Ep. 659 Combination Therapy for Hepatocellular Carcinoma with Dr. Beau Toskich and Dr. Lingling Du
How do you safely combine locoregional and systemic therapies to treat hepatocellular carcinoma (HCC) when traditional guidelines suggest your hands are tied? In this episode of the 2026 HCC Creator Weekend™, medical oncologist Dr. Lingling Du (Ochsner Health) and interventional radiologist Dr. Beau Toskich (Mayo Clinic Florida) join Dr. Tyler Sandow to break down patient selection, timing strategies, and the practical application of clinical trial outcomes when integrating Y90 radioembolization and immunotherapy in HCC management. --- Get the BackTable app https://www.backtable.com/app --- This podcast is supported by an educational grant from Sirtex and Boston Scientific. --- Timestamps 00:00 - Introduction 01:48 - Two HCC Cases 03:31 - Disease Progression on Combination Therapy 07:05 - Alternatives After Immunotherapy Failure 09:09 - Salvage with Ablative Y90 13:41 - Mechanism of Immunotherapy 15:43 - EMERALD-1 and LEAP-012 20:52 - Adverse Events with Combination Therapy 27:21 - Treatment Timing and Sequencing 28:48 - Case: Borderline BCLC B 33:48 - Case: BCLC C with Portal Vein Thrombus 37:06 - Raising the Survival Tail 40:11 - Final Thoughts and Closing Remarks --- More about this episode The physicians highlight how selective local treatment can achieve complete responses and salvage cases with aggressive disease. They emphasize that treatment based on anatomical and biological phenotype may yield better results than strictly adhering to rigid staging categories, while acknowledging the challenges of managing microscopic disease and unpredictable long-term tumor behavior. Dr. Du and Dr. Toskich also note that selecting the right combination regimens requires balancing aggressive tumor kinetics against the patient’s baseline liver function, pointing out that well-tolerated regimens like STRIDE are often easier to pair with Y90 than checkpoint or VEGFR inhibitors that alter tumor blood flow. While recent TACE-immunotherapy trials (EMERALD-1 and LEAP-012) may be confounded by patient heterogeneity, the physicians observe that a distinct subset of patients achieves durable, long-term remission, effectively raising the survival tail for an otherwise incurable population. Ultimately, they conclude that cross-specialty education and leaning into the expert intuition of a multidisciplinary team are essential for securing the best outcomes for patients with intermediate and advanced HCC. --- Resources Study of Durvalumab and Tremelimumab as First-line Treatment in Patients With Advanced Hepatocellular Carcinoma (HIMALAYA) https://clinicaltrials.gov/study/NCT03298451 A Study of Atezolizumab in Combination With Bevacizumab Compared With Sorafenib in Patients With Untreated Locally Advanced or Metastatic Hepatocellular Carcinoma (IMbrave150) https://clinicaltrials.gov/study/NCT03434379 Nivolumab plus ipilimumab versus lenvatinib or sorafenib as first-line treatment for unresectable hepatocellular carcinoma (CheckMate 9DW): an open-label, randomised, phase 3 trial https://doi.org/10.1016/S0140-6736(25)00403-9 Durvalumab with or without bevacizumab with transarterial chemoembolisation in hepatocellular carcinoma (EMERALD-1): a multiregional, randomised, double-blind, placebo-controlled, phase 3 study https://doi.org/10.1016/S0140-6736(24)02551-0 Transarterial chemoembolisation combined with lenvatinib plus pembrolizumab versus dual placebo for unresectable, non-metastatic hepatocellular carcinoma (LEAP-012): a multicentre, randomised, double-blind, phase 3 study https://doi.org/10.1016/S0140-6736(24)02575-3 --- BackTable Vascular & Interventional (VI) is the go-to podcast for interventional radiologists, vascular surgeons, and interventional cardiologists. Download the free BackTable app to get early access to new episodes, cases, and courses curated by physicians in your specialty. ► https://www.backtable.com/app
