Treatment outcomes of transcatheter arterial chemoembolization combined with local ablative therapy versus monotherapy in hepatocellular carcinoma: a meta-analysis

The combination of transcatheter arterial chemoembolisation (TACE) and thermal ablation versus TACE alone for hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma is the sixth most common cancer worldwide. Hepatic resection is regarded as the curative therapy for hepatocellular carcinoma. However, only about 20% of people with hepatocellular carcinoma are candidates for resection, which highlights the importance of effective nonsurgical therapies. Until now, transcatheter arterial chemoembolisation (TACE) is the most common palliative therapy for hepatocellular carcinoma, but its clinical benefits remain unsatisfactory. During recent years, some studies have reported that the combination of TACE plus thermal ablation can confer a more favourable prognosis than TACE alone. However, clear and compelling evidence to prove the beneficial or harmful effects of the combination of TACE and thermal ablation therapy is lacking.

OBJECTIVES

To assess the beneficial and harmful effects of the combination of thermal ablation with TACE versus TACE alone in people with hepatocellular carcinoma.

SEARCH METHODS

We performed searches in the Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials in the Cochrane Library, MEDLINE, Embase, LILACS, Science Citation Index Expanded, and Conference Proceedings Citation Index-Science. We endeavoured to identify relevant randomised clinical trials also in the China National Knowledge Infrastructure (CNKI) and Wanfang databases. We searched trial registration websites for ongoing studies. We also handsearched grey literature sources. The date of last search was 22 December 2020.

SELECTION CRITERIA

We planned to include all randomised clinical trials comparing the combination of TACE plus thermal ablation versus TACE alone for hepatocellular carcinoma, no matter the language, year of publication, publication status, and reported outcomes.

DATA COLLECTION AND ANALYSIS

We planned to use standard methodological procedures expected by Cochrane. We planned to calculate risk ratios (RRs) with the corresponding 95% confidence intervals (CIs). For time-to-event variables, we planned to use the methods of survival analysis and express the intervention effect as a hazard ratio (HR) with 95% Cl. If the log HR and the variance were not directly reported in reports, we planned to calculate them indirectly, following methods for incorporating summary time-to-event data into meta-analysis. We planned to assess the risk of bias of the included studies using the RoB 2 tool. We planned to assess the certainty of evidence with GRADE and present the evidence in a summary of findings table.

MAIN RESULTS

Out of 2224 records retrieved with the searches, we considered 135 records eligible for full-text screening. We excluded 21 of these records because the interventions used were outside the scope of our review or the studies were not randomised clinical trials. We listed the remaining 114 records, reporting on 114 studies, under studies awaiting classification because we could not be sure that these were randomised clinical trials from the information in the study paper. We could not obtain information on the registration of the study protocol for any of the 114 studies. We could not obtain information on study approval by regional research ethics committees, either from the study authors or through our own searches of trial registries. Corresponding authors did not respond to our enquiries about the design and conduct of the studies, except for one from whom we did not receive a satisfactory response. We also raised awareness of our concerns to editors of the journals that published the 114 studies, and we did not hear back with useful information. Moreover, there seemed to be inappropriate inclusion of trial participants, based on cancer stage and severity of liver disease, who should have obtained other interventions according to guidelines from learned societies. Accordingly, we found no confirmed randomised clinical trials evaluating the combination of TACE plus thermal ablation versus TACE alone for people with hepatocellular carcinoma for inclusion in our review. We identified five ongoing trials, by handsearching in clinical trial websites.

AUTHORS' CONCLUSIONS

We could not find for inclusion any confirmed randomised clinical trials assessing the beneficial or harmful effects of the combination of TACE plus thermal ablation versus TACE alone in people with hepatocellular carcinoma. Therefore, our results did not show or reject the efficiency of the combination of TACE plus thermal ablation versus TACE alone for people with hepatocellular carcinoma. We need trials that compare the beneficial and harmful effects of the combination of TACE plus thermal ablation versus TACE alone in people with hepatocellular carcinoma, not eligible for treatments with curative intent (liver transplantation, ablation surgical resection) and who have sufficient liver reserve, as assessed by the Child Pugh score, and who do not have extrahepatic metastases. Therefore, future trial participants must be classified at Barcelona Clinic Liver Cancer Stage B (intermediate stage) (BCLC-B) or an equivalent, with other staging systems.

