Optimizing Transarterial Chemoembolization in Hepatocellular Carcinoma: Current Strategies, Innovations, and Future Directions

Hepatocellular carcinoma (HCC) remains a major global health challenge with high mortality, particularly in patients with intermediate-stage disease, where curative options are limited. Transarterial chemoembolization (TACE) is the mainstay of treatment in such cases, offering locoregional tumor control by combining targeted chemotherapy and embolization. This review explores current strategies to optimize TACE, including advancements in drug delivery systems such as drug-eluting beads and balloon-occluded techniques, and highlights the importance of patient selection based on Barcelona Clinic Liver Cancer (BCLC) staging, liver function, and performance status. Emerging combination therapies, such as TACE with systemic agents like sorafenib, lenvatinib, and apatinib, or immunotherapies like atezolizumab-bevacizumab, show promise in improving progression-free and overall survival. Additionally, TACE plays a critical role in bridging and downstaging patients for liver transplantation. Future directions focus on integrating radiomics, artificial intelligence, and inflammatory biomarkers to enhance treatment personalization and predict therapeutic response. Despite its established role, TACE is not without risks, including post-embolization syndrome and organ-specific ischemic complications. Continued research is essential to refine selection criteria, minimize adverse effects, and validate innovative approaches, ultimately improving outcomes for HCC patients across diverse clinical scenarios.