Trans-arterial Chemoembolisation

(TACE)
TACE (trans-arterial chemoembolisation) is a palliative treatment that is used to treat liver cancer (hepatocellular carcinoma or HCC and certain liver secondaries) that cannot be removed surgically. Administering chemotherapy this way can reduce the size of the cancer/tumour and therefore provide relief of your symptoms.

Why do we administer chemotherapy this way?

The liver receives its blood supply from two sources. The first is the portal vein and the second is the hepatic artery. Liver cancers receive their blood principally from the hepatic artery. During TACE, chemotherapy is administered directly into the hepatic artery via a catheter placed in the groin (femoral artery). As the chemotherapy goes directly to the tumour, the tumour receives a greater concentration of the drug/s and more cancer cells are destroyed. Because the chemotherapy remains mainly in the liver, you will experience fewer side effects than if you had chemotherapy via the vein.

Pre-TACE Consultation
Before the procedure you will see the Oncologist (cancer doctor) to see whether TACE is indicated as a treatment for you. The Oncologist will also need to consult with an interventional Radiologist who will review your CT / MRI scans to see if the procedure is technically possible. If you are to receive TACE your Oncologist will arrange for you to have bloods taken and possibly another CT scan of your liver. You will also be referred to a Cancer Nurse Coordinator who will assist you with future appointments and follow-up care. You will be notified of a day and time for the procedure within the week following this appointment.

Day of Procedure
You will be admitted to Hospital on the day of or the day before the procedure, depending on your medical requirements. You will need to have fasted (no food or fluids) from four hours prior to the procedure. It is important that you discuss with your Oncologist / Cancer Nurse Coordinator which regular medications, you can take the night before / morning of the procedure (this includes alternative / herbal medications). Medications such as Warfarin or antiplatelet drugs e.g. Clopidigrel / Plavix will probably need to be ceased up to a week before the procedure. Aspirin is usually alright to continue. On the day of admission you will need to present to the Admissions office on the ground floor at the time recommended by your Clinical Nurse Coordinator. The necessary paperwork will be completed here. You will then be directed to the Ambulatory Care ward for overnight admission. Depending on the availability of a bed you may have the pre-procedure treatment commenced in Ambulatory Care. Before the procedure a cannula (needle) will be inserted into a vein in your hand or arm. A doctor will see you to take your medical history, explain the procedure and witness your written consent to the procedure. You will have to wear a hospital gown. Anti-emetics (antinausea drugs) will be administered to you via your cannula, as well as any other premedications required.
N Consoli Cancer Care Coordinator, V Freeman Clinical Nurse Consultant, RNSH, January 2009

Procedure
When all the pre-procedure requirements are completed, you will be taken on a bed to the angiography suite in X-ray. You will meet the interventional radiologist, nurse and radiographer performing the procedure / treatment. Because you will be awake during the procedure (during which you will need to hold your breath occasionally when images are being acquired), the procedure is performed using a local anaesthetic to the groin. You may experience mild discomfort for a few seconds. A small incision is then made into the femoral artery in the groin; a catheter (fine tubing) is inserted into the artery and directed up to the hepatic artery in the liver, close to the tumour. The chemotherapy drug/s (mixed with X-ray dye to enable the proceduralist to see on the Xray screen where the tumour is in your liver) will be injected into the catheter and delivered directly to the tumour. The size and position of your liver cancer will determine how much liver is treated. Following administration of the chemotherapy, small Gelfoam particles (sterile sponge) are injected through the catheter to temporarily close the artery. This will starve the tumour cells of blood (normal liver will survive on the portal vein flow) as well as try to prevent the chemotherapy leaching out away from the tumour. You will not feel the catheter or the delivery of the chemotherapy and Gelfoam particles into your liver but you may develop some discomfort in the general area of the liver and / or shoulder tip toward the end of the procedure. This will be controlled with pain medications via the drip in your veins. The procedure usually takes 1 to 2 hrs to complete.

Post-Procedure
At the end of the procedure, the catheter is removed. Firm pressure is then applied to your groin to stop any bleeding. Occasionally a stitch is required to close the hole, this will dissolve in time. You will need to lie flat in bed for four hours, keeping your leg still at the same time so that the hole in the artery will heal properly. During this time you will be taken to Recovery for a short time where a nurse will check this site periodically for signs of bleeding. The nurse will also check your vital signs (BP, Pulse) and the pulse in the foot on the side of the body that the catheter was inserted. Following Recovery you will be transferred back to the Ambulatory ward, where the nurses will continue to monitor you. You will be able to eat and drink as normal post procedure at the nurses discretion. You may experience some side effects following the procedure. These may include: nausea/vomiting, abdominal pain, sluggish bowel motion or low grade temperature. Please advise the nurse monitoring you of any side effects as measures can be taken to alleviate these. You will be required to stay in hospital overnight.

Discharge
You will be discharged the day following your procedure after review by your Oncology team. Your Cancer Nurse Co-ordinator will arrange your follow-up CT scan and consultation with your Oncologist prior to discharge. This usually occurs 6-8 weeks after your initial treatment. During this follow-up consultation your scan results and the effectiveness of the treatment on your liver tumour/s will be discussed. Depending on the response of the tumour to treatment and your general health, another session of TACE may be performed again in 2-3 months. Some side effects from the procedure may persist for a few days. You will be given some antinausea drugs on discharge to relieve any nausea you may experience. Panadol can be taken to relieve pain or low grade fever. If your side effects persist please notify someone from your Oncology team.
N Consoli Cancer Care Coordinator, V Freeman Clinical Nurse Consultant, RNSH, January 2009