TACE Combined with HIFU Versus Surgical Resection for Single Hepatocellular Carcinoma with Child-Pugh B Cirrhosis in Overall Survival and Progression-Free Survival: A Retrospective Study

Objective: To compare the effectiveness, safety and survival outcome of transcatheter arterial chemoembolization (TACE) combined with high-intensity focused ultrasound (HIFU) versus surgical resection for treating single hepatocellular carcinoma (HCC) with Child-Pugh B cirrhosis. Methods: A hospital-based retrospective study with 146 patients diagnosed with single HCC with Child-Pugh B cirrhosis from July 2010 to July 2018 was conducted in a tertiary teaching hospital. A total of 49 patients underwent TACE combined with HIFU (the combined group), and 97 patients underwent surgical resection (the resection group). Of them, 22 patients undergoing TACE combined with HIFU and 45 patients undergoing surgical resection had small HCC (tumor diameter ≤3 cm). The overall survival (OS) time, progression-free survival (PFS) time and postoperative complications were compared between the two groups. Results: In the single HCC tumor cohort, there was no significant difference in OS between the two groups [hazard ratio (HR) = 0.6379; 95% confidence interval (95% CI) = 0.3737 to 1.089; P = .0995], while the resection group showed an obvious superiority to the combined group regarding PFS (HR = 0.3545; 95% CI = 0.2176-0.5775; P < .0001). The 1-year, 3-year and 5-year recurrence rates were 30.9%, 55.7%, 86.6% in the resection group and 53.1%, 77.6%, 89.8% in the combined group, respectively. In the small HCC tumor cohort, there was also no difference in OS between the two groups (HR = 0.8808; 95% CI = 0.3295-2.355; P = .06396), while the resection group showed an obvious superiority to the combined group regarding PFS (HR = 0.4273; 95% CI = 0.1927-0.9473; P = .0363). The 1-year, 3-year and 5-year recurrence rates were 28.9%, 53.3%, 93.3% in the resection group and 40.9%, 68.2%, 81.8% in the combined group, respectively. Furthermore, the incidence of complications of the combined group was 38.8%, which was significantly less than the 56.7% of the resection group (P = .041), and the duration of general anesthesia in the combined group was shorter than that in the resection group (P = .001). Therein, there was no difference in the incidence of grade I complications (Clavien-Dindo classification) between the two groups (P = .866). Conclusion: For patients with single or single small HCCs, TACE combined with HIFU may not be inferior to surgical resection in terms of the long-term survival rate, while surgical resection still has a definite advantage in terms of delaying recurrence. In addition, the combination of TACE and HIFU has higher safety than surgical resection.

GraphSynergy: a network-inspired deep learning model for anticancer drug combination prediction

OBJECTIVE

To develop an end-to-end deep learning framework based on a protein-protein interaction (PPI) network to make synergistic anticancer drug combination predictions.

MATERIALS AND METHODS

We propose a deep learning framework named Graph Convolutional Network for Drug Synergy (GraphSynergy). GraphSynergy adapts a spatial-based Graph Convolutional Network component to encode the high-order topological relationships in the PPI network of protein modules targeted by a pair of drugs, as well as the protein modules associated with a specific cancer cell line. The pharmacological effects of drug combinations are explicitly evaluated by their therapy and toxicity scores. An attention component is also introduced in GraphSynergy, which aims to capture the pivotal proteins that play a part in both PPI network and biomolecular interactions between drug combinations and cancer cell lines.

RESULTS

GraphSynergy outperforms the classic and state-of-the-art models in predicting synergistic drug combinations on the 2 latest drug combination datasets. Specifically, GraphSynergy achieves accuracy values of 0.7553 (11.94% improvement compared to DeepSynergy, the latest published drug combination prediction algorithm) and 0.7557 (10.95% improvement compared to DeepSynergy) on DrugCombDB and Oncology-Screen datasets, respectively. Furthermore, the proteins allocated with high contribution weights during the training of GraphSynergy are proved to play a role in view of molecular functions and biological processes, such as transcription and transcription regulation.

CONCLUSION

The introduction of topological relations between drug combination and cell line within the PPI network can significantly improve the capability of synergistic drug combination identification.

