TACE vs DEB-TACE: Who wins?

Abstract

Transarterial chemoembolization (TACE) is the recommended reatment modality for patients with intermediate stage hepatoellular carcinoma (HCC), or stage B as defined by the Barcelona linic Liver Cancer (BCLC) classification system [1]. According to he EASL/EORTC clinical practice guidelines for the management f HCC, the use of TACE is indicated in patients with unresectable, ultinodular cancers who are asymptomatic and do not display vidence of vascular invasion or extrahepatic spread of the tumour 2]. The rationale behind the use of TACE is based on the concept hat, since HCC growth is characterized by a marked increase in rterial neovascularization, the selective intra-arterial infusion of chemotherapeutic agent to be delivered in proximity of tumour odules, followed by the permanent embolization of the arterial essel supporting the blood supply, would determine both a cytooxic and an ischaemic effect, leading to tumoral necrosis. Studies ave shown that the combination of a chemotherapeutic agent with n ischaemic agent exerts greater effects compared to chemotherpy alone, although debate remains about the effectiveness of rterial embolization alone [3]. Conventional TACE (c-TACE) is based on the use of different hemotherapeutic agents, most commonly doxorubicin, epirubicin, r mytomycin. TACE is seldom curative in patients with intermedite HCC, but several randomized controlled trials (RCT) have shown ts use to be associated with delayed tumoral progression, reduced ascular invasion, and improved patient survival, with an averge life gain of 4 months (i.e., from a median survival of 16–20 onths) [4]. These favourable data, despite being disputed by a ecent Cochrane review [5], have driven the current EASL/EORTC uidelines, recommending the use of TACE in patients with interediate (BCLC stage B) HCC. Notably, this recommendation has een established by the highest level, both for the supporting evience as for the strength of recommendation. Yet, several questions remain unanswered about the use of ACE. First, TACE is not a standardized procedure: it is still unclear hich is the preferred chemotherapeutic agent to be used, the ost appropriate size of the embolizing particles, and the maxium number and the timing of procedures that can be performed. econd, there is a clear need to better select the patient population eserving TACE treatment, as patients with previous decompen-