Safety and efficacy of combined trans-arterial radioembolization and systemic therapy for advanced hepatocellular carcinoma

The current management of advanced hepatocellular carcinoma (HCC) is limited to systemic therapy alone. However the combination of trans-arterial radioembolization (TARE) and systemic therapies has been investigated in a small number of retrospective studies. Results have shown that this combination is generally safe. This study aimed to study the safety and efficacy combining TARE and systemic therapy.

This retrospective review was done for all patients with advanced HCC (BCLC-C and bilobar/infiltrative subtype of BCLC-B) who received TARE within 180 days of initiation of systemic therapy. Adverse events and response rates were reviewed. Survival from diagnosis and initiation of systemic therapy were calculated.

Total of 20 patients (17 males; 85%) with mean age 70.5 years were included. Performance status was 0 in 9 patients (45%), and 1 in 8 patients (40%). Child Pugh class was A in 18 patients (90%) and B score 7 in 2 patients (10%). Baseline mean ALBI score was -2.3 and mean Neutrophil to Lymphocyte ratio was 2.8. Mean baseline Alpha feto protein was 19533ng/mL. BCLC stage was C in 14 patients (70%) and B in 6 patients (30%). Tumoral portal vein thrombosis was present in 58% of patients. The extent of intrahepatic disease was unilobar in 56% and bilobar in 44% of patients. Mean largest lesion size was 5.6cm (+/-4.7cm). Several systemic therapies were administered including Atezolizumab Bevacizumab in 60% of the patients. Mean Yttrium90 tumor dose was 122 Gy. Objective response rate was 70% (complete response in 4 patients, partial response in 10 patients). Median overall survival was 20.3 months. Eight patients remain alive (40%). One patient reached liver transplant and another reached liver resection after initiation of the combination. Systemic treatment related adverse events (trAE) in patients receiving Atezolizumab included transaminitis in 2 patients (grade 2 and 4 as per CTCAEv5). TrAE attributed to bevacizumab occurred in 4 patients with 3 having bleeding episodes (grade 2 in 2 patients and grade 3 in one patient), and one having grade 2 rash. TARE related adverse events occurred in 2 patients (one was mild and one was moderate as per SIR reporting criteria).

Combining TARE and systemic therapy for advanced HCC showed high objective response rates, with an acceptable safety profile. Careful selection of patients is necessary. Studying the combination prospectively with new immunotherapy agents may help determine the optimal treatment protocol.

The authors.

Has not received any funding.

M. Arabi: Advisory / Consultancy: SIRtex. All other authors have declared no conflicts of interest.