Consensus of Minimally Invasive and Multidisciplinary Comprehensive Treatment for Hepatocellular Carcinoma - 2020 Guangzhou Recommendations

In China, the majority of patients with hepatocellular carcinoma (HCC) result from long-term infection of hepatitis B. Pathologically, HCC is characterized by rich blood supply, multicentric origins, early vascular invasion and intrahepatic metastasis. Therefore, HCC is not a local disease but a systemic disease at the beginning of its occurrence. For this reason, a comprehensive treatment strategy should be adopted in the management of HCC, including local treatments (such as surgical resection, radiofrequency ablation, microwave ablation, chemical ablation and cryoablation, etc.), organ-level treatments [such as transcatheter arterial infusion of chemotherapy and transcatheter arterial chemoembolization (TACE)], and systemic treatments (such as immunotherapy, antiviral therapy and molecular targeted therapy, etc.). This consensus sets forth the minimally-invasive and multidisciplinary comprehensive guideline of HCC, focusing on the following eight aspects (1) using hepaticarteriography, CT hepatic arteriography (CTHA), CT arterial portography (CTAP), lipiodol CT (Lp-CT), TACE-CT to find the intrahepatic lesion and make precise staging (2) TACE combined with ablation or ablation as the first choice of treatment for early stage or small HCC, while other therapies are considered only when ablation is not applicable (3) infiltrating HCC should be regarded as an independent subtype of HCC (4) minimally-invasive comprehensive treatment could be adopted in treating metastatic lymph nodes (5) multi-level subdivision of M-staging should be used for individualized treatment and predicting prognosis (6) HCC with severe hepatic decompensation is the only candidate criterion for liver transplantation (7) bio-immunotherapy, traditional Chinese medicine therapy, antiviral therapy, and psychosocial and psychopharmacological interventions should be advocated through the whole course of HCC treatment (8) implementation of multicenter randomized controlled trials of minimally-invasive therapy versus surgery for early and intermediate stage HCC is recommended.

TACE combined with microwave ablation therapy vs. TACE alone for treatment of early- and intermediate-stage hepatocellular carcinomas larger than 5 cm: a meta-analysis

There are many therapeutic options for primary hepatocellular carcinoma (HCC), but very limited options for unresectable HCC with a single lesion larger than 5 cm (Barcelona Clinic Liver Cancer [BCLC] stage A) or with 2-3 nodules beyond 5 cm (BCLC stage B). Transcatheter arterial chemoembolization (TACE) is considered the first-line treatment for these patients, and combination therapy has also been tried. However, the effectiveness of microwave ablation (MWA) combined with TACE in the treatment of the above tumors remains to be further confirmed. Therefore, this meta-analysis aimed to compare the effectiveness of combination therapy and TACE monotherapy on these patients. PubMed, Cochrane Library, Embase, China National Knowledge Infrastructure, and the Wan Fang electronic databases were retrieved to search for studies comparing combination therapy and TACE monotherapy, published between the earliest available date and August 20, 2019. A total of 20 articles (reporting 1736 patients) were included. Meta-analysis showed that, compared to TACE alone, TACE + MWA resulted in significantly higher 1-, 2-, and 3-year overall survival (OS) (1-year OS rate: RR = 1.36, 95% CI 1.28-1.44, P < 0.001; 2-year OS rate: RR = 1.56, 95% CI 1.40-1.74, P < 0.001 and 3-year OS rate: RR = 2.07, 95% CI: 1.67-2.57, P < 0.001). Complete response, partial response, and objective response rates were significantly higher in TACE + MWA than those in TACE alone (P < 0.001). Meanwhile, publication bias and sensitivity analysis were performed and did not show statistical significance.

Interventional oncology treatments for unresectable early stage HCC in patients with a high risk for intraprocedural bleeding: Is a single-step combined therapy safe and feasible?

PURPOSE

This study was designed to assess the feasibility and safety of a single-step combined therapy using radiofrequency ablation and transarterial chemoembolization (RFA + TACE) in patients with hepatocellular carcinoma (HCC) and uncontrolled coagulopathy. The study also aimed to compare the effectiveness of this approach with TACE alone, performed in a control group.

