Lipiodol transarterial chemoembolization for hepatocellular carcinoma: A systematic review of efficacy and safety data

Abstract

Transarterial chemoembolization (TACE) using lipiodol-based regimens, including the administration of an anticancer-in-oil emulsion followed by embolic agents, is widely used in the treatment of hepatocellular carcinoma (HCC). This approach has been supported by meta-analyses of randomized, controlled trials (RCTs) performed more than a decade ago. We performed a systematic review to understand current efficacy and safety data of lipiodol TACE in treatment of HCC. A search of the literature published between January 1, 1980 and June 30, 2013 was performed using MEDLINE and EMBASE databases. All potentially relevant publications were reviewed and articles were selected based on predefined inclusion and exclusion criteria. Of a total of 1,564 articles reviewed, 101 articles, including a total of 10,108 patients treated with lipiodol TACE, were selected for the efficacy analysis. Objective response rate was 52.5% (95% confidence interval [CI]: 43.6-61.5). Overall survival (OS) was 70.3% at 1 year, 51.8% at 2 years, 40.4% at 3 years, and 32.4% at 5 years. Median OS was 19.4 months (95% CI: 16.2-22.6). A total of 217 articles presenting precise description on numbers of adverse events (AEs) were selected for the safety review: In these studies, a total of 21,461 AEs were reported in 15,351 patients. Liver enzyme abnormalities were the most commonly observed AE, followed by the symptoms associated with postembolization syndrome. Overall mortality rate was 0.6% and the most common cause of death was related to acute liver insufficiency. Conclusions: In a systematic literature review, survival figures of HCC patients undergoing lipiodol TACE appear to be in line with those reported in previous RCTs, and no new or unexpected safety concerns were identified. (HEPATOLOGY 2016;64:106-116) SEE EDITORIAL ON PAGE 23H epatocellular carcinoma (HCC) is the thirdleading cause of cancer-related death worldwide. (1) Unlike most solid cancers, future incidence and mortality rates for HCC were projected to largely increase in several regions around the world over the next several years, mostly as a result of the dissemination of hepatitis C virus infection. (2,3) Despite the widespread implementation of surveillance programs of at-risk populations, the majority of patients with HCC are diagnosed late, when curative treatments-including liver transplantation, hepatic resection, and image-guided ablation-cannot be applied. (4) Transarterial chemoembolization (TACE) is widely used in treatment of HCC patients unsuitable for radical therapies. The data collected in the Global Investigation of therapeutic DEcisions in hepatocellular

Patient Selection for Transarterial Chemoembolization in Hepatocellular Carcinoma: Importance of Benefit/Risk Assessment

“…Furthermore, the trials were not designed for patient selection. A more recent systematic review with data from more than 10,000 patients with HCC undergoing TACE found that the objective response was 52.5%, while overall survival was 70.3% at 1 year, 51.8% at 2 years, 40.4% at 3 years, and 32.4% at 5 years [21]. These findings are in line with those reported previously.…”

“…material, see www.karger.com/doi/10.1159/000485471) [11][12][13][14][15][16][17][18][19]. Although the findings from these trials were rather heterogeneous, meta-analyses have confirmed an overall survival benefit of TACE [20,21]. One meta-analysis of randomized controlled trials assessed the survival benefit of arterial embolization/chemoembolization in 6 trials reporting 2-year survival and 1 trial reporting 1-year survival in a total of 545 patients [20]; 2-year survival was 41% (range 19-63%) in the treatment group and 27% (range 11-50%) in the control group.…”

“…In the systematic literature review described previously [21], 21,461 adverse events (including complications and toxicities) were reported in 15,351 patients undergoing 27,497 TACE treatments. The most common adverse events were related to the postembolization syndrome, and included liver enzyme abnormalities (18.1%), fever (17.2%), abdominal pain (11.0%), vomiting (6.0%), and nausea (1.7%).…”

Guidelines for Diagnosis and Treatment of Primary Liver Cancer in China (2017 Edition)

“…It has been recognized as one of the most common nonsurgical treatments for liver cancer [80, 82-86] (evidence level 1).…”

“…(5) TACE can be combined with another local treatment or systemic treatment [82], for example: (1) TACE in combination with ablation therapy (RFA, MWA, etc.) [88] (evidence level 2); (2) TACE in combination with radiation therapy [84] (evidence level 2), which could be selectively used for patients with tumor emboli in the portal trunk and inferior vena cava or localized large HCC after TACE; (3) TACE in combination with surgical resection, which should be recommended for large HCCs that have shrunk after TACE and are suitable for surgical resection [88] (evidence level 3); and (4) TACE in combination with systemic treatment, including molecular target drugs, arsenic trioxide, radiolabeled drugs, gene therapy, immunotherapy, and systemic chemotherapy [93, 94].…”