Meta-analysis: evaluation of adjuvant therapy after curative liver resection for hepatocellular carcinoma

Recent updates in the use of pharmacological therapies for downstaging in patients with hepatocellular carcinoma

INTRODUCTION

Hepatocellular carcinoma (HCC) is the most frequent primary liver cancer, but only 20-30% of patients benefit from potentially curative treatments such as liver resection or transplantation. This article reviews conventional treatments and recent progress in pharmacotherapy for advanced HCC, with a focus on downstaging unresectable tumors to resectable status.

AREAS COVERED

In this article, conventional treatments and recent progress in pharmacotherapy for advanced HCC, aiming at downstaging from unresectable to resectable status, are reviewed. Future prospectives of combination therapies using immune checkpoint inhibitors were also introduced by reviewing recent clinical trials, paying attention to the objective response rate as its potential of downstaging treatments.

EXPERT OPINION

The newly developed pharmacological therapies showed higher responses. Although various tumor statuses in advanced HCC hamper detailed analysis of successful conversion rate, the novel combined immunotherapies are expected to provide more opportunities for subsequent curative surgery for initially unresectable advanced HCC. The conversion treatment strategies for unresectable HCC should be separately discussed for 'technically resectable but oncologically unfavorable' HCC and metastatic or invasive HCC beyond curative surgical treatments. The optimal downstaging treatment strategy for advanced HCC is awaited. Elucidation of preoperatively available factors that predict successful downstaging will allow the tailoring of promising initial treatments leading to conversion surgery.

Vessels that encapsulate tumor clusters (VETC) pattern predicts the efficacy of adjuvant TACE in hepatocellular carcinoma

PURPOSE

Postoperative adjuvant trans-catheter arterial chemoembolization (TACE) is regarded as a common strategy for hepatocellular carcinoma (HCC) patients at a high risk of recurrence. However, there are currently no clinically available biomarkers to predict adjuvant TACE response. Vessels that encapsulate tumor clusters (VETC) can be used as an independent predictor of HCC prognosis. In this study, we aimed to explore whether the VETC pattern could predict adjuvant TACE benefit.

METHODS

Vascular pattern and HIF-1α expression were detected in immunohistochemistry. The survival benefit of adjuvant TACE therapy for patients with or without VETC pattern (VETC+ /VETC-) was evaluated.

RESULTS

The adjuvant TACE therapy obviously improved the TTR and OS in VETC+ patients, while adjuvant TACE therapy could not benefit from VETC- patients. Univariate and multivariate analysis revealed that adjuvant TACE therapy significantly improved the TTR and OS in VETC+ patients, but not in VETC- patients. In addition, the VETC+ , but not VETC- , patients could benefit from adjuvant TACE therapy in patients with high-risk factors of vascular invasion, larger tumor or multiple tumor. The mechanistic investigations revealed that the favorable efficacy of adjuvant TACE on VETC+ patients, but not VETC- ones, may be not due to the activation of HIF-1α pathway.

CONCLUSION

The VETC pattern may represent a novel and reliable factor for selecting HCC patients who may benefit from adjuvant TACE therapy, and the combination of VETC pattern and tumor characteristics may help stratify patients' outcomes and responses to adjuvant TACE therapy.

Robotic and robotic-assisted vs laparoscopic rectal cancer surgery: A meta-analysis of short-term and long-term results

The usage of robotic surgery in rectal cancer (RC) is increasing, but there is an ongoing debate as to whether it provides any benefit. This study conducted a meta-analysis of rectal cancer surgery for short-term and long-term outcome by Robotic and robotic-assisted surgery (RS) vs laparoscopic surgery (LS).Pubmed, Embase, Ovid, CNKI, Cochrane Library and Web of Science databases were searched. Studies clearly documenting a comparison of short-term and long-term effect between RS and LS for RC were selected. Lymph node harvested, operation time, hospital stay, circumferential resection margins（CRM), complications, 3-year disease-free survival (DFS) and 5-year DFS parameters were evaluated. All data were performed by Review Manager 5.3 software. Nine studies were collected that included 1436 cases in total, 716 (49.86%) in the RS group, 720(50.14%) in the LS group. Compared with LS, RS was associated with longer operation time (MD 35.19, 95%CI [7.57, 62.81]; P = 0.01), but similar hospital stay (MD -0.43, 95%CI [-0.87,0.01]; P = 0.05).Lymph node harvested, CRM, complications, 3-year DFS, 5-year DFS had no significance difference between RS and LS groups（MD -0.67，95%CI[-1.53，0.19]；P = 0.13；MD 0.86，95%CI[0.54,1.37]；P = 0.52；MD 0.97，95%CI [0.73,1.29]；P = 0.86；MD 0.94，95%CI[0.60,1.48]；P = 0.79；MD 0.88，95%CI[0.52,1.47]；P = 0.61 respectively）.RS is feasible and safe for RC. It has an advantage in short -term outcome and a similar effect in long-term outcome compared with LS.

Adjuvant transarterial chemotherapy for margin-positive resection of hepatocellular carcinoma-a propensity score matched analysis

BACKGROUND AND AIMS

Hepatectomy is a well-established curative treatment for hepatocellular carcinoma. However, the role of adjuvant therapy is controversial. This study examines the efficacy of adjuvant transarterial chemotherapy for hepatocellular carcinoma.

METHODS

The data of hepatocellular carcinoma patients undergoing curative hepatectomy was reviewed. Those with adjuvant transarterial chemotherapy were matched with those without using propensity score analysis, by tumour size and number, indocyanine green retention rate, disease staging and Child-Pugh grading. The groups were compared.

RESULTS

Eighty-seven patients with hepatocellular carcinoma who underwent hepatectomy received adjuvant transarterial chemotherapy (TAC group), and were matched with 870 patients who did not (no-TAC group). The groups were largely comparable in patient and disease characteristics, but the TAC group experienced more blood loss, higher transfusion rates, narrower margins and more positive margins. The two groups were found to be comparable in disease-free and overall survival rates. In margin-positive patients, those given TAC survived longer than those without, and margin-positive patients in the TAC group had overall survival rates similar to margin-negative patients in the no-TAC group.

CONCLUSIONS

Margin involvement is an adverse factor for survival in HCC. Adjuvant transarterial chemotherapy may offer survival benefits to hepatocellular carcinoma patients with positive surgical margins.

Adjuvant Transarterial Chemoembolization Following Curative-Intent Hepatectomy Versus Hepatectomy Alone for Hepatocellular Carcinoma: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

The role of adjuvant transarterial chemoembolization (TACE) for patients with resectable hepatocellular carcinoma (HCC) undergoing hepatectomy is currently unclear. We performed a systematic review of the literature using the MEDLINE, Embase, and Cochrane Library databases. Random-effects meta-analysis was carried out to compare the overall survival (OS) and recurrence-free survival (RFS) of patients with resectable HCC undergoing hepatectomy followed by adjuvant TACE vs. hepatectomy alone in randomized controlled trials (RCTs). The risk of bias was assessed using the Risk of Bias 2.0 tool. Meta-regression analyses were performed to explore the effect of hepatitis B viral status, microvascular invasion, type of resection (anatomic vs. parenchymal-sparing), and tumor size on the outcomes. Ten eligible RCTs, reporting on 1216 patients in total, were identified. The combination of hepatectomy and adjuvant TACE was associated with superior OS (hazard ratio (HR): 0.66, 95% confidence interval (CI): 0.52 to 0.85; p < 0.001) and RFS (HR: 0.70, 95% CI: 0.56 to 0.88; p < 0.001) compared to hepatectomy alone. There were significant concerns regarding the risk of bias in most of the included studies. Overall, adjuvant TACE may be associated with an oncologic benefit in select HCC patients. However, the applicability of these findings may be limited to Eastern Asian populations, due to the geographically restricted sample. High-quality multinational RCTs, as well as predictive tools to optimize patient selection, are necessary before adjuvant TACE can be routinely implemented into standard practice. PROSPERO Registration ID: CRD42021245758.

Is Postoperative Adjuvant Transcatheter Arterial Infusion Therapy Effective for Patients with Hepatocellular Carcinoma who Underwent Hepatectomy? A Prospective Randomized Controlled Trial

BACKGROUND

The effectiveness of adjuvant transcatheter arterial chemo- or/and chemoembolization therapy after curative hepatectomy of initial hepatocellular carcinoma (HCC) is controversial. This study aimed to evaluate whether hepatectomy combined with adjuvant transcatheter arterial infusion therapy (TAI) for initial HCC has better long-term survival outcomes than hepatectomy alone.

METHODS

From January 2012 to December 2014, a prospective randomized controlled trial of patients with initial HCC was conducted. Then, 114 initial HCC patients were recruited to undergo hepatectomy with adjuvant TAI (TAI group, n = 55) or hepatectomy alone (control group, n = 59) at our institution. The TAI therapy was performed twice, at 3 and 6 months after curative hepatectomy (UMIN 000011900).

