Transarterial chemoembolization

TACE is performed under imaging guidance, typically using fluoroscopy and angiography. A catheter is inserted into the femoral artery and advanced into the hepatic artery. Contrast dye identifies the tumor's vascular supply. Chemotherapeutic agents—often doxorubicin, cisplatin, or mitomycin—are mixed with lipiodol (an oily contrast agent) to form an emulsion that is injected directly into the tumor-feeding vessels. This is followed by embolization with particles such as gelatin sponge, polyvinyl alcohol, or drug-eluting beads to occlude the artery and trap the drug within the tumor.

Drug-eluting bead TACE (DEB-TACE) uses microspheres that release chemotherapy slowly, potentially reducing systemic side effects and improving tumor drug concentration. The procedure is usually repeated every 4–6 weeks until tumor response or disease progression, and it is often combined with ablation or systemic therapy.

TACE is the standard of care for patients with intermediate-stage HCC (Barcelona Clinic Liver Cancer stage B) who have preserved liver function and no vascular invasion or extrahepatic spread. It is also used for downstaging tumors to enable resection or transplantation, and for palliation in patients with liver-dominant metastases from colorectal cancer or neuroendocrine tumors.

Randomized trials and meta-analyses have shown that TACE improves survival compared with supportive care, with median survival ranging from 19 to 28 months in selected cohorts. Objective response rates of 50–80% are reported, but outcomes vary with tumor burden, liver function, and embolization technique. Post-embolization syndrome—fever, pain, and nausea—occurs in up to 90% of patients but is usually self-limiting. Major complications include liver abscess, biliary injury, and hepatic failure, especially in patients with poor liver reserve.

TACE has evolved from simple hepatic artery ligation and systemic chemotherapy to a refined locoregional therapy. The concept of combining intra-arterial chemotherapy with embolization was pioneered in the 1970s, and the use of lipiodol as a drug carrier became widespread in the 1980s. The introduction of drug-eluting beads in the 2000s aimed to standardize drug delivery and minimize systemic exposure.

Balloon-occluded TACE (B-TACE) uses a microballoon catheter to temporarily occlude the artery, increasing intratumoral drug concentration. Cone-beam CT during TACE improves tumor targeting and reduces nontarget embolization. TACE is also being combined with immunotherapy, as embolization-induced hypoxia may enhance the antitumor immune response. Ongoing trials are evaluating the optimal embolic agent, drug dose, and combination strategies.

One lesser-known fact is that TACE can be used to treat hepatocellular adenomas and focal nodular hyperplasia when surgery is contraindicated, though this is off-label. Another is the 'TACE-refractory' concept: patients who do not respond after two consecutive TACE sessions are considered refractory, and switching to sorafenib or other systemic agents is recommended.

Historically, the first TACE-like procedure was reported in 1976 by Yamada and colleagues, who used gelatin sponge embolization alone. The addition of chemotherapy came later. In some centers, TACE is performed via the radial artery to reduce patient discomfort, and 'transarterial radioembolization' (TARE) with yttrium-90 microspheres is a distinct alternative that delivers radiation rather than chemotherapy. TACE can also be used to treat liver-dominant metastases from breast cancer, though evidence is limited.

Hepatocellular carcinoma (HCC)

The most common type of primary liver cancer, often arising in the setting of cirrhosis.

Embolization

The deliberate occlusion of a blood vessel using particles or coils to cut off blood flow.

Lipiodol

An oily contrast agent used to carry chemotherapy and to visualize tumors during TACE.

Drug-eluting beads

Microspheres that release chemotherapy slowly, designed to improve local drug delivery.

Post-embolization syndrome

A common side effect of TACE characterized by fever, pain, and nausea, usually resolving within days.