Position 2: Transarterial Radioembolization Should Be the Primary Locoregional Therapy for Unresectable Hepatocellular Carcinoma

Short abstract

http://aasldpubs.onlinelibrary.wiley.com/hub/journal/10.1002/(ISSN)2046-2484/video/15-2-reading-rahman a video presentation of this article

Abbreviations

BCLC

Barcelona Clinic Liver Cancer

HCC

hepatocellular carcinoma

TACE

transarterial chemoembolization

TARE

transarterial radioembolization

Key Points

• Both transarterial chemoembolization (TACE) and transarterial radioembolization (TARE) provide similar benefits in terms of overall survival and delay of progression in patients with hepatocellular carcinoma (HCC).

• TARE has a wider range of applications, including use in patients with more advanced liver disease, multifocal disease, vascular invasion, and portal venous thrombosis.

• TARE has better health‐related quality‐of‐life metrics and toxicity profile compared with TACE.

• Although a single TARE versus a single TACE session is more costly, the overall cost favors TARE over TACE for an individual patient with unresectable HCC.

The incidence of HCC has been increasing in the United States over the last 20 years.1 Data from the Surveillance, Epidemiology, and End Results registry projects that the incidence of HCC will continue to increase until 2030.2 For this reason, advancements in our understanding of the proper utilization of locoregional therapies for unresectable HCC are key to successful outcomes for these patients.

Because TACE was the initial modality developed for locoregional therapies for HCC and has the largest body of evidence, it had been adopted in many consensus recommendations and treatment algorithms for unresectable HCC. As the experience of TARE has evolved, it has had an increasingly important role in the treatment of unresectable HCC and has many potential advantages over TACE. For these reasons, treatment algorithms are beginning to incorporate TARE or have left the treatment option more open‐ended to the treating medical team. In the most recent update of the American Association for the Study of Liver Diseases guidelines for HCC management, it recommends locoregional therapy over no treatment in this patient population, but does not recommend one treatment modality over another.3 As the experience with TARE evolves, its potential advantages over TACE will become clearer, but there is already substantial evidence to favor TARE over TACE.

Efficacy of TARE Versus TACE

A meta‐analysis comparing the efficacy of TARE and TACE in treating patients with unresectable HCC showed similar overall survival at 1 year between TARE and TACE.4 Progression‐free survival at 1 year is also similar between the two treatments. In addition, there was a trend toward an increase in rate of transplantation among the TARE group compared with the TACE group, although this did not reach statistical significance. Other studies have shown that TARE may be associated with a longer time to progression of HCC compared with TACE.5 Some retrospective studies have shown a statistically significant overall survival advantage with TARE compared with TACE.6

Advantages of TARE Compared With TACE

Several studies have shown a lower risk for postembolization syndrome with TARE compared with TACE.5, 7 TARE is also more suitable for patients with HCC with portal vein thrombosis because of the small size of TARE particles compared with TACE, which tends to induce more ischemia and necrosis.8 Although the data are limited regarding quality‐of‐life measures following locoregional therapy, the evidence suggests that TARE is associated with better quality‐of‐life measures compared with TACE.9, 10 Lastly, the use of radiation segmentectomy, the application of segmental, high‐dose radioembolization, provides high tumor dose, maximizing the cytotoxic radiation delivery, whereas the focused delivery minimizes risk for collateral parenchymal damage. In patients with early‐stage HCC and preserved liver function who were not candidates for radiofrequency ablation, radiation segmentectomy provides response rates, tumor control, and survival outcomes similar to curative approaches, such as resection and radiofrequency ablation.11

Cost of TARE Versus TACE

Data regarding the cost‐effectiveness of TACE versus TARE are limited. A Monte Carlo case‐based simulation study suggests that the cost of TARE may be equivalent to TACE in patients with moderate disease burden (Barcelona Clinic Liver Cancer [BCLC] stage B) and is more cost‐effective compared with TACE in patients with more advanced disease (BCLC‐C).12 The upfront cost of a single TARE session is much higher than the cost of a single TACE treatment. However, when considering the cost of hospital admission, pain control, treatment multiplicity, and toxicity, the overall cost‐effectiveness of TARE is likely to be superior to TACE in patients with unresectable HCC.

Conclusions

TARE appears to be as efficacious as TACE in terms of overall survival and delay of progression in patients with unresectable HCC. TARE has an evolving role in the treatment of HCC with evidence‐based applications across the range of BCLC stages, including radiation segmentectomy for patients with solitary lesions, lobar therapy for patients with multifocal HCC, and treatment of advanced disease with portal vein thrombosis. The more favorable side effects profile and cost are other potential advantages of TARE compared with TACE. For these reasons, TARE should be the primary locoregional therapy for unresectable HCC.