Balloon-occluded transarterial chemoembolization for hepatocellular carcinoma : History, background, and the roles

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Super-selective lipiodol balloon-occluded transarterial chemoembolization (SSLB-TACE) increases lipiodol accumulation in the targeted nodule. To understand the mechanism of increased accumulation, it is necessary to understand intra-hepatic collateral system and rheology of lipiodol. Although SSLB-TACE is thought to be a promising technique, randomized prospective controlled trials to compare local control rates with conventional super-selective lipiodol (c-TACE) are still lacking. Another problem for SSLB-TACE is change of TACE candidates by development of radiofrequency ablation (RFA) technology. Patients with limited number of small nodules are good candidates for both SSLB-TACE and c-TACE, but these are also good candidates for RFA. Because higher priority is given to RFA, TACE is usually indicated for patients with 4 or more nodules, with large nodule(s), and/or with proximal Glisson attaching nodule(s). However, these cases are known as TACE-refractory, and the chance to perform SSLBTACE or c-TACE would be markedly decreased in institutions where RFA is aggressively performed. In the past, paradigm shift from non-selective TACE to super-selective TACE occurred, and the goal of SSLB-TACE and c-TACE is prolonged complete remission of the treated nodules while sacrificing small volume of liver parenchyma. But another TACE technique, aiming treatment of wide region (hemi-lobe or more) and effective tumor volume reduction while minimizing liver parenchymal damage, is mandatory in RFA era. For this purpose, we developed a new balloon-occluded TACE without using lipiodol; alternate infusion of cisplatin solution and sparse gelatin slurry was repeated under balloon-occlusion (RAIB-TACE) until stasis of gelatin slurry in proximal hepatic arteries was seen. However, not only RFA but also recent development of molecular targeted drugs strongly influences on the indication and the aim of TACE. The goal and technique of TACE should be properly selected in each era, in each institution, and for each patient.

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