Intra-arterial hepatocellular carcinoma treatment at the dawn of systemic therapy

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From left: Anna Maria Belli, Bruno Sangro, Thomas Helmberger and Jose Ignacio Bilbao

Bruno Sangro, director of the Liver Unit and co-director, of the HPB Oncology Area, Clinca Universidad de Navarra, Pamplona, Spain, delivered the European Conference on Interventional Oncology (ECIO) Honorary Lecture on the topic “Intra-arterial treatment of hepatocellular carcinoma (HCC) at the dawn of systemic therapy”. ECIO took place 17–20 April, in Dublin, Ireland.

Sangro, a hepatologist, who has had a close, decades-long collaboration with interventional radiologist Jose Ignacio Bilbao from the same insitution, said: “I consider myself an interventional oncologist, despite not being an interventional radiologist.”

“The availability of effective systemic therapies will certainly impact the way we use intra-arterial therapies for the treatment of hepatocellular carcinoma. We need prospective well-designed studies to help identify patients in the early stages of the disease at which point intra-arterial treatments provide a cure, either on their own or followed by ablative therapies. Research is also needed to identify combinations of intra-arterial therapies and systemic agents that may have additive or even synergistic effects, and to select the best candidates for intra-arterial therapies or systemic agents,” he said.

Sangro first outlined the basis for intra-arterial therapies used to treat liver tumours by stating that there is a sound rationale behind transarterial embolotherapy and radioembolization. “There is also evidence of patient benefit in subgroups. Other than that, there is currently loose regulation for medical devices in Europe. Further, in many instances there are no better therapeutic options than these treatments,” he explained.

“In the dawn of systemic therapy, the pathophysiology of cancer is being revealed. Targeted therapies are providing incremental benefits for many human tumour types. Sorafenib has set the proof of principle in hepatocellular carcinoma. Despite recent trial failures, more effective targeted therapies will soon join sorafenib in the armamentarium against primary liver cancer and there could be at least two drugs that are widely effective across tumour stages by 2020.” Commenting on the rationale for combining interventional oncology agents with intra-arterial therapies, Sangro noted that they had a good safety profile (as monotherapy) for combination strategies. “There is also potential synergy based on the induction of immunogenic cell death,” he noted.

Concluding, Sangro called for more research: “We need to produce strong and good science. In Europe, the regulatory environment is going to change and will require stronger evidence, not only to refine the indications and to treat our patients, but also to survive as a discipline,” he said.