Comparison of Survival and Effectiveness

between Transarterial Chemoembolization

versus Transarterial Radioembolization for
Unresectable Hepatocellular carcinoma : An
Evidence-Based Case Report

dr Fita Fitrianti
Sourceperson: Prof.Dr.dr Rino A Gani, SPPD-KGEH
 INTRODUCTION

 Hepatocellular carcinoma (HCC) is the fifth most common cancer

 Treatments of HCC is widely guided by Barcelona Clinic Liver Cancer (BCLC)
staging system
 For intermediate HCC, conventional transarterial chemoembolization (cTACE) has
been recommended as standard therapy
 In recent years, both drug-eluting beads (DEB-TACE) and transarterial
radioembolization (TARE) have been considered as alternative therapies to
cTACE for unresectable HCC

EASL CPG HCC. J Hepatol 2018

AASLD CPG HCC. J Hepatol 2018.
 INTRODUCTION

TACE (Transarterial chemoembolization)

 Conventional TACE (cTACE) is based on injection of chemotherapeutic agents
and selective vascular embolization into the arteries feeding the tumor, resulting in
a high intratumoral concentration of chemotherapeutic agents as well as strong
cytotoxic effects
 DEB-TACE  involves the selective application of chemotherapy-loaded
microbeads which embolize the tumor arteries and ensure the loaded
chemotherapeutic agent slowly releases to achieve a lower systemic drug peak
compared to cTACE
INTRODUCTION

Transarterial radioembolization (TARE, also called selective internal radiation

therapy or SIRT)
 Consists of the intra-arterial infusion of much smaller beads that are
loaded with a radioactive isotope (yttrium-90), and it relies on the beta
radiation emitted by the isotope to induce tumor necrosis
 CLINICAL SCENARIO
MALE, 51 YO LAB
Total bilirubin 1.9 mg/dl,
CHIEF COMPLAIN
Albumin 3.5 g/dl, cr 0.9mg/dl,
• Abdominal pain (RUQ)
• Loss of appetite and weight INR 1.03, AST 47 ALT 41.5
AFP 450 ml/IU
MEDICAL HISTORY
• Chronic HBV infection (+) CT SCAN ABDOMEN :
• Child Pugh A Cirrhosis large lobulated mass on the
right lobe (12.7 x 10.5 x 15.2
PHYSICAL EXAMINATION cm), without evidence of portal
Fully alert, BP 100/70, HR 70x, RR 18x
vein thrombosis.
BMI 20 kg/m2
Icteric sclera
Ascites(-) ECOG : 0

 BCLC-B
CLINICAL QUESTION

Which transarterial treatment option would give better

outcome on survival for patient with unresectable HCC?

Patient Intervention Comparison Outcome

Individual with TACE TARE Overall survival

unresectable (c-TACE and
HCC DEB-TACE)
STUDY SELECTION

•Systematic review, meta analysis

Study Design •Subjects : hepatocellular carcinoma

• Transarterial chemoembolization (cTACE & DEB-

Intervention TACE)

Comparison • Transarterial Radioembolization (TARE) or SIRT

Outcome • Overall Survival

METHODS : Search Strategy and Selection

 Search engine : PubMed (National Library of Medicine®), Cochrane

and Google Scholar
 Keywords used included transarterial chemoembolization/TACE/c-
TACE/DEB-TACE AND transarterial radioembolization/
TARE/SIRT/yttrium-90 AND hepatocellular carcinoma
METHODS : Critical Appraisal

After the articles were selected, each article will be weighted for
its validity, importance and applicability using the assessment
sheet provided by the Center of Evidence-based Medicine,
University of Oxford (www.cebm.net)
 (Transarterial chemoembolization OR TACE OR c-TACE OR
DEB-TACE AND Transarterial radioembolization OR TARE OR
RESULTS SIRT OR yttrium-90 AND hepatocellular carcinoma)

Pubmed Cochrane Google Scholar

N = 187 N=4 N = 591

Title and abstract screening

(human study, publication within the last 5 years, full text, English,
systematic review, meta-analysis, RCT)

