radiol. 33(1):41-52, 2010
                                                                          7. Wible BC et al: Longitudinal quality of life assessment of patients with hepatocellular carcinoma after primary transarterial chemoembolization. J Vasc Interv Radiol. 21(7):1024-30, 2010
                                                                          8. Moreno Planas JM et al: Efficacy of hepatocellular carcinoma locoregional therapies on patients waiting for liver transplantation. Transplant Proc. 37(3):1484-5, 2005
                                                                          9. Llovet JM et al: The Barcelona approach: diagnosis, staging, and treatment of hepatocellular carcinoma. Liver Transpl. 10(2 Suppl 1):S115-20, 2004
                                                                          10. Llovet JM et al: Systematic review of randomized trials for unresectable hepatocellular carcinoma: Chemoembolization improves survival. Hepatology. 37(2):429-42, 2003
                                                                          11. Lo CM et al: Randomized controlled trial of transarterial lipiodol chemoembolization for unresectable hepatocellular carcinoma. Hepatology. 35(5):1164-71, 2002