Update on transarterial approaches to locoregional treatment in hepatocellular carcinoma.

PURPOSE OF REVIEW: This review explores current knowledge and recent data about vascular-centered locoregional treatments and proposes alternate algorithms.

RECENT FINDINGS: Hepatocellular carcinoma represents the sixth most common neoplasm worldwide. Currently, the Barcelona Clinic Liver Cancer (BCLC) staging is the most commonly used in Europe for treatment allocation. According to this classification, European Society for Medical Oncology (ESMO) guidelines currently recommend transarterial chemoembolization for intermediate stage HCC and systemic treatments, such as, sorafenib in more advanced stages. However, strong evidences are still lacking to conclude to the superiority of one technique over another, as the optimal treatment choice remains challenging and should take into consideration more clinical, biological and imaging findings than reported in the BCLC staging system, such as patient age or clinical status, tumor characteristics (including distribution and heterogeneity), tumor vascularization and concomitant portal hypertension or biliary anomalies.

SUMMARY: Many controversies remain, in particular, the relative place of bland embolization versus chemoembolization, the clinical benefit of drug-eluting bead chemoembolization (DEB-TACE) over conventional chemoembolization (cTACE), as well as the real place of radioembolization in general setting as well as innovative applications, such as radiation segmentectomy and radiation lobectomy.