Transarterial Chemoembolization for Refractory Hepatocellular Carcinoma Following Anti-angiogenic Therapy Combined with Immune Checkpoint Inhibitors: A Retrospective Single-center Analysis

Background: Hepatocellular carcinoma (HCC) is characterized by high morbidity and mortality rates around the world, ranking the sixth most common malignant tumor and the second cause of cancer-related mortality. Most patients are diagnosed in the advanced stage, and therefore, there are limited therapeutic options. Transarterial chemoembolization (TACE), anti-angiogenic therapy, and immune checkpoint inhibitors (ICIs) are the research hotspots in HCC treatment. Objectives: This study aimed to explore the treatment efficacy and safety of TACE for refractory HCC patients after anti-angiogenic therapy combined with ICIs. Patients and Methods: In this study, patients with HCC, who progressed after anti-angiogenic therapy combined with ICIs, were included from July 2019 to October 2022. The progression-free survival (PFS) was evaluated by the Kaplan-Meier method, and the tumor response was determined based on the modified Immune Response Evaluation Criteria in Solid Tumors (iRECIST). The Common Terminology Criteria for Adverse Events version 5.0 were also used to assess the adverse events. Results: A total of 34 patients were evaluated in this study, with a median PFS of five months (95% CI: 3.7 months, 6.3 months). The univariate analysis suggested that the level of aspartate aminotransferase was significantly associated with PFS (P < 0.05). The objective response rates within three and six months were 26.4% and 14.6%, and the disease control rates were 58.8% and 55.9%, respectively. During the follow-up, one or more types of adverse events were reported in 10 (58.8%) patients after treatment with atezolizumab and bevacizumab, while severe adverse events beyond grade III did not occur in any of the patients. Conclusion: The TACE may improve the survival of HCC patients, whose disease progresses after anti-angiogenic therapy combined with ICIs. However, the lack of a control group is one of the limitations of this study.