Minimally Invasive Tumor Therapy (MITT)

Department of Radiology, Charité – Universitätsmedizin Berlin

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References

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Transarterial Chemoembolization (TACE) for the Treatment of Primary Liver Tumors

 

Chemoembolization is an angiographic procedure for the local treatment of liver tumors with a rich blood supply.

 

How Does TACE Work?

 

Primary cancer of the liver cells (hepatocellular carcinoma (HCC)) has a specific feature, namely that it receives most of its blood supply from the liver artery. In contrast, normal liver tissue is mainly supplied by the portal vein. Other liver tumors and liver metastases also receive their blood supply through the hepatic artery. They can also be treated by transarterial chemoembolization (TACE).

 

TACE takes advantage of the dual blood supply to the liver. The predominantly arterial blood supply of most malignant liver tumors allows the targeted delivery of medications to the tumor through a catheter placed in the hepatic artery (the main artery of the liver).

 

The catheter used for TACE is a very thin, flexible plastic tube (microcatheter) that is advanced through the hepatic artery until its tip lies just in front of the liver tumor (Figure 1). Proper positioning is important for direct delivery of the chemotherapeutic agents into the tumor. At the Charité, we use a mixture of lipiodol, doxorubicin, and mitomycin C. After administration of the chemotherapeutic drugs, the tumor-feeding arterial branches are blocked (occluded) by releasing tiny particles into the bloodstream (embolization) so the chemotherapy stays in the tumor longer.

 

Figure 1: The tumor in the liver receives its blood supply from the hepatic artery. A thin tube (catheter) is advanced to the hepatic artery via an artery in the groin. This catheter (represented by the white line) is used to inject the chemotherapeutic medication and the embolic (occlusive) agent directly into the artery supplying the tumor.

 

As the name suggests, TACE thus combines two mechanisms to destroy a tumor: the strong tumor-killing effect of high-dose chemotherapy at the tumor site and blocking of tumor blood supply (embolization) to starve the tumor cells of oxygen and nutrients (Figure 2a and 2b).

 

Who are Candidates for TACE?

 

TACE is a minimally invasive treatment option for different patient groups with liver tumors. It is most commonly used in patients who cannot have surgery because of the size, number, or location of their tumors or because of other serious health problems. In these patients, the aim of TACE is to delay further disease progression in the liver (tumor growth) and to relieve symptoms (palliative treatment). As a palliative treatment, TACE competes with CT-guided high-dose rate brachytherapy (CT-HDRBT), radiofrequency ablation (RFA), radioembolization (SIRT), and medical treatment with drugs like sorafenib (Nexavar).

 

A second group of patients who may benefit from TACE are those with liver tumors which are initially too large to be removed surgically. In these cases, TACE can be used to shrink the tumor for possible surgery afterwards (downsizing). Moreover, TACE is an option for patients who are on the waiting list for a liver transplant. Because donor organs are scarce in Germany, it may take several months before a transplant liver becomes available. During the waiting time, TACE can prevent further tumor growth and maintain a patient’s candidacy for a liver transplant, thus serving as a bridge to transplant.

 

Your physician will discuss your treatment options with you. At the Charité, a multidisciplinary tumor board brings together a team of medical experts from different specialties to review each case and tailor treatment to each patient’s unique condition.

 

What Happens after TACE?

 

TACE, like nearly all angiographic procedures, is typically performed by inserting a catheter into an artery in the groin. To prevent bleeding from this site after the procedure, a pressure bandage is applied, and patients need to lie still for a couple of hours. The day after the intervention, a CT scan of the upper abdomen ensures that the medications were properly delivered to the tumor.

 

As a rule, the procedure is repeated after 6 – 8 weeks. A second session is necessary because liver tumors tend to form new blood vessels, which must be occluded for a good therapeutic effect.

 

What are Possible Complications and Side Effects of TACE?

 

Serious complications are very rare. The medications and contrast medium administered can cause allergic reactions. We try to minimize these reactions by thoroughly screening for risk factors and pretreating patients at risk before they undergo TACE. As with all angiographic procedures, there may be bleeding from the catheter insertion site. A tight bandage and lying still after the procedure will typically prevent bleeding. In addition, we will perform an ultrasound of the puncture site the day after the procedure to identify possible problems.

 

The so-called postembolization syndrome is a specific complication after TACE. This syndrome describes a set of symptoms that include nausea, upper abdominal pressure, aches, joint pain, and sweating. It is a normal body reaction to the treatment caused by the dying tumor cells. The severity of the postembolization syndrome typically correlates with the size of the tumor and the response to treatment. In most cases, these symptoms can be adequately controlled during the hospital stay.

 

Aftercare

 

Patients scheduled for TACE will be admitted to our ward for about 3 – 4 days. After the procedure, there are no restrictions on daily activities. As mentioned above, we schedule a second treatment session 6 – 8 weeks after the first TACE procedure. After two sessions of TACE, the effect will be assessed by a computed tomography (CT) scan or a magnetic resonance imaging (MRI) examination. The imaging findings serve to decide whether a third TACE treatment may be beneficial or whether alternative treatment appears more appropriate.

 

  • Contact:

Minimally Invasive Tumor Therapy (MITT)

Charité, Campus Virchow-Klinikum

Department of Radiology

Augustenburger Platz 1

13353 Berlin, Germany

Phone: +49 (0)30/450-557309

Fax: +49 (0)30/450-557947

minimal-invasive-ambulanz@charite.de oder mia@charite.de

 

Case Example

 

Figure 2a

 

Figure 2b

 

Figure 2

This case illustrates how transarterial chemoembolization (TACE) is performed to treat a patient with hepatocellular carcinoma (HCC).

  1. The image obtained before treatment shows a large tumor with a rich blood supply (upper arrow). The lower arrow indicates the microcatheter in the artery supplying the tumor.
  2. The image obtained after TACE shows absence of blood flow in the tumor (arrow). Both the chemotherapeutic drug and embolic particles are inside the tumor (asterisk).