Transarterial chemoembolization for hepatocellular carcinoma with portal vein tumor thrombus: a meta-analysis

Abstract

Background: Although transarterial chemoembolization (TACE) has been used extensively for advanced hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT), no consensus has been reached and an evidence base for practice is lacking. This meta-analysis evaluated the efficacy and safety of TACE for treatment of HCC with PVTT.

Methods: Ovid Medline, EMBASE, Web of Knowledge, and Cochrane library databases were searched up to August 2012 for controlled trials assessing TACE in patients with PVTT. Data concerning the study design, characteristics of trials, and outcomes were extracted. Hazard ratio (HR) and 95% confidence interval (CI) were calculated using random effects models.

Results: Eight controlled trials involving 1601 HCC patients were included. TACE significantly improved the 6-month (HR, 0.41; 95% CI: 0.32-0.53; z, 6.28; p = 0.000) and 1-year (HR, 0.44; 95% CI: 0.34-0.57; z, 6.22; p = 0.000) overall survival of patients with PVTT compared with conservative treatment. Subgroup analyses showed that TACE was significantly effective in HCC patients whether with main portal vein (MPV) obstruction or with segmental PVTT. Fatal complications were rare, even in patients with MPV obstruction. Temporary liver decompensation and postembolization syndrome occurred frequently. However, they could be treated successfully with conservative treatment.

Conclusions: TACE, as a safe treatment, has potential for incurring a survival benefit for advanced HCC with PVTT, even with MPV obstruction. Further large randomized controlled trials may be needed to confirm this result.

Figure 1

Search flow diagram for studies included in the meta-analysis.

Figure 2

Forest plot of the comparison between TACE and conservative treatment for 6-month OS. A random effects model was used for HCC with PVTT. Each line represents an individual study result with the width of the horizontal line indicating 95% CI, the position of the box representing the point estimate, and the size of the box being proportional to the weight of the study. (KM Kim-1, 2: subgroup Child–Pugh A or Child–Pugh B in HCC with MPV invasion; KM Kim-3, 4: subgroup Child–Pugh A or Child–Pugh B in HCC with segmental PVTT).

Figure 3

Forest plots of the favored effect of TACE for 6-month OS. The plots were based on the degree of portal vein invasion. (A) Subgroup analysis in HCC with MPV. (B) Subgroup analysis in HCC with segmental PVTT. Each line represents an individual study result with the width of the horizontal line indicating 95% CI, the position of the box representing the point estimate, and the size of the box being proportional to the weight of the study. (KM Kim-1, 2: subgroup Child–Pugh A or Child–Pugh B in HCC with MPV invasion).

Figure 4

Forest plots of the favored effect of TACE for 6-month OS. The plot was based on the liver function, Child–Pugh A or B. (A) Subgroup analysis in HCC with PVTT. (B) Subgroup analysis in HCC with MPV invasion only. Each line represents an individual study result with the width of the horizontal line indicating 95% CI, the position of the box representing the point estimate, and the size of the box being proportional to the weight of the study. (KM Kim-1, 3: subgroup MPV invasion or segmental PVTT in HCC with Child–Pugh A; KM Kim-2, 4: subgroup MPV invasion or segmental PVTT in HCC with Child–Pugh B).

Figure 5

Forest plots of the comparison between TACE and hepatic resection or TACI. A random effects model was used for HCC with PVTT. (A) Subgroup analysis between TACE and hepatic resection for 1-year OS based on MPV invasion. (B) Comparison between TACE and TACI for 6-month OS. Each line represents an individual study result with the width of the horizontal line indicating 95% CI, the position of the box representing the point estimate, and the size of the box being proportional to the weight of the study.