Transarterial Chemoembolisation (TACE) for Liver Cancer

Transarterial Chemoembolization (TACE) is a procedure that helps shrink the liver tumour by cutting off the blood supply and locally delivering chemotherapeutic drugs. This is achieved by chemoembolisation, which is a combination of embolisation and chemotherapy.

Anatomy and Physiology of Liver

As the TACE procedure is mainly performed in the liver, understanding the anatomy and physiology of the liver becomes an essential step in studying in depth about the procedure. 
The liver is the second largest organ in the body that weighs around 1.5 kg. It is situated below the diaphragm and under the lower ribs on the right side of the abdomen. Its main function is to digest food and remove toxic substances from the body.
The liver is unique since it has two blood supplies: the hepatic artery and the portal vein.
In liver cancer, most of the blood supply to the tumour comes from the hepatic artery. Normally, the liver receives approximately 75% of its blood supply from the portal vein and only 25% from the hepatic artery.
So chemotherapeutic drugs are targeted in the hepatic artery, preserving most of the liver tissue because of the alternate blood supply from the portal vein.

TACE procedure can be a standalone treatment or used in combination with surgery, radiation therapy or radiofrequency ablation. It is mainly used to manage cancers like:

1. Hepatocellular carcinoma (liver cancer)
2. Cholangiocarcinoma (cancer of the bile ducts)
3. Tumours in the liver that can't be removed by surgery

TACE procedure is also beneficial when the tumour has metastasised to the liver from cancer of the other body parts such as

1. Breast
2. Colon
3. Tumours from Islet cells of the pancreas 
4. Neuroendocrine tumours
5. Sarcomas

Although these conditions can be successfully treated by TACE, choosing the right candidate for the TACE procedure remains an important step.

The TACE procedure is not for everyone but for a selected group of patients. Surgeons, liver specialists, interventional radiologists, and oncologists review and collectively select the right candidates for the TACE procedure. 
The right candidates for the TACE procedure are those with the following:

1. Hepatocellular carcinoma 
2. Hepatoma
3. Preserved liver function
4. Large or multinodular HCC without tumour thrombosis of the portal vein
5. Metastasis to other organs

Being an invasive procedure, it can take roughly about 60 to 90 minutes to complete, depending on the patient's health condition and the complexity of the case. The procedure is conducted under general anaesthesia or sedatives to make the patient comfortable during the surgery. It is performed by an interventional radiologist in a hospital setting. The following steps are carried out during the TACE procedure:

1. For surgery, the patient will be asked to lie down on the back.
2. The patient will then be covered with a sterile drape.
3. The nurse inserts an intravenous (IV) line in the hand or arm so that medication can be injected and IV fluids can be administered if necessary.
4. The surgeon will then administer general anaesthesia to the patient.
5. Vitals such as heart rate, blood pressure, and pulse will be monitored.
6. Once the patient is stable, the surgeon will prepare the groin area using saline solution or iodine to clean it.
7. The surgeon will then make a minor cut in the groin region to insert the catheter into the skin. (A cut can also be made in the wrist region)
8. A thin catheter is then passed through the skin into the femoral artery (artery present in the thigh region) under X-ray-guided vision or real-time imaging techniques like fluoroscopy.
9. The catheter is guided and moved upwards until it reaches the liver.
10. Contrast dye is injected via the catheter to help visualise the arterial tree which is feeding the tumour. After insertion of the contrast dye, the patient might notice a feeling of urination.
11. The chemotherapeutic (anti-cancer) drugs and embolic agents are then mixed and injected through the catheter.
12. After injecting, the catheter is remote, and pressure is applied at the incision site to prevent bleeding. 
13. Sutures (stitches), adhesive strips, or special glue will then be applied to close the incision.
14. A bandage or dressing is applied on the incision site.
15. Once stable, the patient will be shifted to a recovery room to monitor vitals and post-operative recovery.

In chemoembolisation, the chemotherapeutic drugs are directly delivered into the artery feeding the tumour-growing cells via a catheter. Chemotherapeutic drugs are medications that stop the abnormal growth of tumour cells. 
The artery is then blocked by embolisation so that the chemotherapeutic drugs can get trapped and stay close to the tumour. Embolisation can be done with the help of oil or tiny plastic particles.
Chemoembolization restricts the chemotherapeutic drugs at the site of action, thus minimising the systemic side effects that are common due to chemotherapy.

The doctors will prepare the patient well before the procedure by performing several tests and diagnostic procedures. These tests and procedures help evaluate the current health status of the patient which helps plan the procedure accordingly.

Before the TACE procedure

The following tests will be done before performing the TACE procedure:

1. 2D ECHO (heart ultrasound)
2. ECG to determine the patient's heart health 
3. CT scan of the chest and abdomen to examine the abdominal area
4. Kidney and Liver function tests to evaluate their health status
5. Complete Blood Count (CBC)
6. The oncologist will determine the dose of chemotherapy based on the patient's condition and discuss the risks and benefits associated with the drug.
7. The interventional radiologist will discuss the risks and benefits associated with the TACE procedure since he's the one who'll actually perform it.

Do's before the TACE procedure

1. Inform the doctor about the current medications.
2. Inform the doctor about any over-the-counter drugs, including herbal medicines.
3. Inform the doctor about any history of allergies, especially to anaesthetic medications or contrast materials like contrast dyes or x-ray dyes.
4. The use of injectable anticoagulants (blood thinners) should be informed to the doctor.

Don'ts before the TACE procedure 

1. Avoid eating or drinking anything after midnight one night before the procedure.
2. Stop taking aspirin, anti-inflammatory drugs or blood thinners five days before the procedure.

