Targeted treatment of primary and secondary hepatic malignancies by injecting therapeutic agent via catheter advanced into hepatic arterial system
Includes bland embolization [transarterial embolization (TAE)], chemoembolization (conventional and drug-eluting bead), radioembolization, immunoembolization
Takes advantage of fact that hepatic cancers receive blood supply primarily from hepatic artery, whereas liver parenchyma less susceptible to intraarterial therapy due to dual supply from hepatic artery and portal vein
Transarterial chemoembolization (TACE)
a.k.a. hepatic arterial chemoembolization
Treatment of hepatic tumor(s) via injection of chemotherapeutic agent and particulate embolization
2 subtypes of TACE, conventional TACE (cTACE) and drug-eluting bead TACE (DEB-TACE), differ primarily in carrier agent for chemotherapeutic drug
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 drug
Aqueous chemotherapeutic solution is emulsified with hydrophobic Lipiodol to create water-in-oil emulsion
Chemolipiodol mixture is injected directly into hepatic arterial system via catheter
Chemolipiodol mixture is preferentially retained within abnormal tumor microvasculature relative to that of surrounding liver
Mixture is followed by particulate embolic agent to produce tumor ischemia and ↓ washout of mixture from tumor
DEB-TACE
Embolization using beads impregnated with chemotherapeutic agent
Embolic beads designed for controlled local delivery of chemotherapeutic drugs with ↓ washout into systemic circulation compared with chemolipiodol
Beads act as both carrier and embolic agent
Chemotherapy slowly released from beads delivers local, sustained dose of drug
↓ systemic release of drug compared with chemolipiodol appears to cause fewer systemic side effects from chemotherapeutic drug
Angiographic endpoint is stasis
Bland particles can be used for embolization if entire dose of drug-coated beads is delivered without achieving stasis
Bland embolization a.k.a. TAE
Arterial embolization using only embolic material (often calibrated microspheres) without chemotherapy/radiotherapy
Data showing similar outcomes to TACE
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
Also used as 1st-line therapy for benign hepatic lesions, such as unresectable hepatic adenomas
Angiographic endpoint is stasis
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
Postprocedure Imaging and Clinical Assessment
OUTCOMES
Complications
Controversies
Expected Outcomes
Selected References
Reig M et al: BCLC strategy for prognosis prediction and treatment recommendation: The 2022 update. J Hepatol. 76(3):681-93, 2022
Benson AB et al: Hepatobiliary cancers, version 2.2021, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. 19(5):541-65, 2021
Roth GS et al: Comparison of trans-arterial chemoembolization and bland embolization for the treatment of hepatocellular carcinoma: a propensity score analysis. Cancers (Basel). 13(4):812, 2021
Shah MH et al: Neuroendocrine and adrenal tumors, version 2.2021, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. 19(7):839-68, 2021
Kishore SA et al: Embolotherapeutic strategies for hepatocellular carcinoma: 2020 update. Cancers (Basel). 12(4):791, 2020
Zhao J et al: Comparison of transcatheter arterial chemoembolization combined with radiofrequency ablation or microwave ablation for the treatment of unresectable hepatocellular carcinoma: a systemic review and meta-analysis. Int J Hyperthermia. 37(1):624-33, 2020
Raoul JL et al: Updated use of TACE for hepatocellular carcinoma treatment: how and when to use it based on clinical evidence. Cancer Treat Rev. 72:28-36, 2019
Facciorusso A et al: Transarterial chemoembolization vs bland embolization in hepatocellular carcinoma: a meta-analysis of randomized trials. United European Gastroenterol J. 5(4):511-8, 2017
Ahmed S et al: Quality of life in hepatocellular carcinoma patients treated with transarterial chemoembolization. HPB Surg. 2016:6120143, 2016
Brown KT et al: Randomized trial of hepatic artery embolization for hepatocellular carcinoma using doxorubicin-eluting microspheres compared with embolization with microspheres alone. J Clin Oncol. 34(17):2046-53, 2016
de Baere T et al: Treatment of liver tumors with Lipiodol TACE: technical recommendations from experts opinion. Cardiovasc Intervent Radiol. 39(3):334-43, 2016
Gaba RC et al: Transcatheter therapy for hepatic malignancy: standardization of terminology and reporting criteria. J Vasc Interv Radiol. 27(4):457-73, 2016
Kouri BE et al: ACR appropriateness criteria radiologic management of hepatic malignancy. J Am Coll Radiol. 13(3):265-73, 2016
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
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
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
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
Moreno Planas JM et al: Efficacy of hepatocellular carcinoma locoregional therapies on patients waiting for liver transplantation. Transplant Proc. 37(3):1484-5, 2005
Llovet JM et al: The Barcelona approach: diagnosis, staging, and treatment of hepatocellular carcinoma. Liver Transpl. 10(2 Suppl 1):S115-20, 2004
Llovet JM et al: Systematic review of randomized trials for unresectable hepatocellular carcinoma: chemoembolization improves survival. Hepatology. 37(2):429-42, 2003
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 arterial system
