title: Hepatic resection alone versus in combination with pre- and post-operative transarterial chemoembolization for the treatment of hepatocellular carcinoma: A systematic review and meta-analysis.
abstract: OBJECTIVE
  The prognosis of hepatocellular carcinoma (HCC) treated with hepatic resection may be improved by the adjunctive use of transarterial chemoembolization (TACE). This study aimed to systematically compare the outcomes between hepatic resection with and without TACE groups.
  
  
  METHODS
  All relevant randomized controlled trials (RCTs) and non-RCTs were searched by the PubMed, EMBASE, and Cochrane Library databases. Overall survival (OS) and disease-free survival (DFS) were two major outcomes. Meta-analyses were performed according to the timing of TACE (pre- or post-operative TACE). Subgroup analyses were also performed. Hazard ratios (HRs) with 95% confidence intervals (95%CIs) were calculated.
  
  
  RESULTS
  Overall, 55 papers were included (14 RCTs and 41 non-RCTs). Overall meta-analyses demonstrated that OS and DFS were statistically similar between hepatic resection with and without pre-operative TACE groups (HR = 1.01, 95%CI = 0.87-1.19, P = 0.87; HR = 0.91, 95%CI = 0.82-1.01, P = 0.07). Subgroup analyses of RCTs or non-RCTs showed that OS and DFS remained statistically similar between hepatic resection with and without pre-operative TACE groups. Subgroup analysis of incomplete or no tumor necrosis showed that OS was worse in hepatic resection with pre-operative TACE group than in hepatic resection without pre-operative TACE group. By contrast, subgroup analysis of complete tumor necrosis showed that DFS was better in hepatic resection with pre-operative TACE group than in hepatic resection without pre-operative TACE group.Overall meta-analyses demonstrated that OS and DFS were better in hepatic resection with post-operative TACE group than in hepatic resection without post-operative TACE group (HR = 0.85, 95%CI = 0.72-1.00, P = 0.06; HR = 0.83, 95%CI = 0.73-0.94, P = 0.004). Subgroup analyses of RCTs, vascular invasion, or large HCC showed that OS and DFS remained better in hepatic resection with post-operative TACE group than in hepatic resection without post-operative TACE group. By contrast, subgroup analyses of non-RCTs, no vascular invasion, or small HCC showed that OS and DFS were statistically similar between the two groups.
  
  
  CONCLUSIONS
  Post-operative TACE, rather than pre-operative TACE, may be considered as an adjunctive treatment option for HCC treated with hepatic resection.
authors.affiliation: Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China.
authors.forename: Xingshun
authors.initials: X
authors.lastname: Qi
authors.affiliation: Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China.
authors.forename: Lei
authors.initials: L
authors.lastname: Liu
authors.affiliation: Department of Occupational and Environmental Health Sciences and the Ministry of Education Key Lab of Hazard Assessment and Control in Special Operational Environment, School of Public Health, Fourth Military Medical University, Xi'an, China.
authors.forename: Diya
authors.initials: D
authors.lastname: Wang
authors.affiliation: Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China.
authors.forename: Hongyu
authors.initials: H
authors.lastname: Li
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: Xiaozhong
authors.initials: X
authors.lastname: Guo
mesh_terms: D006528:Carcinoma, Hepatocellular / Q000473:pathology / Q000601:surgery / Q000628:therapy*; D016461:Chemoembolization, Therapeutic / Q000379:methods*; D015331:Cohort Studies; D018572:Disease-Free Survival; D006498:Hepatectomy / Q000379:methods*; D006801:Humans; D008113:Liver Neoplasms / Q000473:pathology / Q000601:surgery / Q000628:therapy*; D011379:Prognosis; D016896:Treatment Outcome
keywords: hepatic resection; hepatocellular carcinoma; recurrence; survival; transarterial chemoembolization