TACE and conformal radiotherapy vs. TACE alone for hepatocellular carcinoma: A randomised controlled trial

Background & Aims

Transcatheter arterial chemoembolisation (TACE) is recommended for patients with hepatocellular carcinoma devoid of macrovascular invasion or extrahepatic spread but not eligible for curative therapies. We compared the efficacy and safety of the combination of a single TACE and external conformal radiotherapy (CRT) vs. classical TACE.

Methods

TACERTE was an open-labelled, randomised controlled trial with a 1:1 allocation rate to two or three TACE (arm A) or one TACE + CRT (arm B). Participants had a mean age of 70 years, and 86% were male. The aetiology was alcohol in 85%. The primary endpoint was liver progression-free survival (PFS) in the intention-to-treat population. The typical CRT schedule was 54 Gy in 18 sessions of 3 Gy.

Results

Of the 120 participants randomised, 64 were in arm A and 56 in arm B; 100 participants underwent the planned schedule and defined the 'per-protocol' group. In intention-to-treat participants, the liver PFS at 12 and 18 months were 59% and 19% in arm A and 61% and 36% in arm B (hazard ratio [HR] 0.69; 95% CI 0.40-1.18; p = 0.17), respectively. In the per-protocol population, treated liver PFS tended to be better in arm B (HR 0.61; 95% CI 0.34-1.06; p = 0.081) than in arm A. Liver-related grade III-IV adverse events were more frequent in arm B than in arm A. Median overall survival reached 30 months (95% CI 23-35) in arm A and 22 months (95% CI 15.7-26.2) in arm B.

Conclusions

Although TACE + CRT tended to improve local control, this first Western randomised controlled trial showed that the combined strategy failed to increase PFS or overall survival and led more frequently to liver-related adverse effects.

Impact and implications

Hepatocellular carcinoma is frequently treated by arterial embolisation of the tumour and more recently by external radiotherapy. We tried to determine whether combination of the two treatments (irradiation after embolisation) might produce interesting results. Our results in this prospective randomised study were not able to demonstrate a beneficial effect of combining embolisation and irradiation in these patients. On the contrary, we observed more adverse effects with the combined treatment.

Clinical Trials Registration

NCT01300143.

Role of external beam radiation therapy in management of hepatocellular carcinoma

Diagnosis at advanced disease stage and early vascular invasion are the bane of majority of patients with hepatocellular carcinoma (HCC) in India. The currently standardized curative and palliative treatment modalities [surgery, ablative techniques, trans-catheter chemotherapy, systemic chemotherapy] are suboptimal for a significant proportion of disease stages. Interest in radiotherapy for hepatocellular carcinoma has seen a resurgence with revolutionary improvements in targeting radiation doses safely. Encouraging results have been reported with a host of radiation techniques from conformal radiotherapy, stereotactic whole body radiation therapy to charged particle based therapies. The dissemination of this knowledge has been slow across other specialties involved in care of patients with HCC. However the increasing availability of radiotherapy services predicts a hopeful future for wider evaluation of radiotherapy in HCC.