Includes bland embolization [transarterial embolization (TAE)], chemoembolization (conventional and drug-eluting bead), radioembolization, immunoembolization
Takes advantage of fact that hepatic cancers receive blood supply primarily from hepatic artery, whereas liver parenchyma less susceptible to intraarterial therapy due to dual supply from hepatic artery and portal vein
Transarterial chemoembolization (TACE)
a.k.a. hepatic arterial chemoembolization
Treatment of hepatic tumor(s) via injection of chemotherapeutic agent and particulate embolization
2 subtypes of TACE, conventional TACE (cTACE) and drug-eluting bead TACE (DEB-TACE), differ primarily in carrier agent for chemotherapeutic drug
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 drug
Aqueous chemotherapeutic solution is emulsified with hydrophobic Lipiodol to create water-in-oil emulsion
Chemolipiodol mixture is injected directly into hepatic arterial system via catheter
Chemolipiodol mixture is preferentially retained within abnormal tumor microvasculature relative to that of surrounding liver
Mixture is followed by particulate embolic agent to produce tumor ischemia and ↓ washout of mixture from tumor
DEB-TACE
Embolization using beads impregnated with chemotherapeutic agent
Embolic beads designed for controlled local delivery of chemotherapeutic drugs with ↓ washout into systemic circulation compared with chemolipiodol
Beads act as both carrier and embolic agent
Chemotherapy slowly released from beads delivers local, sustained dose of drug
↓ systemic release of drug compared with chemolipiodol appears to cause fewer systemic side effects from chemotherapeutic drug
Angiographic endpoint is stasis
Bland particles can be used for embolization if entire dose of drug-coated beads is delivered without achieving stasis
Bland embolization a.k.a. TAE
Arterial embolization using only embolic material (often calibrated microspheres) without chemotherapy/radiotherapy
Data showing similar outcomes to TACE
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
Also used as 1st-line therapy for benign hepatic lesions, such as unresectable hepatic adenomas
Angiographic endpoint is stasis
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
Postprocedure Imaging and Clinical Assessment
OUTCOMES
Complications
Controversies
Expected Outcomes
Selected References
Reig M et al: BCLC strategy for prognosis prediction and treatment recommendation: The 2022 update. J Hepatol. 76(3):681-93, 2022
Benson AB et al: Hepatobiliary cancers, version 2.2021, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. 19(5):541-65, 2021
Roth GS et al: Comparison of trans-arterial chemoembolization and bland embolization for the treatment of hepatocellular carcinoma: a propensity score analysis. Cancers (Basel). 13(4):812, 2021
Shah MH et al: Neuroendocrine and adrenal tumors, version 2.2021, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. 19(7):839-68, 2021
Kishore SA et al: Embolotherapeutic strategies for hepatocellular carcinoma: 2020 update. Cancers (Basel). 12(4):791, 2020
Zhao J et al: Comparison of transcatheter arterial chemoembolization combined with radiofrequency ablation or microwave ablation for the treatment of unresectable hepatocellular carcinoma: a systemic review and meta-analysis. Int J Hyperthermia. 37(1):624-33, 2020
Raoul JL et al: Updated use of TACE for hepatocellular carcinoma treatment: how and when to use it based on clinical evidence. Cancer Treat Rev. 72:28-36, 2019
Facciorusso A et al: Transarterial chemoembolization vs bland embolization in hepatocellular carcinoma: a meta-analysis of randomized trials. United European Gastroenterol J. 5(4):511-8, 2017
Ahmed S et al: Quality of life in hepatocellular carcinoma patients treated with transarterial chemoembolization. HPB Surg. 2016:6120143, 2016
Brown KT et al: Randomized trial of hepatic artery embolization for hepatocellular carcinoma using doxorubicin-eluting microspheres compared with embolization with microspheres alone. J Clin Oncol. 34(17):2046-53, 2016
de Baere T et al: Treatment of liver tumors with Lipiodol TACE: technical recommendations from experts opinion. Cardiovasc Intervent Radiol. 39(3):334-43, 2016
Gaba RC et al: Transcatheter therapy for hepatic malignancy: standardization of terminology and reporting criteria. J Vasc Interv Radiol. 27(4):457-73, 2016
Kouri BE et al: ACR appropriateness criteria radiologic management of hepatic malignancy. J Am Coll Radiol. 13(3):265-73, 2016
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
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
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
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
Moreno Planas JM et al: Efficacy of hepatocellular carcinoma locoregional therapies on patients waiting for liver transplantation. Transplant Proc. 37(3):1484-5, 2005
Llovet JM et al: The Barcelona approach: diagnosis, staging, and treatment of hepatocellular carcinoma. Liver Transpl. 10(2 Suppl 1):S115-20, 2004
Llovet JM et al: Systematic review of randomized trials for unresectable hepatocellular carcinoma: chemoembolization improves survival. Hepatology. 37(2):429-42, 2003
Lo CM et al: Randomized controlled trial of transarterial lipiodol chemoembolization for unresectable hepatocellular carcinoma. Hepatology. 35(5):1164-71, 2002
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