www.nature.com/scientificreports
OPEN
received: 31 August 2016 accepted: 22 December 2016 Published: 03 February 2017
Preoperative adjuvant transarterial chemoembolization cannot improve the long term outcome of radical therapies for hepatocellular carcinoma Lei Jianyong1,2, Zhong Jinjing3, Yan Lunan1, Zhu Jingqiang2, Wang Wentao1, Zeng Yong1, Li Bo1, Wen Tianfu1 & Yang Jiaying4 Combinations of transarterial chemoembolization (TACE) and radical therapies (pretransplantation, resection and radiofrequency ablation) for hepatocellular carcinoma (HCC) have been reported as controversial issues in recent years. A consecutive sample of 1560 patients with Barcelona Clinic Liver Cancer (BCLC) stage A/B HCC who underwent solitary Radiofrequency ablation (RFA), resection or liver transplantation (LT) or adjuvant pre-operative TACE were included. The 1-, 3- and 5-year overall survival rates and tumor-free survival rates were comparable between the solitary radical therapy group and TACE combined group in the whole group and in each of the subgroups (RFA, resection and LT) (P > 0.05). In the subgroup analysis, according to BCLC stage A or B, the advantages of adjuvant TACE were also not observed (P > 0.05). A Neutrophil-lymphocyte ratio (NLR) more than 4, multiple tumor targets, BCLC stage B, and poor histological grade were significant contributors to the overall and tumor-free survival rates. In conclusions, our results indicated that preoperative adjuvant TACE did not prolong long-term overall or tumor-free survival, but LT should nevertheless be considered the first choice for BCLC stage A or B HCC patients. Radical therapies should be performed very carefully in BCLC stage B HCC patients. Hepatocellular carcinoma (HCC), the fifth most common malignant tumor worldwide, is the third most common tumor resulting in death1. International consensus regarding a common treatment strategy for patients with HCC has not been attained because radical therapies, including resection, liver transplantation and radiofrequency ablation (RFA), are applicable in only 30–40% of patients with HCC, according to the commonly used algorithms, with the majority of patients requiring different approaches2. Liver transplantation (LT) should be considered the first choice for these early-stage liver cancer cases in the absence of an extrahepatic target; however, the shortage of liver grafts from deceased donors, as a result of recently decreasing organ donorship and the high risks, including the donor’s death, has limited the development of liver transplantation methodologies3. Fortunately, hepatic resection and local ablation therapies have also served as curative therapies for early-stage patients4. Treatment outcomes for HCC patients are affected by multiple variables, including tumor burden, the Child-Pugh score of liver function reserve, the performance status of the patient, and preoperative adjuvant therapies5. Transarterial chemoembolization (TACE) is an effective regional therapy that has widely been used since the 1980s for unresectable HCC. Complete necrosis was previously observed in only 30% to 64% of patients with HCC who received TACE before resection6. At the same time, even with resectable HCCs, some researchers7–10 reported that TACE might reduce the viability of HCC cells before radical surgery and thus reduce postoperative tumor recurrence. However, others11–14 failed to show any significant survival benefits. Therefore, the role 1 Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu 610041, China. 2Thyroid and Parathyroid Surgery Center, West China Hospital of Sichuan University, Chengdu 610041, China. 3Department of Pathology, West China Hospital of Sichuan University, Chengdu 610041, China. 4Transplantation Center, West China Hospital of Sichuan University, Chengdu 610041, China. Correspondence and requests for materials should be addressed to Y.L.N. (email: [email protected]) or W.W.T. (email: [email protected])
Scientific Reports | 7:41624 | DOI: 10.1038/srep41624
1
www.nature.com/scientificreports/ Inclusion criteria Primary hepatocellular carcinoma Targets with no previous treatment Liver cirrhosis classified as Child class A or B BCLC-HCC stage 0 or A Accepting RFA, resection or LT Exclusion criteria Presence of macro-vascular invasion Present of extrahepatic target Severe impairment of another organ Metastatic hepatic malignancies Child class C Gastrointestinal hemorrhage in the past month Gallbladder carcinoma or extrahepatic primary biliary carcinoma Intrahepatic cholangiocarcinoma Metastatic liver disease Rupture of HCC Loss to follow-up
Table 1. Main inclusion/exclusion criteria of the study. HCC: hepatocellular carcinoma; RFA: Radiofrequency ablation; LT: liver transplantation.