Full text articles excluded,

with reasons (n=29)
Screening full text (32) - Potential duplicates
(include in systematic
review & metaanalysis),
n= 28
3 articles - Letter, n= 1
1st ARTICLE
2nd ARTICLE
3rd ARTICLE
Unresectable Hepatocellular Carcinoma: Radioembolization Versus
Chemoembolization: A Systematic Review and Metaanalysis
by Lobo,et al 2016

Study Design Systematic review & Meta-analysis

Subjects 5 studies
Results No statistically significant difference in survival for up to 4 years between the
two groups (HR = 1.06; 95 % CI 0.81–1.46, p = 0.567)
TACE had more post-treatment pain than TARE (RR = 0.51, 95 % CI 0.36–0.72,
p\0.01), but less subjective fatigue (RR = 1.68, 95 % CI 1.08–2.62, p\0.01).
There was no difference in partial or complete response rates between the
two groups.
Conclusion TARE appears to be a safe alternative treatment to TACE with comparable
complication profile and survival rates.
 Radioembolization versus chemoembolization for
unresectable HCC : a meta-analysis of randomized trials
by Casadei,et al 2018

Study Design Meta-analysis

Subjects 3 studies
Results Overall survival at 1 year was similar between the two
treatment groups (OR =1.31, 95% CI: 0.56–3.04, P=0.53)
Progression-free survival at 1 year was also not
statistically different between the two treatments (OR
=0.23, 95% CI: 0.02–2.45, P=0.22)
Conclusion TARE and TACE provide similar outcomes in unresectable
HCC. The role of TARE should be explored in selected
patient subpopulations in future clinical trials
Transarterial strategies for the treatment of unresectable
hepatocellular carcinoma: A systematic review
by Yang B,et al 2020

Study Design Systematic review & Meta-analysis

Subjects 28 studies
Results The comparison of DEB-TACE with cTACE indicated that DEB-TACE has a
better OS at 1 year (RR 0.79, 95% CI 0.67–0.93, p = 0.006), 2 years (RR 0.89; 95%
CI 0.81– 0.99, p = 0.046), and 3 years (RR 0.89; 95% CI 0.81–0.99, p = 0.035)
The comparison of TARE with cTACE indicated that TARE has a better OS than
cTACE at 2 years (RR 0.87; 95% CI 0.80–0.95, p = 0.003) and 3 years (RR 0.90;
95% CI 0.85–0.96, p = 0.001)
The comparison of DEB-TACE with TARE indicated that DEB-TACE has a better
OS than TARE at 2 years (RR 0.40; 95% CI 0.19–0.84, p = 0.016).
Conclusion The current meta-analysis suggests that DEB-TACE is superior to both TARE
and cTACE in terms of OS. TARE has significantly lower complications than
both DEB-TACE and cTACE for patients with HCC.
 CRITICAL APPRAISSAL

Lobo,et al, Casadei, et al, Yang B, et al,

2016 2018 2020
What question (PICO) did the systematic Yes Yes Yes
review address?
Is it unlikely that important, relevant studies Yes Yes Yes
were missed?
Were the criteria used to select articles for Yes Yes Yes
inclusion appropriate?
Were the included studies sufficiently valid Yes Yes Yes
for the type of question asked?

Were the results similar from study to study? Yes Yes Yes
DISCUSSION

 From all the studies included to compare the efficacy of DEB-TACE with
cTACE, TARE-TACE with cTACE and DEB-TACE with TARE in patients with
HCC.
 The results indicated :
 DEB-TACE has a better 1-, 2-, and 3-year OS than cTACE
 TARE has a similar 1-year and better 2-year and 3-year OS as cTACE
 DEB-TACE and TARE have a similar 1-year OS. However, DEB-TACE
showed a longer OS when the follow-up time was prolonged to 2 years
DISCUSSION (2)

 Compared with cTACE, TARE showed a higher DCR.

 No significant differences were observed in the comparison of DEB-
TACE vs. cTACE or in the comparison of TARE vs. cTACE in terms of
PFS.
 Compared with cTACE, DEB-TACE showed significantly lower rates
of fatigue and infection/fever.
CONCLUSION

 Both DEB-TACE and TARE are superior to cTACE in terms of OS and

complications.
 DEB-TACE has significantly better OS rates for patients with
unresectable HCC than TARE.
 Further multicenter, well-designed randomized trials are needed,
especially to compare DEB-TACE with TARE.
THANK YOU