**2.4.1 Transarterial Chemoembolization (TACE)**

Despite the results from repeat hepatic resection for intra-hepatic recurrence was well recognised, the re-resection rate is low because of the impairment of functional reserve in the liver remnant and multiplicity of nodules (Eguchi et al., 2006; Kanematsu et al., 1984; Poon et al., 2002). Local ablation should be best performed in patients with recurrences featuring three or fewer small nodules (Shimada et al., 2007). In contrast, transarterial chemoembolization (TACE) can be applied in any type of HCC, irrespective of tumor size, location, or number of lesions provided that patients have reasonable liver function. In addition, the benefit of TACE on survival in patients with unresectable HCC had already been demonstrated (Llovet & Bruix, 2003; Shim et al., 2009). Therefore, TACE is widely applicable and practical in patients with intra-hepatic HCC recurrence (Choi et al., 2009; Eguchi et al., 2008; Shim et al., 2010).

Fig. 5. CT image of a patient with a 5cm segment VIII recurrent HCC at 6 months after microwave ablation. Three passes were performed for a bigger ablative zone and the needle tracts were showed on the follow up scan.

TACE is the intra-arterial administration of chemotherapy combined with arterial embolization and is commonly used as an alternate treatment for recurrent HCC (Figure. 6). There is no standardized protocol in the optimal time interval between treatments and also the choice, dosage, concentration, rate of injection of the chemotherapeutic and the embolizing agents.

featuring three or fewer small nodules (Shimada et al., 2007). In contrast, transarterial chemoembolization (TACE) can be applied in any type of HCC, irrespective of tumor size, location, or number of lesions provided that patients have reasonable liver function. In addition, the benefit of TACE on survival in patients with unresectable HCC had already been demonstrated (Llovet & Bruix, 2003; Shim et al., 2009). Therefore, TACE is widely applicable and practical in patients with intra-hepatic HCC recurrence (Choi et al., 2009;

Fig. 5. CT image of a patient with a 5cm segment VIII recurrent HCC at 6 months after microwave ablation. Three passes were performed for a bigger ablative zone and the needle

TACE is the intra-arterial administration of chemotherapy combined with arterial embolization and is commonly used as an alternate treatment for recurrent HCC (Figure. 6). There is no standardized protocol in the optimal time interval between treatments and also the choice, dosage, concentration, rate of injection of the chemotherapeutic and the

Eguchi et al., 2008; Shim et al., 2010).

tracts were showed on the follow up scan.

embolizing agents.

Fig. 6a. Hepatic angiogram showing a hypervascular tumor supplied by left hepatic artery.

Fig. 6b. The tumor was stained by lipiodol after TACE.

Shim et al analysed data from 199 consecutive HCC patients who underwent curative liver resection and later received repeat TACE for intra-hepatic HCC recurrence. They found that complete tumor necrosis after repeated TACE offered favorable long-term survival outcomes to HCC-recurrent patients, with a median survival time after first TACE of 48.9 months. Despite this, unlike repeat hepatectomy and RFA, TACE cannot be regarded as a curative treatment for recurrent HCC yet.

Although it is not a surgical procedure, the problems of decreased liver reserves and anatomic changes due to previous operation still exist. Moreover, neovascularisation or collaterals that feed the recurrent tumour, damage to the non-tumorous liver tissue, and accumulation of drug toxicity from repeated TACE sessions are the main concern for the use of TACE. Post-embolization syndrome, which is a combination of fever, abdominal pain, nausea and vomiting, elevated liver enzymes and white cell counts for a few hours to a few days, is the most common complication of TACE. Although this syndrome is experienced after 80-90% of TACE procedures, it is mostly self-limited and the treatment is mainly symptomatic. Occasionally, more severe complications like acute cholecystitis, biliary tract necrosis, pancreatitis, gastric erosion or even ulcers can occur as a result of inadvertent injection of the chemotherapeutic and embolizing agents into these organs. Liver failure can develop after TACE and may result in mortality after TACE especially in patients with borderline liver function before treatment. Therefore, patients with portal vein thrombosis or poor liver function are contraindication to TACE.
