TREATMENT OF HEPATOCELLULAR CARCINOMA WITH MACROSCOPIC VASCULAR INVASION: A SYSTEMATIC REVIEW AND NETWORK META-ANALYSIS
Francisco Tustumi*, Fabrício F. Coelho, Daniel d. Magalhães, Sergio Silveira, Vagner B. Jeismann, Gilton M. Fonseca, Jaime Arthur Pirola Kruger, Luiz C. D'Albuquerque, Paulo Herman
Universidade de Sao Paulo, Sao Paulo, São Paulo, Brazil
BACKGROUND: Hepatocellular carcinoma (HCC) with macroscopic vascular invasion is frequently addressed with non-curative treatments, especially systemic chemotherapy. Otherwise, some centers advocate liver resection (LR) for HCC with non-main trunk portal vein invasion. In fact, the best approach for this subgroup of patients is controversial. The aim of this study was to evaluate the outcomes of different treatments for patients with HCC and macroscopic vascular invasion.
METHODS: A systematic review and meta-analysis following the PRISMA recommendations were performed. The search was performed in PubMed, Embase, Cochrane (CENTRAL), and LILACS/BVS. We included retrospective or prospective studies that compared LR with other types of treatment, including transarterial chemoembolization (TACE) and systemic chemotherapy, in patients with HCC and macrovascular invasion. Risk of bias was performed with Robins-I and certainty assessment with GRADEPro. Results were expressed as risk difference (RD) with the corresponding 95% confidence interval (95% CI). The I2 statistics were applied to investigate statistical heterogeneity, and a random model was used. A network analysis was used to compare LR with TACE and chemotherapy.
RESULTS: The initial search found 890 articles, and after applying eligibility criteria, 13 studies were finally included. All included studies were observational, with the mean age across the studies ranging from 47 to 65 years. There was a male predominance in all studies (range 75 to 95%). All studies comprised mainly Child-Pugh A patients (range 73 to 100%). LR had similar mortality to non-LR alternatives (RD= 0.00; 95% CI -0.00 to 0.00; I2=1.5%). LR had a higher rate of complications than non-LR therapies (RD= 0.06; 95% CI 0.00 to 0.12; I2=62.5%). LR showed a higher 3-year overall survival rate (RD= 0.12; 95% CI 0.05 to 0.20; I2 85%). In the network meta-analysis, the risk of death in 3-year follow-up was lower in the LR group than in the TACE group (network RD: -0.149; 95% CI -0.227 to -0.071) and than the chemotherapy group (network RD: -0.117; 95% CI -0.006 to -0.227). Chemotherapy and TACE had similar survival outcomes (network RD: -0.033; 95% CI -0.148 to 0.083). There was no significant inconsistency. See Figure 1. The main risk of bias was related to the risk of selection bias, and certainty was very low.
CONCLUSION: LR was associated with a higher risk of procedure-related complications; however, offers a higher chance for long-term survival than non-LR alternatives in patients with HCC and macroscopic vascular invasion.
Figure 1. Network meta-analysis (NMA) and Network map for 3-year overall survival. NMA compared direct and indirect evidence for liver resection (LR), transarterial chemoembolization (TACE), and chemotherapy.
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