TARE Procedure for Liver - Steps, Side Effects, Recovery Time

Liver malignancies, including primary tumours like hepatocellular carcinoma (HCC) and secondary hepatic metastases, are a major contributor to mortality, and their incidence is on the rise. 

Unfortunately, HCC, which accounts for a significant portion, offers a bleak prognosis due to underlying liver diseases and late diagnosis. It allows curative surgery for only 20 to 30% of patients.

Transarterial Radioembolization (TARE), a procedure where a radiolabelled embolizing substance is injected into an artery, has delivered promising results. Read below to know more about the TARE procedure, its benefits, complications and cost.

TARE is a minimally invasive medical procedure conducted using radiology techniques to block the blood supply to a tumour. It combines radiotherapy and embolization and is particularly useful for cancers that cannot be removed through surgery, such as kidney and liver cancer. 

While TARE doesn't cure cancer, it serves as a palliative treatment, slowing down the progression of the disease. It provides relief from the symptoms.

It shows promise as an alternative to TACE. Various materials and radioisotopes, such as 32P, 90Y, 131I, 166Ho, 177Lu, and 186/188Re, have been used for this purpose. 

Among them, 90Y (Ytterium 90) loaded microspheres have gained recognition. It has proven to be a safe and effective treatment for both primary and secondary liver cancers.

Anatomy and Physiology of the Liver

The liver is the largest organ in the human body. It has a reddish-brown appearance and weighs about 1.4 kg. It is the only organ capable of regenerating.

The organ is divided into two lobes: the right and left lobes. Each is further divided into a thousand smaller lobes, which are connected to tiny ducts. These tiny ducts eventually merge into a larger one known as the common hepatic duct. 

The hepatic duct is responsible for transporting the bile, which is produced by the liver, to the gallbladder and the intestines.

The liver plays over 500 functions, including:

1. Production of bile
2. Synthesis of essential plasma proteins and cholesterol
3. Storage of glycogen for quick energy
4. Regulation of amino acid levels in the bloodstream
5. Helps in the clotting of the blood
   

TARE involves delivering radioactive material directly to the liver tumour through an artery. It minimizes radiation exposure to the rest of the body and preserves the healthy liver as much as possible. 

The transarterial Radioembolization procedure can be helpful in the following situations:

1. Primary Liver Cancer (Hepatocellular Carcinoma - HCC): This procedure is primarily used when surgery is not a feasible option due to factors like tumour size, location, or the patient's overall health. It is a treatment option for localised HCC within the liver.
2. Metastatic Liver Tumors: Transarterial Radioembolization treats secondary liver tumours originating from primary cancers like colorectal, pancreatic, or breast cancer. It aims to control the spread and growth of liver metastases.
3. Inoperable Tumors: This procedure is chosen when liver tumours cannot be operated on due to reasons like size, critical location, or the patient's unsuitability for surgery. 
4. Tumour Growth Control: The primary objective is to control the growth of tumours by delivering microscopic radioactive beads directly to the tumour site via the hepatic artery. This internal radiation can reduce the tumour's size, alleviate symptoms, and slow its progression.
   

TARE has led to significant advances in both preclinical and clinical studies. There are numerous benefits of the procedure that includes:

1. Improved Quality of Life: This procedure can enhance a patient's quality of life by effectively treating liver tumours or conditions that might otherwise cause discomfort or pain. Additionally, it may extend life expectancy by effectively targeting and managing the disease.
2. Short Stay in Hospital: TARE typically involves a relatively short hospital stay compared to traditional surgery. 
3. Quick Recovery: The recovery time after a TARE procedure is often shorter than that of major surgical interventions. Patients can return to normal activities more swiftly, minimising the disruption caused by the treatment.
4. Safe and Effective: It is a safe and effective treatment option. It is minimally invasive, reducing the risk of complications associated with open surgery.

Patients often have questions about what occurs before and on the day of the surgery. This section aims to clarify the preparation process for surgery.

Before TARE Procedure

Prior to any surgical procedure, the healthcare team follows a set of guidelines. It ensures the patient's safety throughout the process.

On the Day of TARE Procedure

On the day of TARE, the patient can anticipate experiencing the following:

TARE is performed by an interventional radiologist, a specialist who uses X-ray guidance. The procedure is done in the following way:

Step 1: Mapping Angiogram

1. In the initial step, known as a mapping angiogram, takes 2 to 4 hours. The patient lies on their back on an X-ray table. 
2. Local anaesthesia is administered so that the patient does not experience any further discomfort.
3. The interventional radiologist inserts a small plastic catheter into an artery in the patient's groyne, going to the liver arteries. This is guided by X-ray imaging.
4. Angiograms (X-ray images) are taken to visualise blood flow to the liver, enabling the interventional radiologist to determine the suitability of further therapy.

Step 2: Y-90 Treatment

1. If the angiogram reveals that Y-90 therapy is unsuitable for the patient, the procedure is concluded. In cases where it is deemed appropriate, the following steps are taken.
2. The interventional radiologist employs small metal wires (coils) to obstruct blood vessels that should not receive radiation.
3. A harmless tracer agent is introduced into the patient's liver arteries to assess the tracer distribution in the surrounding tissues.
4. A SPECT scan helps determine how the tracer is distributed in the patient's body. If it shows minimal tracer outside the liver, the patient progresses to the next step.

Step 3: 2nd Y-90 Infusion (if needed)

1. In many cases, only half of the liver is treated in Step 2. If additional treatment for other liver areas is necessary, it will occur 4 to 6 weeks after Step 2.

Step 4: Scans

1. Approximately one month after the patient's last Y-90 infusion, an MRI or CT scan is performed. This scan reveals how the tumours have responded to the treatment.
2. The doctor reviews the scan results, blood tests and the patient's overall health to discuss any further treatments if required.
   

