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Immune checkpoint inhibitors: use them early, combined and instead of TACE?
  1. Enrico N De Toni
  1. Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
  1. Correspondence to Prof Enrico N De Toni, Department of Medicine II, University Hospital, LMU Munich, Munich, Germany; enrico.detoni{at}

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We read with interest the recent Gut roundtable paper by Gerbes et al. As highlighted by these authors, treatment of HCC has rapidly changed1: currently, four tyrosine kinase inhibitors, ramucirumab and two immune checkpoint inhibitors (ICP) are approved in different lines of treatment.2 3 Survival of patients with advanced disease have improved correspondingly, and more progress is expected from the burgeoning of trials of ICP-based combination treatment schemas (figure 1).

Figure 1

Schematic representation of the development in the treatment of advanced-stage HCC based on median overall survival (mOS) data from some recent trials. The arrows are proportional to the reported (grey) or hypothetical (blue) mOS indicated by the respective numbers. The green overlapping arrows represent respectively the real-world and the expected survival (ie, based on the selection of ‘ideal’ candidates for TACE) in BCLC-B patients. The list of trials is not exhaustive and, due to the heterogeneity of patients’ population, not suitable for direct cross-comparison between the trials. Atezo/Bev: combined atezolizumab and bevacizumab; pH, phase of clinical study; TACE, trans-arterial chemoembolisation.

Due to the increasing efficacy of pharmacological treatment, many physicians are inclined to initiate systemic therapy, rather than trans-arterial chemoembolisation …

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