Locoregional Therapy Approaches for Hepatocellular Carcinoma: Recent Advances and Management Strategies

Abstract

Hepatocellular carcinoma (HCC) is the most common primary liver malignancy and third leading cause of cancer-related mortality worldwide. While surgical resection and transplantation are the standard first-line treatments for early-stage HCC, most patients do not fulfill criteria for surgery. Fortunately, catheter-directed and percutaneous locoregional approaches have evolved as major treatment modalities for unresectable HCC. Improved outcomes have been achieved with novel techniques which can be employed for diverse applications ranging from curative-intent for small localized tumors, to downstaging or bridging to resection and transplantation for early and intermediate disease, and locoregional control and palliation for advanced disease. This review explores recent advances in liver-directed techniques for HCC including bland transarterial embolization, chemoembolization, radioembolization, and ablative therapies, with a focus on patient selection, procedural technique, periprocedural management, and outcomes.

Keywords: SIRT; TACE; TAE; TARE; ablation; chemoembolization; hepatocellular carcinoma; immunotherapy; radioembolization; transarterial embolization.

Figure 1

Treatment options for hepatocellular carcinoma stratified by BCLC class. Note that any locoregional approach can be used to maintain or downstage to transplant eligibility. Contraindications to resection include significant portal hypertension, hyperbilirubinemia, multiple nodules, and comorbidities. Contraindications to ablation include lesion > 5 cm, > 4 nodules, and anatomic infeasibility.