RESULTS

The patients treated with TAI had no serious side effects, and operative outcomes did not differ between the two groups. No significant differences were found in the pattern of intrahepatic recurrence or time until recurrence between the two groups. Moreover, no significant differences were found in the relapse-free survival or overall survival. Low cholinesterase level (< 200) had been identified as a risk factor affecting relapse-free survival. Furthermore, compared with surgery alone, adjuvant TAI with hepatectomy improved the overall survival for lower-cholinesterase patients.

CONCLUSIONS

Adjuvant TAI is safe and feasible, but it cannot reduce the incidence of postoperative recurrence or prolong survival for patients who underwent curative hepatectomy for initial HCC.

Postoperative adjuvant transarterial chemoembolization improves the prognosis of hepatocellular carcinoma patients with microvascular invasion: a systematic review and meta-analysis

BACKGROUND

Microvascular invasion has been widely accepted as a major risk factor of hepatocellular carcinoma prognoses after surgery. It is still controversial whether postoperative adjuvant transarterial chemoembolization could improve the survival of hepatocellular carcinoma patients with microvascular invasion.

PURPOSE

To evaluate the effect of postoperative adjuvant transarterial chemoembolization for postoperative hepatocellular carcinoma patients with microvascular invasion.

MATERIAL AND METHODS

PubMed, Web of Science, and Embase databases were searched for eligible studies, and the one-, three-, and five-year recurrence rates and overall survival rates were extracted for meta-analysis.

RESULTS

A total of eight studies were included in this study. The results showed that the one-, three-, and five-year recurrence rate of the postoperative adjuvant transarterial chemoembolization group were better than those of the hepatectomy alone group, with a pooled risk ratio (RR) of 0.66 (95% confidence interval [CI] 0.58-0.75, P < 0.00001), 0.82 (95% CI 0.76-0.88, P < 0.00001), and 0.89 (95% CI 0.82-0.97, P = 0.007), respectively. The overall survival rates with one-, three-, and five-year pooled RR were 0.34 (95% CI 0.25-0.47, P < 0.00001), 0.69 (95% CI 0.60-0.79, P < 0.00001), and 0.78 (95% CI 0.69-0.89, P = 0.0001), respectively. No serious side effects have been reported, indicating that postoperative intervention is safe.

CONCLUSION

For hepatocellular carcinoma patients with microvascular invasion confirmed by postoperative pathology, postoperative adjuvant transarterial chemoembolization is a safe treatment, which could reduce the tumor recurrence rate and improve the patient's overall survival.

A systematic review and meta-analysis of adjuvant transarterial chemoembolization after curative resection for patients with hepatocellular carcinoma

BACKGROUND

The aim of this study was to systematically evaluate and determine those patients with hepatocellular carcinoma (HCC) that would benefit from the administration of postoperative adjuvant transarterial chemoembolization (PA-TACE).

METHODS

PubMed, Embase and Cochrane Library were searched for randomized controlled trials (RCTs) and observational studies up to July 30, 2019. The outcome of Overall survival (OS) and disease-free survival (DFS) were extracted and converted to hazard ratios (HRs) with 95% confidence intervals (95%CIs).

RESULTS

A total of 40 studies (10 RCTs and 30 non-RCTs) involving 11,165 patients were included. Overall, PA-TACE was associated with an increased OS [HR, 0.71 (95% CI, 0.65-0.77); P < 0.001] and DFS [HR, 0.73 (95% CI, 0.66-0.80); P < 0.001]. Subgroup analysis in patients with microvascular invasion (MVI), tumor diameter >5 cm or multinodular tumors demonstrated that PA-TACE improved OS and DFS. In patients without MVI, PA-TACE showed no improvement in OS [HR, 1.14 (95% CI, 0.85-1.53); P = 0.370], and resulted in worse DFS than curative resection alone [HR, 1.20 (95% CI, 1.03-1.39); P = 0.002].

CONCLUSION

This meta-analysis indicated that PA-TACE was beneficial in patients with HCC who were at high risk of postoperative recurrence including tumor diameter >5 cm, multinodular tumors and MVI-positive. In patients with tumor diameter ≤5 cm, single tumor or MVI-negative. PA-TACE does not appear to improve outcomes and may potentially promote postoperative recurrence in certain patients.

Effect of prophylactic transcatheter arterial chemoembolization on hepatocellular carcinoma with microvascular invasion after R0 resection. A case-control study

BACKGROUND

Transcatheter arterial chemoembolization (TACE) is thought to prevent recurrence of hepatocellular carcinoma (HCC), but its efficacy is a matter of controversy.

OBJECTIVES

We investigated the effect of preventive TACE on the tumor, nodes, metastasis (TNM) classification in cases of stage II HCC (T2N0M0) after R0 resection.

DESIGN AND SETTING

Case-control study conducted in a tertiary-level public hospital.

METHODS

We analyzed recurrence rates and mortality rates over time for 250 consecutive cases of HCC in TNM classification cases of stage II HCC (T2N0M0) after R0 resection. These cases were divided into patients who underwent TACE (TACE+) and presented microvascular invasion (MVI+; n = 80); TACE+ but did not present MVI (MIV-; n = 100); MVI+ but did not undergo TACE (TACE-, n = 30); and TACE-/MVI- (n = 40).

RESULTS

MVI+ patients in the TACE+ group had significantly lower recurrence rates and mortality rates at one, two and three years than those in the TACE- group (all P < 0.05). Among MVI- patients, the TACE+ group did not have significantly lower recurrence rates and mortality rates at one, two and three years than the TACE- group (all P > 0.05). Regardless of whether TACE was performed or not, MVI- patients had significantly lower recurrence rates and mortality rates at two and three years after their procedures than did MVI+ patients (all P < 0.05).

CONCLUSION

Recurrence rates and mortality rates for MVI+ patients were significantly higher than for MVI- patients, beyond the first year after TACE. Postoperative adjuvant TACE may be beneficial for HCC patients with MVI.

Adjuvant transarterial chemoembolization for patients with hepatocellular carcinoma after radical hepatectomy: a real world study

Objective: To investigate the clinical value of the adjuvant transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) after radical resection, and identify the potential beneficiaries.Methods: Patients were identified through the primary liver cancer big data (PLCBD) between 2012 and 2015. Overall survival (OS) between adjuvant TACE group and non-TACE was evaluated by Kaplan-Meier before and after propensity scoring match (PSM). Subgroup analysis was conducted stratified by risk factors.Results: A total of 2066 HCC patients receiving radical resection were identified. Patients with multiple tumors, tumor diameter >5 cm, satellite, and advanced stage were more likely to accept adjuvant TACE. Before PSM, the 1-, 3-, and 5-year OS rates in the TACE group and non-TACE group were 89%, 58%, 17%, and 88%, 53%, 13% (p = .43), respectively. While, the corresponding rates were 89%, 58%, 17%, and 86%, 49%, 11%, (p = .038), respectively after 1:1 PSM. In addition, patients were found to significantly benefit from adjuvant TACE if they had age ≥50 years, no cirrhosis, AFP ≤ 200 ng/ml, surgical margin <1 cm, tumor diameter >5 cm, no capsule, no satellite, or CN stage Ib/IIa (all p < .05), but patients with age < 50 years, tumor size ≤5 cm, or CN stage Ia were found to significantly benefit from radical resection in DFS (all p < .05).Conclusion: Currently, we concluded that not all of patients with HCC would benefit from adjuvant TACE. Patients with age ≥50 years, tumor size >5 cm, or CN stage Ib/IIa were strongly recommended to receive adjuvant TACE.

Radiofrequency ablation vs. surgical resection for resectable hepatocellular carcinoma: A systematic review and meta-analysis

The treatment of hepatocellular carcinoma (HCC) is a significant challenge. Although radiofrequency ablation (RFA) has emerged as a popular therapeutic option for patients with resectable HCC, whether it can achieve comparable survival outcomes compared with surgical resection (RES) remains unclear. The aim of the present study was to conduct a meta-analysis to assess the survival outcomes of RFA vs. RES in patients with early resectable HCC tumors. A Medline, Embase, and Cochrane Library search was performed for data published between January 2000 and February 2018. A meta-analysis of the efficacy of RFA compared with RES for HCC was subsequently performed, with particular emphasis on overall survival and disease-free survival (DFS) rates. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using the random-effects model. In the present study, a total of 13,147 patients with HCC were included; of which, 6,727 were treated with RFA and 6,420 were treated with RES. The overall survival rates (OR_1-year, 0.757, 95% CI, 0.578–0.989; OR_3-year, 0.530, 95% CI, 0.401–0.700; OR_5-year, 0.566, 95% CI, 0.423–0.758) and the DRS rates (OR_1-year, 0.569, 95% CI, 0.456–0.711; OR_3-year, 0.418, 95% CI, 0.267–0.653; OR_5-year, 0.374, 95% CI, 0.231–0.606) of RES were significantly higher than those of RFA. The results indicate that RES is superior to RFA for promoting the survival of selected patients with resectable HCC. However, future randomized controlled trials are required to investigate the specific relevance of these modalities in the treatment of HCC.

