Editor’s Note:

With the advancement and innovation in surgical techniques, interventions, radiofrequency ablation, and other treatment methods, there are increasing treatments for early hepatocellular carcinoma. Curative treatments, including liver resection, liver transplantation, interventional treatment, ablative treatment, and radiotherapy, have all achieved satisfactory results. However, how to effectively and minimally invasively treat early hepatocellular carcinoma and manage it in the long term, while ensuring patients achieve long-term survival and improving their quality of life, has been widely discussed in recent years. From July 6-8, 2023, the 13th Asia-Pacific Primary Liver Cancer Expert Meeting (APPLE 2023) was held in Seoul, South Korea. A special session on the evolving management of early HCC was set up. Notably, Dr. Hyo-Cheol Kim from Seoul University, introduced the application of arterial therapy in early hepatocellular carcinoma and shared experiences from Korean hospitals.

Hepatocellular carcinoma (HCC) is the most common primary liver cancer, with a high mortality rate. Early diagnosis and timely treatment of HCC are crucial for patient survival. Early-stage HCC is defined as a solitary tumor with a size of ≤5 cm, or no more than 3 nodules each ≤3 cm in size.

Arterial therapy has been established as a valuable treatment option for early HCC and has been included in major guidelines. This includes traditional chemoembolization (cTACE), drug-eluting bead embolization (DEB-TACE), and radioembolization (TARE).

cTACE is the most commonly used arterial treatment for early HCC. It involves injecting chemotherapy drugs mixed with iodized oil into the hepatic artery, followed by embolic agents. These embolic agents prevent the chemotherapy drugs from being washed away, thereby increasing their concentration and duration at the tumor site. cTACE has been shown to improve the overall survival and disease-free survival of inoperable HCC patients.

DEB-TACE is a newer technique, using drug-eluting beads in place of iodized oil. These beads carry chemotherapy drugs and release them slowly over time to the tumor.

Several international clinical studies have compared the efficacy and safety of cTACE and DEB-ACE. Overall, results are mixed. In Korea, cTACE demonstrated superior anti-tumor effects in small liver cancers with tumor sizes <3 cm. At Seoul University Clinical Hospital, cTACE is the preferred treatment for such patients. For medium-sized HCC (3-7 cm), DEB-ACE is preferred due to milder post-embolization syndromes.

TARE is a newer arterial treatment, involving injecting radioactive isotopes. These isotopes selectively remain in the tumor’s blood vessels, delivering high doses of radiation while sparing normal liver tissue. TARE has shown superior anti-tumor effects compared to TACE, with fewer side effects and shorter hospital stays. However, TARE is more expensive than TACE and requires specialized equipment and trained medical personnel.

In conclusion, arterial therapy has become an essential treatment option for early HCC. cTACE is the most commonly used due to its proven efficacy and accessibility. TARE shows promise as an alternative to TACE, offering better anti-tumor effects and fewer side effects, but its higher cost and specialized requirements limit its clinical use.