title: Hepatic resection versus transarterial chemoembolization for the initial treatment of hepatocellular carcinoma: A systematic review and meta-analysis.
abstract: OBJECTIVE
  According to the Barcelona Clinic Liver Cancer (BCLC) staging system, hepatic resection and transarterial chemoembolization (TACE) should be recommended in patients with hepatocellular carcinoma (HCC) within and beyond the BCLC stage A, respectively. We conducted a systematic review and meta-analysis to compare the overall survival between HCC patients undergoing hepatic resection and TACE.
  
  
  METHODS
  PubMed, EMBASE, and Cochrane library databases were searched. All relevant studies were considered, if they reported the survival data in HCC patients undergoing hepatic resection and TACE. Hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated for the comparison of cumulative overall survival. Odds ratios (ORs) with 95%CIs were calculated for the comparison of 1-, 3-, and 5-year survival rates. Subgroup analyses were performed according to the BCLC stages and portal vein tumor thrombus (PVTT). Sensitivity analyses were performed in moderate- and high-quality studies and in studies published after 2005.
  
  
  RESULTS
  Fifty of 2029 retrieved papers were included. One, 15, and 34 studies were of high-, moderate-, and low-quality, respectively. The overall meta-analysis demonstrated a statistically significantly higher overall survival in hepatic resection group than in TACE group (HR=0.60, 95%CI=0.55-0.66). Additionally, 1-, 3-, and 5-year survival rates were statistically significantly higher in hepatic resection group than in TACE group (OR=1.82, 95%CI=1.56-2.14; OR=3.09, 95%CI=2.60-3.67; OR=3.48, 95%CI=2.83-4.27). The subgroup meta-analyses confirmed the statistical significance in HCC within the BCLC stage A (HR=0.72, 95%CI=0.64-0.80), in HCC beyond the BCLC stage A (HR=0.60, 95%CI=0.51-0.69), in HCC within the BCLC stage B alone (HR=0.48, 95%CI=0.25-0.90), and in HCC with PVTT (HR=0.78, 95%CI=0.68-0.91). The statistical significance was also confirmed by sensitivity analyses in moderate- and high-quality studies (HR=0.62, 95%CI=0.53-0.71) and in studies published after 2005 (HR=0.59, 95%CI=0.53-0.66).
  
  
  CONCLUSIONS
  Based on a systematic review and meta-analysis, hepatic resection may be considered in HCC beyond the BCLC stage A. However, given the limitations of study quality, more well-designed randomized controlled trials should be warranted to confirm these findings.
authors.affiliation: Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China.
authors.forename: Xingshun
authors.initials: X
authors.lastname: Qi
authors.affiliation: Department of Occupational and Environmental Health Sciences, Fourth Military Medical University, Xi'an, China.
authors.forename: Diya
authors.initials: D
authors.lastname: Wang
authors.affiliation: Library of Fourth Military Medical University, Xi'an, China.
authors.forename: Chunping
authors.initials: C
authors.lastname: Su
authors.affiliation: Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China.
authors.forename: Hongyu
authors.initials: H
authors.lastname: Li
authors.affiliation: Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China.
authors.forename: Xiaozhong
authors.initials: X
authors.lastname: Guo
mesh_terms: D006528:Carcinoma, Hepatocellular / Q000401:mortality / Q000601:surgery* / Q000628:therapy*; D016461:Chemoembolization, Therapeutic / Q000379:methods*; D006498:Hepatectomy / Q000379:methods*; D006801:Humans; D008113:Liver Neoplasms / Q000401:mortality / Q000601:surgery* / Q000628:therapy*; D009367:Neoplasm Staging; D017063:Outcome Assessment, Health Care / Q000379:methods / Q000706:statistics & numerical data; D016016:Proportional Hazards Models; D016019:Survival Analysis; D015996:Survival Rate
keywords: BCLC stage; chemoembolization; hepatocellular carcinoma; resection; survival