TACE and TARE for Unresectable HCC: History and Modern Uses

Note: At 7:12, Dr. Lindquist references the LEGACY study and mentions an objective response rate of 100%. The LEGACY study had an actual objective response rate of 88.3% and complete imaging response rate of 84.0%.

In the first part of this video series, Christopher Lieu, MD, a gastrointestinal medical oncologist at the University of Colorado, and Jonathan Lindquist, MD, a vascular and interventional radiologist also at the University of Colorado, detail the histories of transarterial chemoembolization (TACE) and transarterial radioembolization (TARE) in practice as well as why the latter may be emerging as a more effective means of treating patients with unresectable hepatocellular carcinoma (uHCC).

Dr. Lieu: In our practice, we primarily administer systemic therapies, while your group specializes in liver-directed therapies. Could you provide a brief overview of transarterial chemoembolization (TACE) and radioembolization (TARE) and how these are utilized in treating HCC?

Dr. Lindquist: TACE has a long history, dating back to the first procedure in 1974. Early randomized controlled trials by Lo and Llovet in 2002 demonstrated improved survival for uHCC patients treated with TACE compared to best supportive care. Over the years, TACE has evolved, initially using a cocktail of doxorubicin, cisplatin, and mitomycin C. While various agents have been explored, doxorubicin is now commonly used in monotherapy in the United States.

However, the efficacy of the chemotherapy component has been questioned, with a 2016 trial by Karen Brown showing no difference between drug-eluting bead chemoembolization with doxorubicin and transarterial embolization alone. The ischemic effect produced by the beads is considered a key mechanism of action.

TACE can be performed using different methods, including conventional TACE and drug-eluting bead TACE. The latter involves loading the chemotherapeutic into calibrated microspheres, providing a sustained release over time. The Precision V trial in the mid-2000s found no significant difference between conventional TACE and TACE with drug-eluting beads. Additionally, newer techniques like balloon TACE and pressure-enabled TACE have emerged, offering greater penetration and embolic ischemic effects.

Dr. Lieu: I’ve noticed a shift towards radioembolization recently. Could you share your insights on the increasing preference for radioembolization and the criteria for selecting TACE or transarterial radioembolization TARE?

Dr. Lindquist: TARE is gaining prominence as a more effective treatment, particularly for patients who can tolerate it. The goal in palliative cases with widespread disease is to control the tumor, but we must be mindful of the radiation’s impact on the background liver. In unresectable patients with existing liver disease, functional hepatic reserve becomes crucial.

Appropriately selected patients with adequate functional hepatic reserve can undergo TARE, even for widespread disease, with favorable outcomes. For more localized disease, radiation segmentectomy can be employed, achieving ablative effects and curative results in many patients. Early-stage disease has shown outstanding results with 88.3% objective response and 84.0% complete imaging response.

In potentially resectable patients lacking sufficient future liver remnant, radiation lobectomy allows for higher doses of radiation in a single lobe. This controls the tumor, induces hypertrophy in the remaining liver, and serves as a biological test of time before major surgery. Overall, TARE offers a versatile approach tailored to the patient’s condition and treatment goals.

View the second part of this video series.