Transarterial Chemoembolization for Hepatocellular Carcinoma: Current Role and Techniques

Abstract

In the current systemic therapy era, such as immunotherapy and molecular targeted therapy, treatment strategy of hepatocellular carcinoma is changing. Transarterial chemoembolization is more expected as a curative treatment option than before. Therefore, it is important to learn key techniques of transarterial chemoembolization procedures to achieve complete response. This article delineates the current indications for transarterial chemoembolization and several techniques used for its implementation.

Keywords: combined therapy; hepatocellular carcinoma (HCC); transarterial chemoembolization (TACE).

Figure 1.

Indication for TACE, adapted from the BCLC staging and treatment strategy in 2022. Transplantation description is not included. TACE is indicated for early-stage HCC when resection and ablation are not feasible and for intermediate-stage HCC with well-defined nodules that can be selectively targeted.

Figure 2.

Heterogeneity of the population beyond Up-to-7. Three nodules with maximum size of 5 cm in diameter. Cases with three nodules of a maximum size of 5 cm in diameter, a single nodule of 10 cm in diameter, and those with 11 nodules, each potentially requiring a different treatment strategy.

Figure 3.

Superselective TACE. a. HCC is located in the liver segment 4. b. A microcatheter was inserted into A4 arising from the left hepatic artery and cTACE was performed. c. CT 3 months after TACE showed well lipiodol accumulation in the tumor.

Figure 4.

Distal protection technique with a microballoon catheter. A microballoon catheter was inserted via the right femoral artery and the balloon was infiltrated at the left hepatic artery (arrowhead). A microcatheter inserted via the left femoral artery and the catheter tip was located at the proximal site of the balloon (white arrow). The targeted branch (A1) was well depicted (black arrow) and cTACE was performed.

Figure 5.

Distal protection technique with a microballoon catheter with a side hole. a. HCC was supplied via a tiny branch of the right hepatic artery (arrow). b. A microballoon catheter with a side hole was inserted and the balloon was infiltrated at the right hepatic artery (arrowhead). Targeted branch was well depicted (arrow) and cTACE was performed.

Figure 6.

TACE navigation image. a. A three-dimensional reconstruction image created from CT during hepatic arteriography (CTHA) revealed three feeding branches to the tumor. The right anterior oblique (RAO) 30° view provided the optimal working angle for clear separation of each branch. b. A microcatheter was inserted into each branch using the same C-arm angle view and cTACE was performed. c. Lipiodol was well accumulated in the tumor.

Figure 7.

a. Pumping emulsification device (MicroMagic^®): This device features a disk-shaped glass membrane with 100 μm micropores, positioned between syringe adapters. The membrane surface is coated with a hydrophobic silicon layer, facilitating the dispersion of the epirubicin solution into the lipiodol in droplet form. b. Water-in-oil emulsion created by glass membrane pumping device.

Figure 8.

Semiwedged technique. a. HCC located in segment 2 of the liver supplied by a branch of A2. b. Lipiodol emulsion was injected from the tumor-feeding branch (arrowhead). Overflow to the proximal site was observed during injection (arrow). c. The microcatheter was advanced further, and lipiodol emulsion was injected under semiwedged conditions to allow for forceful injection while preventing overflow. Subsequently, the portal vein was visualized.

Figure 9.

Bland TAE followed by cTACE for huge HCC (beyond Up-to-11). a. Huge HCC 11 cm in diameter (three nodules) located in the liver right lobe. b. Bland TAE was performed using microspheres (Embosphere^®) 100 to 300 μm in size. c. Contrast-enhanced CT at 3 weeks after the bland TAE showed large part of the tumor became necrosis, but in the dorsal side residual tumor presented (arrow). d. cTACE was performed for the residual viable tumor. The noncontrast-enhanced CT showed that the lipiodol accumulation was obtained and complete response was achieved.

Figure 10.

Schemas of superselective TACE with “semiwedged technique” and balloon-occluded TACE (B-TACE). a. Superselective TACE with “semiwedged technique”: A microcatheter is placed at the periphery of the tumor-feeding artery, allowing for controlled injection of lipiodol emulsion under semiwedged conditions. This technique ensures adequate distribution of lipiodol emulsion within the tumor and its peritumoral surroundings. b. B-TACE: A microballoon catheter is positioned at the segmental level, enabling injection of lipiodol emulsion under balloon-inflated conditions. This method facilitates forceful injection of lipiodol emulsion, although attention must be paid to potential liver parenchymal damage depending on tumor location and catheter position.

Figure 11.

Preparation and injection techniques of drug-eluting beads (DEB)-TACE. a Epirubicin-loaded DC bead (100–300 μm) prepared by shacking on vortex mixer for 30 s. A fractured bead is observed (arrow). b Epirubicin-loaded DC beads (100–300 μm), mixed with diluted contrast material (180 mgI/mL), are injected through a microcatheter. The microspheres are dispersed within the syringe and the hub of the microcatheter.

Figure 12.

Treatment strategy of intermediate- and advanced-stage HCC. LEN-TACE can be applied to most intermediate-stage and a portion of advanced-stage HCC with the goal of achieving CR. Large, large tumor; Multi, multiple tumors; PVTT, portal vein thrombus; ICI, immune checkpoint inhibitor; Atez/Bev, atezolizumab/bevacizumab; Dur/Tre, durvalumab/tremelimumab