MATERIAL AND METHODS

One hundred and forty-three consecutive cirrhotic patients having a single HCC < 8 cm were enrolled in this observational prospective single-center study from January 2010 to June 2017 and were divided, according to coagulation tests, into three groups (A: low risk; B: intermediate risk and C: high risk of bleeding). The feasibility and safety of a single-step combined treatment (RFA followed by TACE) were evaluated in terms of technical success rate, periprocedural complications, and laboratory values variations. Tumor response obtained at 1-month CT follow-up for group C was compared with that of control group, composed by 16 matched patients with severe coagulopathy and single HCC < 8 cm, who underwent only TACE in a previous period, performed by the same operator.

RESULTS

Technical success was achieved in all patients, without any major complications. Minor complications rate was significantly higher in group C after RFA; however, the patients were successfully treated with subsequent TACE therapy, without any differences between pre- and post-procedural laboratory values. One-month complete response rates were similar in all the three groups; however, the response rates of group C were significantly higher as compared to that of the control TACE Group (p < .001).

CONCLUSION

The single-step RFA plus TACE therapy allows expansion of the indication for percutaneous thermal ablation, allowing to also include cases previously contraindicated due to the procedural high-risk of complications associated with bleeding, thus improving short-term patient outcome.

Blood oxygen level–dependent functional magnetic resonance imaging can evaluate the efficiency of transcatheter arterial chemoembolization in hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is among the most common malignant tumors worldwide, and transcatheter arterial chemoembolization (TACE) technology has become the first-line treatment for advanced HCC. Another important, recently developed technique is blood oxygen level–dependent functional magnetic resonance imaging (BOLD-fMRI), which utilizes hemoglobin as an endogenous contrast agent and measures deoxygenated hemoglobin content by sampling the oxygen content of tissues, thus reflecting the hemodynamics and pathophysiologic changes in body organs. Currently this technology is being used in patients with liver tumors; that is, it serves as an important tool in follow-up after TACE. The present paper summarizes these developments.

Transcatheter arterial chemoembolization combined with radiofrequency or microwave ablation for hepatocellular carcinoma: a review

Hepatocellular carcinoma (HCC) is the sixth most common type of malignancy. Several therapies are available for HCC and are determined by stage of presentation, patient clinical status and liver function. Local–regional treatment options, including transcatheter arterial chemoembolization, radiofrequency ablation or microwave ablation, are safe and effective for HCC but are accompanied by limitations. The synergistic effects of combined transcatheter arterial chemoembolization and radiofrequency ablation/microwave ablation may overcome these limitations and improve the therapeutic outcome. The purpose of this article is to review the current literature on these combined therapies and examine their efficacy, safety and influence on the overall and recurrence-free survival in patients with HCC.

Network Propagation Predicts Drug Synergy in Cancers

Combination therapies are commonly used to treat patients with complex diseases that respond poorly to single-agent therapies. In vitro high-throughput drug screening is a standard method for preclinical prioritization of synergistic drug combinations, but it can be impractical for large drug sets. Computational methods are thus being actively explored; however, most published methods were built on a limited size of cancer cell lines or drugs, and it remains a challenge to predict synergism at a large scale where the diversity within the data escalates the difficulty of prediction. Here, we present a state-of-the-field synergy prediction algorithm, which ranked first in all subchallenges in the AstraZeneca-Sanger Drug Combination Prediction DREAM Challenge. The model was built and evaluated using the largest drug combination screening dataset at the time of the competition, consisting of approximately 11,500 experimentally tested synergy scores of 118 drugs in 85 cancer cell lines. We developed a novel feature extraction strategy by integrating the cross-cell and cross-drug information with a novel network propagation method and then assembled the information in monotherapy and simulated molecular data to predict drug synergy. This represents a significant conceptual advancement of synergy prediction, using extracted features in the form of simulated posttreatment molecular profiles when only the pretreatment molecular profile is available. Our cross-tissue synergism prediction algorithm achieves promising accuracy comparable with the correlation between experimental replicates and can be applied to other cancer cell lines and drugs to guide therapeutic choices.Significance: This study presents a novel network propagation-based method that predicts anticancer drug synergy to the accuracy of experimental replicates, which establishes a state-of-the-field method as benchmarked by the pharmacogenomics research community involving models generated by 160 teams. Cancer Res; 78(18); 5446-57. ©2018 AACR.

A concept for electromagnetic navigated targeting of liver tumors using an angiographic approach

BACKGROUND

The benefits of using navigation technology for percutaneous local ablation of selected hepatocellular carcinoma (HCC) have been shown. Due to additional efforts in the procedural workflow, barriers to introducing navigation systems on a broad clinical level remain high. In this work, initial steps toward a novel concept for simple and precise targeting of HCC are evaluated.

