Indications and Patient Selection
TACE is most effective in patients with Barcelona Clinic Liver Cancer (BCLC) stage B — multinodular HCC confined to the liver, preserved liver function (Child-Pugh A or B7), and no vascular invasion or extrahepatic spread. Beyond Milan criteria with no extrahepatic disease, TACE may be used as a bridge to transplant.
- BCLC stage B — primary TACE indication
- Bridge to transplant — within or beyond Milan criteria
- Downstaging — reduce tumor burden for transplant eligibility
- Colorectal liver metastases — selected cases, DEB-TACE
- Neuroendocrine liver metastases — TAE or TACE
- Child-Pugh A/B7 — acceptable liver function
- Contraindication — portal vein thrombosis (relative), Child-Pugh C
- Bilobar disease — staged TACE, one lobe at a time
Conventional TACE vs DEB-TACE
Conventional TACE (cTACE) mixes chemotherapy (doxorubicin, cisplatin, mitomycin C) with Lipiodol and follows with embolic particles. DEB-TACE uses drug-eluting beads pre-loaded with doxorubicin, providing sustained drug release with lower systemic drug exposure. No survival difference has been definitively proven; DEB-TACE has a lower systemic toxicity profile.
- cTACE — Lipiodol + chemo + embolic (Gelfoam, PVA)
- DEB-TACE — drug-eluting beads (LC Bead, HepaSphere)
- Lipiodol retention on CT — surrogate for tumor necrosis
- Particle size — 100–300 µm for hepatic arterial embolization
- Superselective technique — reduces non-target embolization
- Cone-beam CT — confirms tumor enhancement and staining
- Endpoint — complete stasis or near-stasis in tumor feeders
- mRECIST — viable tumor enhancement as response metric
Full TACE Procedure Playbook
Angiography technique, microcatheter selection, troubleshooting, postembolization management
Response Assessment and Follow-up
- mRECIST — viable arterial enhancement, not total size
- Follow-up MRI/CT — 4–6 weeks post-procedure
- Complete response — no viable arterial enhancement
- Residual enhancement — retreatment vs ablation vs Y-90
- AFP trend — correlates with treatment response
- Postembolization syndrome — fever, pain, nausea, self-limited
- Hepatic toxicity — LFT elevation expected post-TACE
- Repeat TACE — typically every 6–8 weeks until complete response