Sreeja Sompalli, Gillian Lieberman, MD
Transarterial Chemoembolization (TACE) of Hepatocellular Carcinoma (HCC) Sreeja Sompalli Jawaharlal Nehru Medical College, India Advanced radiology clerkship 6/1/2013 to 6/30/2013 Gillian Lieberman, MD
OVERVIEW: Introduction to TACE Indication and contraindications Brief history of patient Technique Complications Follow up Outcomes Future evolution of TACE
WHAT IS TACE?
A targeted therapy for HCC confined to the liver
Launched by Yamada as a palliative treatment in patients with non-operable HCC
Sedlinger technique
Catheter in Femoral artery Hepatic artery
Chemotherapeutic agent & embolising agent
Aorta
Principles- two fold Delivering high concentration of chemo therapeutic agent to the tumor Cutting off the blood supply and essentially starving it to death
http://www.idahoarteryandvein.com/treatments/chemoembolization.php
Rationale for TACE:
In HCC, Hepatic artery supplies 90 to 100% of blood
In non tumorous liver, Portal vein supplies 75 to 83 % of blood while Hepatic artery supplies 20 to 25% only
Effects of TACE:
In TACE, high concentration of drug to HCC but much less to non tumorous liver lipoidal - slow release of drug from lipoid drug emulsion--prolonged contact time of tumor cells to drug particle embolisation -Synergistic effect of tumor necrosis due to ischemia and drug effects slows down blood flow - increases contact time Ischemia induces trans membrane pump greater absorption of drug
Candidates: • Palliative treatment for unresectable HCC Patients on transplant list
Prior to Radio frequency ablation
Residual tumors Patients with metastatic neuroendocrine tumors in liver
Contra indications: ABSOLUTE ◉Extensive liver disease ◉Encephalopathy
◉Large burden metastatic disease outside the liver
RELATIVE ◉Borderline Liver function ◉Total bilirubin >4mg/dl ◉Serum creatinine >2mg/dl ◉Portal vein thrombosis ◉Uncorrectable coagulopathy ◉Poor general health ◉Significant AV shunting through tumor ◉Anaphylactic reaction to chemotherapeutic drugs, contrast
OUR PATIENT: 74 y.o. male with chronic Hep C infection and liver cirrhosis Dx with well differentiated HCC by Biopsy 5 months ago On CT - HCC without evidence of metastatic disease cirrhotic liver, mild splenomegaly with mild gastro esophageal varices, changes in lung consistent with pulmonary fibrosis and emphysema and aortic valve calcifications enrolled himself in RFA trial
Post RFA: CT demonstrated successful ablation with some residual tumor in segment VIII of the liver
http://www.radiologyassistant.nl/en/p4375bb8dc241d
Post RFA: HCC in segment VIII of Liver measuring 6.2cm TV * 6.4cm AP * 6cm cc.
PACS BIDMC
Patient preparation: • Clotting parameters should be checked and corrected Platelet count ideally >1,00,000cells/mm³ INR< 1.5
• NPO status for at least 8 hrs prior to sedation/anesthesia • Good iv hydration • pre medication : antibiotics anti emetics
• Informed consent • Anesthesia: Local anesthesia with lidocaine moderate sedation- divided doses of midazolam and fentanyl • Total time - 1hr 25min
Technique
Access to the Right femoral artery
PACS BIDMC
Diagnostic arteriograms: - SMA
to exclude the aberrant supply to the tumor -to demonstrate the patency of portal vein
PACS BIDMC
• Advanced to Celiac artery
PACS BIDMC
• Advanced further into Common Hepatic artery • using micro catheter advanced into main segment VIII artery
PACS BIDMC
• Delivery of chemo embolization mixture (lipoidal and doxorubicin) under continuous fluoroscopic visualization. • Additional embolization to near stasis was performed using 100 micron Embozene particles.
