Classic Concepts of TACE
TACE, initially launched by Yamada, exploits HCC’s preferential blood supply by the hepatic artery to precisely deliver chemotherapeutic and embolic agents to the tumour, while sparing the surrounding liver parenchyma and avoiding concomitant systemic toxicity. Since TACE was first introduced as a palliative treatment in patients with unresectable HCC, it has become one of the most commonly performed procedures in interventional radiology. Nowadays, chemoembolisation is the preferred treatment for unresectable HCC. Moreover, for unresectable HCC larger than 10cm in diameter, TACE is the only treatment option. TACE is also employed as an adjunctive therapy to liver resection or as a bridge to liver transplantation, as well as prior to radiofrequency ablation.
TACE typically involves the injection of chemotherapeutic agents, with or without lipiodol and embolic agents, into the branch of the hepatic artery that feeds the tumour. The most commonly used chemotherapeutic drug combination includes doxorubicin, cisplatin and mitomycin C, whereas doxorubicin is the most common single agent used. The absolute and relative contraindications to this technique are listed in Table 1. Patient selection is important, as not every patient with HCC may benefit from chemoembolisation. One important aspect in the selection of patients is the presence of adequate liver function. In patients with advanced liver disease, treatment-induced liver failure may offset the anti-tumoural effect or survival benefit of the intervention. Predictors of outcome are related to tumour burden (tumour size, vascular invasion, and alpha-fetoprotein (AFP) levels), liver functional impairment (Child-Pugh, bilirubin, ascites), performance status (Karnofsky index, Eastern Cooperative Oncology Group (ECOG)) and response to treatment. Thus, the best candidates are patients with preserved liver function and asymptomatic lesions without vascular invasion or extrahepatic spread.