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Physics, Techniques and Procedures

Transarterial chemoembolization (tace)

intraarterial administration of chemotherapeutic drugs mixed with an embolizing material. TACE combines therapeutic effects of peripheral arterial occlusion with the local administration of cytotoxic drugs. Theoretically, there should be synergistic effects by hypoxia causing an increased effect of the chemotherapeutic drug, and the higher extraction of the drug with a slowed passage through the liver.

Indications and techniques

The main indications for TACE are palliation of inoperable primary or secondary hepatic malignancies and reduction of pain. It may be performed preoperatively to reduce tumour mass or postoperatively to influence tumour rests or recurrences. Palliative indications include treatment of hormone producing tumours and reduction of shunt volumes in haemangioendothelioma. TACE should not be performed if more than 75% of the liver is involved by tumour, in the presence of insufficiency of the liver, significant portal hypertension, occlusion of the portal vein or hepatorenal syndrome.

Initial angiography is followed by superselective catheterization. Co-axial systems (e.g. Tracker) may be necessary to obtain positioning that are close enough to the tumour for embolization (Fig.1). Lipiodol and Lipiodol/chemotherapeutic agent are infused. Additional occlusion devices such as coils, Gelfoam or microspheres can be used.

Classically, Doxorubicin and Mitomycin, Cisplatin, Epirubicin and 5-FU have been used as chemotherapeutic agents. Frequently multiple sessions are needed at intervals of 3 to 6 weeks.

Promising results have been encountered with hepatocellular carcinoma (HCC). Several studies have shown a prolonged survival rate with a medium survival time of approximately 14 months. In hormone-producing endocrine liver tumours there have been good responses with reduction of hormone activity. The results in colorectal liver metastasis vary, and are at least partly dependent on the vascularity of the tumours. Generally the results are not as favourable as in HCC.

CLZ

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Fig.1

Patient with hepatocellular carcinoma of left liver lobe supplied by middle hepatic and left hepatic artery (common trunk left gastric + left hepatic artery; replaced right hepatic artery to SMA). a: Injection in coeliac trunc shows anatomy of middle and left hepatic artery. b: Super-selective injection in middle hepatic artery with coaxial system. c: Super-selective injection in left hepatic artery with coaxial system. d: Injection into coeliac trunc after chemoembolization with 80 mg of Doxorubicin and Gelfoam shows complete occlusion of middle + left hepatic artery with preservation of gastroduodenal and left gastric artery.
Transarterial chemoembolization (tace), Fig.1 (a)
Transarterial chemoembolization (tace), Fig.1 (b)
Transarterial chemoembolization (tace), Fig.1 (c)
Transarterial chemoembolization (tace), Fig.1 (d)