Abstract
BackgroundThe role of transarterial chemoembolization (TACE) as the standard treatment for intermediate‐stage hepatocellular carcinoma (HCC) is being challenged by increasing studies supporting liver resection (LR); but evidence of survival benefits of LR is lacking. We aimed to compare the overall survival (OS) of LR with that of TACE for the treatment of intermediate‐stage HCC in cirrhotic patients.MethodsA Markov model, comparing LR with TACE over 15 years, was developed based on the data from 31 literatures. Additionally, external validation of the model was performed using a data set (n = 1735; LR: 701; TACE: 1034) from a tertiary center with propensity score matching method. We conducted one‐way and two‐way sensitivity analyses, in addition to a Monte Carlo analysis with 10 000 patients allocated into each arm.ResultsThe mean expected survival times and survival rates at 5 years were 77.8 months and 47.1% in LR group, and 48.6 months and 25.7% in TACE group, respectively. Sensitivity analyses found that initial LR was the most favorable treatment. The 95% CI for the difference in OS was 2.42‐2.46 years between the two groups (P < 0.001). In the validation set, the 5‐year survival rates after LR were significantly better than those after TACE before (40.2% vs. 25.9%, P < 0.001) and after matching (43.2% vs 30.9%, P < 0.001), which was comparable to the model results.ConclusionsFor cirrhotic patients with resectable intermediate‐stage HCC, LR may provide survival benefit over TACE, but large‐scale studies are required to further stratify patients at this stage for different optimal treatments.
Highlights
There were no significant differences in baseline characteristics between liver resection (LR) and transarterial chemoembolization (TACE) groups (Table 2)
Other detailed perioperative and operative data were showed in Supplementary Results, Table S5 and S6
The role of TACE as the standard therapy for intermediate‐ stage hepatocellular carcinoma (HCC) is being challenged by increasing studies which show that LR is safe and feasible with better survival outcomes than TACE.[5,29,34,59,60]
Summary
Intermediate‐stage hepatocellular carcinoma (HCC) can be moderately controlled with appropriate treatments.[1,2] the management strategies for intermediate‐ stage HCC remain controversial without a global consensus.[3,4,5,6,7,8] The Barcelona Clinic Liver Cancer staging system, endorsed by many HCC associations, recommends liver resection (LR) for very‐early and early‐stage HCC, while recommending transarterial chemoembolization (TACE) for intermediate‐stage HCC.[3,6,9,10] It seems that patients with intermediate‐stage tumors are not the candidates for curative treatment. The role of TACE was established by one randomized controlled trial (RCT), as well as a meta‐analysis with the demonstration of improved survival of TACE compared to the best available supportive care These did not compare TACE to other treatment modalities such as resection.[11,12] observational studies from Eastern and Western countries have emerged to show that LR was safer and yielded better survival than TACE for selected patients with intermediate‐stage HCC.[4,5,7,8] Simultaneously, several guidelines and consensuses have come to state that tumor multifocality is not a contraindication to LR Some Asian studies even recommend LR for intermediated‐stage HCC.[13,14,15,16,17] these observational studies were conducted with non‐negligible biases, and the guidelines/consensuses were largely based on expert opinions. The 5‐year survival rates after LR were significantly better than those after TACE before (40.2% vs. 25.9%, P < 0.001) and after matching (43.2% vs 30.9%, P < 0.001), which was comparable to the model results
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