In the Era of Systemic Therapy for Hepatocellular Carcinoma Is Transarterial Chemoembolization Still a Card to Play?

SIMPLE SUMMARY: Hepatocellular carcinoma (HCC) is a growing healthcare problem, with most of the cases occurring in patients with an underlying chronic liver disease. Transarterial chemoembolization (TACE) is recommended for unresectable tumors, mostly in a palliative setting. Several developments have seen the day during the last few years, with technique improvements in terms of efficacy and safety due to more selective therapies and better patient selection. Nevertheless, this is the era of systemic treatment for HCC, where immunotherapy and combination systemic treatments are taking the lead. As such, we have to ask ourselves, where does TACE stand today and is there a tomorrow? ABSTRACT: Conventional transarterial embolization (cTACE) has been proven to be effective for intermediate stage hepatocellular carcinoma (HCC), with a recent systematic review showing an overall survival (OS) of 19.4 months. Nevertheless, due to the rapid development of the systemic therapeutic landscape, the place of TACE is becoming questionable. Is there still a niche for TACE in the era of immunotherapy and combination treatments such as atezolizumab–bevacizumab, which has shown an OS of 19.2 months with excellent tolerance? The development of drug-eluting microspheres (DEMs) has led to the standardization of the technique, and along with adequate selection, it showed an OS of 48 months in a retrospective study. In order to increase treatment selectivity, new catheters have also been added to the TACE arsenal as well as the use of cone-beam CT (CBCT), which provides three-dimensional volumetric images and guidance during procedures. Moreover, the TACE indications have also widened. It may serve as a “bridging therapy” for liver transplantation candidates while they are on the waiting list, and it represents a valuable downstaging tool to transplantation criteria. The aim of this review is to explore the current data on the advancements of TACE and its future place amongst the growing panel of treatments.