Locoregional Therapy in HCC

Ghassan K. Abou-Alfa, MD:The important question though over here is, is there anything else that can be added? This is a classic question that we get all the time. What is the role of sorafenib, for example, after TACE or around TACE? Many studies have taken place, and all of them have been reported, mainly focusing on the combination of the sorafenib plus chemoembolization, ie, TACE in the setting of locally advanced disease. Among those, the one that’s most recognized and reported at all times is the SPACE study, which was led by Dr. Riccardo Lencioni, our colleague from interventional radiology. There’s the TACE II study from the UK, there’s an ECOG 1208 study from the Corporate Groups here in the United States, and before that, there was a Japanese/Korean study.

As a very important example, and really a reference to that discussion, the SPACE study randomized patients to chemoembolization with sorafenib without any stopping of the sorafenib, ie, through and through. Patients continued taking the sorafenib and just the TACE in between. Unfortunately, there was no difference between patients who received that kind of intervention versus patients who received TACE alone without sorafenib. And any thoughts about sorafenib contributing to local therapy in the setting of TACE, unfortunately, did not pan out. As such, it is strongly recommended that the combination of TACE and sorafenib is not the right approach. If anything, if a patient has local disease, then by all means, local therapy like TACE is appropriate, but the combination is not really appropriate per se.

TACE, or transarterial chemoembolization, will depend really on the size of the tumor as well as the location of the tumor. In general, it would be nice to think that TACE will be applied once and to control all the disease. Sometimes, however, TACE is staged, ie, the interventional radiologist might plan more than 1 TACE based on how much they can cover of the tumor. However, nobody really has put any data in place, except our colleagues in Japan, in regard to how many TACE or how frequent they should be. This is really always a subject of contentious debate because people don’t really realize what’s necessary to do. And, if anything here, of course patient care comes first. In other words, the simplest scenarios, if there is a metastatic disease situation while on TACE, by all means, this is a time to go to systemic therapy. If we try TACE more than several times, let’s say 3 or 4 times, and especially if there is a narrow sequence in between, ie, about 1 to 2 months in between, this is telling us that it’s probably time to go to systemic therapy.

Transcript edited for clarity.

May 2015

• 64-year old obese female presented with fatigue and unexplained weight loss
• History of nonalcoholic fatty liver disease (NAFLD), then nonalcoholic steatohepatitis (NASH)
• Lab results: AFP= 1,500 IU/ml
• ECOG=1; Child-Pugh A
• CT revealed 1 large liver mass, right side of liver close to a major blood vessel
• No extrahepatic disease
• Liver-directed therapy with DEB-TACE was performed
• Patient reported abdominal pain following DEB-TACE and required analgesics; low-grade fever
• Patient had a complete response
• AFP= 200 IU/ml at follow up

February 2017

• Follow-up imaging showed progression and evidence of bone metastases
• Therapy was initiated with sorafenib at 400 mg BID
• Follow-up testing showed liver decompensation