Comparison of transarterial chemoembolization with radiofrequency ablation for unresectable Barcelona Clinic Liver Cancer stage 0/A hepatocellular carcinoma: a propensity score matching

The Impact of Portal Hypertension Assessment Method on the Outcomes of Hepatocellular Carcinoma Resection: A Meta-Analysis of Matched Cohort and Prospective Studies

OBJECTIVE

Examine portal hypertension (PHT) impact on postoperative and survival outcomes in hepatocellular carcinoma (HCC) patients after liver resection (LR), specifically exploring distinctions between indirect signs and invasive measurements of PHT.

BACKGROUND

PHT has historically discouraged LR in individuals with HCC due to the elevated risk of morbidity, including liver decompensation (LD).

METHODS

A systematic review was conducted using 3 databases to identify prospective-controlled and matched cohort studies until December 28, 2022. Focus on comparing postoperative outcomes (mortality, morbidity, and liver-related complications) and overall survival in HCC patients with and without PHT undergoing LR. Three meta-analysis models were utilized: for aggregated data (fixed-effects inverse variance model), for patient-level survival data (one-stage frequentist meta-analysis with gamma-shared frailty Cox proportional hazards model), and for pooled data (Freeman-Tukey exact and double arcsine method).

RESULTS

Nine studies involving 1124 patients were analyzed. Indirect signs of PHT were not significantly associated with higher mortality, overall complications, PHLF or LD. However, LR in patients with hepatic venous pressure gradient (HVPG) ≥10 mm Hg significantly increased the risk of overall complications, PHLF, and LD. Despite elevated risks, the procedure resulted in a 5-year overall survival rate of 55.2%. Open LR significantly increased the risk of overall complications, PHLF, and LD. Conversely, PHT did not show a significant association with worse postoperative outcomes in minimally invasive LR.

CONCLUSIONS

LR in the presence of indirect signs of PHT poses no increased risk of complications. Yet, in HVPG ≥10 mm Hg patients, LR increases overall morbidity and liver-related complications risk. Transjugular HVPG assessment is crucial for LR decisions. Minimally invasive approach seems to be vital for favorable outcomes, especially in HVPG ≥10 mm Hg patients.

Nomogram for predicting pathologic complete response after transarterial chemoembolization in patients with hepatocellular carcinoma

Background

The pathologic responses to transarterial chemoembolization (TACE) in patients with hepatocellular carcinoma (HCC) are heterogeneous and result in disparate outcomes. The study aimed to establish and validate an effective nomogram for predicting pathologic complete response (PCR) after TACE.

Methods

We analyzed the clinicopathologic characteristics of HCC patients undergoing hepatectomy following TACE. Variables with statistical significance in a multivariate logistic regression analysis were incorporated in the nomogram.

Results

We detected PCR in 64 (50.4%) patients in the training cohort and 18 (37.5%) patients in the validation cohort. Univariable and multivariable logistic regression revealed that hepatitis B virus (HBV) DNA load (P=0.031), α-fetoprotein (AFP, P=0.040), maximum tumor diameter (P=0.003), preoperative TACE session (P=0.026), and modified Response Evaluation Criteria in Solid Tumors (mRECIST) complete response (P=0.030) were identified as significant predictors of PCR. Incorporating these 5 factors, a nomogram was developed which attained concordance indexes of 0.80 [95% confidence interval (CI): 0.72–0.87] and 0.82 (95% CI: 0.68–0.95) for predicting PCR in the training and validation cohorts, respectively.

Conclusions

The easy-to-use nomogram achieved a good post-TACE prediction of PCR in HCC patients. Using the model, patients who would benefit most from TACE could be identified, and the subsequent appropriate procedures could be guided accordingly.

Prognostic nomogram for hepatocellular carcinoma with fibrosis of varying degrees: a retrospective cohort study

Background

Hepatocellular carcinoma (HCC) is a common and biologically aggressive malignancy linked to cirrhotic and pre-cirrhotic changes in the liver. We analyzed degrees of fibrosis in affected patients as indices of survival, to establish an effective prognostic nomogram.

Methods

Eligible patients with HCC and hepatic fibrosis, of varying degrees, were selected from the Surveillance, Epidemiology, and End Results (SEER) database for propensity score matching (PSM). The prognostic value of data was determined using Kaplan-Meier and Cox proportional hazards model. A nomogram based on variables derived from multivariate analyses was established and subjected to internal validation. Its predictive accuracy was tested by concordance index (C-index) and calibration plots.

