Insights From: Arndt Vogel, MD, Hannover Medical School; Oliver Waidmann, MD, Goethe-Universitat Frankfurt am Main
Oliver Waidmann, MD: Locoregional therapies are the standard of care in intermediate-stage HCC, so-called BCLC-B patients. I think the most important and most familiar used treatment option is so-called transarterial chemoembolization, or TACE.
TACE is an appropriate choice in every patient who has local and regional disease, so-called BCLC-B disease. You can do it even in some patients with BCLC-C stage, but with these patients, you should not have an infiltration of the main portal vein and you should not have complete portal vein thrombosis. These patients are, in principle, eligible for TACE, but you have to consider that the patients, if they have decrease of liver function after 1 or 2 cycles of TACE, won’t benefit from further cycles and then you should switch to another treatment option.
Arndt Vogel, MD: TACE is a very good treatment option for patients with intermediate-stage HCC. Those patients are now candidates for radiofrequency ablation or surgery, and they are not yet candidates for systemic therapies. We do have good evidence for the use of TACE, but we always have to keep in mind how this evidence was based. So, a study was performed many, many years ago in highly selected patients with an extremely good liver function and also small tumors. And nowadays, we tend to also use TACE in patients with more reduced liver function and also larger tumors. We don’t really have good prospective evidence on how good this treatment is and how we really improve the overall survival of our patients. Nevertheless, if we stick to the criteria—tumors not larger than 7 cm, no vascular invasion—TACE is clearly a very good option.
The problem with TACE is that if we overuse it and if we repeatedly use it in patients, we will harm the liver in the end. So, when we look at the liver function before the start of treatment and at the end of treatment, we have to realize that liver function has deteriorated in most cases. If we do 1 or 2 TACEs, it’s good, but then we really need to critically evaluate the reuse of TACE. And this is a problem because it’s not very defined. It has never been really analyzed in prospective trials. So, in general, we are used that stable disease is an acceptable outcome for the treatment of patients with cancer. In respect to TACE, I do not think that this is really true because we harm the liver if you overuse TACE. That’s why we really need to be careful, and maybe we need to be more strict and require response after TACE to continue with TACE. And if you do not have a response after TACE and only stable disease, you really should double-check that we maybe transfer these patients to systemic therapies.
Oliver Waidmann, MD: The problem about TACE is—there are some problems, and I think the biggest problem in TACE is—that it’s not standardized at all. Every hospital does it a different way, so there is no standardization concerning the chemotherapeutic agents used: doxorubicin, mitomycin, cisplatin, gemcitabine, and irinotecan. So, it’s not at all standardized. And embolization is not standardized among different countries and different hospitals. Even with different radiologists in the same hospital, they do it a different way. All the embolization agents—such as drug-eluting beads, Lipiodol, or other embolization stuff—are not standardized. It’s a big problem. And I think the second problem about TACE is that we don’t have really good stopping rules. That means that we don’t know how long we should TACE the patient because the side effects of TACE can be decreasing liver function or even causing liver failure.
Of course, in every patient you do locoregional ablation or regional therapy, you should try to decrease the size of the tumor. It should be tried in every patient if it’s possible. However, we sometimes have the problem that the tumor doesn’t decrease, even if we do a few cycles of TACE. And so, I think these patients should not undergo several more cycles of TACE. In such patients if you don’t have a response, you should switch to a systemic treatment, and we have new treatment options now coming.