Targeting intra-tumoral lactic acidosis in hepatocellular carcinoma: a long way to go

Hepatocellular carcinoma (HCC) is the sixth commonest cancer worldwide and at first presentation more than 80% of patients are beyond surgical resection and cure (1). The Barcelona Clinic Liver Cancer (BCLC) staging system, which links the disease stage to a specific treatment strategy, is used to inform treatment decisions. According to this algorithm, transarterial chemoembolization (TACE) is offered in patients with intermediate stage HCC, who do not have a curative potential (2). TACE consists of the selective injection of a chemotherapy agent in the hepatic artery branch that feeds the tumor, followed by the administration of an embolizing agent (3). HCC demonstrates neo-angiogenic activity and meta-analysis have shown that bland embolization (TAE) or TACE confer a survival benefit, improving the median survival from 16 to 20 months (2).