Re‐evaluating transarterial chemoembolization for the treatment of Hepatocellular Carcinoma: Consensus recommendations and review by an International Expert Panel

Abstract

Patients with unresectable hepatocellular carcinoma (HCC) usually receive transarterial chemoembolization (TACE) or systemic therapies with intermediate and advanced-stage disease. However, intermediate-stage HCC patients often have unsatisfactory clinical outcomes with repeated TACE and there is considerable uncertainty surrounding the criteria for repeating or stopping TACE treatment. In July 2012, an Expert Panel Opinion on Interventions in Hepatocellular Carcinoma (EPOIHCC) was re-convened in Shanghai in an attempt to provide a consensus on the practice of TACE, particularly in regard to evaluating TACE 'failure'. To that end, current clinical practice throughout Asia was reviewed in detail including safety and efficacy data on TACE alone as well as in combination with targeted systemic therapies for intermediate HCC. This review summarizes the evidence discussed at the meeting and provides expert recommendations regarding the use of TACE for unresectable intermediate-stage HCC. A key consensus of the Expert Panel was that the current definitions of TACE failure are not useful in differentiating between situations where TACE is no longer effective in controlling disease locally vs. systemically. By redefining these concepts, it may be possible to provide a clearer indication of when TACE should be repeated and more importantly, when TACE should be discontinued.The preferred curative treatments for hepatocellular carcinoma (HCC) include liver transplantation, surgical resection or local ablation. These treatments offer the best survival advantages but in practice, most patients either present when the tumour is in an advanced stage or the degree of underlying liver disease precludes these options. Subsequently, treatment algorithms recommend treatment stratification based on the stage of disease. For intermediate-stage patients (1) with unresectable, large/multifocal HCC, most guidelines recommend TACE as a first-line treatment (2-6) whereas for patients with advanced-stage HCC (1) Liver International (2014)

Prognostic significance of sarcopenia in patients with hepatocellular carcinoma undergoing sorafenib therapy

“…The majority of analyzed patients received previous therapies for HCC. Sorafenib therapy was recommended for patients with unresectable HCC and the following features, as determined by dynamic computed tomography (CT): i) The presence of distant metastases; ii) refractory response to previous transcatheter arterial therapies for HCC [transcatheter arterial chemoembolization (TACE) or transcatheter arterial infusion (TAI) chemotherapy]; iii) unsuitability for TACE or TAI due to anatomical reasons; iv) vascular invasion such as tumor thrombus in the portal vein (28)(29)(30). Patients with poor performance status [PS; Eastern Cooperative Oncology Group (ECOG) classification ≥3] were not recommended for sorafenib therapy (28,29).…”

Locoregional and systemic therapy for hepatocellular carcinoma

“…TACE is the most commonly employed option for locoregional therapy, with multiple guidelines endorsing this approach in intermediate stage HCC (13,81). Despite the significant improvement in TTP and OS with TACE, BCLC stage B HCC is largely incurable.…”

Feasibility of combining adjuvant transarterial chemoembolization with nucleos(t)ide analog therapy for patients with HBV-associated hepatocellular carcinoma after hepatectomy

“…The goal of adjuvant transarterial chemoembolization (TACE) is to destroy small intrahepatic metastases that may not have been detected during surgery, as well as to eliminate tumor cells that may have been released during surgical manipulation of the liver (11). Adjuvant TACE appears to benefit only patients with HCC at high risk of early recurrence, including patients with multiple nodules, large tumors, vascular invasion, poor tumor differentiation, incomplete or absent tumor capsule, or a resection margin <1 cm.…”