Dual-Modality Liver-Directed Therapy for Primary Liver Cancer

Hepatocellular carcinoma (HCC) is one of the most common solidtumorsworldwideandcontinuestobeamajorpublichealth problem.Whilethereare level 1datasupportingtheuseofsmallmolecule, tyrosine kinase inhibitors against thepathways involved in angiogenesis and tumorproliferation for locally advancedormetastaticHCC,the incorporationofdifferent liverdirected therapeutic agents continues to evolve.1 The goals of HCCtreatment includeaspectrumfrompurepalliation toservingasabridge-to-liver transplant.The intersectionof interventional radiology and radiationoncology is part of themultidisciplinaryapproachtoprimarylivercancer.2 Inthis issueofJAMA Oncology, Huo and Eslick3 report on a systematic review and meta-analysis comparingsingle-modality transcatheterarterial chemoembolization (TACE)with dual-modality TACEplus radiotherapy,with the latter approachbeing superior. This study wouldhavebeenstrengthened if recentlystandardized imaging guidelines of HCC, the Liver Imaging Reporting and Data System (LI-RADS) had been followed.4 This study does not tell us whether radiofrequencyablation,oftenusedasaconsolidative liver-directedapproach, is equal to consolidative radiotherapy, nor does it define the impact of other predictive and prognostic factors, such as initial BCLC (BarcelonaClinic Liver Cancer) stage[EASL-EORTC2012],variability intargetdelineation, treatmentplanning,useandtypeof image-guidance techniques, radiotherapydose-fractionation, anddifferencesbetweenAsian andnon-Asianpatients.5Theanalysis fromHuoandEslick3provide some rationale for dual-modality liver-directed therapy beingconductedatmanycenters.Nevertheless, the ill-defined therapeutic landscape for localizedHCC requires the completion and reporting of well-designed prospective trials that incorporate amultidisciplinary approach and include investigators working together.