Comparative effectiveness of different transarterial embolization therapies alone or in combination with local ablative or adjuvant systemic treatments for unresectable hepatocellular carcinoma: A network meta-analysis of randomized controlled trials

Abstract

BackgroundThe optimal transcatheter embolization strategy for patients with unresectable hepatocellular carcinoma (HCC) remains elusive. We conducted a systematic review and network meta-analysis (NMA) of different embolization options for unresectable HCC.MethodsMedical databases were searched for randomized controlled trials evaluating bland transarterial embolization (TAE), conventional TACE, drug-eluting bead chemoembolization (DEB-TACE), or transarterial radioembolization (TARE), either alone or combined with adjuvant chemotherapy, or local liver ablation, or external radiotherapy for unresectable HCC up to June 2017. Random effects Bayesian models with a binomial and normal likelihood were fitted (WinBUGS). Primary endpoint was patient survival expressed as hazard ratios (HR) and 95% credible intervals. An exponential model was used to fit patient survival curves. Safety and objective response were calculated as odds ratios (OR) and accompanying 95% credible intervals. Competing treatments were ranked with the SUCRA statistic. Heterogeneity-adjusted effective sample sizes were calculated to evaluate information size for each comparison. Quality of evidence (QoE) was assessed with the GRADE system adapted for NMA reports. All analyses complied with the ISPOR-AMCP-NCP Task Force Report for good practice in NMA.FindingsThe network of evidence included 55 RCTs (12 direct comparisons) with 5,763 patients with preserved liver function and unresectable HCC (intermediate to advanced stage). All embolization strategies achieved a significant survival gain over control treatment (HR range, 0.42–0.76; very low-to-moderate QoE). However, TACE, DEB-TACE, TARE and adjuvant systemic agents did not confer any survival benefit over bland TAE alone (moderate QoE, except low in case of TARE). There was moderate QoE that TACE combined with external radiation or liver ablation achieved the best patient survival (SUCRA 86% and 96%, respectively). Estimated median survival was 13.9 months in control, 18.1 months in TACE, 20.6 months with DEB-TACE, 20.8 months with bland TAE, 30.1 months in TACE plus external radiotherapy, and 33.3 months in TACE plus liver ablation. TARE was the safest treatment (SUCRA 77%), however, all examined therapies were associated with a significantly higher risk of toxicity over control (OR range, 6.35 to 68.5). TACE, DEB-TACE, TARE and adjuvant systemic agents did not improve objective response over bland embolization alone (OR range, 0.85 to 1.65). There was clinical diversity among included randomized controlled trials, but statistical heterogeneity was low.ConclusionsChemo- and radio-embolization for unresectable hepatocellular carcinoma may improve tumour objective response and patient survival, but are not more effective than bland particle embolization. Chemoembolization combined with external radiotherapy or local liver ablation may significantly improve tumour response and patient survival rates over embolization monotherapies. Quality of evidence remains mostly low to moderate because of clinic...

Stereotactic image‐guided microwave ablation of hepatocellular carcinoma using a computer‐assisted navigation system

“…Indeed, with 5‐year overall survival rates of up to 75%, ablation has been validated as an alternative to resection for very small tumours (Barcelona Clinic Liver Cancer classification [BCLC] stage 0) and patients with limited disease non‐resectable because of associated liver disease (BCLC stage A) . In addition, ablation has shown promising results within combination therapies for advanced disease and is commonly used as bridging to OLT (as recommended by the current AASLD and EASL guidelines) . The major advantage of ablation lies in its minimal‐invasive tissue‐sparing yet locally destructive character, with short hospital stays and low morbidity .…”

Combined Treatments in Liver Ablations

“…31 Despite the limited number of randomized studies, several meta-analyses have been published in the attempt to assess the value of combined TACE-RFA compared with monotherapies (►Table 2). [32][33][34][35][36][37][38][39] The majority of these meta-analyses confirmed that the combination therapy is able to significantly improve local tumor control and OS compared with either RFA or TACE, in selected populations. In particular, while there seems not to be any advantage in small and large-size tumors, the combined approach should be indicated for lesions 3 to 5 cm in size.…”

An incidentally Diagnosed Hepatocellular Carcinoma That Exhibited Unusual Metastasis

“…[13,14] Combined chemoembolization, external radiotherapy, or localized liver ablation are better than embolization alone, prolonging the median survival time by up to 20 months. [13,15] Chemoembolization was performed employing Adriamycin.…”