MATERIAL AND METHODS

The proposed technique is based on an angiographic approach using an intrahepatic electromagnetic (EM) reference, for consecutive percutaneous navigated positioning of ablation probes. We evaluated the environmental influence of the angiography suite on EM tracking accuracy, the measurement of a 3 D offset from two 2 D fluoroscopy images, and the accuracy and efficiency of the proposed approach in a porcine liver model.

RESULTS

The C-arm had a major influence on EM tracking accuracy, with an error up to 3.8 mm. The methodology applied for measurement of a 3 D offset from 2 D fluoroscopy images was confirmed to be feasible with a mean error of 0.76 mm. In the porcine liver model experiment, the overall target positioning error (TPE) was 2.0 mm and time for navigated targeting was 17.9 seconds, when using a tracked ablation probe.

CONCLUSIONS

The initial methodology of the proposed technique was confirmed to be feasible, introducing a novel concept for simple and precise navigated targeting of HCC.

Surrogate endpoint for overall survival in assessment of adjuvant therapies after curative treatment for hepatocellular carcinoma: a re-analysis of meta-analyses of individual patients' data

The gold standard endpoint to evaluate the effect of treatment for hepatocellular carcinoma (HCC) is overall survival (OS), but it requires a longer follow-up period to observe. This study aimed to identify whether disease-free survival (DFS) could be used as a surrogate endpoint for OS to assess the efficacy of adjuvant therapies after curative treatment (surgical resection and ablation) for HCC patients. A systematic review was conducted to identify trials about curative treatment combined with or without adjuvant therapies (interferon, IFN; or transarterial chemoembolization, TACE) for HCC. Total of 2211 patients' data from 17 trials were analyzed. At the individual study level, DFS was strongly correlated to OS (ρ = 0.988 and 0.930, 95% CI: 0.965-0.996 and 0.806-0.976 for the studies comparing Radiofrequency ablation (RFA) + TACE to RFA alone; and for the studies comparing curative treatment + IFN to curative treatment alone, respectively). At the trial level, the effects of treatment on DFS and OS were also strongly correlated to each other (R = 0.815 and 0.854, 95% CI: 0.536-0.934 and 0.621-0.948, respectively). In conclusion, DFS could be used as a potential surrogate endpoint for OS to assess the effect of adjuvant therapies after curative treatment for HCC.

Comparison of laparoscopic hepatectomy, percutaneous radiofrequency ablation and open hepatectomy in the treatment of small hepatocellular carcinoma

OBJECTIVE

Three mainstream techniques--laparoscopic hepatectomy (LH), percutaneous radiofrequency ablation (pRFA), and open hepatectomy (OH)--were compared in this study, in terms of their efficacies in the treatment of small hepatocellular carcinoma (HCC).

METHODS

A comparative study was performed within a total of 94 patients diagnosed with small HCC in our hospital from 2005 to 2010, who underwent LH (28), RFA (33), or OH (33). They had either a single tumor lesion of less than or up to three nodules with diameters of less than each. Outcomes were carefully evaluated throughout a 3-year follow-up interval and statistically interpreted.

RESULTS

The pRFA group had a significantly lower disease-free survival rate compared with the two surgical groups (P=0.001) and significantly shorter overall survival (P=0.005), while the LH group and the OH group had no difference in survival results. For patients younger than 60 years old, surgical approaches offered a better long-term overall survival prognosis (P=0.008). There were no statistically significant differences among the three groups in overall survival for elderly patients (P=0.104).

CONCLUSIONS

Among patients with small HCC, LH may provide better curative effects than pRFA without increasing complication rates. pRFA leads to faster recurrence than surgical resections. LH has similar therapeutic effects to OH and causes less trauma. For patients younger than 60 years old, LH may be the best curative treatment. Elderly patients may choose either surgery or pRFA.

