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Hepatic intraarterial chemotherapy without embolization in unresectable hepatocellular carcinoma (November 2021)

Transarterial chemoembolization (TACE) is a standard treatment for large unresectable hepatocellular carcinomas (HCCs) that are not amenable to local thermal ablation; however, each treatment can cause hepatic arterial and parenchymal ischemic damage leading to hepatic decompensation and inability to carry out repeated procedures. In a Chinese trial comparing repeated courses of multiagent hepatic arterial infusional chemotherapy (HAIC) without embolization versus TACE in 315 patients with unresectable large (>=7 cm) HCCs without macrovascular invasion or extrahepatic spread (81 percent hepatitis B virus-related), patients treated with HAIC had improved survival and less toxicity [1]. However, the trial had important limitations, and the results may not be generalizable to other populations with HCC. Where the technical expertise is available, HAIC is an alternative to TACE for large unresectable HCCs, but we await further studies before concluding that HAIC is preferred.


Adjuvant pembrolizumab in localized renal cell carcinoma (December 2021)

In patients with localized renal cell carcinoma (RCC) treated with nephrectomy, adjuvant immunotherapy is being evaluated. In a randomized trial of approximately 1000 patients with clear cell RCC treated with nephrectomy, one year of adjuvant pembrolizumab improved disease-free survival (DFS) compared with placebo (two-year DFS, 77 versus 68 percent), and was well tolerated [2]. Based on these data, the US Food and Drug Administration approved adjuvant pembrolizumab in patients with RCC at intermediate-high or high risk of disease recurrence following nephrectomy [3]. We suggest adjuvant pembrolizumab for those with resected RCC who have an estimated five-year recurrence risk of >=30 percent.


Long-term follow-up of nivolumab plus ipilimumab in patients with metastatic melanoma (August 2021, Modified December 2021)

In patients with treatment-naive metastatic melanoma, studies are ongoing to assess the long-term efficacy of combination immunotherapy with nivolumab plus ipilimumab. In extended follow-up of a phase III trial (Checkmate-067), among almost 1000 patients with treatment-naive metastatic melanoma, the 6.5 year overall survival rate for nivolumab plus ipilimumab was 49 percent versus 42 percent with nivolumab alone and 23 percent for ipilimumab alone [4]. These data continue to confirm a survival benefit for nivolumab plus ipilimumab, and it remains one of our preferred options for initial therapy in eligible patients with metastatic melanoma.


Radiation fields in children >3 years with average-risk medulloblastoma (November 2021)

The Results of a recent multicenter randomized trial in children with medulloblastoma support providing lower doses of radiation therapy (RT) to some areas of normal brain without sacrificing tumor control. In the Children's Oncology Group ACNS0331 trial, 549 patients age 3 to 21 years with average-risk medulloblastoma were treated with craniospinal RT plus a boost to either the entire posterior fossa (standard) or to the tumor bed only (narrower volume) [5]. Survival outcomes were similar between groups, and there were no local failures outside the narrower boost volume. Thus, use of a boost confined to the tumor bed plus a margin is now appropriate for patients receiving craniospinal RT for medulloblastoma.


1. Li QJ, He MK, Chen HW, et al. Hepatic Arterial Infusion of Oxaliplatin, Fluorouracil, and Leucovorin Versus Transarterial Chemoembolization for Large Hepatocellular Carcinoma: A Randomized Phase III Trial.


2. J Clin Oncol. 2021; PMID: 34648352.


3. Choueiri TK, Tomczak P, Park SH, et al. Adjuvant Pembrolizumab after Nephrectomy in Renal-Cell Carcinoma. N Engl J Med. 2021;385(8):683.


4. Pembrolizumab: United States (US) Food and Drug Administration (FDA) Label (Accessed on November 19, 2021).


5. Wolchok JD, Chiarion-Sileni V, Gonzalez R, et al. Long-Term Outcomes With Nivolumab Plus Ipilimumab or Nivolumab Alone Versus Ipilimumab in Patients With Advanced Melanoma. J Clin Oncol. 2021; PMID: 34818112.


6. Michalski JM, Janss AJ, Vezina LG, et al. Children's Oncology Group Phase III Trial of Reduced-Dose and Reduced-Volume Radiotherapy With Chemotherapy for Newly Diagnosed Average-Risk Medulloblastoma. J Clin Oncol. 2021;39(24):2685. Epub 2021 Jun 10.


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