Association of Addition of Ablative Therapy Following Transarterial Chemoembolization With Survival Rates in Patients With Hepatocellular Carcinoma

Abstract

IMPORTANCE Hepatocellular carcinoma (HCC) is a heterogeneous disease with many available treatment modalities. Transarterial chemoembolization (TACE) is a valuable treatment modality for HCC lesions. This article seeks to evaluate the utility of additional ablative therapy in the management of patients with HCC who received an initial TACE procedure. OBJECTIVE To compare the overall survival (OS) and freedom from local progression (FFLP) outcomes after TACE alone with TACE that is followed by an ablative treatment regimen using stereotactic body radiation therapy, radiofrequency ablation, or microwave ablation for patients with HCC. DESIGN, SETTING, AND PARTICIPANTS This cohort study of 289 adults at a single urban medical center examined survival outcomes for patients with nonmetastatic, unresectable HCC who received ablative therapies following TACE or TACE alone from January 2010 through December 2018. The Lee, Wei, Amato common baseline hazard model was applied for within-patient correlation with robust variance and Cox regression analysis was used to assess the association between treatment group (TACE vs TACE and ablative therapy) and failure time events (FFLP per individual lesion and OS per patient), respectively. In both analyses, the treatment indication was modeled as a time-varying covariate. Landmark analysis was used as a further sensitivity test for bias by treatment indication. EXPOSURES TACE alone vs TACE followed by ablative therapy. MAIN OUTCOMES AND MEASURES Freedom from local progression and overall survival. Hypotheses were generated before data collection. RESULTS Of the 289 patients identified, 176 (60.9%) received TACE only and 113 (39.1%) received TACE plus ablative therapy. Ablative therapy included 45 patients receiving stereotactic body radiation therapy, 39 receiving microwave ablation, 20 receiving radiofrequency ablation, and 9 receiving a combination of these following TACE. With a median (interquartile range) follow-up of 17.4 (9.5-29.5) months, 242 of 512 (47.3%) lesions progressed, 211 in the group with TACE alone and 31 in the group with TACE plus ablative therapy (P < .001). Over 3 years, FFLP was 28.1% for TACE alone vs 67.4% for TACE with ablative therapy (P < .001). The 1-year and 3-year OS was 87.5% and 47.1% for patients with lesions treated with TACE alone vs 98.7% and 85.3% for patients where any lesion received TACE plus ablative therapy, respectively (P = .01), and this benefit remained robust on landmark analyses at 6 and 12 months. The addition of ablative therapy was independently associated with OS on multivariable analysis for all patients (hazard ratio, 0.26; 95% CI, 0.13-0.49; (continued) Key Points Question Is the addition of ablative treatment using stereotactic body radiation therapy, radiofrequency ablation, or microwave ablation to transarterial chemoembolization associated with improved treatment outcomes and survival for patients with hepatocellular carcinoma (HCC)? Findings In this cohort study of 289 patients with HCC, the addition of ablative therapy...

Current Status and Future Direction of Albumin-Bilirubin in Hepatocellular Carcinoma: A Bibliometric Analysis

“…4, 5), it can also be found that radiofrequency ablation (RFA) applied to early HCC has also been studied in HCC [32]. Furthermore, RFA and TACE are also the hot spots of many researchers [33‒35].…”

Improving Adjuvant Liver-Directed Treatment Recommendations for Unresectable Hepatocellular Carcinoma: An Artificial Intelligence–Based Decision-Making Tool

“…For patients who had previously received surveillance after initial TACE, our ML model was consistent in recommending combination local modalities for PFS benefit. Our institution 10 along with other groups 25,29 has previously demonstrated the potential advantage of additional ablative treatment modalities after TACE, which included patients with advanced tumors and tumor with complete response on imaging after initial TACE. In addition, the model recommended an alternative combination treatment in approximately one third of patients.…”

“…In this study, we analyzed an expanded subset of a previously reported 10 institutional cohort of HCC treated with TACE with and without consolidative SBRT or RFA. The overall aim is to assess the feasibility for a ML model to predict survival in the definitive management of patients previously treated with TACE, with the goal of identifying patients who may benefit from a specific modality of LDT using SBRT or RFA.…”

Combination transarterial chemoembolization and microwave ablation vs. microwave ablation monotherapy for hepatocellular carcinomas greater than 3 cm: a comparative study

“… 7 These dual synergies (combination therapy) of TACE and MWA have led to overall improved primary efficacy and progression-free survival in larger tumor cases when compared with monotherapy TACE. 8 However, this treatment strategy requires two interventional procedures to be delivered upfront instead of one.…”