Results

In this propensity score-matched cohort, advanced fibrosis/cirrhosis (vs. none-to-moderate fibrosis) correlated with poorer survival [hazard ratio (HR): 1.131, 95% confidence interval (CI): 1.032-1.240; P=0.009]. Multivariate analysis identified the following as independent risk factors for HCC: age >63 years, higher fibrosis score, American Joint Cancer Committee (AJCC) stages T3-4, distant metastasis (M1), tumor size >1 cm, major vascular invasion, and elevated alpha-fetoprotein (AFP) level. A nomogram that integrated these factors offered a superior prognostic prediction for HCC patients (C-index: 0.749, 95% CI: 0.7485-0.7495) relative to conventional tumor staging the AJCC tumor-node-metastasis (TNM) staging system (0.730). In calibration plots, optimal agreement between nomogram-predicted and observed survival was evident.

Conclusions

Increased fibrosis was an independent risk factor for survival of HCC patients. A prognostic nomogram integrating fibrosis score and other independent risk factors offered more accurate depictions in this regard.

Evaluation of efficacy, safety and treatment-related outcomes of percutaneous radiofrequency ablation versus partial hepatectomy for small primary liver cancer meeting the Milan criteria: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND AND OBJECTIVE

To systematically evaluate the efficacy, safety, and treatment-related outcomes between percutaneous radiofrequency ablation (PtRFA) and partial hepatectomy (PH) for small primary liver cancer meeting the Milan criteria.

METHODS

A systematic review and meta-analysis were conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement. A priori protocol was registered in the PROSPERO database, and a literature search of all relevant studies published on PubMed, Cochrane library, Web of Science database, and Science Direct until July 2019 was performed. Only randomized controlled trials published in English were eligible for inclusion.

RESULTS

Of the 385 identified articles, only five randomized controlled trials involving 761 adult patients with small liver cancer were included in the final analysis. The 1-year, 2-year, 3-year, 4-year, 5-year overall survival and disease-free survival between PtRFA and PH did not reach significant difference (P-value>0.05). The long-term recurrence rate was higher and the recurrence-free survival was lower in patients treated with PtRFA compared with those treated with PH (P-value<0.05), but short-term (1-year) comparisons did not reach statistical significance. With regard to treatment-related complications, serious adverse event risks, analgesics needs, hospital stay and costs, PtRFA had significant superiority compared with PH.

CONCLUSIONS

The overall treatment effects of PtRFA are comparable to PH for small liver cancer. Though patients with PtRFA have a higher long-term recurrence rate, these patients share less complications, few serious adverse event risks, less analgesics needs, shorter hospital stay, and lower costs. PtRFA may be recommended as the preferred treatment of solitary liver tumors<3cm in diameter.

Not All Hepatocellular Carcinoma Patients with Microvascular Invasion After R0 Resection Could Be Benefited from Prophylactic Transarterial Chemoembolization: A Propensity Score Matching Study

Background

Prophylactic transarterial chemoembolization (p-TACE) is strongly recommended for hepatocellular carcinoma (HCC) patients with microvascular invasion (MVI), but the potential beneficiaries remain controversial.

Methods

Data of HCC patients with MVI who underwent R0 resection between December 2013 and December 2015 were identified through the primary liver cancer big data. Disease-free survival (DFS) and overall survival (OS) were compared between patients who received p-TACE or not using Kaplan–Meier survival curves before and after propensity scoring match (PSM).

Results

A total of 695 patients were eligible for this study, including 199 patients (28.6%) receiving p-TACE and 496 patients (71.4%) receiving resection alone. In the crude cohort, median DFS and OS were longer in the p-TACE group than those in the non-TACE group without significant differences (25.0 months vs 24.2 months, P=0.100; 48.0 months vs 46.5 months, P=0.150; respectively), but significant differences were observed both in DFS and OS (both P<0.05) after 1:1 PSM. p-TACE was identified as one of the independent risk factors of both DFS and OS using multivariate analysis in the matched cohort (HR=0.69, 95% CI=0.54–0.88; HR=0.66, 95% CI=0.50–0.88; respectively). Subgroup analysis showed that p-TACE could beneficiate patients if they were male, aged ≥50 years old, had HBV infection, preoperative AFP level ≥400 ng/mL, Child-Pugh grading A, no transfusion, single tumor, tumor diameter ≥5cm, Edmondson–Steiner grading I/II, capsule, or BCLC stage A, CNLC stage Ib, AJCC stage II both in DFS and OS (all P<0.05).