On the day of the TACE procedure

1. The patient will need to sign a consent form to provide permission to do the surgery. The patient or his/her family member should read this form thoroughly and should also ask questions if something is not clear.
2. The healthcare staff will ask the patient to remove any jewellery or other objects interfering with the surgery.
3. The patient will be asked to wear a hospital gown.
4. A soft strap will be placed across the wrist to include the patient’s details.
5. An IV line shall be established to ensure the infusion of extra fluid and medications.
6. Antibiotics will be administered to prevent infection.
7. Once the patient has been prepared and ready for surgery, he/she will be taken to the operating room.

After chemoembolisation, one may experience postoperative symptoms for up to 2 to 3 weeks. These side effects are minimised with the help of medications and lifestyle modifications. 

The recovery process at the hospital

1. The patient is shifted to the recovery room after the TACE procedure for observing and monitoring the vital signs such as heart rate, blood pressure, breathing rate, temperature, etc.
2. The nurse will regularly check the incision site to notice any bleeding or swelling.
3. The patient is advised to stay in bed without bending the treated side for at least eight hours.
4. Side effects like pain are controlled by medications given via oral or intravenous route.
5. Urine output is regularly tracked.
6. Antibiotics started before the procedure are continued further to reduce the risk of infection.
7. After the TACE procedure, one may experience post-embolisation syndrome, which includes a feeling of pain, nausea, vomiting and a low-grade fever. The patient may be advised to stay in the hospital for a day or two until these symptoms go away.
8. The patient is discharged with an antibiotic prescription and medications for nausea and pain.

Recovery process/expectation after hospital discharge 

1. Stay hydrated by drinking at least eight ounces of fluid (1 cup) every 2 hours. The fluids like water, diluted juices, soups, or tea should be consumed.
2. Eat in small amounts during the day.
3. Add whole foods like cereals, eggs, oats, yoghurt, and rice once the patient feels better. 
4. Add fibre-rich fruits and vegetables to avoid constipation.
5. Start walking for smaller durations once better.
6. Get enough sleep.
7. Avoid eating spicy, greasy, and fried food items when experiencing nausea.
8. Avoid lifting weights or doing heavy exercises.

First follow-up appointment

1. The patient is expected to come for the first follow-up 4 to 6 weeks after treatment. 
2. The follow-up visits are scheduled every three months to evaluate the function of the liver, tumour growth using CT and MRI, and possible recurrence.
3. Serum tumour markers such as AFP and DCP levels are also evaluated to check the response to treatment. These tumour markers are high at the time of diagnosis, low after the treatment, and high again when the lesions disappear or are very small in size. 

TACE procedure benefits are the major reason why doctors recommend this procedure for liver cancer patients. TACE procedure benefits are as follows: 

1. The TACE procedure is better than other cancer treatment options that are aggressive and harsh on the body. Sometimes, it is the only treatment option that can be used without severe adverse effects. 
2. High success rate as it stops the growth of tumours in approximately 70% of the patients.
3. Minimal side effects and maximum effectiveness due to the targeted action at the site of cancer
4. Liver function is preserved, thus giving a good quality of life to the patient. 
5. Short recovery time than other cancer treatments; hence can be preferred in treating conditions whenever possible.

Like any other procedure, TACE Procedure also comes with its own set of risks and complications. Since TACE combines both chemotherapy and embolisation, patients can feel the side effects of both these procedures.
TACE procedure side effects due to chemotherapy are:

1. Easy bruising or bleeding due to low platelet count
2. High risk of infections due to low white blood cell count
3. Anaemia (low Red blood cell count)
4. Mouth sores
5. Hair loss or hair thinning, which usually begins 5 to 14 days after the procedure 
6. Fatigue (feeling of tiredness)

TACE procedure side effects due to embolisation can include:

1. Abdominal pain
2. Bloating 
3. Loss of appetite
4. Fever
5. Nausea

These TACE procedure side effects usually go away 16 to 20 days after the procedure; however, weakness may be felt for as long as up to five weeks.
Some serious and comparatively rare TACE procedure side effects include:

1. Abscess formation (pus)
2. Liver failure
3. Abnormal lodging of embolisation material in other important arteries, leading to their blockage
4. Kidney damage
5. Allergic response to contrast dyes used in CT
6. In very rare cases, tumour rupture can also occur.
7. These complications are related to the procedure, the patient's overall health status, and liver functions. 

When is consultation with the doctor needed?

The patient can consult the doctor if he/she experiences:

1. Fever or chills
2. Increased pain, redness, swelling, bleeding or other drainages from the insertion site
3. Chest pain/pressure, nausea and/or vomiting, profuse sweating, dizziness and/or fainting

Most patients who undergo the TACE procedure show good recovery with a high success rate. Since cancer has the potential to spread to other parts of the body, it becomes imperative to treat it at the right time. If it is delayed, cancer in the liver can metastasise to bile ducts, lymph nodes, and other body organs and lead to advanced-stage disease.
If TACE is delayed, the patients may survive for a maximum period of five years, depending upon the stage of the liver cancer. 

The cost of the TACE procedure ranges from INR 1,80,000 to 3,00,000. The cost varies based on the following factors:

1. The patient’s age
2. The current medical status of the patient
3. Type of technique used
4. The type of room (private/ semi-private, deluxe, semi-deluxe)
5. The hospital and doctor fees
6. Duration of hospital stay

We at HexaHealth are known to offer the best treatment at reasonable prices. Our largest network of doctors and hospitals helps get the best treatment possible. Visit HexaHealth right now to get in touch with our excellent team of doctors!