TACE and TARE for Unresectable HCC: Selection Criteria and Clinical Trial Takeaways

In the second 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, provide an overview of the patient selection criteria for transarterial chemoembolization (TACE) and transarterial radioembolization (TARE) in unresectable hepatocellular carcinoma (uHCC), as well as key points to take home from some of the most notable clinical trials to date.

Dr. Lindquist: You touched on key selection criteria for both TACE and TARE, emphasizing the importance of assessing the patient’s functional reserve, Child-Pugh class, and ECOG performance status. This leads us to the BCLC criteria for staging liver cancer patients. It’s crucial to ensure that we aren’t treating individuals who are suitable candidates for curative therapies like resection or ablation. If unresectable, ablation is favored. For those not eligible for curative options, transplant candidacy is explored, and TACE or TARE can be used to bridge patients to transplant.

In cases where a patient is not a Y-90 candidate, TARE is preferred due to its improved durability and efficacy, as indicated by recent trials. Patient selection involves assessing functional reserve and excluding extrahepatic disease, which is better addressed by systemic therapies. TACE and TARE show similar benefits for imminent resections or transplants, but TARE is considered a better option for patients on a waiting list.

Dr. Lieu: Moving on to clinical trials, could you briefly summarize key findings on disease-free survival and overall survival from trials involving TACE and TARE?

Dr. Lindquist: It is important to note the heterogeneity of this disease, with varying degrees of indolent and aggressive biology. While we often lack knowledge of disease biology at decision-making points, the trials provide valuable insights.

The original TACE trials by Lo and Llovet demonstrated significantly improved overall survival, with a two-year survival rate of 63% versus 27% in the best supportive care arm. Riad Salem’s Premiere trial compared conventional TACE with radioembolization, showing a progression-free survival of seven months with TACE. In Northwestern’s hands, Y-90 had over 26 months of progression-free survival. A recent Belgian trial comparing DEB-TACE with Y-90 in BCLC B HCC found a time to progression of 17 versus 9 months, and overall survival of 30 months versus 16 months, favoring Y-90. My takeaway is the preference for Y-90 when possible and the need for a nuanced approach to TACE, considering alternative techniques and limiting non-target deposition.

Dr. Lieu: Thank you for sharing those valuable insights, Dr. Lindquist. It’s enlightening to learn about the recent clinical trials, and your expertise adds depth to our understanding of these treatments.

View the first part of this video series.