Transarterial therapy for hepatocellular carcinoma: Which technique is more effective? A systematic review of cohort and randomized studies

Background: Chemoembolization ( TACE) improves survival in cirrhotic patients with hepatocellular carcinoma (HCC). The optimal schedule, or whether embolization (TAE) alone gives the same survival advantage, is not known. Purpose: To evaluate whether specific patient characteristics and/or radiological transarterial techniques result in better outcomes. Method: A PubMed search was carried out for cohort and randomized trials (n = 175) testing transarterial therapies; meta-analysis was performed where appropriate. Results: Anticancer drugs were used as sole agent in 75% of cases ( double 15% and triple 6%): doxorubicin (36%), cisplatin (31%), epirubicin (12%), mitoxantrone (8%), mitomycin ( 8%), and SMANCS (5%). Embolizing agents used were: gelatin sponge particles (71%), polyvinyl alcohol (PVA) particles ( 8%), degradable starch microspheres (DSM) (4%), and embospheres ( 4%). Sessions per patient were 2.5 +/- 1.5 ( interval: 2 months). Objective response was 40 +/- 20%; survival rates at 1, 2, 3, and 5 years were: 62 +/- 20%, 42 +/- 17%, 30 +/- 15%, and 19 +/- 16%, respectively, and survival time was 18 +/- 9.5 months. The post-TACE complications were: acute liver failure, 7.5% ( range 0 - 49%); acute renal failure, 1.8% ( 0 - 13%); encephalopathy, 1.8% ( 0 - 16%); ascites, 8.3% ( 0 - 52%); upper gastrointestinal bleeding; 3% ( 0 - 22%); and hepatic or splenic abscess, 1.3% ( 0 - 2.5%). Treatment-related mortality was 2.4% ( 0 - 9.5%), mainly due to acute liver failure. Our metaanalysis of nine randomized controlled trials (RCTs) confirmed that TACE improves survival; but a meta-analysis of TACE versus TAE alone ( 3 RCTs, 412 patients) demonstrated no survival difference. Conclusions: No chemotherapeutic agent appears better than any other. There is no evidence for benefit with lipiodol. Gelatin sponge is the most used embolic agent, but PVA particles may be better. TAE appears as effective as TACE. New strategies to reduce the risk of post-TACE complications are required.