In that HB is generally chemosensitive, systemic neoadjuvant chemotherapy is typically the preferred initial treatment course prior to or following surgical resection [2]. However, in up to 30 % of children, the tumor will not respond adequately to systemic chemotherapy, and TACE can be considered as an additional treatment option. TACE has been shown to be effective as a salvage preoperative technique to convert unresectable tumor into a resectable tumor [12]. Children that have bilobar or multicentric disease and despite an apparent effective response of the tumor to the systemic or localized regional chemotherapy, surgery may not be able to achieve an adequate resection and still maintain sufficient tissue volume to preserve function. In these circumstances liver transplantation is increasingly considered a viable option, and TACE can serve as a bridging technique until an appropriate organ is available (Fig. 25.2) [13, 14].

Less than 30 % of children with HCC present with a primarily resectable tumor. Liver transplantation has been shown to be much more successful than conventional systemic chemotherapy in children with HCC, even if they were outside the Milan transplant criteria (adult basis for liver transplantation) [15]. In these circumstances TACE clearly has a role as a bridging technique until an organ is available.

Finally TACE has a role as a palliative treatment option for those with symptoms related to the mass effect caused by the tumor burden. TACE has been shown with randomized controlled trials to prolong survival compared to conservative medical management in the adult population [16, 17].

Contraindications are listed in Table 25.1.

There are three major categories that relate to contraindications for TACE. First are those issues related to the angiographic procedure (see Chap. 4). Second are contraindications related to the chemotherapeutic agents such as severe thrombocytopenia, neutropenia, and cardiac or renal dysfunction. Finally, there are issues related to hepatic function and vascular involvement. The child must have adequate reserves and sufficient hepatic function following the embolization of the hepatic artery. This requires adequate portal venous support at baseline. An occluded portal vein is not necessarily a contraindication to TACE as long as there is sufficient collateral flow from cavernous transformation to support the liver should the arterial supply become compromised as is the case with an effective TACE (Fig. 25.3). In these circumstances the tumor should be embolized as selectively as possible to minimize risk of inducing hepatic failure. Children with biliary obstruction should have this relieved prior to a TACE due to the increased risk of developing a post-TACE hepatic abscess, sepsis, or hepatic failure [18]. Tumors that have excessive arterial venous shunting may not be appropriate for TACE treatment due to the risk of developing clinically significant pulmonary emboli as a result of the embolic material.

The workup before the actual procedure is an extremely important step in the entire process. This includes not only imaging and laboratory values but also a frank discussion at tumor board and a clinic visit for the child and family.

Typically, when a patient is to be worked up for a chemoembolization procedure, by the time referral is made to the interventional radiology service, a definitive diagnosis along with the necessary imaging and lab workup has been completed. However it must be kept in mind that the imaging and labs should be relatively recent prior to the procedure. The imaging modality preferred is usually a multiphase contrast-enhanced MRI. This is especially helpful compared to a CT in the event that there has been prior percutaneous therapy. However if an MRI is not available or obtainable for various reasons, then a multiphase CT with contrast is sufficient.

Along with the imaging, the bloodwork is undertaken to assess for ability to tolerate TACE. The standard bloodwork performed should include a CBC, liver and renal function, coagulation profile, serum electrolytes, and tumor markers. A differential white count and an absolute neutrophil count may be required for those children previously treated with systemic chemotherapy. Once these facts are in hand, the case is discussed in the multidisciplinary tumor board. This is the forum to clarify the ultimate goal of the TACE, i.e., whether this is being done as a primary preoperative procedure, salvage, bridge to transplant, or palliative procedure.

Having made the decision to offer a TACE, the candidacy of the patient needs to be determined. This is done based on the performance status of the patient, the imaging findings, and the lab values. Usually patients with an Eastern Cooperative Oncology Group (ECOG) Performance Status score of more than 2 are poor candidates (see Table 25.2). However, ECOG scoring is always challenging in the pediatric population. On imaging one needs to ascertain the degree of the liver parenchyma replaced. If more than 70 % of the liver is replaced by tumor, then the patient is a poor candidate in terms of tolerating the procedure due to the risk of inducing hepatic failure. Tumor distribution, i.e., unilobar or bilobar, also plays a role in the planning of the procedure. Bilobar disease will need good documentation of the areas treated at each session to make sure that all lesions are treated. Unilobar disease consisting of a solitary lesion is the best scenario as it allows a more targeted delivery of the chemoembolic agent with the best results.

Next, one needs to assess the lab values. The coagulation parameters and the total bilirubin are critical values to consider. A total bilirubin of more than 2 mg/dL can suggest increased risk for complications, and proceeding with treatment should be taken into careful consideration with the care team. Also remember that when using Adriamycin, since it has cardiac side effects, it requires that cardiac function be evaluated in advance. Some of the lab value cutoffs are mentioned in the Table 25.3.