title: Treatment outcomes for hepatocellular carcinoma using chemoembolization in combination with other therapies.
abstract: BACKGROUND
  Although transarterial chemoembolization (TACE) improves survival in patients with hepatocellular carcinoma (HCC), it is not known if TACE combined with other treatments is beneficial.
  
  
  OBJECTIVE
  To evaluate the evidence for improved outcomes in HCC with a multimodal treatment approach involving TACE.
  
  
  METHODS
  PubMed search for all cohort and randomized trials (n=84) evaluating TACE combined with other therapies; meta-analysis performed where appropriate.
  
  
  RESULTS
  A meta-analysis involving 4 RCTs showed a significant decrease in mortality favouring combination treatment (TACE plus percutaneous ablation) compared to monotherapy in patients with either small (<3cm) or large HCC nodules (>3cm) (OR, 0.534; 95% CI, 0.288-0.990; p=0.046). TACE combined with local radiotherapy improved survival in patients with tumour thrombosis of the portal vein in 7 non-randomized studies. Two RCTs and 13 non-randomized studies showed that TACE prior to hepatic resection does not improve survival nor tumour recurrence. Conversely, 2 RCTs and 5 comparative studies showed that transarterial injection of chemotherapeutic drugs mixed with lipiodol (TOCE) following hepatectomy confers survival benefit and less tumour recurrence. TACE before liver transplantation is safe and reduces drop-out rate from the waiting list, but there is no current evidence of improvement in subsequent survival or recurrence rate.
  
  
  CONCLUSIONS
  A combined approach involving TACE and percutaneous ablation improves survival. Adjuvant TOCE improves outcome after hepatectomy. TACE is useful to control tumours burden while on the waiting list for OLT. Multimodal treatment seems to be the best way to optimize TACE outcomes in HCC.
authors.affiliation: Liver Transplantation and Hepatobiliary Medicine Unit, Royal Free Hospital, Pond Street, NW3 2QG London, UK. marellilaura@tiscali.it
authors.forename: Laura
authors.initials: L
authors.lastname: Marelli
authors.forename: Rosa
authors.initials: R
authors.lastname: Stigliano
authors.forename: Christos
authors.initials: C
authors.lastname: Triantos
authors.forename: Marco
authors.initials: M
authors.lastname: Senzolo
authors.forename: Evangelos
authors.initials: E
authors.lastname: Cholongitas
authors.forename: Neil
authors.initials: N
authors.lastname: Davies
authors.forename: Dominic
authors.initials: D
authors.lastname: Yu
authors.forename: Tim
authors.initials: T
authors.lastname: Meyer
authors.forename: David W
authors.initials: DW
authors.lastname: Patch
authors.forename: A K
authors.initials: AK
authors.lastname: Burroughs
mesh_terms: D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use; D001158:Arteries / Q000601:surgery; D006528:Carcinoma, Hepatocellular / Q000401:mortality* / Q000473:pathology / Q000628:therapy*; D016461:Chemoembolization, Therapeutic; D017024:Chemotherapy, Adjuvant; D003131:Combined Modality Therapy; D006801:Humans; D008113:Liver Neoplasms / Q000401:mortality* / Q000473:pathology / Q000628:therapy*; D018714:Radiotherapy, Adjuvant; D016032:Randomized Controlled Trials as Topic; D016019:Survival Analysis; D016896:Treatment Outcome