Transarterial chemoembolization (TACE) has been established as the most widely used therapeutic intervention for patients with intermediate-stage hepatocellular carcinoma (HCC) (BCLC stage B). Systemic therapy is the recommended treatment for advanced stage HCC (BCLC stage C) but different treatment strategies such as hepatic arterial chemo-infusion and radiotherapy are applied in Asian countries. TACE is commonly used beyond the guideline and outcomes may be compromised.
There are now multiple systemic agents that have been approved in the first- and second-line setting for hepatocellular carcinoma (HCC), increasing the therapeutic options for patient and clinicians. Therefore, with a greater number of systemic agents available, the role of locoregional therapy (LRT) has become a topic of debate, especially regarding sequencing therapy from LRT to systemic therapy as well as combination treatment. There are several trials such as OPTIMIS, TACTICS, BRISKS-TA trial, showing the potential opportunities for sequencing and combining LRTs with systemic therapies. Recently, immunotherapies such as nivolumab, pembrolizumab and atezolizumab have been introduced. However, immunotherapy alone may not be enough to deplete Tregs or to stimulate antitumor response and therefore their effect may be boosted by LRT. We will discuss the guide to select patients for combination of LRT and systemic treatment/immunotherapy based on scientific rational. |
