Balloon-Occluded Transarterial Chemoembolization for Intermediate-Stage Hepatocellular Carcinoma

Abstract Transarterial chemoembolization (TACE) is considered standard therapy for intermediate-stage hepatocellular carcinoma (HCC). However, conventional TACE (cTACE) and drug-eluting bead TACE (DEB-TACE) are limited by high recurrence rates. Recent studies have shown that balloon-occluded TACE (B-TACE) allows enhanced intratumoral drug deposition and may improve outcomes. This study aimed to evaluate the short-term outcome of B-TACE for HCC. This retrospective single-center study was conducted after obtaining approval from the institutional review board. Fifty patients with unresectable HCC were treated with B-TACE between October 2023 and September 2024. Tumor response was assessed using LI-RADS Treatment Response (LR-TR) and mRECIST (Modified Response Evaluation Criteria in Solid Tumors). Progression-free survival (PFS) was analyzed with Kaplan–Meier methods, and predictors of response were evaluated by logistic regression. Lipiodol deposition was classified into three types as a surrogate marker of drug distribution. The overall response rate was 72.0%, with a complete response in 54.0% of patients. Subgroup analysis revealed that patients with Barcelona Clinic Liver Cancer (BCLC) stage A and B achieved a higher overall response rate of 77.3% (34/44), compared with 33.3% (2/6) in patients with BCLC stage C. At 1 year, 68.0% remained progression-free, with significantly higher PFS in those achieving early complete response/partial response compared with stable disease/progressive disease (83.3 vs. 28.6%, p < 0.001). Type I lipiodol deposition strongly correlated with complete response (93.8 vs. 37.5% for type II and 0% for type III; p < 0.001) and superior PFS. Multivariable analysis identified lipiodol deposition pattern, number of lesions, and baseline AFP as independent predictors of response. Complications were manageable (30.0%, mainly fever and transaminitis), with no treatment-related mortality. B-TACE demonstrated high efficacy and acceptable safety in HCC, with lipiodol deposition serving as a key predictor of outcome. These findings support B-TACE as a promising alternative to cTACE/DEB-TACE, particularly in intermediate-stage disease.