Current Strategies to Identify Patients That Will Benefit from TACE Treatment and Future Directions a Practical Step-by-Step Guide

Abstract

Treatment of hepatocellular carcinoma (HCC) depends on the stage of disease. In the Western Hemisphere, the Barcelona Clinic Liver Cancer classification (BCLC) is the preferred staging system. Approximately one-third of patients initially present with intermediate-stage disease. For these patients, transarterial chemoembolization (TACE) is the treatment of choice. However, the intermediate-stage comprises a heterogeneous subgroup of patients with considerable differences in tumor burden and liver function. In addition, differences in individual factors that are not captured by the BCLC framework, such as the tumor growth pattern, degree of hypervascularity, and vascular supply, complicate further evaluation of these patients. Due to these differences, not all patients benefit equally from TACE. Several tools and scoring systems have been devised to provide decision-making support. All of these have shown promising initial results but failed external evaluation and have not been translated to the clinic. Nevertheless, criteria for objectifying treatment decisions in daily clinical practice are needed in all stages of disease. Therefore, this review provides a concise practical step-by-step guide on current strategies for patient selection and decisionmaking, with a focus on TACE, to critically evaluate the existing decision-support tools and provide a summary of the latest updates in the field.

Immunonutritive Scoring for Patients with Hepatocellular Carcinoma Undergoing Transarterial Chemoembolization: Evaluation of the CALLY Index

“…Several conventional tools and scoring systems have been developed to provide support for clinicians making treatment decisions for patients with HCC that undergo TACE [ 39 ]. Unfortunately, despite promising initial results, all the conventional risk scores have failed in external evaluations [ 9 , 10 , 11 , 12 , 13 ].…”

Local and Regional Therapies for Hepatocellular Carcinoma and Future Combinations

“…However, their prognostic value in external validation was only moderate and a direct head-to-head comparison of the various scores and cut-offs is missing. Apart from tumor size, number and growth type, pre-procedural imaging offers an insight into various prognosis-related tumor features [23]. One of the most important features is the degree and anatomy of tumor vascularity, which highly influences the treatment success.…”

“…Thus, liver function and performance status have to be monitored closely in order to avoid "overtreatment" [33]. From our point of view, regardless of the re-treatment type, continuous re-evaluation of each patient by an interdisciplinary tumor board is of the utmost importance [23]. Each indication should be jointly approved by this board.…”

“…Another common problem during follow-up is the optimal time-point to switch to other treatment modalities in case of tumor progress and/or ongoing decrease in the remaining liver function. In clinical routine, the optimal time-point for a therapy switch may be hard to determine, particularly as defined cut-off criteria are missing [23].…”

Quantitative washout in patients with hepatocellular carcinoma undergoing TACE: an imaging biomarker for predicting prognosis?

“…However, considerable differences in tumor burden and liver function are observed within the intermediate stage, leading to remarkable heterogeneity in this patient group [ 7 ]. Thus, the prediction of prognosis and treatment decision-making remain difficult in these patients [ 8 ].…”