# An Image-Guided Combination Strategy: Immediate Hepatic Arterial Infusion of Nivolumab Following Transarterial Chemoembolization for Unresectable Hepatocellular Carcinoma

## TL;DR

A new treatment for advanced liver cancer combines a standard procedure with immediate immunotherapy to improve survival and shrink tumors.

## Contribution

A novel image-guided combination therapy using TACE followed by hepatic arterial infusion of nivolumab is proposed for unresectable hepatocellular carcinoma.

## Key findings

- Patients receiving the combination therapy had significantly longer median overall and progression-free survival.
- The treatment increased tumor response rates and suppressed post-TACE angiogenesis while boosting immune markers.
- Adverse events were comparable to standard treatment, indicating safety and efficacy.

## Abstract

Primary liver cancer is a leading cause of cancer-related death, often treated with transarterial chemoembolization (TACE), a procedure that cuts off the tumor’s blood supply. However, the resulting lack of oxygen can paradoxically trigger new blood vessel growth and suppress the immune system, causing the tumor to return. This study investigated a novel strategy: infusing an immunotherapy drug, nivolumab, directly into the hepatic artery immediately after the standard procedure. The authors aimed to create a localized “immune shock” to counteract the tumor’s defensive mechanisms. The results indicate that this combination may extend patient survival and improve tumor shrinkage compared to standard treatment alone. By effectively stopping abnormal blood vessel formation and reactivating the body’s immune response, this image-guided approach provides a promising new therapeutic strategy for patients with inoperable liver tumors.

Background: Transarterial chemoembolization (TACE) is an established image-guided, minimally invasive therapy for unresectable hepatocellular carcinoma (HCC). However, post-embolization hypoxia often triggers compensatory angiogenesis and an immunosuppressive microenvironment, limiting long-term efficacy. We hypothesized that the immediate image-guided hepatic arterial infusion (HAI) of a PD-1 inhibitor following TACE could synergistically enhance local tumor control. Methods: In this retrospective, propensity-score-matched study, 226 patients with unresectable HCC (January 2021–June 2024) were analyzed. After 1:1 matching, 84 pairs were included: Study Group (TACE + HAI-nivolumab) and Control Group (TACE alone). Nivolumab (3 mg/kg) was infused via the hepatic artery under fluoroscopic guidance immediately after embolization. Primary endpoints were overall survival (OS) and progression-free survival (PFS); secondary endpoints included objective response rate (ORR) by mRECIST and changes in serum angiogenesis/immune biomarkers. Results: The Study Group demonstrated significantly longer median OS (16.2 vs. 12.8 months; HR 0.62, 95% CI: 0.44–0.88, p = 0.007) and median PFS (9.8 vs. 6.5 months; p < 0.001). ORR was higher with combination therapy (58.3% vs. 36.9%, p = 0.006). Mechanistically, HAI-nivolumab suppressed the post-TACE surge in VEGF and Ang-2 (p < 0.001) and increased the peripheral CD4+/CD8+ T-cell ratio. Grade 3/4 adverse events were comparable between groups (14.3% vs. 10.7%, p = 0.485). Conclusions: The image-guided combination of TACE with immediate HAI of nivolumab is associated with improved survival and tumor response in unresectable HCC. This strategy may counteract the adverse post-embolization microenvironment by simultaneously inhibiting angiogenesis and reactivating local immunity, representing an advanced image-guided combination therapy with strong translational relevance.