Transcatheter Hepatic Arterial Chemoembolization
Transcatheter arterial chemoembolization (TACE) of the liver is a proposed alternative to conventional systemic or intra-arterial chemotherapy and to various nonsurgical ablative techniques, to treat nonresectable tumors. TACE is a minimally invasive procedure performed by interventional radiologists who inject highly concentrated doses of chemotherapeutic agents into the tumor tissues to restrict tumor blood supply. The embolic agent(s) causes ischemia and necrosis of the tumor, extending the retention of the chemotherapeutic agent and decreasing systemic toxicity. The liver is especially amenable to such an approach, given its distinct lobular anatomy, the existence of two independent blood supplies and the ability of healthy hepatic tissue to grow and thus compensate for tissue mass lost during chemoembolization.
The TACE procedure requires hospitalization for placement of a hepatic artery catheter and workup to establish eligibility for chemoembolization. Prior to the procedure, the patency of the portal vein must be demonstrated to ensure an adequate post-treatment hepatic blood supply. Typically, only one lobe of the liver is treated during a single session, with subsequent embolization procedures scheduled from 5 days to 6 weeks later. In addition, since the embolized vessel recanalizes, chemoembolization can be repeated as many times as necessary.
Note: This policy does not apply to requests for venous occlusion of the portal vein.
Transcatheter hepatic arterial chemoembolization is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Transcatheter hepatic arterial chemoembolization for all other conditions including, but not limited to, resectable hepatocellular cancer, unresectable cholangiocarcinoma and any other tumors is considered investigational.
Transcatheter hepatic arterial chemoembolization is considered medically appropriate if ALL of the following criteria are met:
Portal venous flow to the affected area of the liver must be demonstrated prior to the procedure
Treatment is indicated for ANY ONE of the following:
Hepatocellular carcinoma when ALL of the following are met:
Tumor is surgically unresectable
Evaluation for metastases outside the liver is negative (should include negative chest x-ray, CT or MRI of the abdomen)
Child Pugh liver function score of A or B (see Additional Information below)
Liver metastases from neuroendocrine tumors when ALL of the following are met:
Symptoms persist despite systemic therapy
Individual is not a candidate for surgical resection
As a bridge to transplant in individuals with hepatocellular cancer when ALL of the following are met:
Intent is to prevent further tumor growth and to maintain candidacy for liver transplant
Child-Pugh score A or B liver function
Absence of extrahepatic disease
Absence of vascular invasion
Tumor characteristics are ANY ONE of the following:
Single tumor, 5 cm or less in diameter
No more than 3 tumors, each 3 cm (or less) in diameter
Liver-dominant metastasis from uveal (ocular) melanoma
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Child-Pugh score is a scoring system used to assess prognosis in individuals with chronic liver disease and cirrhosis. The score considers total bilirubin, serum albumin, INR, degree of ascites and hepatic encephalopathy.
American Association of Liver Disease. (2018). AASLD guidelines for the treatment of hepatocellular carcinoma. Hepatology, 67 (1), 358-380.
BlueCross BlueShield Association. Evidence Positioning System. (7:2018). Transcatheter arterial chemoembolization to treat primary or metastatic liver malignancies (8.01.11). Retrieved January 17, 2019 from http://www.evidencepositioningsystem.com. (80 articles and/or guidelines reviewed)
BlueCross BlueShield of Tennessee network providers. April 2009.
BlueCross BlueShield of Tennessee network providers. July-August 2005.
BlueCross BlueShield of Tennessee network providers. June-August 2000.
Finn, R., Zhu, A., Farah, W., Almasri, J., Zaiem, F., & Prokop, L. (2018). Therapies for advanced stage hepatocellular carcinoma with macrovascular invasion or metastatic disease: a systematic review and meta-analysis. Hepatology, 67 (1), 422–435. (Level 1 evidence)
Heimbach, J., Kulik, L., Finn, R., Sirlin, C., Abecassis, M., Roberts, L., et al. (2018). AASLD guidelines for the treatment of hepatocellular carcinoma. Hepatology, 67 (1), 358-380. (Level 1 evidence)
Kulik, L., Heimbach, J., Zaiem, F., Almasri, J., Prokop, L., Wang, Z (2018). Therapies for patients with hepatocellular carcinoma awaiting liver transplantation: a systematic review and meta-analysis. Hepatology, 67 (1), 381=400. (Level 1 evidence)
Li, L., Tian, J., Liu, P., Wang, X., & Zhu, Z. (2016, June). Transarterial chemoembolization combination therapy vs monotherapy in unresectable hepatocellular carcinoma: a meta-analysis. Tumori Journal, 2016 (3), 301 - 310. Abstract retrieved February 9, 2017 from PubMed database.
National Comprehensive Cancer Network. (2018, December). NCCN clinical practice guidelines in oncology (NCCN Guidelines®). Hepatobiliary cancers. (V.1.2019). Retrieved January 17, 2019 the National Comprehensive Cancer Network.
National Comprehensive Cancer Network. (2018, March). NCCN clinical practice guidelines in oncology (NCCN Guidelines®). Uveal Melanoma. (V.1.2018). Retrieved January 17, 2019 the National Comprehensive Cancer Network.
National Comprehensive Cancer Network. (2019, January). NCCN clinical practice guidelines in oncology (NCCN Guidelines®). Neuroendocrine Tumors. (V.4.2018). Retrieved January 17, 2019 the National Comprehensive Cancer Network.
Zacharias, A. J., Jayakrishnan, T. T., Rajeev, R., Rilling, W. S., Thomas, J. P., George, B., et al. (2015). Comparative effectiveness of hepatic artery based therapies for unresectable colorectal liver metastases: a meta-analysis. PloS One, 10 (10), 1-10. (Level 1 evidence)
ORIGINAL EFFECTIVE DATE: 6/1/2000
MOST RECENT REVIEW DATE: 3/28/2019
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