Transcatheter arterial chemoembolization

The transarterial chemoembolization (TACE ) is a mininimal - invasive radiological method for the treatment of inoperable hepatocellular carcinoma ( HCC) (liver cancer ) or in certain selected cases of liver metastases (eg, from neuroendocrine carcinomas ). It is carried out in an angiography procedure combines multiple courses of medications such as a chemotherapeutic agent with simultaneous targeted constipation ( embolization ) of arteries by means of small particles.

A sole treatment with TACE does not lead in most cases to a cure (exception: small, single HCC nodules ), but to an increase in life expectancy at tumor control with repetition of TACE at fixed intervals.

The TACE has increasing importance as a bridging therapy ( so-called " bridging" ) of liver disease patients before liver transplantation.

Indication criteria

Indication criteria for TACE are:

  • Hepatocellular carcinoma ( HCC)
  • In some cases, liver metastases

Exclusion criteria

Exclusion criteria ( contraindications ) are:

  • Extensive tumor involvement of the liver
  • Infestation of the portal vein or hepatic veins, infiltration of adjacent organs (T4 status after TNM classification )
  • Metastases outside the liver
  • Pedunculated tumor
  • Severe heart failure
  • Severe hepatic insufficiency ( Child C stage )
  • Heavy contrast agent allergy
  • Severe coagulopathy
  • Poor general condition ( Karnofsky index <70%)

Implementation

The special feature of the hepatocellular carcinoma is its arterial blood flow (it is mainly fed by small arterial vessels and only slightly from Pfortaderästchen ) what the interventional radiologist is the possibility to visit this arterial territory by angiography catheter and thus to treat the tumor target.

For this purpose, after the puncture of the femoral artery ( femoral artery ), a special exploratory catheter through the aorta into the disposal of the liver supply ( celiac trunk ) is placed. By contrast, the tumor and the location of the catheter tip are presented. About the probing catheter is a catheter in the common hepatic artery (arteria hepatica communis or their main branches, the hepatic artery vein or artery ) advanced. The positioning of the tip of the catheter (ie the place from where the embolization will be performed) is determined depending on the location of, or tumors in the liver. It is a further positioning of the catheter to the tumor is advantageous because such a more aggressive Embolisationtechnik ( achieving a higher effect of the chemotherapeutic agent within the tumor ) can be used. This " lower " position in the hepatic vessels needed instead of using the so-called selective catheter ( 4-5 French in diameter ), a super- selective catheter ( synonym: microcatheter; 1.8-2.7 French in diameter), which can be advanced through the catheter into smaller selective segmental arteries. This super selective TACE performed ( some centers are talking about the S- TACE ) results compared to conventional TACE (without using this microcatheter ) to an improvement of survival.

The further away from the tumor embolization is performed, the higher the risk for a Mitembolisation of the pancreas and small intestine (called non -target embolization of the gastroduodenal artery ).

There are concerning the choice of Embolisate and the chemotherapeutic agent as yet no generally accepted standards. A common method uses the following substances:

It rarely comes to a complete, permanent occlusion of the tumor nurturing blood vessels. TACE treatment should be repeated several times, depending on the success of treatment. Here different regimens (two to four treatments, which are repeated after four to eight weeks ) may be used depending on the center.

Results

2003 was a meta-analysis ( only randomized trials with a total of 545 patients with HCC), a significant improvement of the ( 2-year ) survival rate after TACE compared to non - treated patients ( so-called best supportive care under tamoxifen therapy ) are occupied. This therapeutic success only concerned the use of TACE (ie a mixture of embolizates and chemotherapy ), but not a simple embolization with lipiodol and particles without chemotherapy.

Despite the massive improvements in the surgery, it is not possible in many instances to operate with overt liver cirrhosis ( which is the precancerous lesion of the occurrence of HCC). A possible removal of a lobe of the liver, where the tumor is located, also does not alter the presence of cirrhosis in the remaining liver lobes. A curative treatment is liver transplantation in such cases. The TACE leads in most cases does not cure, so it is a palliative treatment. Whether a patient can be transplanted liver, (also called a descriptor for your Mazzaferro criteria) based on the so-called Milan criteria chosen. This therapy decisions can be made for example by the so-called Barcelona Staging and Treatment Schedule ( BCLC ).

With the TACE as a bridging method for patients on the liver transplant waiting list 5-year survival rates of 81 % to 94 % were achieved.

Alternative Treatments

Alternative treatments, which are often combined with TACE, are:

  • Percutaneous ethanol injection therapy ( PEI)
  • Radiofrequency ablation (RFA )
  • Selective internal radiation therapy ( SIRT )
  • Sorafenib chemotherapy
  • Surgical resection
  • Liver transplantation ( LTx )
Metastatic liver disease Child-Pugh-Score Contrast medium Performance status Carboplatin Mitomycin
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