TRANSARTERIAL CHEMO

EMBOLISATION (TACE)
AND HAE
DR T V ADITYA CHOWDARY

70% of patients with HCC present with a metastatic and incurable

disease at presentation
The majority of metastatic cancers involve the liver at some point
as disease progresses.
Despite the presence of extrahepatic spread, many patients with
liver involvement die as a consequence of local tumor growth and
hepatic parenchymal destruction
Hepatic artery embolotherapy (HAE) has been outstanding
among these methods as the most commonly used procedure to
palliate symptoms and prolong survival.

BLOOD SUPPLY OF LIVER TUMORS

LIVER DUAL BLOOD SUPPY 75% Portal and 25% H.Areterial
Breedis & Young: 1954 90 100% of blood supply to liver tumors
comes from the hepatic artery

embolization of tumor-feeding arteries leads to selective ischemic

damage of the tumor, while sparing the normal liver parenchyma,
mainly supplied by the portal vein

locoregional drug administration enhances the theoretic benefit with

reduced systemic toxicity

HCC BLOOD SUPPLY

Pang & Poon, 2006: Hepatocarcinogenesis is a multistep process that
causes gradual arterialization in blood supply to tumors
Tumors less than 200 m is supplied almost exclusively by sinusoidal
blood
Encapsulated nodular HCC is almost exclusively supplied by the hepatic
artery
Advanced HCC can be supplied by the portal vein or both the portal vein
and the hepatic artery
In Metastatic tumors initial supply is sinusoidal, Later becomes arterialised
but even the advanced stages retain a distinct portal blood supply

THEREFORE EARLY STAGE TUMORS AND SOME FRACTION OF ADVANCED

TUMORS MAY BE RESISTANT TO HEPATIC ARTERIAL EMBOLOTHERAPY

TACE
Transarterial chemoembolization (TACE) was first introduced in 1977
by Dr. Yamada, who exploited hepatocellular carcinomas (HCC)
preferential blood supply from the hepatic artery for the delivery of
antitumor therapy.
IT involves selective injection of a chemotherapeutic agent, or a
combination of different chemotherapeutic agents emulsified, in a
viscous carrier (lipiodol), followed by embolic material, into the feeding
arteries of the tumor.
The aim is to obtain higher intratumoral drug concentrations compared
with intravenous therapy, with tumor infarction and necrosis due to
vascular occlusion

Transarterial embolization:
Defined as the blockade of hepatic arterial flow with different embolic
materials (e.g., PVA particles and gelfoam).
Conventional transarterial chemoembolization (c-TACE):
Defined as infusion of a mixture of chemotherapeutic agents, with or
without ethiodized oil, followed by embolization with permanent (polyvinyl
alcohol [PVA] particles or spherical embolic agents) or temporary
(gelfoam) materials.
Drug eluting beadstransarterial chemoembolization (DEB-TACE):
Defined as injection of DEB loaded with chemotherapeutics into the
tumor-feeding artery , with or without further embolization, using regular
(i.e., unloaded) microspheres.

The goal of chemoembolization = to combine the effects of targeted

tumor ischemia by embolization with intraarterial chemotherapy.

Common sole-agent chemotherapeutic drug are

doxorubicin, cisplatin, epirubicin, mitoxantrone, mitomycin C, synthetic
copolymer of styrene maleic acid and neocarcinostatin (SMANCS)
Vehicle medium for the chemotherapeutic drug

Lipiodol c TACE (all chemotheraputic drugs may be emulsified)

PVA microspheres (Hepasphere/DC Beads) DEB TACE
[Doxurubicin]

Lipiodol - iodinated ethyl ester of poppy seed oil,

an oily contrast medium

is

The chemotherapeutic drug is dissolved in water or

water-soluble contrast agent and is then mixed with
Lipiodol and administered as an emulsion

Every 10 mg of doxorubicin hydrochloride is dissolved in 0.5 mL of the

water-soluble contrast medium; iodized oil and dissolved doxorubicin
hydrochloride were drawn separately into syringes interconnected with
a three-way stopcock and emulsified by means of vigorous pushing of
each syringe in alternation

Light
photomicrograph
shows the formation of oil
in water in oil-type emulsion
with variably sized (10 to 50
m)
water
droplets
containing
doxorubicin
hydrochloride in the oil
base

When injected into the hepatic artery, iodized oil is trapped selectively in
the tumor because of the hemodynamic difference between the tumor and
normal liver parenchyma and presumably the absence of Kupffer cells in
the tumor
The drug laced lipiodol allows for slow release of the drug over a
period of 6 to 12 weeks
In the normal liver parenchyma, the iodized oil does not occlude the
hepatic artery; rather it accumulates in the peripheral portal vein through
arterioportal communications and subsequently passes through sinusoids
into the systemic circulation or is cleared by the kupffers cells
HAE after infusion of chemotherapeutic drugs increases drug dwelling time
in the tumor by slowing the rate of efflux from the hepatic
Ischemic damage by embolization potentiates absorption of
chemotherapeutic drugs by impeding the function of transmembrane
pumps in tumor cells