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Interventional Radiology
Procedures
Oncologic Procedures
Hepatic Chemoembolization
Hepatic Chemoembolization
Chad Davis, MD; 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 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

                                      1. Reig M et al: BCLC strategy for prognosis prediction and treatment recommendation: The 2022 update. J Hepatol. 76(3):681-93, 2022
                                      2. 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
                                      3. 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
                                      4. 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
                                      5. Kishore SA et al: Embolotherapeutic strategies for hepatocellular carcinoma: 2020 update. Cancers (Basel). 12(4):791, 2020
                                      6. 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
                                      7. 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
                                      8. 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
                                      9. Ahmed S et al: Quality of life in hepatocellular carcinoma patients treated with transarterial chemoembolization. HPB Surg. 2016:6120143, 2016
                                      10. 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
                                      11. 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
                                      12. Gaba RC et al: Transcatheter therapy for hepatic malignancy: standardization of terminology and reporting criteria. J Vasc Interv Radiol. 27(4):457-73, 2016
                                      13. Kouri BE et al: ACR appropriateness criteria radiologic management of hepatic malignancy. J Am Coll Radiol. 13(3):265-73, 2016
                                      14. 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
                                      15. 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
                                      16. 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
                                      17. 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
                                      18. Moreno Planas JM et al: Efficacy of hepatocellular carcinoma locoregional therapies on patients waiting for liver transplantation. Transplant Proc. 37(3):1484-5, 2005
                                      19. Llovet JM et al: The Barcelona approach: diagnosis, staging, and treatment of hepatocellular carcinoma. Liver Transpl. 10(2 Suppl 1):S115-20, 2004
                                      20. Llovet JM et al: Systematic review of randomized trials for unresectable hepatocellular carcinoma: chemoembolization improves survival. Hepatology. 37(2):429-42, 2003
                                      21. 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

                                                                          1. Reig M et al: BCLC strategy for prognosis prediction and treatment recommendation: The 2022 update. J Hepatol. 76(3):681-93, 2022
                                                                          2. 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
                                                                          3. 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
                                                                          4. 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
                                                                          5. Kishore SA et al: Embolotherapeutic strategies for hepatocellular carcinoma: 2020 update. Cancers (Basel). 12(4):791, 2020
                                                                          6. 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
                                                                          7. 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
                                                                          8. 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
                                                                          9. Ahmed S et al: Quality of life in hepatocellular carcinoma patients treated with transarterial chemoembolization. HPB Surg. 2016:6120143, 2016
                                                                          10. 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
                                                                          11. 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
                                                                          12. Gaba RC et al: Transcatheter therapy for hepatic malignancy: standardization of terminology and reporting criteria. J Vasc Interv Radiol. 27(4):457-73, 2016
                                                                          13. Kouri BE et al: ACR appropriateness criteria radiologic management of hepatic malignancy. J Am Coll Radiol. 13(3):265-73, 2016
                                                                          14. 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
                                                                          15. 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
                                                                          16. 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
                                                                          17. 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
                                                                          18. Moreno Planas JM et al: Efficacy of hepatocellular carcinoma locoregional therapies on patients waiting for liver transplantation. Transplant Proc. 37(3):1484-5, 2005
                                                                          19. Llovet JM et al: The Barcelona approach: diagnosis, staging, and treatment of hepatocellular carcinoma. Liver Transpl. 10(2 Suppl 1):S115-20, 2004
                                                                          20. Llovet JM et al: Systematic review of randomized trials for unresectable hepatocellular carcinoma: chemoembolization improves survival. Hepatology. 37(2):429-42, 2003
                                                                          21. Lo CM et al: Randomized controlled trial of transarterial lipiodol chemoembolization for unresectable hepatocellular carcinoma. Hepatology. 35(5):1164-71, 2002