TACE Treatment - Transarterial Chemoembolization

A liver tumor feeds from the artery. The rest of the liver mostly does not. TACE uses that difference to starve and poison the tumor from inside its own blood supply.

No treatment before it had lengthened the lives of people with liver cancer that could not be removed. Transarterial chemoembolization did, in randomized trials. In a Barcelona trial, two-year survival rose from 27 percent to 63 percent, and a Hong Kong trial run in the same year found the same direction. Twenty years on it remains the standard treatment for the middle stage of the disease, and the trials since have refined who gains from it, which beads to use and which drugs to add. Send us your scans, your liver blood tests and your tumor board notes, and a hepatologist and an interventional radiologist will tell you whether TACE is your stage.

How does it work, and what did the trials find?

• A normal liver receives about three quarters of its blood from the portal vein and one quarter from the hepatic artery. Hepatocellular carcinoma reverses that, drawing nearly all of its supply from the artery. Blocking the artery therefore hurts the tumor far more than the liver around it.
• Drug delivered straight into that artery reaches the tumor at concentrations that intravenous chemotherapy cannot approach, and the blockade keeps it there.
• The blockade also causes the deep, sudden death of tumor tissue that scans show as a loss of enhancement, which is the sign of a successful session.
• The same anatomy sets the limit. When the portal vein is itself blocked by tumor, the liver depends on the artery, and embolizing it can cause liver failure. Portal vein invasion is the classic reason TACE is refused.

The trials that made TACE the standard

Two randomized trials published in 2002 settled a question that had been argued for a decade. In Barcelona, 903 patients with liver cancer were screened and 112 met the strict criteria, a tumor that could not be cured by surgery or ablation, preserved liver function and no spread beyond the liver, and they were randomized to embolization, to chemoembolization with doxorubicin, or to supportive care.

Early stopping followed once the chemoembolization arm pulled ahead. Survival at one and two years was 82 and 63 percent with chemoembolization against 63 and 27 percent with supportive care, and the risk of death was halved. Hong Kong followed the same year. There, 80 of 279 patients met similar criteria and were randomized to chemoembolization with cisplatin or to supportive care, and survival at three years was 26 percent against 3 percent.

Twelve percent of those screened were suitable.

Hold on to it. The Barcelona investigators used the phrase stringently selected patients in their conclusion, and the Barcelona investigators used the phrase stringently selected patients in their conclusion. TACE lengthens life in the right patient, and the right patient is defined by the liver's reserve as much as by the tumor.

Chemoembolisation improved survival of stringently selected patients with unresectable hepatocellular carcinoma.

Conclusion of the Barcelona randomized trial, The Lancet, 2002

Adding drugs to the procedure

Drugs can extend the gain.

The Japanese TACTICS trial asked whether a targeted drug, sorafenib, taken before and between sessions, could hold the tumor longer. Among 156 patients, the median time before the disease progressed beyond what TACE could treat was 25.2 months with the combination and 13.5 months with TACE alone, and two-year survival was 82.7 against 64.6 percent. Immunotherapy combinations now face the same test. Ask whether drug treatment alongside TACE is planned for you, and on what evidence.

Median progression-free survival was 25.2 months with TACE plus sorafenib and 13.5 months with TACE alone.

TACTICS trial, Gut, 2020

Who is TACE for?

The Barcelona Clinic Liver Cancer system stages liver cancer by weighing the tumor, the liver's reserve and the patient's fitness together and assigns a treatment to each stage. Its 2022 update, published in the Journal of Hepatology, places TACE at the intermediate stage and describes when a patient can move between stages.

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How do I prepare, and what does the day involve?

Preparation is short.

The liver tests decide more than anything you do, and they are read twice, once before the procedure is agreed and once on the morning it is done.

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• Bilirubin, albumin, clotting and platelet count, which together grade the liver's reserve and decide whether TACE is safe.
• Creatinine, for the contrast dose.
• Hepatitis B and C status, and whether antiviral treatment is under way.
• AFP, the tumor marker, as a baseline for follow-up.
• Any previous TACE, ablation or surgery, with the dates and the images afterward.

1. Arrival. Checks, a cannula, fluids and pre-medication. Consent through your interpreter.
2. The procedure. One to two hours in the angiography suite, lying flat, with the radiologist talking you through the steps.
3. Recovery. Lying flat for a few hours after groin access, with pain relief and fluids, and a check of the puncture site.
4. The night. Fever, right upper abdominal pain and nausea for one to three days are expected and are treated with fluids, painkillers and anti-sickness drugs.
5. Discharge. Blood tests in the morning, a check that the liver enzymes have not risen too far, and home with painkillers and instructions.

