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Transarterielle Chemoembolisation bei hepatozellulärem Karzinom – neue Entwicklungen

Transarterial chemoembolization for hepatocellular carcinoma – new developments

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Zusammenfassung

Die transarterielle Chemoembolisation (TACE) ist ein generischer Begriff für eine ganze Palette verschiedener Therapieverfahren. Gemeinsames Prinzip ist die katheterbasierte transarterielle Einbringung zytotoxischer Materialien, die an embolisierende Trägersubstanzen gekoppelt sind und damit erstens zu einer verlangsamten kapillären Passagezeit der therapeutisch wirksamen Agenzien und zweitens zu einer lokalen Hypoxie im Tumor führen. Die TACE profitiert dabei von der Tatsache, dass hepatozelluäre Karzinome (HCC) überwiegend arteriell perfundiert werden, während normale Hepatozyten vorwiegend (zu ca. 70–80%) portalvenös versorgt werden. Prinzip der TACE ist es, diese differente Gefäßversorgung zu nutzen, um eine selektive Therapie des HCC unter maximaler Schonung des gesunden bzw. nichttumortragenden Lebergewebes zu erreichen. Dabei unterscheiden sich die verschiedenen TACE-Verfahren hinsichtlich der Wahl des Chemotherapeutikums, des Embolisatmaterials und der angiographischen Vorgehensweise (d. h. der Selektivität der transarteriellen Darreichung) ganz erheblich. Diese prozedurale Flexibilität erlaubt es, ein jeweils an die individuelle Erkrankungssituation, das Tumorstadium und die Leberreserve angepasstes Vorgehen auszuwählen. Aufgrund dieser „therapeutischen Breite“ ist die TACE zur adjuvanten bzw. palliativen Behandlung von Patienten der BCLC-Stadien 0, A, B und C einsetzbar – wobei sich Behandlungsintention und technische Vorgehensweise je nach Stadium unterscheiden. Aktuelle Entwicklungen betreffen innovative embolisierende Trägersubstanzen („drug-eluting beads“), neue Formulierungen etablierter Substanzen (speziell die Lipiodol-Ethanol-Ablation), die Verwendung des β-Strahlers Yttrium-90 (90Y) anstelle von Chemotherapeutika im Rahmen der Radioembolisation sowie die Kombination von transarteriellen und lokalablativen Verfahren (TACE-RFA).

Abstract

Transarterial chemoembolization (TACE) is a generic term for a whole range of various interventional procedures. The common principle is a catheter-based transarterial administration of cytotoxic substances which are bound to embolizing carrier substrates and, therefore, lead to prolonged capillary transit time of the therapeutically active agents and give rise to local hypoxia in the tumor. TACE profits from the fact that hepatocellular carcinomas are predominantly perfused by arteries, whereas normal hepatocytes are predominantly supplied via the portal vein (approximately 70–80%). The principle of TACE is to use this difference in vascular supply to enable a selective therapy of hepatocellular carcinomas with maximum protection of the healthy or non-tumor bearing liver tissue. The various TACE procedures differ substantially with respect to the choice of chemotherapeutic agent, choice of the embolizing substances and of the angiographic approach (i.e. the selectivity of the transarterial administration). This procedural flexibility allows selection of an approach adjusted to the individual patient’s situation in terms of tumor stage, and liver reserve. Because of this therapeutic range, TACE can be applied to adjuvant or palliative treatment of patients in BCLC stages 0, A, B and C, whereby the respective aims of treatment and the respective technical approach for TACE differ with BCLC stage. Current developments include innovative embolizing carrier substrates (drug-eluting beads), new formulations of established substances (in particular lipiodol-ethanol ablation), the use of the β-emitter yttrium 90 in place of chemotherapeutic agents within the framework of radio-embolization as well as a combination of transarterial and local ablative procedures (TACE-RFA).

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Abbreviations

BCLC:

Barcelona Clinics Liver Cancer staging system

HCC:

Hepatozelluläres Karzinom

LEM:

Lipiodol-ethanol mixture

MELD:

Model for end stage liver disease

OLTx:

Orthotope Lebertransplantation

PEI:

Perkutane Alkoholinjektion

RFA:

Radiofrequenzablation

RILD:

Radiation-induced liver disease

SIRT:

Selektive intraarterielle Radiottherapie

TACE:

Transarterielle Chemoembolisation

TAE:

Transarterielle Embolisation

TARE:

Transarterielle Radioembolisation

TEA:

Transarterial ethanol ablation

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  1. Radiologisch-Onkologische Diagnostik und Intervention, Radiologische Universitätsklinik Bonn, Sigmund-Freud-Str. 25, 53105 , Bonn, Deutschland

    C. Kuhl

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Kuhl, C. Transarterielle Chemoembolisation bei hepatozellulärem Karzinom – neue Entwicklungen. Gastroenterologe 4, 330–339 (2009). https://doi.org/10.1007/s11377-009-0309-z

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