Conclusion

With the current data, we concluded that not all HCC patients with MVI would be benefited from p-TACE, and p-TACE could benefit patients with “middle risk” according to the current staging systems.

Comparison of Microwave Ablation and Transarterial Chemoembolization for Single-Nodule Hepatocellular Carcinoma Smaller Than 5cm: A Propensity Score Matching Analysis

Purpose

To compare overall survival (OS) and progression-free survival (PFS) between microwave ablation (MWA) and transarterial chemoembolization (TACE) for solitary hepatocellular carcinoma (HCC) smaller than 5 cm.

Methods

Patients with solitary HCC smaller than 5cm who initially underwent MWA or TACE were identified in Chinese PLA General Hospital from June 2010 to October 2015. Propensity score matching (PSM) was performed with a 1:1 matching protocol. OS and PFS were compared by using the log-rank test. After matching, subgroup analysis based on tumor size (≤3cm/3.1–5cm) was also conducted. Prognostic factors for OS and PFS were assessed with Cox proportional hazard regression model.

Results

A total of 202 patients (MWA, n=120; TACE, n=82) were identified. After matching, 116 patients were included (58 patients for each treatment group). MWA provided significantly better OS and PFS than TACE for both the entire cohort (OS, P<0.001; PFS, P<0.001) and the matched cohort (OS, P=0.015; PFS, P<0.001). Subgroup analysis showed that among patients with tumor of 3cm or less, the MWA group had significantly better OS (P=0.027) and PFS (P=0.008) than the TACE group. Multivariate Cox regression analysis showed TACE was associated with worse OS (hazard ratio, 2.385; 95% CI: 1.427, 3.985; P=0.001) and PFS (hazard ratio, 2.567; 95% CI: 1.820, 3.622; P<0.001).

Conclusion

MWA outperformed TACE for solitary HCC smaller than 5cm in OS and PFS. For single tumors less than 5cm, especially those smaller ones (≤3cm), priority should be given to MWA when making treatment options between MWA and TACE.

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.

Changes in real-life practice for hepatocellular carcinoma patients in the Republic of Korea over a 12-year period: A nationwide random sample study

Backgrounds & aims

Comprehensive analyses through nationwide hepatocellular carcinoma (HCC) registries are important to understand health care issues. We assessed changes in real-life practice for HCC over a long time period.

Methods

The Korean Liver Cancer Association and the Korean Central Cancer Registry jointly established the nationwide cohorts of newly diagnosed HCC patients between 2003 and 2005 and between 2008 and 2014. According to sorafenib reimbursement in the Republic of Korea (January 2011), patients were divided into early (E-Cohort: 2003~2010) and late (L-Cohort: 2011~2014) cohorts.

Results

L-Cohort (n = 4776) comprised patients with older age (60.8 vs. 58.3 years), higher proportions of patients with well-preserved liver function (75.6% vs. 68.2%) and non-viral etiologies (28.6% vs. 19.4%), and lower proportion of patients with Barcelona Clinic Liver Cancer [BCLC] 0~A stage (46.2% vs. 53.9%) than E-Cohort (n = 8203) (all p<0.05). Proportions of patients undergoing curative treatments were higher in L-Cohort than in E-Cohort (55.0% vs. 35.1%, 23.2 vs. 11.3%, and 17.3% vs. 9.6% in BCLC 0A, B, and C stages, respectively; all p<0.05). Accordingly, compared with that in E-Cohort, overall survival in L-Cohort significantly improved in patients with BCLC 0~A, B, and C stages (all p<0.05). As first-line treatment, 62.4% underwent locoregional treatments (LRTs), whereas only 9.7% received sorafenib, among BCLC stage C patients in L-Cohort.

Conclusions

For the past 12 years, curative treatments became more widely available to BCLC 0~A, B, and C stage patients, generally improving prognosis. Despite sorafenib reimbursement, LRTs remain the mainstay of first-line treatment for BCLC C stage patients.

