What is the recommended treatment approach between DSM (Drug-Eluting Microspheres) TACE (Transarterial Chemoembolization) and conventional TACE for unresectable hepatocellular carcinoma?

DSM-TACE versus Conventional TACE for Unresectable Hepatocellular Carcinoma

Both conventional TACE (cTACE) and drug-eluting microsphere TACE (DEB-TACE/DSM-TACE) are considered equivalent treatment options for unresectable hepatocellular carcinoma, with DEB-TACE showing particular benefit for HCCs ≥3 cm in size. 1

Overview of Treatment Options

• Transarterial chemoembolization (TACE) is the recommended first-line therapy for patients with BCLC stage B (intermediate) HCC who have good performance status without major vascular invasion or extrahepatic spread 1
• TACE should be performed through tumor-feeding arteries in a superselective manner to maximize efficacy and minimize complications 1, 2
• Two main types of TACE are available:
  • Conventional TACE (cTACE): Uses Lipiodol emulsion with chemotherapy followed by embolic particles
  • Drug-eluting bead TACE (DEB-TACE/DSM-TACE): Uses microspheres that both deliver chemotherapy and cause embolization 1, 2

Efficacy Comparison

• According to the 2023 Korean clinical practice guidelines, DEB-TACE can be considered an alternative treatment to cTACE in HCCs ≥3 cm with similar survival benefits 1
• The 2018 EASL guidelines state that drug-eluting beads have shown similar benefit to conventional TACE, and either approach can be utilized 1
• DSM-TACE has demonstrated promising efficacy with objective response rates of 44% and disease control rates of 70% in patients with intermediate HCC 3
• In a prospective pilot study, DSM-TACE achieved complete response rates of 20.8%, 23.5%, and 41.6% after first, second, and third procedures, respectively 4

Safety Considerations

• DSM-TACE has demonstrated a favorable safety profile in multiple studies 5, 3, 4
• In a multicenter study, 48% of patients did not encounter any immediate adverse events during DSM-TACE treatment 3
• The temporary nature of DSM embolic agents may result in less permanent damage to non-tumoral liver tissue compared to permanent embolic agents 6, 3
• Post-embolization syndrome (fever, nausea, pain) is common with both types of TACE but typically manageable 2

Patient Selection Factors

• TACE (either type) should not be used in patients with:
  • Decompensated liver disease
  • Advanced liver and/or kidney dysfunction
  • Macroscopic vascular invasion
  • Extrahepatic spread 1
• Child-Pugh class A or B7 patients are generally considered good candidates for either type of TACE 1, 2
• For patients with multiple nodules or bilobar disease, DSM-TACE has shown similar complete response rates regardless of tumor distribution 4

Practical Considerations for Implementation

• Superselective catheterization of tumor-feeding arteries should be performed using microcatheters for optimal targeting 6
• Cone-beam CT during the procedure can enhance therapeutic efficacy and safety 6
• Antibiotic prophylaxis should be considered, especially in patients with biliary abnormalities 6
• Follow-up imaging (CT or MRI) should be performed within 4-6 weeks to assess treatment response using modified RECIST criteria 6

Treatment Algorithm

1. For unresectable HCC with BCLC stage B:

   • First option: Either cTACE or DEB-TACE based on tumor size 1
   • For tumors ≥3 cm: Consider DEB-TACE for potentially better drug delivery and reduced systemic effects 1, 7
   • For tumors <3 cm: Either approach is acceptable 1

2. For patients with multiple nodules:

   • DSM-TACE may be particularly beneficial due to its temporary embolic nature, allowing repeated treatments 4

3. For patients with compromised liver function (Child-Pugh B7):

   • Consider DSM-TACE as it may have less permanent impact on non-tumoral liver tissue 5, 3

4. Monitor for TACE refractoriness:

   • Defined as absence of objective response after two consecutive TACE sessions within six months 1
   • Consider alternative treatment modalities when TACE refractoriness occurs 1

Common Pitfalls and Caveats

• Avoid TACE in patients with decompensated liver disease or advanced liver dysfunction as it may precipitate liver failure 1, 2
• Do not continue TACE indefinitely without evaluating response; consider TACE refractoriness criteria to determine when to switch to alternative therapies 1
• Be vigilant for rare but serious complications including hepatic necrosis and liver failure 2
• Consider the patient's BCLC stage and liver function when selecting between cTACE and DEB-TACE, as outcomes are strictly dependent on these factors 5