Effects of TACE and preventive antiviral therapy on HBV reactivation and subsequent hepatitis in hepatocellular carcinoma: a meta-analysis

Background and aim

The impact of transarterial chemoembolization (TACE) and preventive antiviral therapy on the occurrence of hepatitis B virus (HBV) reactivation and subsequent hepatitis remains controversial. This meta-analysis aimed to evaluate the effect of TACE and preventive antiviral therapy on the risk of HBV reactivation and subsequent hepatitis. Meanwhile, we explored the role of HBeAg status in HBV reactivation after TACE.

Methods

We performed this meta-analysis with 11 included studies to assess the effect of TACE and preventive antiviral therapy on predicting clinical outcomes in HBV-related hepatocellular carcinoma (HCC). The pooled odds ratios (OR) were calculated using a random or fixed effects model. PUBMED, MEDLINE, EMBASE and the Cochrane Central Register of Controlled were searched for the included articles (from 2000 to December 2017).

Results

Our results showed that TACE significantly increased the risk of HBV reactivation (OR: 3.70; 95% CI 1.45–9.42; P < 0.01) and subsequent hepatitis (OR: 4.30; 95% CI 2.28–8.13; P < 0.01) in HCC patients. There was no significant difference in HBV reactivation after TACE between HBeAg positive and negative patients (OR: 1.28; 95% CI 0.31–5.34; P = 0.73). Preventive antiviral therapy could statistically reduce the rate of HBV reactivation (OR: 0.08; 95% CI 0.02–0.32; P < 0.01) and hepatitis (OR: 0.22; 95% CI 0.06–0.80; P = 0.02) in those with TACE treatment.

Conclusions

The present study suggested that TACE was associated with a higher possibility of HBV reactivation and subsequent hepatitis. Preventive antiviral therapy is significantly in favor of a protective effect.

Transcatheter hepatic arterial infusion chemotherapy vs sorafenib in the treatment of patients with hepatocellular carcinoma of Barcelona Clinic Liver Cancer stage C: a meta-analysis of Asian population

Objective

To compare the clinical efficacy and safety of transcatheter hepatic arterial infusion chemotherapy (HAIC) with those of sorafenib in the treatment of patients with hepatocellular carcinoma (HCC) of Barcelona Clinic Liver Cancer (BCLC) stage C.

Methods

Potentially relevant studies comparing the clinical efficacy and safety of HAIC with those of sorafenib were searched using Medline, PubMed, Embase, Cochrane Library, and Chinese databases (Wanfang Data and China National Knowledge Infrastructure). Overall survival rate (OSR), tumor response rate, disease control rate (DCR), and serious adverse events (SAEs) were compared and analyzed. Pooled ORs with 95% CIs were calculated using either the fixed-effects model or the random-effects model. All statistical analyses were conducted using Review Manager (version 5.3) from the Cochrane Collaboration.

Results

A total of 1,264 patients were included in this meta-analysis. The results of this study showed that HAIC was associated with significantly higher 1-, 2-, and 3-year OSRs than sorafenib (OR 1.88, 95% CI1-year: [1.27-2.78], P1-year=0.002; OR 2.15, 95% CI2-year: [1.06-4.37], P2-year=0.03; OR 7.90, 95% CI3-year: [2.12-29.42], P3-year=0.002). Compared to sorafenib, HAIC was associated with superior complete response (CR), partial response (PR), and objective response rate (ORR) (OR 3.90, 95% CI_CR: [1.89-8.03], P _CR =0.0002; OR 3.47, 95% CI_PR: [2.31-5.24], P _PR <0.00001; OR 3.02, 95% CI_OR: [2.05-4.45], P _OR <0.0001). There was no statistically significant difference between HAIC and sorafenib in stable disease (SD), progressive disease (PD), DCR, and SAEs (OR 0.86, 95% CI_SD: [0.51-1.45], P _SD =0.56; OR 0.62, 95% CI_PD: [0.35-1.11], P _PD =0.11; OR 0.53, 95% CI_SAE: [0.14-1.92], P _SAE =0.33).

Conclusion

This study showed that HAIC was associated with better efficacy than sorafenib in terms of OSR and tumor response. Therefore, HAIC can be considered as an alternative treatment option for patients with HCCs of BCLC stage C.

Laparoscopic vs open hepatectomy for hepatocellular carcinoma in patients with cirrhosis: A meta-analysis of the long-term survival outcomes

BACKGROUND

In patients with hepatocellular carcinoma (HCC) and cirrhosis, laparoscopic hepatectomy (LH) confers short-term benefits over open hepatectomy (OH) but the long-term outcomes of this procedure are unclear. This systematic review aims to compare the long-term survival outcomes of LH and OH for patients with HCC and underlying cirrhosis.

METHODS

EMBASE, MEDLINE and Scopus databases were searched from date of inception to 7th October 2016. Controlled clinical studies comparing LH to OH for HCC in cirrhotic patients, which reported long-term overall and disease-free survival were included. The studies were evaluated using the MOOSE guidelines and Newcastle-Ottawa Scale. Data were extracted and analysed using a fixed-effects model.

RESULTS

Five non-randomised, retrospective observational studies representing 888 patients were included. LH was associated with significantly lower tumour recurrence [OR: 0.65, 95% CI: 0.48, 0.89]. LH conferred greater overall survival at 1- [HR: 0.41, 95% CI: 0.25, 0.68], 3- [HR: 0.63, 95% CI: 0.46, 0.87] and 5-years [HR: 0.60, 95% CI: 0.45, 0.80]. With LH, there was higher disease-free survival at 1-year [HR: 0.71, 95% CI: 0.53, 0.96], but not at 3- [HR: 0.89, 95% CI: 0.70, 1.14]; and 5-years [HR: 0.85, 95% CI: 0.70, 1.04].

CONCLUSIONS

Laparoscopic surgery is associated with comparable postoperative and survival outcomes in patients with HCC and underlying cirrhosis. With careful selection of patients, this approach is safe, feasible and advantageous.

Adjuvant transarterial chemoembolization for patients after curative resection of hepatocellular carcinoma: a meta-analysis

OBJECTIVE

To evaluate the efficacy and safety of adjuvant transarterial chemoembolization (TACE) after curative hepatectomy in improving the survival of patients with primary hepatocellular carcinoma (HCC).

METHODS

MEDLINE, Embase and the Cochrane Library were searched for randomized or nonrandomized studies comparing postoperative adjuvant TACE with curative resection alone. Meta-analysis was performed after converting time-event data into a hazard ratio (HR), using an inverse diversity model.

RESULTS

Eight randomized controlled trials (RCTs) and 12 retrospective studies matched the selection criteria, thereby including 3191 patients (779 in RCT, 2412 in observational studies) for the meta-analysis. The meta-analysis showed that receiving adjuvant TACE was associated with improved overall survival (OS, ln[HR] = 0.70, 95%CI: 0.63-0.78, p < .001) and recurrence-free survival (RFS, ln[HR] = 0.69, 95%CI: 0.63-0.76, p < .001) after curative hepatectomies. The results of observational studies were consistent with those of RCTs. Furthermore, meta-regression was utilized to detect study-level factors associated with treatment outcome. It revealed that overall survival was similar among patients treated with various combinations of chemotherapeutic drugs. Subgroup analyses demonstrated that repeated TACE interventions do not provide a higher survival benefit compared with a single course, and patients with a single tumor or tumor size ≥5cm might stand to benefit the most from adjuvant TACE therapy.

CONCLUSIONS

This meta-analysis demonstrated that postoperative adjuvant TACE could achieve higher OS and RFS than surgical resection alone. However, these results need to be validated through further high-quality clinical studies.

Perioperative outcomes of robotic surgery for the treatment of lung cancer compared to a conventional video-assisted thoracoscopic surgery (VATS) technique

Aim

To conduct a meta-analysis to determine the relative merits between robotic video-assisted thoracoscopic surgery (R-VATS) and conventional video-assisted thoracoscopic surgery (VATS) for lung cancer.

Results

Fifteen studies matched the selection criterion, which reported 8827 subjects, of whom 1704 underwent R-VATS and 7123 underwent VATS. Compared the perioperative outcomes with VATS, reports of R-VATS indicated unfavorable outcomes considering the operative time (SMD = 0.48, 95% CI 0.15 to 0.81). Meanwhile, the number of dissected lymph nodes (SMD = 0.12, 95% CI -0.27 to 0.51) and hospital stay following surgery (SMD = -0.1; 95% CI -0.27 to 0.07), conversion (RR = 0.68; 95% CI 0.42 to 1.11), morbidity (RR = 0.99, 95% CI 0.92 to 1.07) and mortality (RR = 0.33, 95% CI 0.1 to 1.09) were similar for both procedures.

Materials and Methods

A literature search was performed to identify comparative studies reporting perioperative outcomes for R-VATS and VATS for lung cancer. Pooled risk ratio (RR) and standardized mean differences (SMDs) with 95% confidence intervals (95% CIs) were calculated using either the fixed effects model or the random effects model.

