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Radiology, Aug 2026, 320 (2) | https://doi.org/10.1148/radiol.253280 Comparison of Second-line Hepatic Arterial Infusion Chemotherapy and Tyrosine Kinase Inhibitors in Advanced Hepatocellular Carcinoma

Jae-Sung Yoo^*,1, Kwon Yong Tak ^*,2,3, Hee Sun Cho^2,3, Ji Won Han ^2,3, Jeong Won Jang ^2,3, Jaejun Lee ^2,4, Hyun Yang ^2,4, Chang Wook Kim ^2,5, Hae Lim Lee ^2,6, Hee Yeon Kim ^2,6, Suho Kim⁷, Jung Suk Oh ⁷, Ho Jong Chun⁷, Heechul Nam ^**,2,5, Pil Soo Sung ^**,2,3

¹Department of Medicine, Graduate School, Kyungpook National University, Daegu, Republic of Korea.
²The Catholic University Liver Research Center, Department of Biomedicine & Health Sciences, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea.
³Division of Gastroenterology and Hepatology, Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea.
⁴Division of Gastroenterology and Hepatology, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
⁵Division of Gastroenterology and Hepatology, Department of Internal Medicine, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Republic of Korea.
⁶Division of Gastroenterology and Hepatology, Department of Internal Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Republic of Korea.
⁷Department of Radiology, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.

^*J.S.Y. and K.Y.T. contributed equally to this work.
^**H.N. and P.S.S. are co-senior authors.
Address correspondence to: P.S.S.

Abstract

Background
With the advent of immune checkpoint inhibitor–based combination therapy, treatment sequencing for advanced hepatocellular carcinoma (HCC) has become increasingly complex. The Barcelona Clinic Liver Cancer (BCLC) 2026 recommendations emphasize individualized decision-making.

Purpose
To compare clinical outcomes of hepatic arterial infusion chemotherapy (HAIC) and tyrosine kinase inhibitors (TKIs) in patients with advanced HCC after atezolizumab-bevacizumab (AB) failure, within the BCLC 2026 treatment paradigm.

Materials and Methods
This multicenter retrospective study included patients who received AB and subsequently received either HAIC or a TKI between March 2022 and August 2025. HAIC used a cisplatin-fluorouracil regimen, and TKIs were given at standard doses. Tumor response and progression-free survival (PFS) were assessed using contrast-enhanced multiphase CT or liver MRI according to routine clinical practice. Imaging was reviewed by radiologists blinded to treatment allocation. Inverse probability of treatment weighting (IPTW) was applied for age, sex, Eastern Cooperative Oncology Group performance status, Child-Pugh class, portal vein tumor thrombosis, and tumor burden based on the up-to-seven criteria.

Results
This study included 90 patients (mean age, 62 years ± 10.9 [SD]; 73 men; HAIC group, n = 51; TKI group, n = 39). Baseline tumor burden was higher in the HAIC group than in the TKI group (percentage of patients with tumors beyond the up-to-seven criteria: 88% [45 of 51] vs 64% [25 of 39]; P = .01). In unweighted analyses, median overall survival (OS) was similar between the HAIC and TKI groups (10.4 vs 6.4 months; P = .62), whereas PFS favored HAIC over TKIs (median, 5.3 vs 3.6 months; P = .008). Objective response rate and disease control rate were higher with HAIC than with TKIs (objective response rate: 35% [18 of 51] vs 5% [two of 39], P = .002; disease control rate: 67% [34 of 51] vs 26% [10 of 39], P < .001). After IPTW, HAIC remained associated with longer PFS than TKIs (median, 7.1 vs 3.4 months; P < .001), and OS remained similar between groups (median, 10.5 vs 6.3 months; P = .32).

Conclusion
In patients with advanced HCC, after AB failure, second-line HAIC yielded higher response rates and longer PFS than TKIs.

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