RFA
TACE + RFA
163
81
Age (year)
51.1 ± 11.8
56.2 ± 12.1
Sex (M/F)
112/51
53/28
Race (Han/Tibetan/other)
152/8/3
BMI (kg/m2) Underlying liver disease (HBV/HCV/negative)
Patient number
Pre-operative anti-viral therapy (yes/no) Child class (A/B/C)
P value
Resection
TACE + resection
633
268
0.002
52.0 ± 12.8
51.4 ± 13.3
0.607
466/167
186/82
75/5/1
0.861
595/31/7
23.4 ± 2.4
23.3 ± 2.5
0.838
135/10/18
70/3/8
82/79
P value
LT
TACE + LT
337
78
P value
0.647
52.2 ± 12.6
53.8 ± 12.1
0.325
0.196
230/107
53/25
0.959
253/11/4
0.824
315/34/5
73/4/0
0.970
23.6 ± 2.3
23.6 ± 2.2
0.854
23.6 ± 2.3
23.5 ± 2.2
0.914
0.831
535/32/66
225/19/24
0.226
282/19/36
65/6/7
0.461
51/30
0.091
391/241
167/101
0.913
195/142
46/32
0.858 0.002
94/69
46/35
0.928
356/277
159/109
0.392
186/107/44
31/25/22
Hemoglobin (g/l)
125.8 ± 26.9
124.9 ± 24.1
0.798
128.2 ± 24.6
131.3 ± 22.1
0.086
131.5 ± 25.7
127.6 ± 22.2
0.230
Platelets (x109/l)
136.5 ± 92.3
163.9 ± 144.7
0.096
146.9 ± 85.2
140.7 ± 81.4
0.355
135.6 ± 82.7
123.9 ± 87.0
0.306
NLR (
OPEN
received: 31 August 2016 accepted: 22 December 2016 Published: 03 February 2017
Preoperative adjuvant transarterial chemoembolization cannot improve the long term outcome of radical therapies for hepatocellular carcinoma Lei Jianyong1,2, Zhong Jinjing3, Yan Lunan1, Zhu Jingqiang2, Wang Wentao1, Zeng Yong1, Li Bo1, Wen Tianfu1 & Yang Jiaying4 Combinations of transarterial chemoembolization (TACE) and radical therapies (pretransplantation, resection and radiofrequency ablation) for hepatocellular carcinoma (HCC) have been reported as controversial issues in recent years. A consecutive sample of 1560 patients with Barcelona Clinic Liver Cancer (BCLC) stage A/B HCC who underwent solitary Radiofrequency ablation (RFA), resection or liver transplantation (LT) or adjuvant pre-operative TACE were included. The 1-, 3- and 5-year overall survival rates and tumor-free survival rates were comparable between the solitary radical therapy group and TACE combined group in the whole group and in each of the subgroups (RFA, resection and LT) (P > 0.05). In the subgroup analysis, according to BCLC stage A or B, the advantages of adjuvant TACE were also not observed (P > 0.05). A Neutrophil-lymphocyte ratio (NLR) more than 4, multiple tumor targets, BCLC stage B, and poor histological grade were significant contributors to the overall and tumor-free survival rates. In conclusions, our results indicated that preoperative adjuvant TACE did not prolong long-term overall or tumor-free survival, but LT should nevertheless be considered the first choice for BCLC stage A or B HCC patients. Radical therapies should be performed very carefully in BCLC stage B HCC patients. Hepatocellular carcinoma (HCC), the fifth most common malignant tumor worldwide, is the third most common tumor resulting in death1. International consensus regarding a common treatment strategy for patients with HCC has not been attained because radical therapies, including resection, liver transplantation and radiofrequency ablation (RFA), are applicable in only 30–40% of patients with HCC, according to the commonly used algorithms, with the majority of patients requiring different approaches2. Liver transplantation (LT) should be considered the first choice for these early-stage liver cancer cases in the absence of an extrahepatic target; however, the shortage of liver grafts