Conclusions

There is no difference in terms of perioperative outcomes between R-VATS and VATS except for the operative time which is significantly high for R-VATS. Further studies are required to confirm these results.

Hepatic artery-infusion chemotherapy improved survival of hepatocellular carcinoma after radical hepatectomy

OBJECTIVE

To evaluate the effect of postoperative hepatic artery-infusion chemotherapy (HAIC) on survival probability in patients with hepatocellular carcinoma (HCC) after radical hepatectomy.

PATIENTS AND METHODS

This retrospective study included 85 patients with HCC who received radical hepatectomy from May 2005 to May 2010. Among these patients, 42 underwent two sessions of HAIC (5-fluoruracil [1,000 mg/m²], oxaliplatin [85 mg/m²], and mitomycin-C [6 mg/m²]) after radical hepatectomy (HAIC group), and 43 underwent radical hepatectomy only (the control group). HAIC-related side effects and long-term survival were retrospectively analyzed.

RESULTS

The HAIC group showed a significantly higher 5-year intrahepatic recurrence-free survival probability and lower risk of intrahepatic recurrence (HR 0.5615, 95% CI 0.3234-0.9749 [log-rank test]; P=0.0332). The HAIC group also had significantly higher 5-year disease-free survival probability (HR 0.591, 95% CI 0.3613-0.9666 [log-rank test]; P=0.0298) and overall survival probability than the control group (HR 0.5768, 95% CI 0.3469-0.9589 [log-rank test]; P=0.0278). No HAIC-related deaths in the HAIC group were reported. All toxicities and complications were controlled, and no patients quit the treatment.

CONCLUSION

HAIC can effectively and safely reduce intrahepatic recurrence and improve the long-term survival of patients with HCC after radical hepatectomy.

CT-based radiomics signature: a potential biomarker for preoperative prediction of early recurrence in hepatocellular carcinoma

PURPOSE

To develop a CT-based radiomics signature and assess its ability for preoperatively predicting the early recurrence (≤1 year) of hepatocellular carcinoma (HCC).

METHODS

A total of 215 HCC patients who underwent partial hepatectomy were enrolled in this retrospective study, and all the patients were followed up at least within 1 year. Radiomics features were extracted from arterial- and portal venous-phase CT images, and a radiomics signature was built by the least absolute shrinkage and selection operator (LASSO) logistic regression model. Preoperative clinical factors associated with early recurrence were evaluated. A radiomics signature, a clinical model, and a combined model were built, and the area under the curve (AUC) of operating characteristics (ROC) was used to explore their performance to discriminate early recurrence.

RESULTS

Twenty-one radiomics features were chosen from 300 candidate features to build a radiomics signature that was significantly associated with early recurrence (P < 0.001), and they presented good performance in the discrimination of early recurrence alone with an AUC of 0.817 (95% CI: 0.758-0.866), sensitivity of 0.794, and specificity of 0.699. The AUCs of the clinical and combined models were 0.781 (95% CI: 0.719-0.834) and 0.836 (95% CI: 0.779-0.883), respectively, with the sensitivity being 0.784 and 0.824, and the specificity being 0.619 and 0.708, respectively. Adding a radiomics signature into conventional clinical variables can significantly improve the accuracy of the preoperative model in predicting early recurrence (P = 0.01).

CONCLUSIONS

The radiomics signature was a significant predictor for early recurrence in HCC. Incorporating radiomics signature into conventional clinical factors performed better for preoperative estimation of early recurrence than with clinical variables alone.

Timely meta-analysis on the efficacy of adoptive immunotherapy for hepatocellular carcinoma patients after curative therapy

Aims

The role of adoptive immunotherapy (AIT) for patients with hepatocellular carcinoma (HCC) who have received curative therapy is still not well illustrated. This timely meta-analysis aims to update the current evidence on efficacy and safety of AIT for patients with HCC who have received curative therapy.

Methods

We searched PubMed, EMBASE, Scopus and the Cochrane Library Through January 2017 for relevant studies. Mortality and tumor recurrence were compared between patients with or without adjuvant AIT. The meta-analysis was performed using Review Manager 5.3.

Results

Eight studies involving 1861 patients met the eligibility criteria and were meta-analyzed. Adjuvant AIT was associated with significantly lower mortality at 1 year (RR 0.64, 95%CI 0.52–0.79), 3 years (RR 0.73, 95%CI 0.65–0.81) and 5 years (RR 0.86, 95%CI 0.79–0.94). Similarly, adjuvant AIT was associated with significantly lower recurrence rate than curative therapies alone at 1 year (RR 0.64, 95%CI 0.49–0.82), 3 years (RR 0.85, 95%CI 0.79–0.91) and 5 years (RR 0.90, 95%CI 0.85–0.95). Short-term outcomes were confirmed in sensitivity analyses based on randomized trials or choice of random- or fixed-effect meta-analysis model. None of the included patients experienced grade 4 adverse events.

Conclusions

This timely meta-analysis confirms the evidence that adjuvant AIT for patients with HCC after curative treatment lowers risk of mortality and tumor recurrence.

Transcatheter Arterial Chemoembolization Plus 131I-Labelled Metuximab versus Transcatheter Arterial Chemoembolization Alone in Intermediate/Advanced Stage Hepatocellular Carcinoma: A Systematic Review and Meta-Analysis

Objective

The aim of the study was to compare transcatheter arterial chemoembolization (TACE) plus ¹³¹I-labelled metuximab with TACE alone for hepatocellular carcinoma (HCC).

Materials and Methods

A comprehensive search was conducted in PubMed, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Chinese BioMedical Literature Database with published date from the earliest to February 29th, 2016. No language restrictions were applied, but only prospective randomized controlled trials (RCTs) or non-RCTs were eligible for a full-text review. The primary outcome was the overall survival (OS) and effective rate (the rate of partial atrophy or complete clearance of the tumor lesion). The odds ratios (ORs) were combined using either the fixed-effects model or random-effects model.

Results

Eight trials (3 RCTs and 5 non-RCTs) were included, involving a total of 1121 patients. Patients receiving combined therapy of TACE plus ¹³¹I-labelled metuximab showed significant improvement in effective rate {OR = 4.00, (95% confidence interval [CI]: 2.40–6.66), p < 0.001}, 1-year OS (OR = 2.03 [95% CI: 1.55–2.67], p < 0.001) and 2-year OS (OR = 2.57 [95% CI: 1.41–4.66], p = 0.002].

Conclusion

TACE plus ¹³¹I-labelled metuximab is more beneficial for treating advanced HCCs than TACE alone in terms of tumor response and OS. Large, multi-center, and blinded randomized trials are required to confirm these findings.

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.

Hepatic resection alone versus in combination with pre- and post-operative transarterial chemoembolization for the treatment of hepatocellular carcinoma: A systematic review and meta-analysis

BACKGROUND AND AIMS

The prognosis of hepatocellular carcinoma (HCC) treated with hepatic resection may be improved by the adjunctive use of transarterial chemoembolization (TACE). This study aimed to systematically compare the outcomes between hepatic resection with and without TACE groups.

METHODS

All relevant randomized controlled trials (RCTs) and non-RCTs were searched by the PubMed, EMBASE, and Cochrane Library databases. Overall survival (OS) and disease-free survival (DFS) were two major outcomes. Meta-analyses were performed according to the timing of TACE (pre- or post-operative TACE). Subgroup analyses were also performed. Hazard ratios (HRs) with 95% confidence intervals (95%CIs) were calculated.

RESULTS

Overall, 55 papers were included (14 RCTs and 41 non-RCTs). Overall meta-analyses demonstrated that OS and DFS were statistically similar between hepatic resection with and without pre-operative TACE groups (HR = 1.01, 95%CI = 0.87-1.19, P = 0.87; HR = 0.91, 95%CI = 0.82-1.01, P = 0.07). Subgroup analyses of RCTs or non-RCTs showed that OS and DFS remained statistically similar between hepatic resection with and without pre-operative TACE groups. Subgroup analysis of incomplete or no tumor necrosis showed that OS was worse in hepatic resection with pre-operative TACE group than in hepatic resection without pre-operative TACE group. By contrast, subgroup analysis of complete tumor necrosis showed that DFS was better in hepatic resection with pre-operative TACE group than in hepatic resection without pre-operative TACE group.Overall meta-analyses demonstrated that OS and DFS were better in hepatic resection with post-operative TACE group than in hepatic resection without post-operative TACE group (HR = 0.85, 95%CI = 0.72-1.00, P = 0.06; HR = 0.83, 95%CI = 0.73-0.94, P = 0.004). Subgroup analyses of RCTs, vascular invasion, or large HCC showed that OS and DFS remained better in hepatic resection with post-operative TACE group than in hepatic resection without post-operative TACE group. By contrast, subgroup analyses of non-RCTs, no vascular invasion, or small HCC showed that OS and DFS were statistically similar between the two groups.

