2021: The Year of Advances in Unresectable HCC? - Episode 4
Practical considerations for TACE (transarterial chemoembolization) in unresectable BCLC stage B HCC, including assessing radiologic response and determining when to initiate systemic therapy.
Masatoshi Kudo, MD, PhD: In the intermediate stage, lenvatinib provides around a 70% response rate by mRECIST [modified RECIST]. By treating with the subsequent super-selective TACE [transarterial chemoembolization], response rate is around 80%, and around 30% of patients achieve a complete response.
There are several definitions of being TACE refractory from Japan, Europe, or Asian countries. In our criteria, in the case of up-to-7 [sum of the size of the largest tumor and total number of tumors] inpatients, we continue with several TACE sessions super selectively. But if we perform 4 or 5 TACE sessions and 2 consecutive sessions do not achieve a response, such as tumor control, or if there is a new lesion after TACE, then we define those as TACE refractory, and we switch to systemic therapy. Partial response to TACE is a success; stable disease is no response.
TACE is basically a good treatment or therapy. When we perform TACE super selectively, often a very good, high response is obtained. If a partial response is obtained, maybe we can continue TACE super selectively. However, if 2 consecutive TACE sessions cannot achieve a partial response, at that point we have to change to systemic therapy. But in the case of high tumor burden, such as up-to-7 outpatient, we introduce systemic therapy without performing any TACE to maximize the TACE efficacy.
The timing to introduce systemic therapy is much earlier than before, just start systemic therapy, then subsequently super-selective TACE should be performed. TACE is a very important technique to obtain a response. But for up-to-7 outpatients, if we perform TACE first, the liver function is imperative. For up-to-7 outpatients, we recommend systemic therapy such as lenvatinib first, then super-selective TACE. That way the response by TACE is maximized and the liver function is preserved. But for up-to-7 inpatients, when 2 consecutive TACE treatments are not effective and do not achieve partial response, then we switch to systemic therapy.
Amit Singal, MD, MS: The role of systemic therapy in the intermediate stage is becoming increasingly interesting. There’s been a push in the field to understand TACE failure, however one defines that concept. In our clinical practice, we typically reassess after each chemoembolization or radioembolization in terms of tumor response and patient status. If a patient receives locoregional therapy and fails to have a response, such as notable shrinkages in terms of the tumor diameter, or that patient suffers some degree of liver injury, we’re much more likely to consider a transition from locoregional therapy to systemic therapy earlier in that patient’s course. Whether you do that after 1 attempt or 2 attempts at a locoregional therapy, I think you see variation in terms of provider and center approach to this.
But I think the key thing is that all of us are becoming increasingly cognizant that it must be considered in a patient who fails to achieve benefit from that locoregional therapy, or has harm from that locoregional therapy, to consider migration to systemic therapies. This is because as we’ve seen advances in the systemic therapy space, all of us want to make sure that our patients can benefit from the immune checkpoint inhibitor therapies and other therapies we have available, not to mention the sequencing therapies available in the systemic therapy space.
Transcript edited for clarity.