Liver Resection Versus Transarterial Chemoembolization for the Treatment of Intermediate-Stage Hepatocellular Carcinoma

Background: The role of transarterial chemoembolization (TACE) as the standard therapy for intermediate-stage hepatocellular carcinoma (HCC) is being challenged by increasing studies supporting liver resection (LR), but evidence of survival benefits of LR is lacking. We aimed to compare the overall survival (OS) of LR with that of TACE for the treatment of intermediate-stage HCC in cirrhotic patients. Methods: A Markov model comparing LR with TACE over 15 years, was constructed based on data from 31 literatures. Sensitivity analyses, and an additional Monte Carlo analysis with 10,000 patients allocated for each arm were conducted. External validation was performed using a data set (n=1735; LR: 701; TACE: 1034) with the propensity score matching method. Findings: The mean expected survival periods and percentages at 5 years were 77.8 months, 47.1% in LR group, and 48.6 months, 25.7% in TACE group, respectively. The 95% confidence interval (CI) for the difference in OS was 2.42-2.46 years (P<0.001). Sensitivity analyses demonstrated that initial LR was the more favorable treatment. In the validation set, the 5-year survival proportions after LR were significantly better than those after TACE before (40.2% vs. 25.9%, P<0.001) and after matching (43.2% vs. 30.9%, P<0.001), which was comparable to the model results. Multivariate analysis revealed that the type of initial treatment was the significant factor for OS (Hazard ratio=1.497, 95% CI: 1.328-1.688, P<0.001). Interpretation: LR may provide survival benefit over TACE for cirrhotic patients with intermediate-stage HCC, based on the Markov model and validated clinical data. Funding: This work is supported by grants from the National Natural Science Foundation of China (NSFC, No. 81771958, 81770608) and the Kelin Outstanding Young Scientist of the First Affiliated Hospital of Sun Yet-sen University (2017). Declaration of Interest: We declare that we have no conflicts of interest.