CONCLUSIONS

Post-operative TACE, rather than pre-operative TACE, may be considered as an adjunctive treatment option for HCC treated with hepatic resection.

Clinical assessment before hepatectomy identifies high-risk patients

BACKGROUND

Liver resection is associated with significant morbidity, and assessment of risk is an important part of preoperative consultations. Objective methods exist to assess operative risk, including cardiopulmonary exercise testing (CPX). Subjective assessment is also made in clinic, and patients perceived to be high-risk are referred for CPX at our institution. This article addresses clinicians' ability to identify patients with a higher risk of surgical complications after hepatectomy, using selection for CPX as a surrogate marker for increased operative risk.

MATERIALS AND METHODS

Prospectively collected data on patients undergoing hepatectomy between February 2008 and November 2013 were retrieved and the cohort divided according to CPX referral. Complications were classified using the Clavien-Dindo system.

RESULTS

CPX testing was carried out before 101 of 405 liver resections during the study period. The median age was 72 and 64 in CPX and non-CPX groups, respectively (P < 0.001). The resection size was similar between the groups. No difference was noted for grade III complications between CPX and non-CPX tested-groups; however, 19 (18.8%) and 28 (9.2%) patients suffered grade IV-V complications, respectively (P = 0.009). There was no difference in long-term survival between groups (P = 0.63).

CONCLUSIONS

This study attempts to assess clinicians' ability to identify patients at greater risk of complications after hepatectomy. The confirmation that patients identified in this way are at greater risk of grade IV-V complications demonstrates the value of preoperative counseling. High-risk patients do not have worse long-term outcomes suggesting survival is determined by other factors, particularly disease recurrence.

[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.

Survey of survival among patients with hepatitis C virus-related hepatocellular carcinoma treated with peretinoin, an acyclic retinoid, after the completion of a randomized, placebo-controlled trial

BACKGROUND

This study examined the effects of peretinoin, an acyclic retinoid, on the survival of patients with hepatitis C virus-related hepatocellular carcinoma (HCC) who had completed curative therapy and participated in a randomized, placebo-controlled trial.

METHODS

This study was an investigator-initiated retrospective cohort study. Subjects were all patients who were administered the investigational drug (peretinoin 600 mg/day, peretinoin 300 mg/day, or placebo) in the randomized trial. Survivals between the groups were compared using the log-rank test, and hazard ratios were estimated by Cox regression.

RESULTS

Survey data were collected from all patients (n = 392) who participated in the randomized trial, all of whom were then divided into the peretinoin 600 mg/day (n = 132), peretinoin 300 mg/day (n = 131), and placebo (n = 129) groups. At the median follow-up of 4.9 years, 5-year cumulative survival rates for patients in the 600 mg/day, 300 mg/day, and placebo groups were 73.9, 56.8, and 64.3 %, respectively. Comparison of overall survival among patients classified as Child-Pugh A revealed that survival of the 600 mg/day group (n = 105) was significantly longer than that of the placebo group (n = 108) (hazard ratio 0.575, 95 % CI 0.341-0.967; P = 0.0347).

CONCLUSIONS

Administration of 600 mg/day peretinoin to patients with hepatitis C virus-related HCC who have completed curative therapy may improve survival for those classified as Child-Pugh A, for whom liver function is relatively stable.

Peretinoin after curative therapy of hepatitis C-related hepatocellular carcinoma: a randomized double-blind placebo-controlled study

BACKGROUND

Effective prophylactic therapies have not been established for hepatocellular carcinoma recurrence. Peretinoin represents one novel option for patients with hepatitis C virus-related hepatocellular carcinoma (HCV-HCC), and it was tested in a multicenter, randomized, double-blind, placebo-controlled study.

METHODS

Patients with curative therapy were assigned to one of the following regimens: peretinoin 600, 300 mg/day, or placebo for up to 96 weeks. The primary outcome was recurrence-free survival (RFS).

RESULTS

Of the 401 patients initially enrolled, 377 patients were analyzed for efficacy. The RFS rates in the 600-mg group, the 300-mg group, and the placebo group were 71.9, 63.6, and 66.0 % at 1 year, and 43.7, 24.9, and 29.3 % at 3 years, respectively. The primary comparison of peretinoin (300 and 600-mg) with placebo was not significant (P = 0.434). The dose-response relationship based on the hypothesis that "efficacy begins to increase at 600 mg/day" was significant (P = 0.023, multiplicity-adjusted P = 0.048). The hazard ratios for RFS in the 600-mg group vs. the placebo group were 0.73 [95 % confidence interval (CI) 0.51-1.03] for the entire study period and 0.27 (95 % CI 0.07-0.96) after 2 years of the randomization. Common adverse events included ascites, increased blood pressure, headache, presence of urine albumin, and increased transaminases.

CONCLUSIONS

Although the superiority of peretinoin to placebo could not be validated, 600 mg/day was shown to be the optimal dose, and treatment may possibly reduce the recurrence of HCV-HCC, particularly after 2 years. The efficacy and safety of peretinoin 600 mg/day should continue to be evaluated in further studies.

Adjuvant chemotherapy for patients with primary hepatocellular carcinoma: a meta-analysis

Numerous studies have investigated the effects of adjuvant chemotherapy for primary hepatocellular carcinoma (HCC) patients. We conducted this analysis to evaluate the efficacy of adjuvant chemotherapy in HCC patients after hepatectomy. PubMed/MEDLINE, EMBASE, Cochrane, and other databases were searched for eligible studies. The major endpoints were overall survival (OS) and disease-free survival (DFS). The pooled odds ratio (OR) was calculated using a random-effects model to summarize the results. In the meta-analysis of 13 randomized control trials (RCTs) and 35 observational studies with 4747 patients, hepatectomy plus adjuvant chemotherapy showed superiority over hepatectomy alone in 1-year DFS (OR = 1.86, 1.38-2.51, p < 0.001), 3-year DFS (OR = 2.37, 1.73-3.24, p < 0.001) and 5-year DFS (OR = 1.99, 1.55-2.55, p < 0.001), as well as 1-year OS (OR = 2.16, 95% confidence interval 1.75-2.68, p < 0.001), 3-year OS (OR = 1.77, 1.48-2.13, p < 0.001) and 5-year OS (OR = 1.92, 1.44-2.56, p < 0.001). Subgroup and sensitivity analysis revealed that only adjuvant TACE had significant survival benefits. The meta-analysis of studies involving patients with portal vein tumor thrombus (PVTT), but not other factors related to recurrence risk, revealed favorable outcomes of the Treatment arm over the Control arm. The present study shows that adjuvant chemotherapy can improve outcomes for HCC patients. The benefits of adjuvant TACE have been confirmed whereas the effects of other adjuvant chemotherapy modalities remain uncertain. Adjuvant chemotherapy is likely to be more applicable to certain patient populations for instance those with PVTT, but further research in identifying these patient factors is of importance for tailoring adjuvant therapies to individual patients in the future.

Laparoscopic vs open approach to resection of hepatocellular carcinoma in patients with known cirrhosis: Systematic review and meta-analysis

AIM: To review the currently available literature comparing laparoscopic to open resection of hepatocellular carcinoma (HCC) in patients with known liver cirrhosis.

METHODS: A literature search of MEDLINE, EMBASE, and Cochrane databases was conducted. The search terms used included (laparoscopic OR laparoscopy) AND (hepatic or liver) AND (surgery or resection) AND “hepatocellular carcinoma” AND (cirrhosis or cirrhotic). Furthermore, to widen the search, we also used the “related articles” section. Studies reporting a comparison of outcomes and methods of open vs laparoscopic hepatic resection for HCC in patients with liver cirrhosis were included. Meta-analysis of results was performed using a random effects model to compute relative risk (RR) and for dichotomous variables and standard mean differences (SMD) for continuous variables.

RESULTS: A total of 420 patients from 4 cohort studies were included in final analysis. Patients undergoing laparoscopic procedures had statistically less blood loss compared to the open cohort, SMD of -1.01 (95%CI: -1.23-0.79), P < 0.001, with a reduced risk of transfusion, RR = 0.19 (95%CI: 0.09-0.38), P < 0.001. A wider clearance at tumour resection margins was achieved following a laparoscopic approach, SMD of 0.34 (95%CI: 0.08-0.60), P = 0.011. No significant difference was noted between laparoscopic and open resection operative times, SMD of -0.15 (95%CI: 0.35-0.05), P = 0.142. The overall RR of suffering from postoperative morbidity is 0.25 in favour of the open surgery cohort (95%CI: 0.17-0.37), P < 0.001. Patients under-going laparoscopic surgery had significantly shorter length of stays in hospital compared to the open cohort, SMD of -0.53 (95%CI: -0.73 to -0.32), P < 0.001.

CONCLUSION: This review suggests that laparoscopic resection of hepatocellular carcinoma in patients with cirrhosis is safe and may provide improved patient outcomes when compared to the open technique.

