Effect of Yttrium-90 transarterial radioembolization in patients with non-surgical hepatocellular carcinoma: A systematic review and meta-analysis

Abstract

Background: Recently, the use of Yttrium-90 transarterial radioembolization in non-surgical hepatocellular carcinoma was suggested but the evidence supporting its use is unclear.

Methods: We searched Medline, Embase, Web of Science and Cochrane CENTRAL from inception up to April 14, 2020 for randomized controlled trials comparing Y90-TARE to standard of care in non-surgical HCC patients. Our primary outcome was overall survival (OS). Our secondary outcomes were progression-free survival, time to progression, disease control rate, grade ≥3 adverse events and rates of gastro-intestinal ulcers. Hazard ratios (HR) and risk ratios (RR) with random-effects model were used for our analyses. The risk of bias of the included studies was assessed using Cochrane's RoB 2 tool.

Results: Of 1,604 citations identified, eight studies (1,439 patients) were included in our analysis. No improvement in overall survival were noted when Yttrium-90 transarterial radioembolization was compared to standard treatments (HR 0.99 [95% CI 0.81-1.21], 6 studies, I2 = 77.6%). However, Yttrium-90 transarterial radioembolization was associated with fewer grade ≥3 adverse events (RR 0.64 [95% CI 0.45-0.92], 7 studies, I2 = 66%). No difference was observed on other secondary outcomes.

Discussion: In non-surgical HCC patients, Yttrium-90 transarterial radioembolization was not associated with significant effect on survival, progression-free survival, time to progression, disease control rate and the incidence of gastro-intestinal ulcers but was however associated with significantly lower rates of grade ≥3 adverse events. Further randomized controlled trials are warranted to better delineate optimal treatment.

Fig 1. PRISMA flow diagram.

The PRISMA flow diagram for the systematic review detailing the database searches, the number of citations screened, and the full texts retrieved.

Fig 2. Risk of bias of the primary outcome, overall survival.

Weighted graph showing the risk of bias according to each domain. Green = low risk. Yellow = some concerns. Red = high risk.

Fig 3. Forest plot of time-to-event outcomes.

Cumulative (log)HR estimates with their 95% confidence intervals in the random-effects model for (A) overall survival, (B) progression-free survival, and (C) time to progression.