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Hepatocellular carcinoma (HCC) is the fifth leading cause of cancer worldwide, and its incidence is constantly increasing.1,2 There are 13,000–19,000 cases per year in the US and 350,000 to one million cases per year worldwide.3–5 Chronic hepatitis C (HCV) infection and improved survival of patients with cirrhosis seem to account for most of this rising incidence.6
Treatment is dependent on disease status, including size and number of lesions, patient’s hepatic reserve and other co-morbidities. Partial hepatic resection with adequate margins and liver transplantation are potentially curative surgical options for selected patients. However, only 30–40% of patients with HCC qualify for surgery, leaving the rest to pursue non-surgical palliative options.7 In this direction, innovative local ablative therapies for HCC have recently shown great progress and promising results. Among them, transcatheter arterial chemoembolisation is a minimally invasive approach for the palliative treatment of unresectable HCC that constantly evolves, in terms of utilized drugs, embolic materials, technical, and technological advances.
This article outlines the current status of this imageguided intervention for treatment of HCC and introduces some new concepts and advances in the era of minimally invasive therapy of HCC.
The technique of transcatheter arterial chemoembolisation (TACE) exploits HCC preferential blood supply from the hepatic artery to deliver the anti-tumor therapy, while sparing the surrounding liver parenchyma.8,9 Since TACE was introduced as a palliative treatment in patients with unresectable HCC, it has become one of the most common procedures in interventional radiology. Currently, chemoembolisation is the preferred treatment for unresectable HCC.10–12 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 (RFA).13–17
TACE involves the injection of chemotherapeutic agents, with or without lipiodol and embolic agents, into the branch of the hepatic artery that feeds the tumor.18 Contraindications to this technique are constantly reviewed.The absence of hepatopedal blood flow (portal vein thrombosis), the presence of encephalopathy and biliary obstruction are currently re-evaluated as absolute contraindications, whereas relative contraindications include a variety of other factors, such as:
• serum bilirubin >2mg/dL;
• lactate dehydrogenase >425U/L;
• aspartate aminotransferase >100U/L;
• tumor burden involving >50% of the liver;
• cardiac or renal insufficiency;
• recent variceal bleeding; or
• significant thrombocytopenia.