Does postoperative adjuvant transarterial chemoembolization benefit for all patients with hepatocellular carcinoma combined with microvascular invasion: a meta-analysis

Purpose: To evaluate the clinical efficacy of postoperative adjuvant transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) patients combined with microvascular invasion (MVI). Patients and methods: Eligible studies were searched by PubMed, MedLine, Embase, the Cochrane Library, Web of Science, from 1st January 2000 to 31st December 2018, comparing the overall survival (OS) rates and disease-free survival (DFS) rates between postoperative adjuvant TACE and operation only for HCC patients with MVI. Hazard ratio (HR) with 95% confidence interval (CI) was used to determine the effect size. Results: Eight studies were enrolled in this meta-analysis, including 774 patients in the postoperative adjuvant TACE group and 856 patients in the operation only group. The pooled HR for the OS and DFS rates were significantly different between the postoperative adjuvant TACE group and the operation only group (HR 0.57, 95%CI 0.48 ∼ 0.68, p < .00001; HR 0.66, 95%CI 0.58 ∼ 0.74, p < .00001; respectively). However, in the subgroup analysis stratified by proportion of multiple-nodules, no significant differences were observed in the pooled HR for the OS/DFS rates between the postoperative adjuvant TACE group and the operation only group (HR 0.83, 95%CI 0.60 ∼ 1.13, p = .23; HR 0.76, 95%CI 0.41 ∼ 1.40, p = .37; respectively). Conclusions: Postoperative adjuvant TACE will benefit patients with HCC and MVI, but not for multiple-HCC with MVI. However, more high-quality studies are warranted to validate the conclusion.

Treatment choice for early-stage hepatocellular carcinoma in real-world practice: impact of treatment stage migration to transarterial chemoembolization and treatment response on survival

OBJECTIVE

The objectives of our study were firstly to characterize the treatment stage migration phenomenon in early (Barcelona Clinic Liver Cancer [BCLC]-0/A) stage hepatocellular carcinoma (HCC) by comparing the efficacy of curative therapies with trans-arterial chemoembolization [TACE] and secondly, determining baseline and on-treatment predictors of survival.

METHODS

All patients within BCLC-0/A stage from six tertiary hospitals who received curative therapy with either resection, transplantation, or ablation or TACE as first-line treatment were included in the analyses. The primary endpoint was overall survival; secondary end-points were transplant-free survival and recurrence-free survival.

RESULTS

Between January 2000 and December 2013, we identified 253 BCLC-0/A HCC patients of whom 148 (58.5%) received curative therapy and 105 (41.5%) migrated to TACE. Patients undergoing TACE had lower median survival (2.7 vs. 6.7 years; p < .0001), transplant-free survival (2.6 vs. 4.8 years; p < .0001) and recurrence-free survival (1.3 vs. 2.7 years; p < .001). On multivariate analysis treatment allocation to TACE was an independent prognostic predictor for both lower overall survival (HR 1.70, p = .04) and for HCC recurrence (HR 2.25, p < .001). The main prognostic determinant for each target outcome was Child-Pugh score.

CONCLUSIONS

Our study confirms that curative treatments should always be preferred when applicable in early-stage HCC, but that in cases where this is not possible, TACE is a reasonable albeit inferior treatment option. In addition, it provides unique prognostic information on a significant proportion of patients with early-stage disease in whom curative therapy is not applicable.

Efficacy and safety of transarterial chemoembolisation with cone-beam CT in patients with hepatocellular carcinoma within the Milan criteria: a retrospective cohort study

AIM

To compare the therapeutic efficacy and safety of transarterial chemoembolisation (TACE) for hepatocellular carcinoma (HCC) within the Milan criteria with or without the use of cone-beam computed tomography (CBCT).

MATERIALS AND METHODS

Patients with HCC within the Milan criteria who underwent conventional angiography-guided TACE (Angio-TACE group: 58 patients from January 2010 to December 2011) were compared with those who underwent CBCT-guided TACE (CBCT-TACE group: 55 patients from January 2013 to December 2014). Local progression-free survival (LPFS), progression-free survival (PFS), and overall survival (OS) were compared. Adverse events after TACE were also investigated.

