Surgical resection versus transarterial chemoembolization for BCLC intermediate stage hepatocellular carcinoma: a systematic review and meta-analysis

Background & objective: Transarterial chemoembolization (TACE) is recommended as the first-line therapy for intermediate stage hepatocellular carcinoma (HCC) according to the Barcelona Clinic Liver Cancer (BCLC) algorithm. However, in clinical practice, many such patients undergo surgical resection. A meta-analysis with a systematic search of the medical literature was conducted to compare these two procedures for BCLC intermediate stage HCC. Methods: PubMed, Embase, Medline and Cochrane library were searched for studies comparing surgical resection with TACE for BCLC intermediate stage HCC that were published before December 2016. The primary outcome was overall survival, and the secondary outcomes were postoperative complications and 30-day mortality. Results: This meta-analysis included 9 studies with 2619 patients (surgical resection, n = 1204 (46%) and TACE, n = 1415 (54%)). When compared with the TACE group, the pooled hazard ratio (HR) for the 1, 3 and 5-year OS rates in patients who underwent surgical resection were 0.62 (95% CI 0.51-0.75, P = 0.39; I-2 = 6%, P < 0.001), 0.58 (95% CI 0.51-0.67, P = 0.25; I-2 = 22%, P < 0.001) and 0.59 (95% CI 0.54-0.64, P = 0.18; I-2 = 20%, P < 0.001). No significant differences in the pooled odds ratios (OR) were found between surgical resection and TACE in postoperative complications and 30-day mortality [OR 1.23 (95% CI 0.87 to 1.74, P = 0.390; I-2 = 0%, P = 0.240) and OR 1.11 (95% CI 0.60 to 2.04, P = 0.89; I-2 = 0%, P = 0.740), respectively]. Conclusion: This meta-analysis on studies on Asian HCC patients demonstrated surgical resection had better overall survival than TACE for patients with intermediate stage HCC, without any significant increase in postoperative complication or 30-day mortality rates. Further studies are needed to validate these results on Western patients, moreover, a reappraisal of the recommended treatments for BCLC intermediate stage HCC should be considered.