In a single-institution cohort study reported in JAMA Network Open, English et al found that the addition of ablative therapy to transarterial chemoembolization improved freedom from local disease progression and overall survival in patients with nonmetastatic unresectable hepatocellular carcinoma.

Keara English, MD

The study involved data from 289 adult patients with a total of 512 lesions who received transarterial chemoembolization alone or transarterial chemoembolization followed by ablative treatment using stereotactic body radiation therapy, radiofrequency ablation, or microwave ablation between January 2010 and December 2018 at a single urban medical center (Montefiore Medical Center, Albert Einstein College of Medicine). The associations between treatment and freedom from local progression for individual lesions and overall survival were analyzed. 

Key Findings

Among the 289 patients, 176 (60.9%) received transarterial chemoembolization alone and 113 (39.1%) received transarterial chemoembolization plus ablative therapy, with ablative therapy consisting of stereotactic body radiation therapy in 45, microwave ablation in 39, radiofrequency ablation in 20, and a combination of treatments in 9.

After median follow-up of 17.4 months (interquartile range = 9.5–29.5 months), progression occurred in 211 (55.7%) of 379 lesions in the transarterial chemoembolization group vs 31 (23.3%) of 133 in the transarterial chemoembolization/ablative therapy group (P < .001). At 3 years, freedom from local progression was 28.1% for lesions in the transarterial chemoembolization group vs 67.4% for lesions in the transarterial chemoembolization/ablative therapy group (P < .001).

On multivariate analysis, transarterial chemoembolization/ablative therapy was significantly associated with improved freedom from local relapse vs transarterial chemoembolization alone (hazard ratio [HR] = 0.34, 95% confidence interval [CI] = 0.21–0.53, P < .001).

Analysis stratified by lesion size ≤ 2 cm and > 2 cm showed a significant improvement in freedom from local progression with transarterial chemoembolization/ablative therapy in both size categories (P < .001). For example, freedom from local progression at 1 year for lesions > 2 cm was 46.5% in the transarterial chemoembolization group vs 79.0% in the transarterial chemoembolization/ablative therapy group (P < .001).

Median overall survival was 33.9 months vs 83.4 months, with 1- and 3-year rates of 87.5% vs 98.7% and 47.1% vs 85.3% (P = .01). On multivariate analysis, transarterial chemoembolization/ablative therapy vs transarterial chemoembolization alone was significantly associated with improved overall survival among all patients (HR = 0.26, 95% CI = 0.13–0.49; P < .001) and in the subgroup of patients with Barcelona Clinic Liver Cancer stage B or C disease (HR = 0.31, 95% CI = 0.14–0.69; P = .004).

The investigators concluded, “Adding ablative therapy following transarterial chemoembolization improved freedom from local progression and overall survival among patients with hepatocellular carcinoma. This study aims to guide the treatment paradigm for patients [with hepatocellular carcinoma] until results from randomized clinical trials become available.”

Rafi Kabarriti, MD, of the Department of Radiation Oncology, Montefiore Medical Center, New York, is the corresponding author for the JAMA Network Open article.

Disclosure: For full disclosures of the study authors, visit jamanetwork.com.