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BackTable / Tumor Board / Article
The HCC Clinical Trials That Every Interventional Radiologist Should Know
Audrey Qian • Updated Jul 11, 2025 • 42 hits
Hepatocellular carcinoma (HCC) is the most common primary tumor of the liver, but disease burden at time of diagnosis often precludes patients from high-risk but often curative interventions like surgical resection or liver transplantation. As a result, image-guided interventions have become central to HCC management, with interventional radiology (IR) playing a critical role in delivering locoregional therapies, including ablation, TACE, and radiation therapy; and contributing to multidisciplinary care.
Interventional radiologist Dr. Richard Finn and medical oncologist Dr. Julius Chapiro cover recent clinical trials that are shaping collaborative interventional oncology practice in HCC. They also highlight the expanding role of IR not only in procedural care, but also in leading clinical research and developing evidence-based strategies that aim to personalize and improve outcomes in HCC. This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable Tumor Board Brief
• Interventional radiology plays a critical role in both delivering locoregional therapies for HCC and obtaining biopsies that support biomarker discovery and personalized treatment approaches.
• Recent pivotal trials, including EMERALD-1, LEAP-012, REFLECT, IMbrave150, and CheckMate-9DW, provide critical evidence on treatment efficacy of locoregional therapies, systemic therapies, and combination therapies.
• Drs. Richard Finn and Julius Chapiro emphasize the importance of interventional radiologists critically evaluating subgroup outcomes, study design, endpoints, and control arms in clinical studies to effectively translate data into personalized HCC treatment planning.
• The evolution of IR in HCC management is supported by increasing collaboration across specialties and expanding opportunities for procedural and research leadership in a rapidly advancing field.
Table of Contents
(1) The Critical Role of Interventional Radiology in HCC Management
(2) The HCC Clinical Trials That Every Interventional Radiologist Should Know
(3) Interventional Radiology at the Forefront of Hepatocellular Carcinoma Innovation & Care
The Critical Role of Interventional Radiology in HCC Management
Hepatocellular carcinoma (HCC) is most often associated with chronic liver diseases, including cirrhosis and hepatitis B and C. From an oncological standpoint liver function is a key determinant of both prognosis and treatment strategy. However, traditional staging systems like TNM – which emphasizes tumor size and metastases – fail to account for liver function in their disease grading. Functionally integrative systems like BCLC account for both tumor burden and liver reserve, offering better guidance for prognosis and clinical trial design.
On the diagnostic front, noninvasive imaging modalities such as LI-RADS, MRI, and triphasic CT facilitate efficient diagnosis but may limit insight into tumor biology by bypassing the need for tissue sampling. While these perspectives illustrate the value of a multidisciplinary approach in HCC care, the evolving role of interventional radiology further expands the treatment and research landscape for HCC. Beyond delivering locoregional therapies, IR is increasingly central to securing biopsies critical for biomarker discovery, enabling more personalized and data-driven HCC care.
[Dr. Richard Finn]
From the oncology standpoint, liver cancer is fairly unique. We know what causes it, chronic liver disease in 90% of patients, where most cancers we don't. I sometimes make parallels to lung cancer because it's a malignancy that's occurring in a very critical organ. Usually, that organ is sick. In the context of lung cancer, it's COPD and lung disease. In the setting of liver cancer, it's cirrhosis. How we approach patients is really not only dictated by the tumor characteristics, but the characteristics of the patient and their underlying physiology.
It's very different to have a two-centimeter tumor in someone who is well-compensated, child PUA, no portal hypertension, as compared to someone with a two-centimeter tumor with a bilirubin of eight, renal failure, and bedbound. Two very different scenarios, and by the TNM staging system, they're the same. Stage one tumor. Obviously, their prognosis is very different. That's where a system like TNM fails our patients with liver cancer, because it ignores this fundamental underlying risk of outcome and death, which is their liver function.
That is why I think largely the Barcelona system has been adopted. There's many very good staging systems globally. In the modern age, most of them try to capture the liver function as well as tumor characteristics. It has served to be prognostic for its various stages. It really has been the backbone for clinical drug development and clinical trials. We can all speak the same language across disciplines and across regions. I could go on for an hour, but I'll let Julius chime in as well.
[Dr. Christopher Beck]
Julius?
[Dr. Julius Chapiro]
Yes, definitely second all these comments from a master. I will say, from a radiological perspective, liver cancer is a bit unique in that it's one of the very few cancers that can actually be diagnosed in non-invasive fashion. In my view, this comes both as a blessing as well as a curse, because as a scientist, I always want tissue and I want to understand the biology of a tumor. Liver cancer is extremely heterogeneous because it's very poorly understood in terms of its molecular bioprofile, mutational map.
