TACE – pro
Chemoembolization (CE) involves the periodic injection of chemotherapy mixed with embolic material into selected branches of the hepatic arteries feeding liver tumors. CE has been successfully used as a palliative treatment of symptoms associated with functioning neuroendocrine tumors involving the liver. The most common such tumor is the carcinoid tumor whose hormone production is associated with the carcinoid syndrome, characterized by debilitating flushing, wheezing and diarrhea. Pancreatic endocrine tumors that produce gastrin, insulin or other pancreatic hormones are unusual types of neuroendocrine tumors. Pancreatic endocrine (i.e., islet cell) tumors must be distinguished from the more common pancreatic epithelial tumors that arise from the exocrine portion of the pancreas.
The prognosis for patients with unresectable hepatocellular carcinoma (HCC) tumors is extremely poor. Even in the case of small nodular lesions detected by US screening, patients receiving no treatment showed a mean 3-year survival rate of 12. For unresectable, primary HCC, TACE is indicated in persons with small encapsulated nodules (less than 4 cm in diameter), no evidence of extrahepatic metastases, and with adequate hepatic (serum bilirubin concentration < 2.9 mg/dl) and renal function (serum creatinine < 2.0 mg/dl).
According to available literature, chemoembolization (TACE) may be indicated for symptomatic treatment of functional neuroendocrine cancers (i.e., carcinoid tumors and pancreatic endocrine tumors) involving the liver, in persons with adequate hepatic function (bilirubin < 2 mg/dl, absence of ascites; no portal vein occlusion; and tumor involvement of < 65 % of liver). For carcinoid tumors, TACE is indicated only in persons who have failed systemic therapy with octreotide to control carcinoid syndrome (e.g., debilitating flushing, wheezing and diarrhea).
Phase II studies of chemoembolization for metastatic colorectalcancer have been reported by several centers in the United States.Patients enrolled in these trials are usually individuals inwhom systemic and/or intraarterial infusion chemotherapy hasfailed. Abramson et al devised a spreadsheet model to determinecost-effectiveness thresholds for palliative chemoembolizationfor colorectal metastases. A mean survival time of 12 monthsor greater was demonstrated to be necessary for chemoembolizationto be considered a cost-effective method of treatment. Langet al used a combination of superselective segmental andselective lobar injections of a doxorubicin/iodized oil emulsionin the treatment of 46 patients. The actuarial survival rateswere 68% at 1 year and 37% at 2 years. In the study of Sanz-Altamiraet al 40 patients received chemoembolization with 5-fluorouracil,mitomycin-c, iodized oil, and gelatin sponge. The median survivaltime after the first chemoembolization procedure was 10 months.A number of prognostic factors predictive of longer survivalwere identified. Patients with an Eastern Cooperative OncologyGroup performance status of 0 or 1 had a median survival of24 months, versus 3 months among patients with a performancestatus of 2. Patients with extrahepatic disease at the timeof initial chemoembolization had a median survival of 3 months,versus 14 months for those with isolated liver metastases. Amongpatients with good performance status and no extrahepatic disease,the survival rates were 73% at 1 year and 61% at 2 years afterchemoembolization. In the study of Tellez et al (46), 30 patientsunderwent chemoembolization with cisplatin, doxorubicin, mitomycin-c,and bovine collagen. Median survival times were 8.6 months fromfirst chemoembolization and 29 months from diagnosis. In a studyby Soulen (47), 51 patients underwent chemoembolization withcisplatin, doxorubicin, mitomycin-c, iodized oil, and polyvinylalcohol. Actuarial survival rates from diagnosis with livermetastases were 86%, 55%, and 23% at 1, 2, and 3 years, witha median of 24 months. Outcomes in patients with isolated livermetastases who were treated with chemoembolization by Salmanet al were similarly encouraging, with a mean survivaltime of 15 months versus 8 months among patients with extrahepaticdisease. The results in these extensively pretreated patientsare promising, but high early response rates do not necessarilycause an improvement in survival. A consistent trend towardsurvival times longer than 12 months after initial therapy hasalso been demonstrated, suggesting that chemoembolization forcolorectal metastases is a cost-effective method of treatmentfor patients with good performance status and disease isolatedto the liver. To best determine absolute survival benefit, amulticenter phase II/III trial was initiated by the AmericanCollege of Radiology Imaging Network. The purpose of the trialwas to compare outcomes with chemoembolization combined withsystemic therapy versus systemic therapy alone. This trial was stopped because of the evolution of new agents and the resultantparadigm shift regarding the standard of systemic therapy. NCCN recommends arterialy directed therapies, which includes chemoembolization.
Absolute contraindications for TACE in patients with unresectable HCC include intractable systemic infection, Child –Pugh C, or the presence of hepatofugal portal flow. Other traditional contraindications include significant cardiac or renal failure, severely impaired liver function, clinically relevant ascites, significant thrombocytopenia, portal vein thrombosis, or patients with a transjugular intrahepatic portosystemic shunt (Maleux 2009).
Relative contraindications include a variety of other factors including, but not limited to: Serum bilirubin >2 mg/dL, Lactate dehydrogenase >425 unit/L, Aspartate aminotransferase >100 unit/L, Tumor burden involving >50 percent of the liver, Cardiac or renal insufficiency, acites, recent variceal bleed, or significant thrombocytopenia.
Transarterial chemoembolization (TACE) of the liver is generally not considered medically necessary for the treatment of liver metastases from other non-neuroendocrine primaries, including colorectal cancer, melanoma, and unknown primaries. The use of TACE in liver mets, of cancers other than neuroendocrine is not supported by credible literature to prolong survival and it is still being studied.
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