Transcatheter Arterial Chemoembolization Plus Radiotherapy Compared With Chemoembolization Alone for Hepatocellular Carcinoma: A Systematic Review and Meta-analysis.

IMPORTANCE Hepatocellular carcinoma (HCC) has the second-highest cancer-related mortality rate in the world because most patients are diagnosed at an intermediate to advanced stage when surgery is not suitable. Transcatheter arterial chemoembolization (TACE) is currently considered a first-line therapy for unresectable HCC. However, advancements in radiotherapy (RT) have resulted in some studies identifying a significant therapeutic benefit of TACE plus RT for unresectable HCC compared with TACE alone. OBJECTIVE To evaluate the efficacy and safety of TACE plus RT compared with TACE alone for unresectable HCC using meta-analytical techniques. DATA SOURCES A search of Medline, EMBASE, PubMed, Cochrane, and Google Scholar databases was done from inception to January 14, 2015. STUDY SELECTION Published trials that included a treatment group receiving TACE plus RT and a control group receiving TACE alone with data for at least 1-year survival or tumor response were included. DATA EXTRACTION AND SYNTHESIS Pooled odds ratios (ORs) and 95% CIs were calculated for the effect of TACE plus RT vs TACE alone on survival, tumor response, and adverse events using a random effects model. Subgroup analyses of study design, anticancer drug, RT type, embolization type, presence of portal venous tumor thrombosis (PVTT), and time between treatments with TACE and RT were performed. MAIN OUTCOMES AND MEASURES Survival, tumor response, adverse events, study design, anticancer drug, RT type, embolization type, presence of PVTT, and time between TACE and RT. RESULTS There were 25 trials (11 RCTs) involving 2577 patients. Patients receiving TACE plus RT showed significantly better 1-year survival (OR, 1.36 [95% CI, 1.19-1.54]) and complete response (clearance of the lesion after treatment) (OR, 2.73 [95% CI, 1.95-3.81]) compared with TACE alone. The survival benefit progressively increased for 2-, 3-, 4-, and 5-year survival (respectively: OR, 1.55 [95% CI, 1.31-1.85]; OR, 1.91 [95% CI, 1.55-2.35]; OR, 3.01 [95% CI, 1.38-6.55]; OR, 3.98 [95% CI, 1.86-8.51]). There was an increased incidence of gastroduodenal ulcers and elevated levels of alanine transaminase and total bilirubin in patients receiving TACE plus RT compared with those receiving TACE alone. Subgroup analyses showed nonsignificant trends in which survival was greater for TACE plus RT in patients with PVTT compared with those without PVTT. CONCLUSIONS AND RELEVANCE TACE plus RT was more therapeutically beneficial than TACE alone for treating HCC, and should be recommended for suitable patients with unresectable HCC.