Percutaneous microwave ablation for benign focal liver lesions: Initial clinical results

Benign focal liver lesions (BFLLs) have become a common disease diagnosed in the clinical setting following the advancement of imaging techniques. The aim of the present study was to evaluate the safety and clinical outcomes of percutaneous microwave (MW) ablation, guided by ultrasound (US), for the treatment of BFLLs. Between May 2005 and January 2011, 44 BFLLs (mean maximum diameter, 33.9±13.1 mm) in 37 patients (23 women and 14 men) were treated by US-guided percutaneous MW ablation with cooled-shaft antennae. The pathological diagnosis of a BFLL was confirmed in 91.9% (34/37) of patients using a US-guided core needle biopsy prior to ablation. The BFLLs in the other 3 cases were diagnosed by typical presentations on contrast-enhanced imaging, as the patients refused to undergo biopsies. Five inclusion criteria, including indeterminate diagnoses of nodules on contrast-enhanced imaging prior to pathological verification, were recommended. The median follow-up period was 27.0 months (range, 6-73 months). The mean MW ablation energy and time were 55.0±41.6 kJ (range, 13.5-207 kJ) and 1,039.9±706.2 sec (range, 270-3,450 sec) per lesion, respectively. In total, 40 nodules (90.9%) were completely ablated, and no evidence of recurrence was demonstrated on contrast-enhanced imaging follow-up. The other 4 nodules (9.1%) were partially ablated due to the proximity of adjacent vital organs. Minor complications without sequelae included local pain and transient hemoglobinuria and no major complications occurred in peri-ablation. Overall, US-guided percutaneous MW ablation is a safe, effective and minimally invasive therapy for BFLLs in selected patients who are non-surgical candidates.

Management of hepatocellular carcinoma: an overview of major findings from meta-analyses

This paper aims to systematically review the major findings from meta-analyses comparing different treatment options for hepatocellular carcinoma (HCC). A total of 153 relevant papers were searched via the PubMed, EMBASE, and Cochrane library databases. They were classified according to the mainstay treatment modalities (i.e., liver transplantation, surgical resection, radiofrequency ablation, transarterial embolization or chemoembolization, sorafenib, and others). The primary outcome data, such as overall survival, diseases-free survival or recurrence-free survival, progression-free survival, and safety, were summarized. The recommendations and uncertainties regarding the treatment of HCC were also proposed.

Radiofrequency ablation plus chemoembolization versus radiofrequency ablation alone for hepatocellular carcinoma: A systematic review and meta-analysis

BACKGROUND

To determine whether the use of radiofrequency ablation (RFA) plus transcatheter arterial chemoembolization (TACE) is more effective than the use of RFA alone for patients with hepatocellular carcinoma (HCC).

METHODS

A computer-based search was performed. Randomised trials comparing RFA plus TACE and RFA alone for treatment of HCC were included in this meta-analysis. The outcome of interest for our analysis was survival (recurrence-free survival and overall survival).

RESULTS

Eight trials with 648 patients were eligible for this meta-analysis. Our pooled results suggest that RFA plus TACE is associated with a significant advantage in recurrence-free survival (RFS) (HR=0.58; 95% CI=0.42-0.80, P=0.001), and overall survival (OS) (HR=0.60; 95% CI=0.47-0.76, P<0.001).

CONCLUSION

TACE combined with RFA was more effective than RFA alone, especially for treatment for intermediate and large-size hepatic tumours or younger patients with HCC.

Transarterial chemoembolization combination therapy vs monotherapy in unresectable hepatocellular carcinoma: a meta-analysis

PURPOSE

To perform a meta-analysis examining the efficacy of transcatheter arterial chemoembolization (TACE) alone or in combination with radiofrequency ablation (RFA), percutaneous ethanol injection (PEI), or high-intensity focused ultrasound (HIFU) for unresectable hepatocellular carcinoma (HCC).

METHODS

Medline, Embase, the Cochrane Library, and Google Scholar were searched through May 31, 2014, using the following keywords: hepatocellular carcinoma, transarterial chemoembolization, percutaneous ethanol ablation, percutaneous ethanol injection, radiofrequency ablation, and high-intensity focused ultrasound. Randomized controlled trials (RCTs) comparing 1- and 3-year mortality rates in patients with unresectable HCC receiving either TACE alone or TACE in combination with RFA, PEI, or HIFU were included. One- and 3-year survival rates were compared.

