| Background:Hepatocellular carcinoma is the sixth most common neoplasm and the third most frequent cause of cancer death. More than700000cases of this malignant disease were diagnosed per year, with an age-adjusted worldwide incidence of16cases per100000inhabitants. Potentially curative treatments for HCC include surgical resection, liver transplantation, and local ablative therapy. Among these, surgical resection is regarded as a standard treatment that offers a chance of cure for patients with preserved liver function. Unfortunately, long-term survival after hepatectomy is unsatisfactory because of the high incidence of tumor recurrence, especially intrahepatic recurrence. Owing to the recurring nature of HCC and the lack of effective adjuvant systemic therapies, it was hypothesized that use of TACE or TAE in the setting of curative HCC may improve survival by reducing recurrences. But available published work reports controversial results.Aim:1. To evaluate the effect of TAE or TACE on recurrence and survival for curative resection of HCC;2. To evaluate the safety of TAE or TACE;3. Stratified analyses:timing of intervention, preoperative or postoperative; HCC characteristics, mean tumor size<5cm or>5cm; the courses of TACE, one course or multiple courses; drugs of TACE, with or without gelatin sponge.Methods:We conducted a systematic search using electronic databases (PubMed, EMBASE, Cochrane Library databases and Science Citation Index Expanded) for all the published studies without restriction of language or publication type (last published work search date:28July2013). Reference lists of all identified papers (included studies and relevant reviews) were checked for additional studies suitable for inclusion. All randomized controlled trials comparing TACE or TAE plus operation versus operation only were considered for this review. Two authors independently identified the trials for inclusion, extracted data and assessed the risk of bias. Results were performed with disease-free survival (DFS) and overall survival (OS) as the primary endpoint. Tumor response and adverse events were secondary endpoints. Results were expressed as Hazard Ratio (HR) for time-to-event outcomes with95%confidence intervals (CI).The statistics were performed by RevMan version5.1. All studies were analyzed using the ’intention to treat’ principle.Results:A total of10studies involving909HCC participants finally fulfilled the predefined inclusion criteria. Four trials assessed preoperative TACE versus control and six trials assessed postoperative TACE versus control. There were significant improvements for DFS (HR0.64[95%CI0.51-0.80]) and OS (HR0.60[0.46-0.79]) in the postoperative TACE compared with the control, especially for DFS when the mean tumor size was bigger than5cm (DFS:HR0.62[0.49-0.79]). However, preoperative TACE did not improve DFS (HR0.92[0.71-1.20]) and OS (HR1.07[0.78-1.46]) for curative resection of HCC. Substantial differences in criteria for assessing tumor response did not allow quantitative analyses. Fever (26.7%-85.9%), abdominal pain (19.3%-71.2%), nausea/vomiting (27.4%-66.3%) were common adverse events. Relatively rare but more serious complications were also reported.Conclusion:Our study suggested postoperative TACE or TAE seems a potential benefits on DFS and OS for curative resection HCC, especially for DFS when the mean tumor size is bigger than5cm. However, there is no firm evidence to support or refute preoperative TACE or TAE for curative resection HCC, further high-quality randomized controlled trials are needed. In addition, Future trials should also focus on other clinically relevant aspects, such as quality of life and adverse effects. |
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