WY Lau, Simon CH Yu, Eric CH Lai, Thomas WT Leung
The approach in treating patients with hepatocellular carcinoma (HCC) is evolving rapidly as the biology and natural history of the disease becomes better understood.1,2 Because HCC almost always develop in patients with underlying cirrhosis or chronic active hepatitis, patient outcomes are determined by the interplay between tumor growth and adequate liver reserve. The underlying cause of the liver disease, eg, hepatitis B, hepatitis C, alcoholism, or cirrhosis of another cause, also has impact on the biology of the cancer.3
It has been widely accepted that partial hepatectomy or total hepatectomy with orthotopic liver transplantation offers the best chance for longterm and disease-free survival for patients with HCC.2,4 Recently, local ablative therapy, in the formof percutaneous radiofrequency ablation or ethanol injection, has emerged as an alternative form of a “curative” treatment for localized but unresectable small volume disease.5 Unfortunately, few patients with HCC are candidates for these treatments at the time of diagnosis because of advanced tumor stage, multicentric disease, poor liver function, or comorbid medical conditions.6 On the other hand, systemic therapy ismostly inactive forHCC.7 SinceHCC tends to be localized within the liver in the early stage of disease, regional therapies have become popular as a treatment option. Of the many forms of regional therapies, transarterial chemoembolization (TACE) is most widely used and studied.
This article systematically reviews the use of TACE for HCC and rates the quality of evidence. Level of evidence (Canadian Task Force, http://www.ctfphc.org/) is categorized as follows:
I. Evidence from randomized controlled trial(s);
II-1. Evidence from controlled trial(s) without randomization;
II-2. Evidence from cohort or patient-control analytic studies, preferably from more than one center or research
II-3. Evidence from comparisons between times or places with or without the intervention; dramatic results in uncontrolled experiments could be included here;and
III. Opinions of respected authorities, based on clinical experience; descriptive studies or reports of expert committees.