RESULTS

Eleven RCTs were included. The total number of patients ranged from 37 to 189, mean age ranged from 52 to 73 years, and percentage male ranged from 54% to 94%. Overall, TACE alone was associated with higher 1-year mortality than TACE combination therapies (pooled odds ratio [OR] 2.47, 95% confidence interval [CI] 1.37 to 4.43, p = 0.003). The 1-year mortality rate between TACE alone vs TACE + PEI was not different, but TACE + PEI was associated with a significantly lower 3-year mortality as compared to TACE alone (pooled OR 6.02, 95% CI 3.03 to 11.93, p&lt;0.001). The RFA alone was associated with higher 1-year mortality compared with TACE + RFA (pooled OR 2.20, 95% CI 1.11 to 4.32, p = 0.023).

CONCLUSIONS

Transcatheter arterial chemoembolization in combination with percutaneous ablation therapies may improve the survival of patients with unresectable HCC.

Transarterial Chemoembolization and (90)Y Radioembolization for Hepatocellular Carcinoma: Review of Current Applications Beyond Intermediate-Stage Disease

OBJECTIVE

The practice guideline of the American Association for the Study of Liver Diseases currently recommends transarterial chemoembolization (TACE) for the treatment of intermediate-stage hepatocellular carcinoma (HCC). The use of transarterial radioembolization (TARE) using (90)Y microspheres is not formally recommended. This article discusses the current clinical applications of TACE and TARE and compares the clinical utility of these techniques for various subpopulations of patients with HCC.

CONCLUSION

For most clinical scenarios, the efficacy and safety of TACE and TARE are probably equivalent. However, TARE appears to have an advantage over TACE in the facilitation of surgical resection by resulting in compensatory hypertrophy of the future liver remnant and possibly in the treatment of patients with portal vein tumor thrombus. On the contrary, TACE is the transarterial treatment of choice for patients with marginal hepatic reserve (i.e., hyperbilirubinemia, ascites) who may be candidates for transplant.

Transarterial chemoembolization for hepatocellular carcinoma: an evidence-based review of its place in therapy

Transarterial chemoembolization (TACE) is the standard treatment for patients with Barcelona Clinic Liver Cancer-intermediate stage hepatocellular carcinoma (HCC). The concept of drug-eluting bead TACE builds on the rationale of intratumoral drug delivery, and drug-eluting bead TACE has been shown to provide consistent and reliable results and to significantly diminish systemic drug exposure, liver toxicity, and drug-related adverse events as compared with conventional TACE. Based on the belief that combinations of TACE and other local or systemic therapies have several theoretical advantages, many clinical trials have been conducted to evaluate the effectiveness of TACE in combination with local treatment such as radiofrequency ablation or radiotherapy, and systemic therapy such as sorafenib or another molecular therapy. TACE has also been used as a preoperative adjuvant chemotherapy in patients with HCC to improve survival and as a bridging therapy before liver transplantation to downstage HCC. In the present evidence-based review, the authors summarize the current status of these transcatheter arterial embolic therapies in HCC.

[Transarterial ablative therapy of hepatocellular carcinoma]

CLINICAL/METHODICAL ISSUE

Due to late diagnosis and a lack of organs only about 30 % of patients suffering from hepatocellular carcinoma (HCC) undergo curative treatment.

STANDARD RADIOLOGICAL METHODS

Transarterial chemoembolization (TACE) is a routine procedure in intermediate stage HCC. In addition transarterial embolization (TAE) and transarterial radioembolization (TARE) are available for these patients.

PERFORMANCE

For inoperable patients with HCC, TACE is superior to best supportive care in terms of survival. Combined with percutaneous ablation TACE achieves results similar to resection.

ACHIEVEMENTS

Current developments, such as drug-eluting beads, TARE and multimodal treatment are well suited to further improve outcome in patients with intermediate stage HCC.

PRACTICAL RECOMMENDATIONS

Transarterial therapies in HCC should be applied in accordance with the Barcelona Clinic Liver Cancer (BCLC) criteria. Due to a better safety profile and potentially improved disease-free survival the use of drug-eluting beads should be liberally considered.

Radiotherapy for liver tumors

Many patients with primary hepatic malignancies present with advanced disease that is not suitable for surgical resection, orthotopic liver transplantation, or radiofrequency ablation. Outcomes are particularly dismal in patients with large, unresectable tumors and/or tumor venous thrombosis. Liver-directed radiotherapy, including stereotactic body radiotherapy (SBRT), is able to treat a variety of tumor sizes and tumors with venous involvement and has demonstrated excellent safety and control outcomes. SBRT should be considered a standard option in patients with early-stage hepatocellular carcinoma who are not candidates for surgical resection, orthotopic liver transplantation or radiofrequency ablation. SBRT should be strongly considered in patients with larger tumors and/or tumors with tumor venous thrombosis who have adequate liver function. Radiotherapy should remain a focus of hepatocellular carcinoma research.

