When seconds come first – my observation of an interesting case of transarterial chemo embolisation (TACE) of the liver

Created - 12.09.2013

A young woman lies on the couch, a look of forced cheeriness on her face. On her finger is a peg, and two small tubes poke up into her nostrils. A kindly nurse strokes her hair and checks her blood pressure. In her groin, shaved and swabbed, there is a catheter, and through this catheter a viscous mix of hope and poison will flow. 

The woman looks too well to be a cancer patient. So well nourished is she, that the radiologist has some difficulty locating her femoral artery. The catheter, guided over a thin wire that glides through the femoral artery, then iliac, then aorta, miraculously arrives at the common hepatic artery. The end of the guide-wire twists and turns against an inscrutable grey liver that looks like nothing, until a streak of black dye splinters across the screen. It’s an upside down lightening bolt, in negative. Now it’s a tree, a beautiful delicate tree, like the ones you see in Japanese landscape paintings. The body is full of branches and trees!

The radiologist is pulling concentrationfaces. From time to time he murmurs instructions to the radiographer or nurse, who evidently have the hearing of owls. The requests ripple out to circulating staff to fetch more contrast, more embolic agent, more Midazolam. He stares at the monitor, inching the guide-wire this way and that, displaying impressive hand-eye coordination. Then I see something an untrained eye couldn’t miss. The ugly nest in the beautiful tree. 

You may be wondering how a woman in her thirties could end up in a fluoroscopy suite having her liver tumours embolised. I wondered this too. Is she an alcoholic, I thought? Did she contract hepatitis? Two vials of different chemicals are combined in a syringe, and a toxic-looking fluid injected through the catheter, into the nest. Then the nurse reveals the patient’s history. The cancers he is treating are metastases; secondary spread from a tumour elsewhere.

I think of probable culprits, expecting the primary to be colorectal cancer. No, it wasn’t that, the nurse says. The truth stuns me. She has melanoma of the eye. It was only diagnosed when she started getting liver pains. 

The patient gives a gentle snore. Though awake throughout most of the procedure, she has now succumbed to the monotony of the ceiling tiles and fallen asleep. A far cry from the surgical equivalent, where she would be intubated with her eyes taped shut, scopes and probes coming out of her tummy. The body has a poker face and is expert in selfmastery, only revealing its cards in the final moments. It has shielded her for so long, years possibly, that surgical resection is not an option. Transarterial chemo-embolisation offers her the best outlook with minimal discomfort and injury. Her side effects will be far milder than with standard chemotherapy. Her future may be uncertain, but she will recover swiftly from the procedure and go home to her family tonight.

Lisa Kelman