PACS BIDMC
• Catheter/sheath removal and groin access hemostasis
Post TACE CT
PACS BIDMC
Follow-up
CT FINDINGS - after 24 hrs - 1 month - 2 months - every 6 months there after
1 WEEK ON DAY
1 MONTH
6 MONTHS
SEQUENCE OF CT SCANS FOLLOWING TACE, SHOWING THE DEVELOPMENT OF INTRATUMORAL NECROSIS AND DISAPPEARANCE OF THE TREATED LESION http://emedicine.medscape.com/article/369936-overview
COMPLICATIONS: Most common is Post embolization syndrome in 80% Triad of Abdominal pain, Nausea, Fever Liver abscess Non target embolization Liver abscess Septicemia Irreversible liver failure Hepatorenal syndrome
OUTCOMES: The survival rates of TACE are appx. 60% to 80% at 1 year 30% to 60% at 2 years 18% to 50% at 3 years Studies have shown that TACE combined with RFA improved the overall survival compared with that of TACE alone.
WHO criteria for Tumor assessment
COMPLETE RESPONSE - The disappearance of all known disease, determined by 2 observations not less than 4 weeks apart
PARTIAL RESPONSE - 50% or more decrease in total tumor size of the lesions which have been measured to determine the effect of therapy by 2 observations not less than 4 weeks apart and there can be no appearance of new lesion
NO CHANGE - 50% decrease in total tumor size cannot be established nor has a 25% increase in size of one or more measurable lesions been demonstrated
PROGRESSIVE DISEASE - 25% increase in size of one or more measurable lesions, or the appearance of new lesions
Future evolution of TACE:
Anti-VEGF antibodies in combination with TACE
Ultra selective catheterization of tumor feeding arteries
TACE in combination with p53 gene therapy.
REFERENCES: • Antoine Bouchard-Fortier, Réal Lapointe, Pierre Perreault, Louis Bouchard, and Gilles Pomier-Layrargues, “Transcatheter Arterial Chemoembolization of Hepatocellular Carcinoma as a Bridge to Liver Transplantation: A Retrospective Study,” International Journal of Hepatology, vol. 2011, Article ID 974514, 7 pages, 2011. doi:10.4061/2011/974514 • Lance C, McLennan G, Obuchowski N, Cheah G, Levitin A, Sands M, Spain J, Srinivas S, Shrikanthan S, Aucejo FN, Kim R, Menon KV., "Comparative analysis of the safety and efficacy of transcatheter arterial chemoembolization and yttrium-90 radioembolization in patients with unresectable hepatocellular carcinoma ",J Vasc Interv Radiol. 2011 Dec;22(12):1697-705. doi: 10.1016/j.jvir.2011.08.013. Epub 2011 Oct 8. • Bruls S, Joskin J, Chauveau R, Delwaide J, Meunier P.,"Ruptured hepatocellular carcinoma following transcatheter arterial chemoembolization ",JBR-BTR. 2011 Mar-Apr;94(2):68-70
• Amit G. Singal, Jorge A. Marrero.,"Recent Advances in the Treatment of Hepatocellular Carcinoma", Curr Opin Gastroenterol. 2010;26(3):189195. • T. U. Haq.,"Transcatheter Chemo-Embolization for Hepatocellular Carcinoma and certain Hepatic Metastasis",JPMA. 2004 Mar: vol.54, No.3 • Sung Wook Shin.,"The Current Practice of Transarterial Chemoembolization for the Treatment of Hepatocellular Carcinoma',Korean J Radiol. 2009 Sep-Oct; 10(5): 425–434. • Published online 2009 August 25. doi: 10.3348/kjr.2009.10.5.425 • Geschwind J F, Ramsey D E, Choti M A, Thuluvath P J, Huncharek M S. Chemoembolization of hepatocellular carcinoma: results of a metaanalysis. American Journal of Clinical Oncology 2003; 26(4): 344349. • Wang."Transarterial chemoembolization in combination with percutaneous ablation therapy in unresectable hepatocellular carcinoma: a meta-analysis" Liver International Volume: 30 Issue: 5 (2010-05-01) p. 741-749. ISSN: 1478-3223
• Peter Huppert."Current concepts in transarterial chemoembolization of hepatocellular carcinoma",Department of Diagnostic and Interventional Radiology, Klinikum Darmstadt GmbH, Grafenstrasse 9,64283 Darmstadt, Germany Published online 2009 August 25. doi: 10.3348/kjr.2009.10.5.425
• doi: 10.1634/theoncologist.8-5-425 The Oncologist October 2003 vol. 8 no. 5 425-437
Acknowledgements: • • • •
Gillian Lieberman, MD Neda Sedora Roman, MD Dr. Rashmi Jayadevan, MD My radiology colleagues
THANK YOU!
