Transarterial chemoembolization

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The trans chemoembolization (TACE) is a minimally invasive, radiological method for the treatment of inoperable hepatocellular carcinoma (HCC, liver cancer) or in certain selected cases of liver metastases (for example of neuroendocrine carcinoma ). This procedure, carried out in an angiography , combines the administration of several drugs, such as a chemotherapeutic agent, with simultaneous targeted clogging ( embolization ) of arteries using small particles.

Treatment with TACE alone does not lead to healing in most cases (exception: small, individual HCC nodules), but rather to an extension of life expectancy with tumor control with repetition of TACE at fixed intervals.

TACE has increasing importance as a bridge therapy (so-called "bridging" ) with liver disease patients prior to liver transplantation .

Indication criteria

Indication criteria for a TACE are:

Exclusion criteria

Exclusion criteria ( contraindications ) are:

execution

What is special about hepatocellular carcinoma is its arterial blood flow (it is mainly nourished by small arterial vessels and only minimally by portal vein boxes), which gives the interventional radiologist the opportunity to visit this arterial vascular area using an angiography catheter and thus treat the tumor in a targeted manner.

For this purpose, after the inguinal artery ( arteria femoralis ) has been punctured, a special probing catheter is placed via the aorta into the exit of the liver supply ( celiac trunk ). By contrast the will tumor and the location of the catheter tip shown. A catheter is advanced through the probing catheter into the common hepatic artery ( arteria hepatica communis or its main branches, the arteria hepatica left or right). The positioning of the tip of the catheter (i.e. the place from where the embolization will be carried out) is determined according to the location of the tumor or tumors in the liver. Positioning the catheter closer to the tumor is advantageous because a more aggressive embolization technique (achieving a higher effect of the chemotherapeutic agent in the tumor) can be used. This “deeper” positioning in the hepatic vessels requires, instead of using the so-called selective catheter (4-5 French diameter), a super-selective catheter (synonym: microcatheter; 1.8-2.7 French diameter), which can be advanced through the selective catheter into smaller segment arteries . This super-selective TACE (some centers refer to it as S-TACE) leads to an improvement in survival compared to conventional TACE (without the use of this microcatheter).

The further away from the tumor the embolization, the higher the risk of co-embolization of the pancreas and small intestine (so-called non-target embolization via the gastroduodenal artery ).

There are still no generally accepted standards for the choice of embolizates and chemotherapeutic agents. A common procedure uses the following substances:

  1. Beginning by injecting an emulsion of Lipiodol , an oily radiopaque liquid. In this way, the supplying blood vessels are temporarily closed by fine oil droplets and the effect of the chemotherapeutic agent in the liver is prolonged.
  2. Optionally, embolization using small, spherical, precisely calibrated (40–120 micrometers) gelatine or plastic particles, which lead to a further slowdown in flow in the tumor bed, is now optional . It is believed that hypoxia (lack of oxygen) in the tumor improves the effectiveness of the subsequently injected chemotherapy drug.
  3. Doxorubicin , Carboplatin , Mitomycin C and others are used as chemotherapeutic agents .
  4. Finally there is another embolization.

Complete, permanent closure of the blood vessels nourishing the tumor rarely occurs. The TACE treatment should be repeated several times depending on the success of the therapy. Depending on the center, different therapy regimes (two to four treatments that are repeated after four to eight weeks) are used here.

Results

In 2003, a meta-analysis (exclusively randomized studies with a total of 545 patients with HCC) showed a significant improvement in the (2-year) survival rate after TACE compared to untreated patients (so-called best supportive care under tamoxifen therapy). This therapeutic success only concerned the use of TACE (i.e. a mixture of embolizates and chemotherapy), but not a simple embolization with lipiodol and particles without chemotherapy.

Despite the massive improvements in surgery, in many cases it is not possible to operate if the liver has cirrhosis (which is the precancerous condition for the occurrence of HCC). A possible removal of a liver lobe in which the tumor is located does not change the presence of liver cirrhosis in the remaining liver lobe. A curative treatment method in such cases is liver transplantation . In most cases, TACE does not lead to a cure, so it is a palliative treatment method. Whether a patient can be liver transplanted is decided on the basis of the so-called Milan criteria (also called Mazzaferro criteria after their description). These therapy decisions can e.g. B. be taken according to the so-called Barcelona Staging and Treatment Schedule (BCLC).

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

Alternative treatments

Alternative treatment methods, which are often combined with TACE, are:

Web link

Individual evidence

  1. ↑ TJ Vogl, p Zangos, JO Balzer, M. Nabil, P. Rao, K. Eichler, WO Bechstein, S. Zeuzem, A. Abdelkader: transarterial chemoembolization (TACE) in hepatocellular carcinoma: technique, indication and results. In: Roefo. 179 (11), Nov 2007, pp. 1113-1126.
  2. ↑ a b M. Staunton, JD Dodd, PA McCormick, DE Malone: Finding evidence-based answers to practical questions in radiology: which patients with inoperable hepatocellular carcinoma will survive longer after transarterial chemoembolization? In: Radiology. 237 (2), Nov 2005, pp. 404-413.
  3. ↑ a b R. Hoffman et al. a .: HCC - ablative & minimally invasive treatment methods. (PDF file; 107 kB) Review article Großhadern Clinic
  4. ↑ SK Ji, YK Cho, YS Ahn, MY Kim, YO Park, JK Kim, WT Kim: Multivariate analysis of the predictors of survival for patients with hepatocellular carcinoma undergoing transarterial chemoembolization: focusing on superselective chemoembolization. In: Korean J Radiol. 9 (6), Nov-Dec 2008, pp. 534-540.
  5. ^ R López-Benítez, BA Radeleff, HM Barragán-Campos, G. Noeldge, L. Grenacher, GM Richter, P. Sauer, M. Buchler, G. Kauffmann, PJ Hallscheidt: Acute pancreatitis after embolization of liver tumors: frequency and associated risk factors. In: Pancreatology. 7 (1), 2007, pp. 53-62.
  6. ↑ a b J. M. Llovet, J. Bruix: Systematic review of randomized trials for unresectable hepatocellular carcinoma: Chemoembolization improves survival. In: Hepatology . 37, 2003, pp. 429-442.
  7. ↑ K. Shirabe et al: Postoperative liver failure after major hepatic resection for hepatocellular carcinoma in the modern era with special reference to remnant liver volume. In: J Am Coll Surg . 188, 1999, pp. 304-309.
  8. ^ V. Mazzaferro et al .: Liver transplantation for the treatment of small hepatocellular carcinomas in patients with cirrhosis. In: NEJM . 334, 1996, pp. 693-699.
  9. ↑ JM Llovet: Updated treatment approach to hepatocellular carcinoma. In: J Gastroenterol . 40, 2005, pp. 225-235.
  10. ↑ IW Graziadei: Liver Transplantation. 9, 2003, pp. 557-563.
  11. ↑ G. Otto, S. Herber, M. Heise et al.: Liver Transplantation. 12, 2006, pp. 1260-1267.