Recurrence and survivals following hepatic resection for hepatocellular carcinoma with major portal/hepatic vein tumor thrombus

AIM

To compare the recurrence and survivals between hepatocellular carcinoma (HCC) with major portal vein tumor thrombus (TT) and major hepatic vein TT after hepatic resection (HR).

METHODS

A retrospective study was carried out with the medical records of 272 patients who underwent hepatic resection and thrombectomy for HCC with major portal vein (group A) or hepatic vein (group B) TT. The clinicopathological parameters, recurrence, survivals and prognostic significance associated with major portal or hepatic vein TT were analyzed.

RESULTS

Patients in group A had a better median survival compared with their counterparts in group B (52 vs 38 weeks; P < 0.001). One-, 2- and 3-year survival rates were markedly greater in group A than in group B (50% vs 38.8%, 26% vs 15.9% and 11.4% vs 6.1%, respectively). There was no statistical difference in recurrence-free survival rate but extrahepatic recurrences were more often seen in group B. In multivariate analysis, TT location (hepatic veins vs portal veins), type of resection (anatomical vs non-anatomical) and liver cirrhosis (none/mild vs moderate/severe) were significant prognostic factors.

CONCLUSION

Patients with HCC and major hepatic vein TT had higher incidence of extrahepatic metastases and worse overall survival after hepatic resection compared with patients with major portal vein TT. With preserved liver function, patients can receive aggressive treatments and survivals could be prolonged.

Postoperative adjuvant arterial chemoembolization improves the survival of hepatitis B virus-related hepatocellular carcinoma: a retrospective control study

BACKGROUND

The survival benefit of postoperative adjuvant transcatheter arterial chemoembolization (TACE) remains controversial.

AIMS

We aim to investigate the survival effect of postoperative adjuvant TACE on the prognosis of hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC) patients (stage B, the Barcelona Clinic Liver Cancer staging).

METHODS

Sixty consecutive HBV-related HCC patients (stage B) from February 2006 to May 2009 undergoing surgical resection were included in this study. Of these 60 patients, 34 patients underwent surgery only (Group A) and 26 patients underwent surgery plus TACE (Group B). We followed-up until May 2013. Overall survival rates as well as prognostic factors were analyzed by the Kaplan-Meier method, the log-rank test or Cox's proportional hazard model. All patients' data were collected from the hospital medical records, which were described precisely after accurate clinical samples detection.

RESULTS

The 1-, 2-, and 3-year overall survival rates in surgery-only group were 58.8, 32.4 and 12.6%, and the rates in surgery plus TACE group were 73.1, 61.5, and 48.9%, respectively (P = 0.033). The median survival time of the two groups after surgery and surgery plus TACE was 15.0 months [95% confidence interval (CI) 10.714-19.286] and 35.0 months (95% CI 20.974-49.026). In multivariate analysis, hemoglobin, HBeAg, peripheral blood regulatory T cells and tumor size were independent prognostic elements for HBV-related HCC patients (stage B).

CONCLUSIONS

Postoperative adjuvant TACE improves the survival of patients with HBV-related HCC (stage B) after curative resection compared to surgery only.

Efficacy and safety of percutaneous radiofrequency ablation versus surgical resection for small hepatocellular carcinoma: a meta-analysis of 23 studies

PURPOSE

The aim of our meta-analysis was to compare the efficacy and safety of radiofrequency ablation (RFA) versus surgical resection for patients with small hepatocellular carcinoma (SHCC).

METHODS

Randomized controlled trials (RCTs) or retrospective studies comparing the RFA with surgical resection for patients with SHCC published from 2004 to 2014 were selected from database of PubMed, EMBASE and Cochrane library. The outcomes including overall survival rate, recurrence-free survival rate, recurrence rate and complications (mortality rate and morbidity rate) were abstracted. Individual and pooled odds ratio with 95% confidence interval of each outcome was analyzed.

RESULTS

Three RCTs and twenty retrospective studies were included with a total of 15,482 patients. The 1-, 3- and 5-year overall survival rate and recurrence-free survival rate of surgical resection were significantly higher than RFA. The 2- and 3-year but not 1-year recurrence rate of RFA was significantly higher than surgical resection. The morbidity rate of complication in surgical resection group was higher than it in RFA group, but the mortality was not different between the two groups.

CONCLUSION

Surgical resection led to a higher overall survival and recurrence-free survival rate in treating SHCC. However, RFA led to a lower morbidity rate of complication than surgical resection.

Postoperative therapy options for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is associated with poor prognosis and often recurs even after curative hepatic resection (HR) or radiofrequency ablation (RFA). In fact, recurrence is the most frequent cause of postoperative death in patients with HCC; it can arise through intrahepatic metastasis by the primary tumor or through the emergence of de novo tumors. Even though studies have examined numerous adjuvant therapies and chemotherapies for their ability to prevent recurrence, no consensus recommendations exist about their clinical application. To gain a comprehensive picture of clinical options, we identified 39 randomized controlled trials, involving 4113 participants, which explore the efficacy of adjuvant or chemotherapies to prevent HCC recurrence after potentially curative HR or RFA. The available evidence suggests a significant improvement in recurrence-free survival and overall survival when transarterial chemoembolization is used for patients who are at high risk for recurrence, lamivudine for patients with hepatitis B virus (HBV)-related HCC (>500 copies of HBV DNA/ml), and interferon-α for patients with hepatitis C virus (HCV)-infected HCC. In contrast, available evidence does not definitively establish clinical benefits of interferon-β for patients with HCV-related HCC, interferon-α for patients with HBV-related HCC, or any of the following therapies for patients with HCC: iodine-125 brachytherapy, autologous tumor vaccination, adoptive immunotherapy, or therapy involving acyclic retinoid, vitamin K2 analog, iodine-131-labeled lipiodol, sorafenib, heparanase inhibitor PI-88, or capecitabine. Though the findings of our review should be interpreted with caution because of clinical heterogeneity and small sample size in the included trials, they highlight gaps in the evidence base, and therefore, may guide future research.

A meta-analysis of adjuvant therapy after potentially curative treatment for hepatocellular carcinoma

BACKGROUND

The high recurrence rate of hepatocellular carcinoma (HCC) after potentially curative treatment determines the long-term prognosis.

OBJECTIVE

To evaluate the efficacy and safety of adjuvant therapies in patients with HCC who have undergone hepatic resection, transplantation or locoregional ablation therapy.

METHODS

Several databases were searched to identify randomized controlled trials (RCTs) fulfilling the predefined selection criteria. Meta-analyses were performed to estimate the effects of adjuvant therapies of any modality on recurrence-free survival (RFS) and overall survival (OS).

RESULTS

Eight adjuvant modalities were identified from 27 eligible RCTs conducted predominantly in Asian populations comparing adjuvant with no adjuvant therapy. Adjuvant chemotherapy, internal radiation and heparanase inhibitor PI-88 therapy failed to improve RFS or OS, while interferon (IFN) therapy yielded significant survival results. The findings of adjuvant vitamin analogue therapy required further examination. Adjuvant adoptive immunotherapy conferred significant benefit for RFS but not for OS. Although cancer vaccine therapy and radioimmunotherapy may improve survival after radical surgery, the results were from single, small-scale trials. Severe side effects were observed in the studies of adjuvant chemotherapy and of IFN therapy.

CONCLUSIONS

Adjuvant IFN therapy can improve both RFS and OS; however, the benefits of using this agent should be weighed against its side effects. Combination of systemic and transhepatic arterial chemotherapy is not recommended for HCC after potentially curative treatment. Other adjuvant therapies produce limited success for survival. Additional RCTs with proper design are required to establish the role of adjuvant therapies for HCC.

Perioperative allogenenic blood transfusion is associated with worse clinical outcomes for hepatocellular carcinoma: a meta-analysis

Background and Objective

The impact of perioperative allogenenic blood transfusion (ABT) on clinical outcomes for hepatocellular carcinoma (HCC) is conflicting and unclear. The aim of this meta-analysis is to evaluate the association between ABT and HCC clinical outcomes. Outcomes evaluated were all-cause death, tumor recurrence and postoperative complications.

Methods

Relevant articles were identified through MEDLINE search (up to November 2012). Meta-analyses were performed by using the fixed or random effect models. Study heterogeneity was assessed by Q-test and I² test. Publication bias was evaluated by funnel plots, Egger′s and Begg’s test.

Results

A total of 5635 cases from 22 studies finally met our inclusion criteria. Meta-analysis indicated HCC patients with ABT had an increased risk of all-cause death at 3 and 5 years after surgery (respectively: OR = 1.92, 95% CI, 1.61–2.29,P<0.001; OR = 1.60, 95% CI, 1.47–1.73,P<0.001 ) compared with those without ABT. The risk of tumor recurrence was significantly higher for ABT cases at 1, 3 and 5 years (respectively: OR = 1.70, 95% CI, 1.38–2.10, P<0.001; OR = 1.22, 95% CI, 1.08–1.38, P<0.001; OR = 1.16, 95% CI, 1.08–1.24, P<0.001). The HCC cases with ABT significantly increased postoperative complications occurrence compared with non-ABT cases (OR = 1.78,95% CI, 1.34–2.37, P<0.001).