RESULTS

Baseline characteristics were balanced between the two groups. LPFS was significantly longer in the CBCT-TACE group than in the Angio-TACE group (median: not reached for 36 versus 19.2 months, respectively; Log-rank p=0.029). In multivariable Cox regression analysis, CBCT guidance had a significantly lower risk of local progression or death (adjusted hazard ratio: 0.585; 95% confidence interval, 0.344-0.995; p=0.048); however, there was no significant difference in PFS (3-year PFS: 15.9% versus 26.8%, respectively; p=0.122) or OS (3-year OS: 85% versus 88.2%, respectively; p=0.761) between the Angio-TACE and CBCT-TACE groups. Post-embolisation syndrome occurred significantly less frequently in the CBCT-TACE group (p=0.002).

CONCLUSION

CBCT-guided TACE could improve local tumour control for HCC within Milan criteria and showed fewer cases of post-embolisation syndrome.

Transarterial chemoembolization as a substitute to radiofrequency ablation for treating Barcelona Clinic Liver Cancer stage 0/A hepatocellular carcinoma

Background and Aim

Transarterial chemoembolization (TACE) is the standard procedure for treating Barcelona clinic liver cancer (BCLC) stage B hepatocellular carcinoma (HCC). However, it is often carried out in the treatment of BCLC stage 0/A HCC for various reasons. This study aimed to elucidate the prognosis for BCLC stage 0/A HCC patients treated with TACE or with radiofrequency ablation (RFA).

Materials and Methods

The prognosis of 242 BCLC stage 0/A HCC patients within Milan criteria who underwent initially TACE or RFA were retrospectively analyzed using propensity score matching analysis.

Results

The analyses of baseline patient characteristics revealed that the maximum tumor size and the proportion of BCLC stage A patients were significantly higher in patients treated with TACE than in those treated with RFA (P<0.001 and 0.047, respectively). After adjusting these factors using propensity score matching (1:3 matching), patients treated with TACE (n=32) and those treated with RFA (n=96) were further analyzed. The local recurrence rate was significantly higher in the TACE group than in the RFA group (P<0.001). However, the overall survival (OS) in HCC patients treated with TACE was comparable to that in HCC patients treated with RFA (1 year, 93.5 vs. 95.8%; 3 years, 75.4 vs. 85.8%; 5 years, 61.8 vs. 70.7%; P=0.196). Multivariate analyses followed by univariate analyses revealed that serum bilirubin level (P=0.032), serum albumin level (P=0.008), HBV-DNA (P=0.013), and tumor number (P=0.021) were independent predictors of OS.

Conclusion

TACE can substitute RFA at least in some patients with BCLC 0/A HCC.

Transarterial chemoembolization prior to liver transplantation for patients with hepatocellular carcinoma: A meta-analysis

BACKGROUND AND AIM

A debate exists over whether using preoperative transarterial chemoembolization for patients with hepatocellular carcinoma before liver transplantation. Numerous studies have been investigating on this, but there is still no unanimous conclusion about the effect of preoperative transarterial chemoembolization. We conducted the meta-analysis of all available studies to systematically evaluate the influence of preoperative transarterial chemoembolization on liver transplant.

METHODS

A systematic search was performed by two authors (Si TF. and Guan RY.) through PubMed, Embase, Cochrane, and Science Citation Index Expanded, combined with Manual Retrieval and Cited Reference Search. The searching cut-off date was 2016/07/31, and all the data obtained were statistically analyzed using Review Manager version 5.1 software (Copenhagen, The Nordic Cochrane Center, The Cochrane Collaboration, 2011) recommended by Cochrane Collaboration.

RESULTS

The study showed that there was no difference between the experimental group and the control group on perioperative mortality (RR = 1.10, 95% confidence interval (CI) = [0.49-2.48], P = 0.82) or biliary complications (RR = 0.96, 95%CI = [0.66-1.39], P = 0.83). Preoperative transarterial chemoembolization had no obvious effect on improving overall survival (HR = 1.05, 95%CI = [0.65-1.72], P = 0. 83) but would result in a higher rate of vascular complications (RR = 2.01, 95%CI = [1.23-3.27], P = 0.005) and a reduction of disease free survival (HR = 1.66, 95%CI = [1.02-2.70], P = 0.04). Subgroup analysis also revealed that patients from transarterial chemoembolization group in Asia had a much lower overall survival rate (HR = 2.65, 95%CI = [1.49-4.71], P = 0.0009) compared with the control group.

CONCLUSIONS

Considering the possible adverse impacts on liver transplantation and the variation in sensitivity to transarterial chemoembolization, clinicians should be more cautious when considering transarterial chemoembolization as the bridging therapy for patients in the waiting list.