TARE Gains Traction as Suitable Alternative to TACE for Locoregional HCC Therapy

Anjana Pillai, MD

Transarterial radioembolization (TARE) and drug-eluting bead transarterial chemoembolization (DEB-TACE) have emerged as options comparable to conventional TACE in the hepatocellular carcinoma (HCC) treatment paradigm, although the American Association for the Study of Liver Diseases (AASLD) does not recommend one locoregional therapy over another, according to Anjana Pillai, MD.

Data published in Gut showed that TARE with Yttrium-90 altered adaptive and innate immune response, which included an increased frequency of activated CD3-positive T cells and CD8- positive subsets, regulatory T cells and inflammatory monocyte populations.1 In the retrospective, single-arm LEGACY trial, patients (n = 162) with treatment-naive, solitary HCC lesions of 8 cm or less experienced an objective response rate of 88.3% (95% CI, 82.4%-92.4%).²

“The data show that the evidence is just as good [with TARE vs TACE], but the numbers [of patients treated] are smaller because TACE has been around longer, and it is more available globally,” Pillai said. “There are more multimodal therapies with combinations of systemic and locoregional therapies that are going to be on the horizon as well. Several trials are underway, and the phase 3 EMERALD-1 trial [NCT03778957] has recently been published as well.”

EMERALD-1 evaluated TACE plus durvalumab (Imfinzi) with and without bevacizumab (Avastin)vs TACE alone in patients with local regional HCC.

In an interview with OncLive®, Pillai detailed a patient case study and key takeaways from a presentation she gave at a State of the Science Summit™ on locoregional therapies for HCC. Pillai is a professor of medicine and surgery, co-director of the Living Donor Liver Transplant Program, medical director of the Liver Tumor Program, and program director of the Transplant Hepatology Fellowship Program all at UChicago Medicine in Illinois.

OncLive: What were the key takeaways from your presentation on HCC?

Pillai: My presentation was reviewing TACE vs TARE for locoregional therapy [in HCC]. There are many treatment options as the HCC landscape is changing. Many societies, including the AASLD do not recommend one locoregional therapy over the other. [Treatment] is based on the size of the tumor, tumor characteristics, [and] location. I highlighted that center and institutional expertise [is important]; TACE has been available globally for decades and is used very often and was in many of the earlier trials, however, TARE has gained traction.

What are the considerations for treatment with TACE vs TARE?

TACE has been available globally for a very long time—it was the first locoregional therapy that we used earlier on. Head-to-head analyses, including the phase 2 PREMIEREtrial [NCT00956930] data, demonstrated that overall survival between the 2 therapies is not that different. But time to progression is longer with TARE and that’s important, especially because many of us are using it as a downstaging strategy to liver transplant.

An analysis published in Clinical Gastroenterology and Hepatology looked at the national trends of locoregional therapy, and [recently] there was a decline in TACE and a nice increase in TARE as physicians [are becoming] more comfortable with it.

Please detail the patient case you presented and what the next best therapy would be for this patient.

I presented a standard case that we had [at the University of Chicago Medicine Comprehensive Cancer Center]; a patient came in for routine surveillance for liver cancer and he had missed a few [appointments] due to logistics and inability to get to the clinic. The patient had missed approximately 1 years’ worth of imaging and then when they did undergo surveillance [imaging], we found a 4.5-cm Liver Imaging Reporting and Data System category 5 [classic HCC lesion] without any evidence of metastatic disease, so it was liver localized. He also had other signs of portal hypertension as he had low platelet [counts and] splenomegaly. I asked the audience, what is the next best therapeutic option?

Looking at the treatment options for HCC, this was not a patient who we’d do resection for because he had portal hypertension and thrombocytopenia. [Additionally], he may not have been the best [candidate] for microwave ablation because his tumor was approximately 5 cm, and the best [size] for microwave ablation is under 3 cm. The [question was whether] TACE or TARE [should be used] as downstaging [therapy] if the patient is a transplant candidate, which our patient eventually was.

At our institution, this patient underwent TARE and did very well—he waited on the transplant list for a little over a year as he didn’t have a living donor, then received a liver transplant and he is now doing great. At other institutions around the world that patient likely would have received TACE and then downstaging [therapy] for transplant. The reason we picked TARE is institutional preference and expertise; we’re able to do both, but also we know patients are waiting on the list longer for HCC, despite the changes to allocation. We wanted to give the patient the best chance for the tumor to be treated and not drop off the waiting list. That was why we picked radioembolization.

References

1. Rivoltini L, Bhoori S, Camisaschi C, et al. Y90-radioembolisation in hepatocellular carcinoma induces immune responses calling for early treatment with multiple checkpoint blockers. Gut. 2023;72(2):406-407. doi:10.1136/gutjnl-2021-326869
2. Salem R, Johnson GE, Kim E, et al. Yttrium-90 radioembolization for the treatment of solitary, unresectable HCC: the LEGACY study. Hepatology. 2021;74(5):2342-2352. doi:10.1002/hep.31819