Post-embolization syndrome

A dying tumor releases the contents of its cells. The body responds with fever, pain and nausea that begin within hours and last one to three days. Doctors call it post-embolization syndrome, and it follows most sessions to some degree. It signals that the embolization has worked, and fluids and medication manage it, so that a patient who feels wretched on the second night can be told, truthfully, that the treatment is doing what it was meant to do. Fever that persists beyond three days, or pain that worsens after improving, needs a scan to look for infection or bile leak.

Chemoembolization was repeated every two to three months unless there was evidence of contraindication or progressive disease, with a median of 4.5 courses per patient.

Hong Kong randomized trial, Hepatology, 2002

What are the risks, how many days do I need, and what decides the cost?

TACE threatens the liver before anything else. Blocking arterial blood in a cirrhotic liver can tip it toward failure. Bilirubin rises. Fluid collects. Confusion follows. In the Hong Kong trial, deaths from liver failure were more frequent after chemoembolization while survival overall was longer, and for that reason the liver tests are read before every session and patients with poor reserve are refused.

Other complications are rarer. Infection in the dead tumor tissue, an abscess, occurs in a small minority, above all in patients whose bile ducts have been operated on, and they receive antibiotics for that reason. Bleeding or a false aneurysm at the puncture site, damage to the bile ducts, an ulcer in the stomach or duodenum from particles that strayed into their arteries, and a reaction to the contrast are each rare. The chemotherapy itself causes little of the hair loss and marrow suppression seen with intravenous treatment, because so little of it reaches the rest of the body. Beads lower those effects further.

Watch for warning signs after discharge. Fever above 38 degrees that returns or persists beyond three days. Abdominal pain that worsens after it had settled. Yellowing of the eyes, swelling of the abdomen or legs, confusion or unusual sleepiness, black stools or vomiting blood, and a swelling or bleeding at the puncture site. Each needs a hospital the same day.

One session needs five days in the city.

Two days cover the consultation, the liver tests and any imaging that needs repeating, the procedure and its night in hospital come next, and a day or two of rest follows while the fever and pain settle, which for the majority means a hotel room, a light diet and painkillers taken by the clock. Fly three to four days after the procedure. Pain must be controlled first. Blood tests must be stable. The follow-up scan at four to six weeks can be done at home and sent for review, and a second session, when needed, means a second trip or a stay of six to eight weeks that covers both.

Price follows two things.

Method and liver set the price of a session. Drug-eluting beads cost more than the conventional oil and drug mixture, and that difference, which published packages in Istanbul put at a fifth to a third of the session, is the largest single variable in the quote. The chemotherapy dose, the contrast, the microcatheters and the closure device for the artery are consumables charged to the session. General anesthetic adds an anesthesiologist. Most quotes include one night, and charge for a second when recovery is slow. Pre-procedure imaging and the follow-up scan sit on separate lines, as are any drug treatment taken alongside and any treatment of a complication. The patient's own liver moves the figure, since poor reserve means more monitoring and a longer stay, and a hepatitis B carrier needs antiviral tablets. Packages published by hospitals in Istanbul for TACE cover the procedure, the interventional radiologist's fee and one night in hospital, and leave the scans, the drugs and the hotel outside. Compare quotes per session and ask what a repeat session costs, because few patients need only one. Your own figure follows the free review of your scans and liver tests.

One coordinator from the international patients team is assigned from your first message and stays with you until you fly. The team works in English, Arabic, French, Russian, Serbian, Romanian and Spanish and arranges interpreting in other languages on request, and an interpreter attends the consultation and consent. An invitation letter naming the hospital and the treating physician is sent about ten days before travel. The international patients office arranges the airport transfer, the hotel for you and a companion, and the rides to the hospital, and a companion is needed on the day of the procedure. Your room that night has a companion bed. Halal, vegetarian and diabetic meals come from the hospital kitchen, and a low-salt diet is prepared for patients with ascites. A prayer room is on site. Ask early for a female doctor if you would prefer one. The request is passed to the department and met wherever the rota allows.

Nobody changes hospital for the next step.

Hepatology, interventional radiology, surgery and medical oncology share one site, so the tumor board that recommends TACE can also arrange ablation, surgery or drug treatment without a change of hospital. Back home, the coordinator stays reachable on the same WhatsApp number. Send the follow-up scan and blood tests there, and the treating team decides on the next session from them, so that you travel only when there is something to treat.

TACE FAQ