(Table 1).10-13 TARE compared to TACE has been reported to be superior in the ability to downstage T3 to T2, shorter median time to radiographic response and associated with significantly prolonged TTP. The potential
implications for patients listed for orthotopic liver transplantation (i.e., enabling patients to wait longer without drop out) INCB024360 cell line are merely speculative. Moreover, data supports the prognostic role of the response to liver directed therapy acting as a biological stress test to provide insight into a tumor’s aggressiveness.14 Any differences exerted in selection pressure by different forms of LDT remains to be seen and can only be addressed in well developed randomized controlled trials. Data comparing sorafenib to TARE in patients with PVT is even sparser, currently existing only across studies and therefore less clinically meaningful. To this end, RCTs comparing standard of care (TACE, sorafenib) to TARE are warranted. Logistic concerns include the number of patients required; a power
calculation performed to determine the sample size to demonstrate therapeutic equivalency between TACE and TARE in BCLC B patients showed that more than 1000 patients would be needed.13 The feasibility KU-60019 datasheet of a large trial due to cost and the number of centers with adequate expertise in both treatment modalities requires careful consideration; however, the number of centers utilizing TARE appears to be increasing making this less of a limitation for conducting such a trial. Lastly, stratification for lobar versus selective selleck chemicals treatment and standardization of TACE methodologies would be required given differences in treatment practices. In BCLC C patients, the anticipated trial design would be sorafenib ± TARE with a primary endpoint of TTP. There are several examples of accepted treatment practices
for HCC that are based on cohort analyses (not RCTs) that have been accepted into treatment guidelines including RFA (<3 cm) versus hepatic resection, transplantation versus hepatic resection, and open versus laparoscopic hepatic resection. Such trials for TARE are unlikely to come to fruition. TARE is currently not recognized by the American Association for the Study of Liver Diseases or EASL in the management of HCC due to lack of randomized data. However the National Comprehensive Cancer Networks have endorsed TARE as one of the treatment options for HCC.15 At our institution on ongoing RCT (PREMIERE Trial) is comparing TARE to various liver directed therapies (RFA, TACE, or RFA+TACE) based on tumor size and number.