Indications and Best Practices for Intra-arterial Therapies to Treat Hepatocellular Carcinoma

Abstract

The purpose of this review is to re-evaluate the role of intra-arterial therapies for hepatocellular carcinoma (HCC) recommended by contemporary staging systems. Currently, intra-arterial therapies are recommended by the Barcelona Clinic Liver Cancer (BCLC) staging system only for patients with BCLC B HCC in the form of trans-arterial chemoembolization. Recently, randomized controlled trials in patients with BCLC C HCC without metastatic disease have suggested a potential role for trans-arterial radioembolization (TARE) with fewer adverse events and better quality of life compared to sorafenib. Randomized controlled trials have also demonstrated the benefit of using combination therapy of trans-arterial chemoembolization (TACE) with ablation for patients with BCLC A HCC [single tumors (3–7 cm)] compared to ablation alone. Finally, promising results from single-center studies indicate that TARE using a radiation segmentectomy technique may be a potentially curative therapy for tumors less than 3 cm, supporting its use in patients with BCLC A HCC that are not amenable to surgical or ablative therapies. Recent randomized clinical trials have demonstrated the benefit of intra-arterial therapies in subpopulations of BCLC stages A, B, and C. These studies highlight the need for careful patient assessment, staging, and multidisciplinary discussion to consider treatments that are not currently included in guidelines but can improve patient outcomes for HCC.