Because it has been diagnosed using LI-RADS in these patients and because we were blessed to have amazing diagnostic tools like the MRI and a triphasic CT that in many of these cancers gives us the diagnosis just by imaging features. At the same time, we've, I think, for a long time missed an opportunity to understand these cancers and to map them out with retrospective and sometimes even perspective data from a biological and pathological perspective.
IR has, once again, a very important role here, not only from the side of local regional therapies where, of course, we're represented, but also from obtaining samples, I think. I think this conversation is picking up a lot right now in light of the so many upcoming drugs and trials.
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The HCC Clinical Trials That Every Interventional Radiologist Should Know
Beyond their expanding role in HCC care via biopsies and locoregional therapies, interventional radiologists must remain informed on recent pivotal clinical trials that continue to shape HCC treatment. Studies such as EMERALD-1 and LEAP-012 generated critical evidence on the integration of locoregional therapies, such as TACE, with systemic immunotherapy. Other key trials, including REFLECT, IMbrave 150, Himalaya, CheckMate-9DW, and emerging studies like CARES-301, offer insights into treatment efficacy across different therapeutic classes and patient subgroups. As Drs. Julius Chapiro and Richard Finn emphasize, understanding these trials requires more than reviewing primary outcomes; interventional radiologists should examine subgroup analyses, study design, endpoints, and control arms to effectively translate the data into improved personalized treatment planning.
[Dr. Christopher Beck]
We mentioned a lot of studies, but any other helpful studies that we haven't mentioned that you think that, if you are someone who's in this space, Julius, from your perspective, what's the data that up-and-coming interventional radiologists need to familiarize themselves with to give them the armamentarium to treat HCC in the data-driven way?
[Dr. Julius Chapiro]
I think it's really important to know the two studies that came out last year. The EMERALD-1 as well as the LEAP-012 study. Those are truly game-changing. It's not only important to know of these studies, it's really important to look at the subgroups that have been treated, be really familiar with the tables and how different patient subtypes responded. It's really important to differentiate between viral hepatitis C and B patients versus MASLD patients, because they have different responses.
One needs to not only take them for granted as a whole, in a holistic fashion, one needs to be really familiar with the detail, but one also needs to know that a lot of studies are currently underway in the field that will result very soon. The EMERALD-3, EMERALD-Y90, other studies that are going to be coming out and presenting us with a lot of data that's yet to come. I love to surf clinicaltrials.gov, I sometimes just go and check it out. What's out there, and who's doing new studies, and what are the most recent additional protocols, and what are they looking at?
I think, aside from reading literature that exists and reading really good, high-quality, high-level reviews and meta-analyses, I think it's important to just know what's out there to practice in a state-of-the-art fashion.
[Dr. Christopher Beck]
Richard, same question to you, but the bend I'd like to take with it is, what's one of the studies that you wish that more interventional radiologists were familiar with that may be outside of IR or that you think are cornerstone resources? Like just understanding HCC?
[Dr. Richard Finn]
They need to be familiar with the at least three or four large studies that have changed practice in advanced liver cancer. It's important to understand who the patients are that are enrolled in those studies and how they behave. Not only in the treatment group but also in the control group. I would start even with an appreciation of lenvantinib from the REFLECT study which looked at len versus sorafenib, and demonstrated how len differentiates itself as a TKI in that population was the standard of care until another study they need to be aware of, the IMbrave150 study which was the Atezolizumab plus Bevacizumab plus Sorafenib study.
The first time we improved survival versus sorafenib, and really long, durable objective response rates of 30%. Then also looking at the subgroups in these studies of the Bs versus the Cs, because the Bs are in your shop as IR, for sure. Then, since IMbrave150, we have the Himalaya study, which is durvalumab and acetyl A4 antibody tremelimumab. That study was positive. Recently, we saw at ASCO the CheckMate-9DW, which is ipilimumab and nivolumab.
This is after they take a course in modern oncology language, [chuckles] but ipilimumab and nivolumab, which is, again, a acetyl A4 and PD-1 combination, which has a very high response rate, 36%. That was compared to lenvantinib mostly, lenvantinib or sorafenib. Then there's another study which is not yet approved in the US though we're awaiting data or a decision by the FDA in the next few weeks, the CARES-301 study.
This was a mostly Chinese cohort, which is why we'll see how the FDA decides, but was rivoceranib or apatinib, a very potent VEGF receptor TKI, in combination with camrelizumab, which is another PD-1 inhibitor. This was, again, a very positive study. There's nuance. Some of these studies include patients with main portal vein invasion, some do not. Some have improvements in PFS, some do not. They need to be aware of the data, but I think if someone's interested in academic medicine, they need to understand clinical trial design, and liver cancer, and endpoints. All this becomes very important.
[Dr. Julius Chapiro]
Maybe I can add, also, one more thing, I think, for interventional radiologists, and particularly in debates and when you make decisions about what instrument to use or what type of therapy to use. Just look also at the control arms. Look at the EMERALD-1 and LEAP-012 control arms with TACE alone. This is prospective data right there collected historically. We have dramatically improved the way we do TACE.
