The Rise of Medical Therapies for the Treatment of Hepatocellular Carcinoma (HCC)

Learn the current state of the expanding number of medical therapies for HCC, including combination therapies.  Review the medical trial results and understand the differences between the medications.

Background:

Interventional Radiologists have dominated the treatment of HCC since less than 20% of patients qualify for surgery and medical therapies have not been particularly effective.  However, recently an increasing number of medical therapies been developed and proven effective in clinical trials including multi-receptor tyrosine kinase inhibitors, immunotherapies, monoclonal antibodies and combinations thereof.  The medications are significantly different, even in the same class and may affect IR procedures.

Clinical Findings/Procedure Details:

Current medical therapies available to treat HCC including multi-receptor tyrosine kinase inhibitors (sorafenib, regorafenib, lenvatinib, cabozantinib); monoclonal antibodies (ramucirumab and bevacizumab) which target vascular endothelial growth factor (VEGF); and immunotherapies (nivolumab, atezolizumab, pembrolizumab, durvalumab, tremelimumab).  The updated trial data of these medical therapies will compare overall survival and time to progression of disease as well as adverse effects.  Important combination medical therapies will be reviewed including: 1) atezolizumab and bevacizumab, the first combination to have improved overall survival over sorafenib and is now first line therapy; 2) tremelimumab and durvalumab, a combination of 2 immunotherapies also finding improved survival over sorafenib; 3) lenvatinib and pembrolizumab which did not find a benefit over lenvatinib alone.  Other medical therapies with phase 3 trial results such as tislelizumab and camrelizumab plus rivoceranib will be reviewed.  The two successful trials combining medical therapy and chemoembolization, TACTICS and LAUNCH, will be reviewed and compared.  Finally, we will review a single arm trial of combined neoadjuvant cabozantinib and nivolumab which converted 80% of non-resectable HCCs to successful resection.

Conclusion and/or Teaching Points:

Interventional Radiologists treating HCC need to stay abreast of the medical therapies available to HCC since the therapies are continuously expanding in number and combinations and may interplay with IR treatments.  Moreover, some oncologists are now espousing medical therapy as neoadjuvant, adjuvant or even as alternative therapies.