3D conformal radiotherapy combined with transcatheter arterial chemoembolization for hepatocellular carcinoma

AIM: To compare transcatheter arterial chemoembolization (TACE) and 3D conformal radiotherapy (3D-CRT) with TACE monotherapy in hepatocellular carcinoma (HCC).

METHODS: We searched all the eligible studies from the Cochrane Library, PubMed, Medline, Embase, and CNKI. The meta-analysis was performed to assess the survival benefit, tumor response, and the decline in α-fetoprotein (AFP) level. According to the heterogeneity of the studies, pooled OR with 95%CI were calculated using the fixed-effects or random-effects model. An observed OR > 1 indicated that the addition of 3D-CRT to TACE offered survival benefits to patients that could be considered statistically significant. Statistical analyses were performed using Review Manager Software.

RESULTS: Ten studies met the criteria to perform a meta-analysis including 908 HCC participants, with 400 patients in the TACE/3D-CRT combination group and 508 in the TACE alone group. TACE combined with 3D-CRT significantly improved 1-, 2- and 3-year overall survival compared with TACE monotherapy (OR = 1.87, 95%CI: 1.37-2.55, P < 0.0001), (OR = 2.38, 95%CI: 1.78-3.17, P < 0.00001) and (OR = 2.97, 95%CI: 2.10-4.21, P < 0.00001). In addition, TACE plus 3D-CRT was associated with a higher tumor response (complete remission and partial remission) (OR = 3.81; 95%CI: 2.70-5.37; P < 0.00001), and decline rates of AFP level (OR = 3.24, 95%CI: 2.09-5.02, P < 0.00001).

CONCLUSION: This meta-analysis demonstrated that TACE combined with 3D-CRT was better than TACE monotherapy for patients with HCC, which needs to be confirmed by large multicenter trials．

Overview and recent trends of systematic reviews and meta-analyses in hepatology

A systematic review (SR) is a research methodology that involves a comprehensive search for and analysis of relevant studies on a specific topic. A strict and objective research process is conducted that comprises a systematic and comprehensive literature search in accordance with predetermined inclusion/exclusion criteria, and an assessment of the risk of bias of the selected literature. SRs require a multidisciplinary approach that necessitates cooperation with clinical experts, methodologists, other experts, and statisticians. A meta-analysis (MA) is a statistical method of quantitatively synthesizing data, where possible, from the primary literature selected for the SR. Review articles differ from SRs in that they lack a systematic methodology such as a literature search, selection of studies according to strict criteria, assessment of risk bias, and synthesis of the study results. The importance of evidence-based medicine (EBM) in the decision-making for public policy has recently been increasing thanks to the realization that it should be based on scientific research data. SRs and MAs are essential for EBM strategy and evidence-based clinical practice guidelines. This review addresses the current trends in SRs and MAs in the field of hepatology via a search of recently published articles in the Cochrane Library and Ovid-MEDLINE.

Latin American Association for the Study of the Liver (LAASL) clinical practice guidelines: management of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer in the world and the third most common cause of cancer death, and accounts for 5.6% of all cancers. Nearly 82% of the approximately 550,000 liver cancer deaths each year occur in Asia. In some regions, cancer-related death from HCC is second only to lung cancer. The incidence and mortality of HCC are increasing in America countries as a result of an ageing cohort infected with chronic hepatitis C, and are expected to continue to rise as a consequence of the obesity epidemic. Clinical care and survival for patients with HCC has advanced considerably during the last two decades, thanks to improvements in patient stratification, an enhanced understanding of the pathophysiology of the disease, and because of developments in diagnostic procedures and the introduction of novel therapies and strategies in prevention. Nevertheless, HCC remains the third most common cause of cancer-related deaths worldwide. These LAASL recommendations on treatment of hepatocellular carcinoma are intended to assist physicians and other healthcare providers, as well as patients and other interested individuals, in the clinical decision-making process by describing the optimal management of patients with liver cancer.