Hepatic resection versus transarterial chemoembolization for the initial treatment of hepatocellular carcinoma: A systematic review and meta-analysis.

Xingshun Qi,Chunping Su,Xiaozhong Guo,Diya Wang,Hongyu Li

doi:10.18632/oncotarget.4134

Abstract

According to the Barcelona Clinic Liver Cancer (BCLC) staging system, hepatic resection and transarterial chemoembolization (TACE) should be recommended in patients with hepatocellular carcinoma (HCC) within and beyond the BCLC stage A, respectively. We conducted a systematic review and meta-analysis to compare the overall survival between HCC patients undergoing hepatic resection and TACE. PubMed, EMBASE, and Cochrane library databases were searched. All relevant studies were considered, if they reported the survival data in HCC patients undergoing hepatic resection and TACE. Hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated for the comparison of cumulative overall survival. Odds ratios (ORs) with 95%CIs were calculated for the comparison of 1-, 3-, and 5-year survival rates. Subgroup analyses were performed according to the BCLC stages and portal vein tumor thrombus (PVTT). Sensitivity analyses were performed in moderate- and high-quality studies and in studies published after 2005. Fifty of 2029 retrieved papers were included. One, 15, and 34 studies were of high-, moderate-, and low-quality, respectively. The overall meta-analysis demonstrated a statistically significantly higher overall survival in hepatic resection group than in TACE group (HR=0.60, 95%CI=0.55-0.66). Additionally, 1-, 3-, and 5-year survival rates were statistically significantly higher in hepatic resection group than in TACE group (OR=1.82, 95%CI=1.56-2.14; OR=3.09, 95%CI=2.60-3.67; OR=3.48, 95%CI=2.83-4.27). The subgroup meta-analyses confirmed the statistical significance in HCC within the BCLC stage A (HR=0.72, 95%CI=0.64-0.80), in HCC beyond the BCLC stage A (HR=0.60, 95%CI=0.51-0.69), in HCC within the BCLC stage B alone (HR=0.48, 95%CI=0.25-0.90), and in HCC with PVTT (HR=0.78, 95%CI=0.68-0.91). The statistical significance was also confirmed by sensitivity analyses in moderate- and high-quality studies (HR=0.62, 95%CI=0.53-0.71) and in studies published after 2005 (HR=0.59, 95%CI=0.53-0.66). Based on a systematic review and meta-analysis, hepatic resection may be considered in HCC beyond the BCLC stage A. However, given the limitations of study quality, more well-designed randomized controlled trials should be warranted to confirm these findings.

Highlights

Barcelona Clinic Liver Cancer (BCLC) stage is the sole system approved by the European Association for Study of the Liver (EASL) and American Association for the Study of Liver Disease (AASLD) guidelines for the prognostic classification and treatment selection of hepatocellular carcinoma (HCC) [1-2]
According to this staging system, hepatic resection should be recommended in the BCLC stage 0 or A HCC with a single nodule (i.e., “the patients do not have liver cirrhosis or have liver cirrhosis but still have well preserved liver function, normal bilirubin and hepatic vein pressure gradient < 10 mmHg”), and transarterial chemoembolization (TACE) should be recommended in the BCLC stage B HCC (i.e., “the patients have large/multifocal HCC but without vascular invasion or extrahepatic spread”)
The overall conclusions of every included study were summarized as follows: 1) the survival benefit of hepatic resection was statistically significant in 29 studies [7-8, 11, 16, 18-19, 23-24, 26, 28-29, 33-34, 36, 38, 40-41, 45-55]; 2) the survival was statistically similar between the two groups in 7 studies [12, 15, 20-22, 27, 30, 43]; and 3) the statistical difference was not reported in 14 studies [6, 9-10, 13-14, 17, 25, 31-32, 35, 37, 39, 42, 44]

Summary

Introduction

Barcelona Clinic Liver Cancer (BCLC) stage is the sole system approved by the European Association for Study of the Liver (EASL) and American Association for the Study of Liver Disease (AASLD) guidelines for the prognostic classification and treatment selection of hepatocellular carcinoma (HCC) [1-2]. According to this staging system, hepatic resection should be recommended in the BCLC stage 0 or A HCC with a single nodule (i.e., “the patients do not have liver cirrhosis or have liver cirrhosis but still have well preserved liver function, normal bilirubin and hepatic vein pressure gradient < 10 mmHg”), and transarterial chemoembolization (TACE) should be recommended in the BCLC stage B HCC (i.e., “the patients have large/multifocal HCC but without vascular invasion or extrahepatic spread”).

Methods

Results

Conclusion