Conclusions

The findings from the current meta-analysis demonstrated that ABT was associated with adverse clinical outcomes for HCC patients undergoing surgery, including increased death, recurrence and complications. Therefore, ABT should not be performed if possible.

Peretinoin, an acyclic retinoid, improves the hepatic gene signature of chronic hepatitis C following curative therapy of hepatocellular carcinoma

Background

The acyclic retinoid, peretinoin, has been shown to be effective for suppressing hepatocellular carcinoma (HCC) recurrence after definitive treatment in a small-scale randomized clinical trial. However, little has been documented about the mechanism by which peretinoin exerts its inhibitory effects against recurrent HCC in humans in vivo.

Methods

Twelve hepatitis C virus-positive patients whose HCC had been eradicated through curative resection or ablation underwent liver biopsy at baseline and week 8 of treatment with either a daily dose of 300 or 600 mg peretinoin. RNA isolated from biopsy samples was subjected to gene expression profile analysis.

Results

Peretinoin treatment elevated the expression levels of IGFBP6, RBP1, PRB4, CEBPA, G0S2, TGM2, GPRC5A, CYP26B1, and many other retinoid target genes. Elevated expression was also observed for interferon-, Wnt-, and tumor suppressor-related genes. By contrast, decreased expression levels were found for mTOR- and tumor progression-related genes. Interestingly, gene expression profiles for week 8 of peretinoin treatment could be classified into two groups of recurrence and non-recurrence with a prediction accuracy rate of 79.6% (P<0.05). In the liver of patients with non-recurrence, expression of PDGFC and other angiogenesis genes, cancer stem cell marker genes, and genes related to tumor progression was down-regulated, while expression of genes related to hepatocyte differentiation, tumor suppression genes, and other genes related to apoptosis induction was up-regulated.

Conclusions

Gene expression profiling at week 8 of peretinoin treatment could successfully predict HCC recurrence within 2 years. This study is the first to show the effect of peretinoin in suppressing HCC recurrence in vivo based on gene expression profiles and provides a molecular basis for understanding the efficacy of peretinoin.

Meta-analysis: preoperative transcatheter arterial chemoembolization does not improve prognosis of patients with resectable hepatocellular carcinoma

BACKGROUND

Long-term outcomes of partial liver resection of hepatocellular carcinoma (HCC) remain satisfactory due to high incidences of recurrence. This study was intended to see whether preoperative transcatheter arterial chemoembolization (TACE) reduces postoperative tumor recurrences and prolongs survival of patients with resectable HCC.

METHODS

A computerized literature search was performed to identify relevant articles. The quality of nonrandomized comparative studies (NRCTs) was assessed using the methodological index for nonrandomized studies (MINORS). Data synthesis was performed using Review Manager 5.0 software.

RESULTS

Twenty-one studies (4 randomized controlled trials and 17 NRCTs) with a total of 3,210 participants were suitable for analysis. There was no significant difference in disease-free and overall survival at 5-year (32.1% vs. 30.0% and 40.2% vs. 45.2%), and intra- and extra-hepatic recurrence (51.2% vs.53.6% and 12.9% vs.10.3%) between patients with and without preoperative TACE. Postoperative morbidity (28.9% vs. 26.8%) and in-hospital mortality (4.1% vs. 3.1%) were also similar between the two groups.

CONCLUSIONS

Preoperative TACE does not seem to improve prognosis and therefore it is prudent to recommend it as a preoperative routine procedure for resectable HCC.

Recurrence after anatomic resection versus nonanatomic resection for hepatocellular carcinoma: a meta-analysis

The impact of anatomic resection (AR) as compared to non-anatomic resection (NAR) for hepatocellular carcinoma (HCC) as a factor for preventing intra-hepatic and local recurrence after the initial surgical procedure remains controversial. A systematic review and meta-analysis of nonrandomized trials comparing anatomic resection with non-anatomic resection for HCC published from 1990 to 2010 in PubMed and Medline, Cochrane Library, Embase, and Science Citation Index were therefore performed. Intra-hepatic recurrence, including early and late, and local recurrence were considered as primary outcomes. As secondary outcomes, 5 year survival and 5 year disease-free survival were considered. Pooled effects were calculated utilizing either fixed effects or random effects models. Eleven non-randomized studies including 1,576 patients were identified and analyzed, with 810 patients in the AR group and 766 in the NAR group. Patients in the AR group were characterized by lower prevalence of cirrhosis, more favorable hepatic function, and larger tumor size and higher prevalence of macrovascular invasion compared with patients in the NAR group. Anatomic resection significantly reduced the risks of local recurrence and achieved a better 5 years disease-free survival. Also, anatomic resection was marginally effective for decreasing the early intra-hepatic recurrence. However, it was not advantageous in preventing late intra-hepatic recurrence compared with non-anatomic resection. No differences were found between AR and NAR with respect to postoperative morbidity, mortality, and hospitalization. Anatomic resection can be recommended as superior to non-anatomic resection in terms of reducing the risks of local recurrence, early intra-hepatic recurrence and achieving a better 5 year disease-free survival in HCC patients.

Meta-analysis of simultaneous versus staged resection for synchronous colorectal liver metastases

AIM

  There is no clear consensus on the optimal timing of surgical resection for synchronous colorectal liver metastases (SCLM). This study is a meta-analysis of the available evidence.

METHODS

  Systematic review and meta-analysis of trials comparing outcomes following simultaneous resection with staged resection for SCLM published from 1990 to 2010 in PubMed, Embase, Ovid and Medline. Pooled odds ratios (OR) or weighted mean differences (WMD) with 95% confidence intervals (95% CI) were calculated using either the fixed effects or random effects model.

RESULTS

  Nineteen non-randomized controlled trials (NRCT) studies were included in this analysis. These studies included a total of 2724 patients: 1116 underwent simultaneous resection and 1608 underwent staged resection. Meta-analysis showed that shorter hospital stay (P < 0.001) and lower total complication rate (P < 0.001) were observed in patients undergoing simultaneous resection group. The overall survival rate in the simultaneous resection group did not statistically differ with that in the staged resection group at 1 year (P = 0.13), 3 years (P = 0.26), 5 years (P = 0.38), as well as the 1, 3 and 5 years disease-free survival rates (respectively, P = 0.55; P = 0.16; P = 0.12). No significant difference was noted between the two groups in terms of mortality (P = 0.16), intraoperative blood loss (P = 0.06) and recurrence (P = 0.47).

CONCLUSION

  Simultaneous resection is safe and efficient in the treatment of patients with SCLM while avoiding a second laparotomy. In selected patients, simultaneous resection might be considered as the preferred approach. However, the findings have to be carefully interpreted due to the lower level of evidence and the existence of heterogeneity.

Robotic thyroidectomy versus endoscopic thyroidectomy: a meta-analysis

Background

To conduct a meta-analysis to determine the relative merits of robotic thyroidectomy (RT) and endoscopic thyroidectomy (ET).

Methods

A literature search was performed to identify comparative studies reporting peri-operative outcomes for RT and ET. Pooled odds ratios (ORs) and weighted mean differences (WMDs) with 95% confidence interval (95% CI) were calculated using either a fixed-effects or a random-effects model.

Results

Six studies matched the selection criteria, which reported on 2048 subjects, of whom 978 underwent RT and 1070 underwent ET. Comparing the outcomes of RT with ET, this meta-analysis indicated that RT was associated with more complications (WMD = 1.51, 95% CI 1.18 to 1.94) and greater amount of drainage fluid (WMD = 17.10, 95% CI 5.69 to 28.51). Meanwhile, operating time (WMD = 1.50, 95% CI −39.59 to 42.58), conversion (WMD = 0.63, 95% CI 0.07 to 6.17), post-operative hospital stay (WMD = −0.05; 95% CI −0.18 to 0.08), and the number of lymph nodes harvested (WMD = 0.62, 95% CI −0.29 to 1.53) were similar for both procedures.

Conclusion

The results of this meta-analysis indicated that RT is associated with an increased risk of complications and a greater amount of drainage fluid. Therefore, RT does not appear to have any advantage over ET. Further studies are required to confirm these results.

Colonic stenting vs emergent surgery for acute left-sided malignant colonic obstruction: A systematic review and meta-analysis

AIM: To investigate the effects of emergent preoperative self-expandable metallic stent (SEMS) vs emergent surgery for acute left-sided malignant colonic obstruction.

METHODS: Two investigators independently searched the MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials, as well as references of included studies to identify randomized controlled trials (RCTs) that compared two or more surgical approaches for acute colonic obstruction. Summary risk ratios (RR) and 95% CI for colonic stenting and emergent surgery were calculated.

