Transarterial chemoembolization

Hepatocellular carcinoma (HCC) represents one of the most common types of cancer, with more than 1 million new cases worldwide and a dramatic increase in the western world. In most cases, HCC is detected at an advanced stage and frequently liver cirrhosis as an underlying disease is present. Therefore, therapeutic options are limited. Beside resection, liver transplantation is regarded the only curative therapy [4]. However, only 10%-15% of patients are candidates for curative surgery - especially due to the shortage of liver donors. There are no effective systemic treatments [4] to date for these patients and transarterial chemoembolization or RE are therefore the only palliative therapies. 

The appropriate examination technique is critical for sensitive detection and specific characterization of focal liver lesions. A biphasic examination of the liver with a late-arterial and a portal venous phase can be regarded as standard today. For specific indications, like the follow-up of hepatocellular carcinoma (HCC) after transarterial chemoembolization (TACE) or for the depiction of the arterial vessels prior to angiography, an early arterial phase scan, which can be post-processed into CT angiography, is helpful (Fig. 3.2). The value of delayed scans (e.g. 5 min after contrast agent injection) is controversial in the literature mainly centers with a focus on imaging in liver cirrhosis consider the use of late phase images as necessary, whereas other authors see no added value for it [21,45]. 

Fig. 3.8. Male patient suffering from a multifocal hepatocellular carcinoma (HCC), treated with repeated sessions of transarterial chemoembolization (TACE). Dyna-CT (Siemens Medical Solutions, Erlangen, Germany) image started together with injection of 10 ml iodinated contrast agent via a super-selective catheter system placed in the right hepatic artery compared with a corresponding MDCT section in the arterial phase after i.v. injection of 120 ml iodinated contrast agent. Note the excellent, direct depiction of arterial blood supply of the HCC nodule in liver segment 5/8 (arrow). The artifacts in the left and right liver lobe are caused by spots of Lipiodol in already treated HCC nodules after earlier transarterial chemoembolization...

Huo TI, Wu JC, Lee PC et al (2004) Incidence and risk factors for acute renal failure in patients with hepatocellular carcinoma undergoing transarterial chemoembolization a prospective study. Liver Int 24 210-215... 

Grieco A, Marcoccia S, Miele L et al (2003) Transarterial chemoembolization (TACE) for unresectable hepatocellular carcinoma in cirrhotics functional hepatic reserve and survival. Hepatogastroenterology 50 207-212... 

Histopathological basis. Radiation-induced cholecystitis or gall bladder infarction is a rare complication of radioembolization and is due to the radiation effect of the microspheres. Unlike transarterial chemoembolization, Y treatment does not produce a significant embolic effect [25] (Fig. 14.2). Animal studies performed in dogs to examine the tolerance to radioembolization with Y labelled resin microspheres have shown that cholecystitis is encountered to some extent in almost all of the animals who received radioactive microspheres, but was absent in the animals infused with nonradioactive microspheres [26]. Similar studies performed in pigs that received Sirtex particles demonstrated the presence of particles in the gall bladder without inflammatory wall changes [27]. 

Kim HK, Cheng YH, Song BC et al (2001) Ischemic bile duct injury as a serious complication after transarterial chemoembolization in patients with hepatocellular carcinoma. I Clin Gastroenterol 32 423-427... 

Chemoembolization Chemoembolization does not appear to induce significant long-term worsening of liver function in patients with Childs class A or B cirrhosis. Caturelli et al. (2000) reviewed their experience with transarterial chemoembolization (TACE) in 111 patients with HCC that involved less than 30% of the hver parenchyma. A chemothera-... 

Gellad FE et al. (1990) Vascular metastatic lesions of the spine preoperative embolization. Radiology 176 683-686 Gerunda GE et al. (2000) Role of transarterial chemoembolization before liver resection for hepatocarcinoma. Liver Transpl 6 619-626... 

Fig. 29.2. Axial and coronal sections in the early arterial phase (left), late arterial phase (middle), and portovenous phase (right) in a female patient suffering from HCC under treatment with transarterial chemoembolization (TACE). In the early arterial phase, only the liver arteries are properly enhanced, the portal vein and the liver parenchyma are not yet opacified. The two HCC nodules in segment 2/3 and segment 6 (marked by large arrows) are also both not properly demarcated. The early arterial phase is, therefore, not suitable for detection of hypervascular tumors it is rather a CT angiographic phase and can be omitted in most cases. The most important phase for detection of hypervascular tumors is the late arterial phase (also called arterial-dominant phase or phase of portovenous inflow). In this phase, there is already enhancement in the por-...

