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Page 2 of 10 Puppala. Hepatoma Res 2019;5:44 I http://dx.doi.org/10.20517/2394-5079.2019.28

Figure 1. A simplified classification of various transarterial image-guided treatment options for HCC. TAE is a bland embolization that is
rarely used unless in an emergency for treating ruptured HCC. TAC is currently not used. TACE is the most commonly used technique
with cisplatin or doxorubicin. HCC: hepatocellular carcinoma; TAE: transarterial embolization; TAC: transarterial chemotherapy; TACE:
transcatheter arterial chemoembolization; cTACE: conventional transcatheter arterial chemoembolization; DEM-TACE: drug-eluting
microsphere-transcatheter arterial chemoembolization

[6]
leading to tumor ischemia, necrosis, and growth control . As most normal hepatocytes are supplied by
the portal vein, embolizing via the hepatic artery minimizes collateral ischemic damage and reduction in
liver function, and the chemotherapy agent is not affected by the first-pass metabolism, as it would be if
administered orally or intravenously.

TACE can be technically classified as conventional (cTACE), which can be selective or less than selective,
and drug-eluting microsphere (DEM-TACE), where the treatment is delivered as close to the tumor as
possible by super-selective catheterization of the feeding arteries. DEM-TACE can be further subdivided
based on the degradable nature of the microsphere [Figure 1].

cTACE is undertaken with lipiodol, a poppy seed oil-based contrast medium, causing transient ischemia,
in which chemotherapy agents such as cisplatin, doxorubicin, or mitomycin are suspended as an emulsion.
Due to the lack of Kupffer cells in the tumor, lipiodol has the benefit of being retained in the tumor for
weeks, thus enabling post-procedural computed tomography (CT) evaluation of the tumor load. However,
lipiodol can lead to severe pain requiring strong opioid analgesia. cTACE lacks the benefit of a sustained
high drug level in the tumor and can also lead to systemic elevation of the drug levels. Post-embolization
[7,8]
syndrome is more common with cTACE . Due to the above disadvantages, DEM-TACE was introduced
in 2006, which produced sustained tumor-selective drug delivery, limited systemic elevation of drug levels,
[9]
and permanent feeding vessel embolization . Fewer courses of TACE are required with DEM-TACE
[10]
compared to cTACE . There is no Level 1 evidence demonstrating superiority in efficacy between the
two techniques; however, there are many single-center prospective cohort studies demonstrating a higher
[11]
complete response and lower rate of progressive disease with DEM-TACE .

CURRENT INDICATIONS AND PATIENT SELECTION
Patient selection for TACE continues to depend on the tumor size, number, extrahepatic spread,
liver function, portal vein involvement, and the patient’s general performance status. Childs-Pugh
[12]
score and Barcelona clinic liver criteria are used to select patients for the appropriate treatment . A
multidisciplinary team approach to consider a patient for TACE and pre-procedure patient counseling are
important to ensure ideal patient selection. Table 1 summarizes the indications for TACE. Decompensated
liver function, infiltrative HCC, untreatable AV fistula, renal dysfunction, and chemotherapy-related