RESULTS: Eight studies met the selection criteria, involving 444 patients, of whom 219 underwent SEMS and 225 underwent emergent surgery. Seven studies reported difference of the one-stage stoma rates between the two groups (RR, 0.60; 95% CI: 0.48-0.76; P < 0.0001). Only three RCTs described the follow-up stoma rates, which showed no significant difference between the two groups (RR, 0.80; 95% CI: 0.59-1.08; P = 0.14). Difference was not significant in the mortality between the two groups (RR, 0.91; 95% CI: 0.50-1.66; P = 0.77), but there was significant difference (RR, 0.57; 95% CI: 0.44-0.74; P < 0.0001) in the overall morbidity. There were no significant differences between the two groups in the anastomotic leak rate (RR, 0.60; 95% CI: 0.28-1.28; P = 0.19), occurrence of abscesses, including peristomal abscess, intraperitoneal abscess and parietal abscess (RR, 0.83; 95% CI: 0.36-1.95; P = 0.68), and other abdominal complications (RR: 0.67; 95% CI: 0.40-1.12; P = 0.13).

CONCLUSION: SEMS is not obviously more advantageous than emergent surgery for patients with acute left-sided malignant colonic obstruction.

Tumor size of hepatocellular carcinoma in noncirrhotic liver: a controversial predictive factor for outcome after resection

BACKGROUND

Hepatocellular carcinoma in noncirrhotic liver (NC-HCC) presents usually with large size, which is seen as a contraindication to liver transplantation (LT) or even resection. The objective of our single-center study was to identify prognostic factors following resection of large NC-HCCs and to subsequently devise a treatment strategy (including LT) in selected patients.

METHODS

From 2000 to 2010, 89 patients who had hepatic resection for NC-HCC (large ≥ 8 cm in 52) were analyzed with regard to pathological findings, postoperative and long-term outcome.

RESULTS

Five patients died postoperatively. After a mean follow-up of 35 ± 30 months, NC-HCC recurred in 36 patients (26/47 survivors in group 8 cm+, 10/37 in group 8 cm-; p = 0.007). Five-year overall (OS) and disease-free survival (DFS) rates were significantly worse for group 8 cm+ (43.4% vs. 89.2% and 39.3% vs. 60.7% for group 8 cm-, p < 0.05). Seven patients underwent re-hepatectomy and/or LT for isolated intrahepatic recurrence, with 5-year DFS of 57.1%. In a multivariate analysis, the factors associated with poor OS and DFS were vascular invasion and tumor size ≥ 8 cm in the overall population and vascular invasion, fibrosis and satellite nodules in group 8 cm+. Adjuvant transarterial chemotherapy was a protective factor in group 8 cm+. In 22 isolated NC-HCC cases with no vascular invasion or fibrosis, tumor size had no impact on five-year DFS (85%).

CONCLUSIONS

Although patients with NC-HCC ≥ 8 cm had a poorer prognosis, the absence of vascular invasion or fibrosis was associated with excellent survival, regardless of the tumor size. In recurrent patients, aggressive treatment (including LT) can be considered.

Efficacy of adjuvant chemotherapy after surgery when considered over all cancer types: a synthesis of meta-analyses

BACKGROUND

Despite a large number of clinical trials having been conducted to assess the efficacy of adjuvant chemotherapy after surgery for various cancers, whether it is best to use this treatment remains a generally contentious issue for many common cancers. The purpose of this study was to ascertain whether any general conclusions can be drawn about the efficacy or inefficacy of this treatment within different cancer classifications.

METHODS

Meta-analyses of randomized, controlled trials (RCTs) of adjuvant chemotherapy after surgery were synthesized over as many types of cancer as possible. Data sources were Medline, Embase, and the Cochrane library. Eligible meta-analyses were meta-analyses of RCTs for any type of cancer that compared surgery followed by adjuvant chemotherapy with surgery followed by no adjuvant chemotherapy.

RESULTS

The literature search found 25 meta-analyses for 15 cancer types that satisfied the criteria necessary for detailed analysis within this study. The estimates of relative risk for all cause mortality were reported as being less than one (indicating adjuvant chemotherapy is beneficial) by all meta-analyses apart from a meta-analysis for colorectal cancer metastasized to the liver. Moreover, 15 of these meta-analyses also reported that the 95% confidence interval for this relative risk is less than one (indicating statistical significance at the 5% level).

CONCLUSIONS

The results for all cancer types included in this study except for cancer metastasized to the liver can be thought of as supporting each other through the idea of there being a common treatment effect or at least a common range of effect across all (or most) of these cancer types. For example, with regard to cancer types where the evidence in favor of adjuvant chemotherapy after surgery is only moderately strong, the results of this study may encourage more clinicians to regard the use of this treatment as standard practice.

Video-assisted thoracoscopic surgery versus open lobectomy for stage I lung cancer: A meta-analysis of long-term outcomes

The present study aimed to evaluate the evidence comparing video-assisted thoracoscopic surgery (VATS) and open lobectomy for the treatment of stage I lung cancer using meta-analytical techniques. A literature search was undertaken until July 2011 to identify comparative studies evaluating survival rates, recurrence rates and complications. Pooled odds ratios (OR) and 95% confidence intervals (95% CI) were calculated with either the fixed- or random-effects model. These studies included a total of 1,362 patients: 668 treated with VATS and 694 treated with open lobectomy. The overall survival was significantly higher in patients treated with VATS than with open thoracotomy (OR=2.01, 95% CI 1.44-2.78) at 5 years. However, there was no statistically significant difference in 1.3-year overall survival between the VATS and open lobectomy groups (OR=3.21, 95% CI 0.77-13.40; OR=0.91, 95% CI 0.49-1.70). The data did not demonstrate a significant difference in locoregional recurrence (OR=0.58, 95% CI 0.33-1.03) compared to the open lobectomy group, but suggested a reduced systemic recurrence rate (OR=0.52, 95% CI 0.23-0.82) and complications (OR=0.36, 95% CI 0.23-0.57) of VATS. VATS was superior to open lobectomy for the prognosis of stage I lung cancer. However, the findings have to be carefully interpreted due to the lower levels of evidence.

Value of transcatheter arterial chemoembolization with gemcitabine plus oxaliplatin in preventing postoperative recurrence of hepatocellular carcinoma in high-risk patients

AIM: To investigate the value of transcatheter arterial chemoembolization (TACE) with gemcitabine plus oxaliplatin (GEMOX) in preventing postoperative recurrence of hepatocellular carcinoma (HCC) in high-risk patients.

METHODS: The clinical data for 120 HCC patients with high risk factors for postoperative recurrence were analyzed retrospectively. Eighty-eight patients (TACE group) received TACE 3-6 weeks postoperatively, of them 43 (GEMOX group) received new chemotherapeutics including gemcitabine and oxaliplatin and 45 (control group) received conventional chemotherapeutics. Thirty-two patients (operation group) did not receive TACE. The recurrence rate of HCC was compared between these groups within 6 months and 1 year of follow-up.

RESULTS: The recurrence rate of HCC was significantly lower in the TACE group than in the operative group within either 6 months (20.5% vs 37.5%) or 1 year (43.8% vs 59.4%) after operative. The recurrence rate of HCC was significantly lower in the GEMOX group than in the control group within 6 months after operation, but showed no significant difference within 1 year of follow-up. The incidence rates of hyperleukocytosis, nausea and emesis in the GEMOX group were significantly lower than those in the control group.

CONCLUSION: Prophylactic TACE contributes to reducing or postponing the short-term recurrence of HCC in patients with high risk factors for postoperative recurrence, and the chemotherapy regimen including gemcitabine and oxaliplatin shows better effects than conventional ones.

Clinical outcomes of radiofrequency ablation and surgical resection for small hepatocellular carcinoma: a meta-analysis

BACKGROUND AND AIM

To evaluate the evidence comparing radiofrequency ablation (RFA) and surgical resection (RES) on the treatment of hepatocellular carcinoma (HCC) using meta-analytical techniques.

METHODS

Literature search was undertaken until March 2011 to identify comparative studies evaluating survival rates, recurrence rates, and complications. Pooled odds ratios (OR) and 95% confidence intervals (95% CI) were calculated with either the fixed or random effect model.

RESULTS

These studies included a total of 877 patients: 441 treated with RFA and 436 treated with RES. The overall survival was significantly higher in patients treated with RES than RFA at 1, 3 and 5 years (respectively: OR: 0.50, 95% CI: 0.29-0.86; OR: 0.51, 95% CI: 0.28-0.94; OR: 0.62, 95% CI: 0.45-0.84). In the RES group the 1, 3, and 5 years recurrence-free survival rates were significantly higher than the RFA group (respectively: OR: 0.65, 95% CI: 0.44-0.97; OR: 0.65, 95% CI: 0.47-0.89; OR: 0.52, 95% CI: 0.35-0.77). RFA had a higher rate of local recurrence (OR: 4.08, 95% CI: 2.03-8.20). For tumors ≤ 3 cm RES was better than RFA in the 3-year overall survival rates (OR: 0.38, 95% CI: 0.16-0.89).

CONCLUSIONS

Surgical resection was superior to RFA in the treatment of HCC. However, the findings have to be carefully interpreted due to the lower level of evidence.