Initial trans-arterial chemo-embolization (TACE) is associated with similar survival outcomes as compared to upfront percutaneous ablation in those with single hepatocellular carcinoma (HCC) <= 3cm: results of a realworld propensity-matched multi-centre Australian cohort study.

Abstract

Background: Percutaneous ablation is recommended in Barcelona Clinic Liver Cancer (BCLC) stage 0/A patients with HCC <= 3cm as a curative treatment modality alongside surgical resection and liver transplantation. Trans-arterial chemo-embolization (TACE) is commonly used in the real-world as an initial treatment in patients with single small HCC in contrast to widelyaccepted clinical practice guidelines which typically describe TACE as a treatment for intermediate-stage HCC. We performed this real-world propensity-matched multi-centre cohort study in patients with single HCC <= 3cm to assess for differences in survival outcomes between those undergoing initial TACE and those receiving upfront ablation. Method(s): Patients with a new diagnosis of BCLC 0/A HCC with a single tumour <= 3cm first diagnosed between 1 January 2016 and 31 December 2020 who received initial TACE or ablation were included in the study. Result(s): A total of 348 patients were included in the study, with 147 patients receiving initial TACE and 201 patients undergoing upfront ablation. After propensity score matching using key covariates including age, sex, liver disease aetiology, diabetes, smoking, Charlson comorbidity index, Child-Pugh score, platelet count and tumour size, 230 patients were available for analysis with 115 in each group. There were no significant differences in overall survival (log-rank test p = 0.652) or liver-related survival (log-rank test p =0.495) over a median follow up of 3 years. Failure to achieve CR during follow-up was similar between the initial TACE and upfront ablation groups (20.0% vs 13.9%, p = 0.219). Of those in the initial TACE group who went on to achieve CR, 71.4% did so immediately after the initial TACE, 12.1% required 2 or more TACE, 15.2% required TACE with subsequent ablation and 2.2% required TACE with subsequent transplantation. In the upfront ablation group, 93.5% of patients who achieved CR did so after the initial ablation, with 6.5% requiring 2 or more ablation treatments, 5.4% required ablation and subsequent TACE and 1.1% required SBRT after ablation. Comparing those who achieved CR in the initial TACE and upfront ablation groups, there was similar recurrence- free survival (log-rank test p = 0.379) and local recurrence-free survival (log-rank test p = 0.390). Conclusion(s): Our study provides valuable real-world evidence that TACE is a reasonable initial management strategy in very-early/early-stage HCC where further treatment can be offered as appropriate during followup, with similar survival outcomes as compared to those managed with upfront ablation. Further work is needed to better define the role for TACE in BCLC 0/A HCC.