The state-of-art Lecture on the Treatment of Liver Cancer

Upfront systemic therapy with subsequent locoregional therapy is a new therapeutic option for intermediate-stage hepatocellular carcinoma (HCC). The first example of such treatment is sorafenib-transarterial chemoembolization (TACE) sequential therapy, which was tested in the TACTICS trial. This was followed by lenvatinib-TACE (LEN-TACE) sequential therapy, which is based on the high response rate (40.6% per mRECIST) achievable with lenvatinib. A recently developed strategy is atezolizumab/bevacizumab curative (ABC) conversion, in which curative treatment such as resection, radiofrequency ablation (RFA), or superselective TACE (curative TACE) is performed after achieving marked tumor shrinkage [objective response rate (ORR) per RECIST v1.1 = 44%] with atezolizumab plus bevacizumab (Atezo/Bev) combination therapy. Given that approximately 20% of patients who undergo ABC conversion therapy become cancer-free and drug-free, the optimal timing of curative conversion during Atezo/Bev treatment must not be missed, even when a sufficient effect of the drug is observed. Generally, the systemic treatment approach for other types of advanced cancer is “continue the treatment as long as the drug remains effective”. However, curative conversion is frequently achievable using Atezo/Bev in patients with intermediate-stage HCC (locally advanced HCC without vascular invasion or extrahepatic spread), which is not possible in advanced HCC. The treatment concept that should be applied to intermediate-stage HCC is thus “switch to curative therapy to achieve cancer-free drug-free status upon achievement of marked tumor shrinkage”, which differs from the treatment concept for other types of advanced cancer or advanced HCC.