Large and in charge.

Top Line: There are a handful of options for approaching unresectable hepatocellular carcinoma (HCC).

The Study: While transarterial chemoembolization (TACE) is a popular approach, its efficacy dwindles with increasing tumor size due to a daunting amount of collateral vessels and increasing hepatic toxicity with larger doses of embolization particles that may or may not go precisely where intended. Here is a rare large prospective randomized phase 3 trial evaluating outcomes for HCC larger than 7cm. 315 patients were randomized to FOLFOX via hepatic artery infusion (n=159) versus TACE (n=156). The hepatic artery infusion was performed on a typical chemo timeline of every 3 weeks, at which time the patient was admitted overnight for an infusion through a catheter temporarily-placed into the hepatic artery via femoral artery. So this makes for quite the interesting comparison of therapies: one that capitalizes on hepatic circulation versus one that cripples it. And the victor for these large tumors was clearly chemo via hepatic artery infusion. The median overall survival was significantly longer after hepatic artery infusion (23 months) than TACE (16 months). This appears due to local treatment successes: hepatic pump resulted in a higher rate of treatment response (46% v 18%) and a longer median progression-free survival (9.6 v 5.4 months). And all this came with significantly less grade 3+ toxicity than with TACE (19% v 30%). The next question is whether chemo has to be delivered in the complicated manner or should these patients just get regular systemic therapy infusions with something like atezo + bev.

TBL: FOlFOX via hepatic infusion is safer and more effective for unresectable HCC larger than 7 cm. | Li, J Clin Oncol 2021

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