A 70-year-old Chinese woman had a gastric varix injected with enbucrilate plus hpiodol followed by transarterial chemoembolization for hepatocellular carcinoma, at which time radio-opaque lipiodol was noted in the gastric varix and in several branches of the right pulmonary artery [29 ]. 

Transarterial chemoembolization (TACE) of the liver for unresectable liver tumors, although controversially discussed, is being used with increasing frequency. Below, anatomical factors, technical realization of the chemoembolization, as well as the results and complications of chemoembolization are discussed. 

Transarterial Chemoembolization (TACE) in Primary and Secondary Liver Tumors... 

Allgaier HP, Deibert P, Olschewski M, Spamer C, Blum U, Gerok W, Blum HE (1998) Survival benefit of patients with inoperable hepatocellular carcinoma treated by a combination of transarterial chemoembolization and percutaneous ethanol injection-a single-center analysis including 132 patients. Int J Cancer 79 601-605... 

Castells A, Bruix J, Ayuso C, Bru C, Montanya X, Boix L, RodesJ (1995) Transarterial embolization for hepatocellular carcinoma. Antibiotic prophylaxis and clinical meaning of postembolization fever. J Hepatol 22 410-415 Caturelli E, Siena DA, Fusilli S, Villani MR, Schiavone G, Nardella M, Balzano S, Florio F (2000) Transcatheter arterial chemoembolization for hepatocellular carcinoma in patients with cirrhosis evaluation of damage to nontumorous liver tissue-long-term prospective study. Radiology 215 123-128... 

Kress 0, Wagner HJ, Wied M et al (2003) Transarterial chemoembolization of advanced liver metastases of neuroendocrine tumors - a retrospective single-center analysis. Digestion 68 94-101... 

Lo CM, Ngan H, Tso WK, Liu CL, Lam CM, Poon RT, Fan ST, WongJ (2002) Randomized controlled trial of transarterial lipiodol chemoembolization for unresectable hepatocellular carcinoma. Hepatology 35 1164-1171... 

K, Woitaschek D, Zangos S (2003) Liver metastases neoadjuvant downsizing with transarterial chemoembolization before laser-induced thermotherapy. Radiology 229 457-464... 

Wasser K, Giebel F, Fischbach R, Tesch H, Landwehr P (2005) Transarterial chemoembolization of liver metastases of colorectal carcinoma using absorbable starch microspheres (Spherex). Our own investigations and review of the literature. Radiologe 45 633-643... 

You YT, Changchien CR, Huang JS, Ng KK (2005) Combining systemic chemotherapy with chemoembolization in the treatment of unresectable hepatic metastases from colorectal cancer. Int J Colorectal Dis 21(l) 33-37 Zangos S, Mack MG, Straub R, Engelmann K, Eichler K, Balzer J, Vogl TJ (2001) Transarterial chemoembolization (TACE) of liver metastases. A palliative therapeutic approach. Radiologe 41 84-90... 

Transarterial chemoembolization (TACE) has widely been proposed as the palliative treatment of choice. However, most data indicate a limited benefit from TACE in patients with advanced liver cirrhosis (Llovet et al. 2003). In the past percutaneous tumor ablation by radiofrequency (RFA) or laser-induced thermo therapy (LITT) has supplemented ethanol injection. Any of these methods has hmitations with respect to tumor size, perfusion and localization, as described above. 

Zangos S, Eichler K, Balzer JO, Straub R, Hammerstingl R, Herzog C et al (2007) Large-sized hepatocellular carcinoma (HCC) a neoadjuvant treatment protocol with repetitive transarterial chemoembolization (TACE) before percutaneous MR-guided laser-induced thermotherapy (LITT). Eur Radiol 17(2) 553-563... 

Transarterial chemoembolization (TACE) is widely used as a palliative non-surgical therapeutic option for the treatment of unresectable HCC, enabled by the fact that liver tumors are almost exclusively supplied by the hepatic artery (Allgaier et al. 1998 Bruix et al. 2004 Tellez et al. 1998 Vogl et al. 2000, 2003 Zangos et al. 2001). TACE interrupts the blood supply to the tumor, resulting in better tumor growth control. However, TACE is only a palliative treatment modality and tumor necrosis can usually be found in variable degrees... 

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