Ep. 256 Origins of TACE with Drs. Michael Soulen and Nicholas Fidelman

In this episode, guest host Dr. Nicholas Fidelman interviews Dr. Michael Solen, a key player in the development and widespread adoption of transarterial chemoembolization (TACE). The doctors discuss how TACE became a major therapeutic option for liver tumors, his preferred method of TACE dosage and management, and exciting new frontiers in chemoembolization.

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SHOW NOTES

Dr. Soulen recalls his first ever TACE patient, who was a patient self-referring for a rare neuroendocrine tumor. As an IR fellow at the University of Pennsylvania, Dr. Soulen recognized the opportunity to incorporate clinic time into his IR practice. His push for clinical management of IR patients resulted in successful medical and financial outcomes, which also led his hospital to establishing an interventional oncology clinic. He emphasizes that a clinic presence is crucial to participating in tumor boards and being able to accept outside referrals.

Next, we delve into the history of the CAM (cisplatin, adriamycin, mitomycin) conventional TACE cocktail, which Dr. Soulen developed alongside medical oncologists and pharmacists. These chemotherapeutics, combined with lipiodol and followed by particle embolics, make up the most widely used TACE protocol in the United States. Dr. Soulen reviews his preferred ratios and mixing method for maximal efficacy. He discusses his current RETNET trial that directly compares treatment of neuroendocrine tumors with conventional TACE versus bland embolization in terms of progression free survival, toxic side effects, and patient quality of life.

Additionally, we address the high prevalence of post-embolization syndrome and SIR consensus guidelines for its management. Since chemoembolization is a highly emetogenic therapy, Dr. Soulen uses an oncology evidence-based combination of Benadryl, Zofran, and Decadron. He administers PRN pain medication on an individual patient basis. Furthermore, we discuss post-TACE management, specifically length of hospital stay. While all patients used to be admitted for overnight monitoring, this has shifted to mostly same-day discharges. This change has allowed the hospital to conserve resources and decrease costs.

Finally, Dr. Soulen shares his perspective on new developments in interventional oncology. He highlights a need to identify TACE drugs that specifically target intratumoral hypoxic response mechanisms. He also compares transarterial radioembolization (TARE) to TACE, noting that the former has not shown superiority to systemic therapy in research trials. However, there are possibilities that TARE or TACE could be useful to slow tumor progression in radiation lobectomy or as immunostimulants for combination therapy with immune checkpoint inhibitors and CAR-T cell therapy.

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RESOURCES

RETNET Trial:

https://clinicaltrials.gov/ct2/show/NCT02724540

Transcatheter oily chemoembolization of hepatocellular carcinoma:

https://pubmed.ncbi.nlm.nih.gov/2536946/

Prospective Randomized Study of Doxorubicin-Eluting-Bead Embolization in the Treatment of Hepatocellular Carcinoma: Results of the PRECISION V Study:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2816794/

Randomised controlled trial of doxorubicin-eluting beads vs conventional chemoembolisation for hepatocellular carcinoma:

https://pubmed.ncbi.nlm.nih.gov/24937669/

Treatment of Liver Tumors with Lipiodol TACE: Technical Recommendations from Experts Opinion:

https://pubmed.ncbi.nlm.nih.gov/26390875/

Outpatient Transarterial Chemoembolization of Hepatocellular Carcinoma: Review of a Same-Day Discharge Strategy:

https://pubmed.ncbi.nlm.nih.gov/29478795/

Phase I Trial on Arterial Embolization with Hypoxia Activated Tirapazamine for Unresectable Hepatocellular Carcinoma:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8139681/