TACE – Good radiological response does not necessarily equate with improved overall survival

Here is my highlight from the March edition of the journal HPB

The treatment options for non-resectable primary hepatocellular carcinoma (HCC) are limited. Trans arterial chemoembolization (TACE) is a therapy which has achieved considerable popularity as a means for treating non-resectable HCC but with variable evidence supporting its use.

One of the issues with TACE is how to evaluate treatment results and this is the subject of a retrospective study from Columbus, Ohio in this month’s edition of HPB. Henry and colleagues looked back at 104 patients who received TACE over a 10-year period in their institution. After exclusions, 78 patients were analysed. Around a third of these had a ‘best radiological response’ to TACE meaning that their tumour either disappeared or showed reduction in size and no new areas of enhancement compatible with untreated HCC. Patients who had a good radiological response went on to have a better progression free survival. In overall terms, there was no difference in outcome between those patients who had a good radiological response or poor response to TACE. The authors explain this apparent anomaly by suggesting that many of the prognostic factors associated with outcome in HCC are related to the extent of underlying liver disease and function rather than specific characteristics of the tumour itself.

How do we interpret these data in terms of a clinical role for TACE? Well, we can say with some confidence that TACE is good at controlling the growth of HCC and has a tumoristatic or tumoricidal effect. This has value in situations where we may wish to stop growth of HCCs to allow a patient to receive other treatment such as patients with HCC awaiting liver transplant. We can also say that despite being able to hold tumour growth, a good response from TACE does not increase overall survival. This implies that TACE needs to be combined with another therapy. There are currently examples of combining TACE with ablation and TACE with biological therapies and it will be interesting to see if these offer a superior survival benefit compared with TACE alone.

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