Effective aftercare in the hospital and the recommended home care measures are key factors that ensure a successful recovery. Below are the guidelines to be followed after the procedure:

Recovery in Hospital

Following the procedure, the patient will be moved to a recovery room and remain in the hospital for two to three days. This stay is necessary because the radioactive material used during the procedure temporarily makes the patient emit radiation. It requires isolation to prevent others from exposure. 

Additionally, doctors will provide medications to manage symptoms such as nausea and pain. They will schedule regular imaging tests every three months to monitor the reduction in the size of the tumour.

At-Home Recovery

Following hospital discharge, follow the recovery instructions for a smooth healing process. At-home recovery after the procedure includes:

1. It's normal to experience fatigue, mild pain, or discomfort for a few days to a week post-procedure. These symptoms typically improve over time. Adhere to the medications to reduce these symptoms.
2. Avoid strenuous activities and heavy lifting during the initial recovery period to ensure the body heals properly.
   

First Follow-up

After the TARE procedure, a follow-up appointment is scheduled within a week.

1. During this appointment, the healthcare team will assess the patient's progress, overall health, and how the liver tumours have responded to the treatment.
2. Imaging tests, such as CT scans or MRI scans, may be conducted to determine the effectiveness of the TARE procedure and plan further treatment steps.

In general, most people tolerate TARE well. After embolisation, patients may experience a condition known as "post-embolisation syndrome." This can include discomfort, nausea, vomiting, and a mild fever, which may persist for up to three days.

In rare instances, when the liver is significantly affected, there might be a temporary worsening of liver function. In very unusual cases, acute liver failure can occur. Nevertheless, the complications are exceedingly uncommon, with serious issues affecting less than 1% of patients.

The complications of TARE include:

1. Increased Risk of Blood Clots: The TARE procedure may carry an elevated risk of blood clots, particularly in paediatric patients. Blood clots can be dangerous, potentially leading to serious health issues like deep vein thrombosis or pulmonary embolism. Close monitoring and appropriate measures are essential to mitigate this risk.
2. Infections: It can be an unintended consequence of the TARE procedure. This includes localised infections at the treatment site or systemic infections that affect the entire body. Prompt medical attention and preventive measures are often taken to minimise this risk.
3. Kidney Damage: While relatively uncommon, TARE can lead to kidney failure. This may result from the contrast agents used during the procedure or other factors.
4. Liver Damage: Although TARE is primarily designed to target liver tumours, there is a potential risk of collateral damage to healthy liver tissue. This unintended liver damage can affect overall liver function and lead to complications, such as jaundice or liver failure, which require additional medical management.
5. Hair Loss: It is an infrequent but possible side effect of TARE, although it occurs in only a small number of cases. The mechanism behind this side effect is not well understood. The hair loss is usually reversible once the treatment is completed.
6. Anaemia: It is a condition characterised by a deficiency of red blood cells that can develop due to the TARE procedure. This may be due to the impact of radiation on the ability of bone marrow to produce red blood cells.
7. Need for Repeating the Procedure: In some cases, the initial TARE procedure may not achieve the desired outcome, and a second or even subsequent treatment may be necessary. This can result in additional healthcare costs and prolonged treatment plans, as well as potential risks associated with repeat procedures.
   
   

When to See a Doctor?

After a TARE procedure, be vigilant about potential complications or warning signs. Recovery from TARE is usually smooth, but be watchful for specific situations. 

If you experience the following, contact your doctor:

1. Severe pain 
2. Persistent fever
3. Excessive bleeding 
4. Shortness of breath
5. Chest pain

Postponing the TARE procedure for liver cancer can pose several risks for patients. It includes:

1. Increased Tumour Growth: Putting off the TARE procedure may allow liver tumours to grow and potentially spread to other body parts. It makes the cancer treatment more challenging and possibly reduces its effectiveness.
2. Limited Treatment Choices: Delaying the TARE procedure can also restrict the available treatment options. Some forms of liver cancer may become too advanced for the procedure to be effective.
3. Aggravation of Symptoms: With continued tumour growth, patients may experience worsening symptoms like pain, fatigue, and weight loss, significantly affecting their quality of life.
4. Requirement for More Aggressive Treatment: Allowing liver cancer to progress might necessitate more aggressive treatments such as surgery or chemotherapy. This can come with more pronounced side effects and more extended recovery periods.
5. Risk of Liver Failure: In certain cases, postponing the TARE procedure can increase the risk of liver failure, especially if the liver has been severely affected by cancer.
   

The TARE procedure cost in India can range from ₹ 1,50,000 to ₹ 4,00,000, depending on various factors. Therefore, patients should discuss with their healthcare provider and their insurance provider to gain a comprehensive understanding of their expenses.

Several factors influence the TARE procedure cost, including:

1. Hospital Location: The cost may vary based on the geographical region of the hospital. The price will be higher if the hospital is situated in an urban location than a rural settlement.
2. Experience of the Doctor: The more experienced a doctor is, the higher the charges.
3. Type and Size of the Tumour: The specific characteristics of the tumour being treated can influence the overall cost of the TARE procedure.
4. Number of Treatment Sessions: The required number of treatment sessions to achieve the desired results can affect the total cost.
5. Type of Medical Insurance: Patients with medical insurance may have some or all of the procedure costs covered, which can significantly reduce their out-of-pocket expenses.

The TARE procedure is a promising treatment for liver cancer patients. It is safe and effective. This treatment may enhance a patient's quality of life, enabling them to return to regular activities sooner.

If you're considering TARE treatment, you can visit HexaHealth for a dedicated consultation. Our experienced professionals will address your concerns and offer excellent medical guidance. Feel free to reach out to us for more information!

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