Treatment Strategy of Transarterial Chemoembolization for Hepatocellular Carcinoma

Transarterial chemoembolization (TACE) is a first-line treatment for patients with hepatocellular carcinoma (HCC) in Barcelona Clinic Liver Cancer stage B (BCLC-B). There are two major techniques of TACE: conventional TACE (cTACE) using iodized oil and gelatin sponge particles, and TACE using drug-eluting beads (DEB-TACE). The latest randomized controlled trial proved the superiority of cTACE regarding local effects over DEB-TACE; however, cTACE also damages the liver more severely. Therefore, cTACE should be performed for localized HCCs as selectively as possible. On the other hand, DEB-TACE has less liver toxicity and is favorable for patients with an advanced age, large and/or bilobar tumors, or a poor liver function. However, some BCLC-B HCCs are TACE-resistant and the concept of TACE unsuitability (mainly up-to-7 criteria out) has been proposed by Asia-Pacific Primary Liver Cancer Expert Meeting. Systemic therapy is recommended for patients with TACE-unsuitable HCC; however, the condition of TACE-unsuitable HCC does not always rule out TACE monotherapy and some up-to-7 criteria out tumors may also be good candidates for superselective cTACE when localized in limited liver segments. The sequential therapy of an antiangiogenic and TACE is also a novel option for patients with TACE-unsuitable HCC, antiangiogenic-refractory HCC, or even down-staged HCC.