In the older studies, we look at median overall survival intermediate stage of like 20 months, 18 to 20 months. Now, some of the control arms are bringing us up to 35, 36, sometimes even close to 40 months. I think that this data is very important to know. The protocols, how it's done is important to know. Study design is critically important. I can only strongly second what Rich said. What is the endpoint in this study? Is this progression-free survival? Is this median overall survival? What is going to be guideline-changing? How can you apply it to your own cohort that you're seeing? Again, just look at the small print in the tables.
[Dr. Christopher Beck]
Richard, I would be remiss if I didn't ask you this question. You've been very kind and judicious with, sometimes, your answers and your commentary on interventional radiologists. What drives you crazy about interventional radiology within the HCC space? What's something that gets you pulling your hair out?
[Dr. Richard Finn]
I alluded to this before. What's termed a positive data, what's supportive data, what's talked about from the microphone or from the podium as high-level evidence. You look at SIRveNIB and the SARAH. These were Y90 with systemic treatment versus sorafenib. Sorafenib versus Y90 and sorafenib. They were negative studies but somehow there's an excuse. They weren't done right, they didn't get the right population, the centers weren't good. Okay, great. Then do it the right way, right?
I give them credit for trying, for doing the study, but you did the study, you got the answer, and it's done. Similarly, as I said before, if we had a drug with those results, they're gone, done. Somehow, it's the limitations of the evidence or the studies that convince people somehow that things are okay, what we do. Generating that high-level evidence is not there. The drive to do it or the commitment to do it is probably the most frustrating thing.
Interventional Radiology at the Forefront of Hepatocellular Carcinoma Innovation & Care
The evolving role of interventional radiologists in HCC care closely ties to the ongoing advances in clinical research, multidisciplinary collaboration, and evidence-based practice. HCC represents a uniquely fitting disease process for interventional radiologists, combining advanced imaging, procedural expertise, and multi-modal therapeutic strategies. With the recently growing industry investment and funding in liver cancer, the opportunity for radiologists to innovate in this field is constantly expanding. As high-quality trial data and multidisciplinary collaboration are especially critical in guiding clinical practice, Drs. Chapiro and Finn express optimism in interventional radiologists’ role to help shape the future of HCC treatment.
[Dr. Christopher Beck]
All right, so something I'll leave off is final thoughts. It can be either how far we come, things that you're excited about in the future. Either upcoming studies, whatever. Julius, where are you at on that?
[Dr. Julius Chapiro]
I'm just very excited to be in a field that is so rapidly evolving and has brought a lot of change into the specialty. I think that liver cancer for interventional radiologists is, in my view, and I'm guilty of being biased, is probably the most interesting intellectual field to deal with because it just offers you so much reward. You can achieve complete cure in patients. You can deal with exciting imaging instruments and image-guided therapies at the same time you interact on a biopathological level and engage in novel therapies, understand cellular mechanisms of tumor response and have so many evolving new drugs.
I think it's for the first time that this kind of disease that we treat also encounters a lot of interest from industry, from pharmaceutical industry. That means that there's a lot of advocacy. A lot of money just, frankly, coming into the specialty. I think that's an opportunity for us to ask the right questions, do the right trials, get them funded and get them done. I think that's a once-in-a-lifetime opportunity where, if we don't lead, we're going to be followers. I think that it's going to be up to us to generate the high-level data that we need to maintain our membership in the multidisciplinary care team.
[Dr. Christopher Beck]
Richard, same question. Final thoughts, something you're looking forward to in the HCC space, or either just how far we've come?
[Dr. Richard Finn]
I think EMERALD-1 and LEAP-012 are very significant studies and should be a backbone for places that don't necessarily have multidisciplinary programs to put them together to build collaboration between IR and medical oncology. These were very large studies that were very complex to do because of data collection from radiology, from medical oncology, from blood draws, from imaging assessments. They both met their endpoints. These types of studies can be done and successfully.
I think it's imperative that we continue to generate this high-level data set to guide practice. I don't think it's an excuse to say it's too expensive, it can't be done, it's people aren't interested. You need to be committed to research, you need to be committed to getting the answers. These studies will continue to give a lot of data, as Julius alluded to, from the subgroup analyses to understanding the natural history of liver cancer in the modern age, and how there'll be biomarkers, correlates coming out of these studies, and really optimize how we approach patients. That should always be based on high level of evidence as these studies have generated.
Again, not every patient, most patients we don't see are going to fit perfectly into any box. There's clinical research and clinical practice, but clinical practice needs to extrapolate, I think, from, high level evidence.
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Cite This Podcast
BackTable, LLC (Producer). (2025, April 29). Ep. 11 – Immunotherapy & TACE in HCC Treatment [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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