Advances in Interventional Oncology for Hepatocellular Carcinoma

Locoregional therapies are used across the hepatocellular carcinoma (HCC) treatment spectrum, including for curative treatment of small tumors, as bridging or downstaging therapy before liver transplant, for treatment of intermediate-stage disease, and as part of combination treatment with systemic therapy in selected patients. This narrative review summarizes recent developments in transarterial radioembolization (TARE), transarterial chemoembolization (TACE), and percutaneous ablation techniques and separates established clinical advances from early investigational work. The strongest evidence supports personalized TARE dosimetry and radiation segmentectomy, selective TACE with reassessment before repeat treatment, and image-guided thermal ablation with objective margin assessment. Phase 3 trials of TACE combined with antiangiogenic and immune checkpoint therapy demonstrated improved progression-free survival in selected patients with unresectable, nonmetastatic HCC, although the survival benefit of these combinations so far extends only to progression-free survival, and the best treatment sequence remains to be defined. Histotripsy, pulsed electric-field ablation, electrochemotherapy, cryoablation, high-intensity focused ultrasound, imageable or alternative radioembolic microspheres, new embolic agents, robotics, and artificial intelligence remain at different stages of clinical development. Most supporting data are derived from single-arm studies, retrospective cohort studies, trials in mixed liver-tumor populations, or studies in preclinical models. Treatment selection should account for tumor burden and location, liver function, portal hypertension, vascular invasion, transplant candidacy, available alternatives, local expertise, and patient preferences. Future studies should focus on durable local control, preservation of liver function, quality of life, transplant eligibility, overall survival, and cost.