from deceased donors, as a result of recently decreasing organ donorship and the high risks, including the donor’s death, has limited the development of liver transplantation methodologies3. Fortunately, hepatic resection and local ablation therapies have also served as curative therapies for early-stage patients4. Treatment outcomes for HCC patients are affected by multiple variables, including tumor burden, the Child-Pugh score of liver function reserve, the performance status of the patient, and preoperative adjuvant therapies5. Transarterial chemoembolization (TACE) is an effective regional therapy that has widely been used since the 1980s for unresectable HCC. Complete necrosis was previously observed in only 30% to 64% of patients with HCC who received TACE before resection6. At the same time, even with resectable HCCs, some researchers7–10 reported that TACE might reduce the viability of HCC cells before radical surgery and thus reduce postoperative tumor recurrence. However, others11–14 failed to show any significant survival benefits. Therefore, the role 1 Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu 610041, China. 2Thyroid and Parathyroid Surgery Center, West China Hospital of Sichuan University, Chengdu 610041, China. 3Department of Pathology, West China Hospital of Sichuan University, Chengdu 610041, China. 4Transplantation Center, West China Hospital of Sichuan University, Chengdu 610041, China. Correspondence and requests for materials should be addressed to Y.L.N. (email: [email protected]) or W.W.T. (email: [email protected])
Scientific Reports | 7:41624 | DOI: 10.1038/srep41624
1
www.nature.com/scientificreports/ Inclusion criteria Primary hepatocellular carcinoma Targets with no previous treatment Liver cirrhosis classified as Child class A or B BCLC-HCC stage 0 or A Accepting RFA, resection or LT Exclusion criteria Presence of macro-vascular invasion Present of extrahepatic target Severe impairment of another organ Metastatic hepatic malignancies Child class C Gastrointestinal hemorrhage in the past month Gallbladder carcinoma or extrahepatic primary biliary carcinoma Intrahepatic cholangiocarcinoma Metastatic liver disease Rupture of HCC Loss to follow-up
Table 1. Main inclusion/exclusion criteria of the study. HCC: hepatocellular carcinoma; RFA: Radiofrequency ablation; LT: liver transplantation.
RFA
TACE + RFA
163
81
Age (year)
51.1 ± 11.8
56.2 ± 12.1
Sex (M/F)
112/51
53/28
Race (Han/Tibetan/other)
152/8/3
BMI (kg/m2) Underlying liver disease (HBV/HCV/negative)
Patient number
Pre-operative anti-viral therapy (yes/no) Child class (A/B/C)
P value
Resection
TACE + resection
633
268
0.002
52.0 ± 12.8
51.4 ± 13.3
0.607
466/167
186/82
75/5/1
0.861
595/31/7
23.4 ± 2.4
23.3 ± 2.5
0.838
135/10/18
70/3/8
82/79
P value
LT
TACE + LT
337
78
P value
0.647
52.2 ± 12.6
53.8 ± 12.1
0.325
0.196
230/107
53/25
0.959
253/11/4
0.824
315/34/5
73/4/0
0.970
23.6 ± 2.3
23.6 ± 2.2
0.854
23.6 ± 2.3
23.5 ± 2.2
0.914
0.831
535/32/66
225/19/24
0.226
282/19/36
65/6/7
0.461
51/30
0.091
391/241
167/101
0.913
195/142
46/32
0.858 0.002
94/69
46/35
0.928
356/277
159/109
0.392
186/107/44
31/25/22
Hemoglobin (g/l)
125.8 ± 26.9
124.9 ± 24.1
0.798
128.2 ± 24.6
131.3 ± 22.1
0.086
131.5 ± 25.7
127.6 ± 22.2
0.230
Platelets (x109/l)
136.5 ± 92.3
163.9 ± 144.7
0.096
146.9 ± 85.2
140.7 ± 81.4
0.355
135.6 ± 82.7
123.9 ± 87.0
0.306
NLR (
