Transarterial Chemoembolization Combined with Immunotherapy-Based Systemic Therapy for Hepatocellular Carcinoma: An International ISMIO Expert Consensus Framework

The combination of transarterial chemoembolization (TACE) with immunotherapy-based systemic therapy is emerging as a promising treatment strategy for unresectable hepatocellular carcinoma (HCC). In addition, emerging data from perioperative immunotherapy-based strategies in resectable, high-risk HCC further support the integration of systemic and TACE across the disease continuum. Recent randomized trials have demonstrated improvements in progression-related outcomes with TACE combined with immunotherapy-based systemic therapies. However, overall survival (OS) benefit has not been consistently demonstrated across randomized studies, with final OS analyses from EMERALD-1 and interim OS analyses from LEAP-012 not showing statistically significant improvement compared with TACE alone. By integrating TACE and immunotherapy-based systemic strategies, this International Society of Multidisciplinary Interventional Oncology (ISMIO) Expert Consensus framework does not advocate routine clinical adoption but aims to provide a structured framework for research design and multidisciplinary decision-making. It summarizes data from pivotal trials and offers guidance on patient selection, treatment sequencing, response evaluation, and safety management. Ten consensus statements through a modified Delphi process, with evidence graded according to the Oxford Centre for Evidence-based Medicine and assessed narratively based on the directness, consistency, maturity, and applicability of available evidence, were developed by ISMIO expert panel. The consensus framework emphasizes multidisciplinary collaboration, individualized therapeutic decision-making based on a comprehensive patient profile, and the need for structured definitions and endpoints to facilitate future research. It aims to provide a flexible, evidence-informed, multidisciplinary framework to facilitate patient stratification, interpretation of emerging evidence, and future research design, while allowing adaptation according to local expertise, treatment availability, and regional practice patterns.