CIO 2021-24 Transarterial Chemoembolization of Hepatocellular Carcinoma: A Primer for Residents

Purpose: The focus of this educational exhibit is to present a concise review of transarterial chemoembolization (TACE) in the treatment of hepatocellular carcinoma (HCC).

Material and Methods: We present a review of TACE and its utility in treating HCC. A concise review of the relevant literature will be added in both text and figure form to discuss the treatment of HCC with TACE detailing its efficacy, adjunctive therapies, and complications/adverse events.

Results: HCC is the most common primary liver tumor and most commonly arises from patients with underlying virus- or alcohol-related cirrhosis. High-risk patients may be evaluated using contrast-enhanced computed tomography or magnetic resonance imaging using a liver protocol, and contrast-enhanced abdominal ultrasound. Despite hepatic transplantation as the first-line for curative therapy, the limited availability of liver donors has prompted the study for alternative therapies. TACE is a catheter-based technique that simultaneously delivers chemotherapeutics and embolizes tumor arterial supply. Conventional TACE uses chemotherapeutic agents (doxorubicin, cisplatin, epirubicin, or mitomycin) mixed with Lipiodol (ethiodized poppyseed agent) as the delivery agent. Interventionalists may use drug-eluting beads (DEBs) to ensure a more standardized drug carry and release are employed, as well as reduce occurrence of systemic toxicities. Some DEB formulations contain iodine to allow the interventionalist to track injected beads in real-time. Embolization may induce tumor hypoxia, which is known to increase proangiogenic factors, which in turn is correlated with poor overall survival and disease-free survival. Given these data, TACE combined with antiangiogenic agents has shown mixed results. Only one clinical trial involving sorafenib (TACTICS trial) showed that TACE with sorafenib had better participant outcomes, though other antiangiogenic agents are under investigation. Additionally, recent data suggest that RFA following downstaging with TACE provide favorable long-term outcomes.

Conclusions: TACE has been increasingly studied for its utility in the treatment of HCC. Further study of optimal chemotherapeutics and adjunctive therapies may yield significant breakthroughs in HCC management.