Transarterial radioembolization vs chemoembolization for hepatocarcinoma patients: A systematic review and meta-analysis

Abstract

Aim: To compare the efficacy and safety of yttrium-90 radioembolization (Y90RE) and transarterial chemoembolization (TACE) in hepatocellular carcinoma patients.

Methods: Bibliographic research was conducted on main scientific databases. When there was no statistically significant heterogeneity, pooled effects were calculated using a fixed-effects model by means of Mantel-Haenszel test, otherwise, a random-effects model was used with DerSimonian and Laird test. Summary estimates were expressed in terms of odds ratios (ORs) and 95%CI. The probability of publication bias was assessed using funnel plots and with Begg and Mazumdar's test. Sensitivity analysis was finally conducted using the method of excluding extreme data.

Results: A total of 10 studies were analyzed, of which 2 randomized controlled trials. Survival rate (SR) assessed at 1 year showed an absolute similarity between the two treatment groups (OR = 1.01, 95%CI: 0.78-1.31, P = 0.93). As long as time elapsed since the treatment, ORs for survival rate tended to significantly increase, thus meaning better long-term outcomes in patients who underwent Y90RE (2-year SR: OR = 1.43, 1.08-1.89, P = 0.01; 3-year SR: OR = 1.48, 1.03-2.13, P = 0.04). Meta-analysis of plotted hazard ratios (HRs) determined a non-significant overall estimate in favor of Y90RE (HR = 0.91, 0.80-1.04, P = 0.16). Y90RE showed a statistically significant benefit as compared to TACE in terms of higher progression-free survival rate assessed at 1 year (OR = 1.67; 95%CI: 1.10-2.55; P = 0.02). Pooled analyses do not revealed a statistically significant increase in OR for tumor objective responses after Y90RE with respect to TACE (OR = 1.22, 95%CI: 0.69-2.16, P = 0.50). A non-significant trend in favor of Y90RE was observed according to adverse event rate (OR = 0.70, 0.38-1.30, P = 0.26).

Conclusion: Our meta-analysis reveals that Y90RE and TACE show similar effects in terms of survival, response rate and safety profile, although tumor progression is delayed after radioembolization.

Keywords: Hepatocellular carcinoma; Prognosis; Recurrence; Survival; Transarterial chemoembolization; Yttrium-90 radioembolization.

Figure 1

Flow chart summarizing study selection. HCC: Hepatocellular carcinoma; TACE: Transarterial chemoembolization; Y90RE: Yttrium-90 radioembolization.

Figure 2

Forest plot of hazard ratios for overall survival after yttrium-90 radioembolization and transarterial chemoembolization. Overall estimate was non-significantly in favor of Y90RE (HR = 0.91, 0.80-1.04, P = 0.16). There was only a low level of heterogeneity among studies [χ² = 7.32, df = 6 (P = 0.29), I² = 18%)]. Y90RE: Yttrium-90 radioembolization; TACE: Transarterial chemoembolization; HR: Hazard ratio.

Figure 3

Funnel plot for detection of publication bias with regard to overall survival. No evidence of publication bias was detected. HR: Hazard ratio.

Figure 4

Forest plot for 1-year progression-free survival after yttrium-90 radioembolization and transarterial chemoembolization. Y90RE showed a statistically significant benefit in terms of higher progression-free survival rate assessed at 1 year (OR = 1.67, 1.10-2.55, P = 0.02). There was no evidence of heterogeneity among individual studies (P = 0.66; I² = 0%). Y90RE: Yttrium-90 radioembolization; TACE: Transarterial chemoembolization; OR: Odds ratio.

Figure 5

Forest plot for objective response rate after yttrium-90 radioembolization and transarterial chemoembolization. Pooled analyses do not revealed a statistically significant increase in odds ratio for tumor objective responses after Y90RE with respect to TACE (OR = 1.22, 95%CI: 0.69-2.16, P = 0.50). There was, however, evidence of heterogeneity across these studies (P = 0.004; I² = 67%), mainly due to some outlier studies. Y90RE: Yttrium-90 radioembolization; TACE: Transarterial chemoembolization; OR: Odds ratio.

Figure 6

Forest plot for serious adverse event rate after yttrium-90 radioembolization and transarterial chemoembolization. A non-significant trend in favor of Y90RE was observed (OR = 0.70, 0.38-1.30, P = 0.26), but with a high evidence of heterogeneity (I² = 52%; P = 0.05). Y90RE: Yttrium-90 radioembolization; TACE: Transarterial chemoembolization; OR: Odds ratio.