Patient Selection for Transarterial Chemoembolization in Hepatocellular Carcinoma: Importance of Benefit/Risk Assessment

Abstract

Background: Liver cancer is the second most common cause of cancer-related death, with hepatocellular carcinoma (HCC) accounting for most primary liver cancers and most commonly arising from a history of advanced chronic liver disease. Among the available therapies, transarterial chemoembolization (TACE) is the most widely utilized and is considered the first-line treatment recommended for patients staged as intermediate HCC (Barcelona Clinic Liver Cancer stage B). If applied correctly, TACE can produce survival benefits without adversely affecting hepatic functional reserve. Summary: The aim of this nonsystematic review is to evaluate the evidence supporting TACE, with a special interest in intermediate HCC, for which this treatment is recommended in first line. However, intermediate HCC represents a broad and heterogeneous group of patients, not all of whom will benefit from TACE. This review highlights the importance of appropriate patient selection for initial TACE and for retreatment. It also evaluates evidence for the treatment of patients who become refractory to TACE. Some patients may, in fact, benefit from early switch (i.e., after 1 or 2 TACE treatments) to systemic therapies rather than continuing retreatments with TACE in order to preserve liver function, thus allowing sequential first- and second-line drug therapies. Key Messages: Careful assessment of an individual patient's benefit/risk ratio is recommended before any TACE session is considered to ensure optimal long-term outcomes in intermediate HCC.

Clinical characteristics and outcomes of candidates for second‐line therapy, including regorafenib and ramucirumab, for advanced hepatocellular carcinoma after sorafenib treatment

“…In the results of the RESORCE trial, the OS of patients with Child–Pugh A5 was significantly longer than that in patients with Child–Pugh A6 . Therefore, in order to increase the number of Child–Pugh A5 patients in whom sorafenib treatment can be introduced, it is important that BCLC stage B patients be switched to sorafenib as soon as transarterial chemoembolization is judged as ineffective, while their Child–Pugh score remains at 5 . Terashima et al .…”

Prognostic impact of transcatheter arterial chemoembolization (TACE) combined with radiofrequency ablation in patients with unresectable hepatocellular carcinoma: Comparison with TACE alone using decision‐tree analysis after propensity score matching

“…Transcatheter arterial chemoembolization (TACE) is a standard therapy for unresectable HCC, especially for patients with BCLC B . Several studies have shown that TACE significantly improves patient survival compared to the best supportive care and can prolong survival in patients with multiple HCC tumors and no macrovascular invasion . However, long‐term prognosis of patients treated with TACE alone is unsatisfactory and overall survival at 3 years remains low (<30%) for intermediate HCC patients because of poor local control of HCC.…”

Recent clinical applications of external beam radiotherapy for hepatocellular carcinoma according to guidelines, major trials and meta‐analyses

“…A study by the Bologna Liver Oncology group revealed that only 8% of patients showed sustained remission (for ≥6 months) for tumours measuring ≥5 cm in size . A development of a possible post‐embolization syndrome also limits the application of TACE for patients with decompensated liver function …”