Percutanous interventions for early hepatocellular carcinoma

Schoppmeyer K, Weis S, Mössner J, Fleig WE

Published Online:

January 20, 2010

Hepatocellular carcinoma (liver cancer) ranks fifth in global cancer burden. Percutaneous techniques such as percutaneous ethanol injection, percutaneous acetic acid injection, and radiofrequency thermal ablation, cryoablation, and transarterial chemoembolisation have been used to treat early hepatocellular carcinoma. While surgical resection has been traditionally considered to be the first-line therapy in early hepatocellular carcinoma, it has considerable morbidity and mortality in patients with liver cirrhosis. The review found no significant difference in overall and recurrence-free survival in patients with early hepatocellular carcinoma treated with percutaneous ethanol injection as compared with percutaneous acetic acid injection. Both methods are minimally invasive and safe. Based on a single randomised trial, surgical resection does not seem to be superior to percutaneous ethanol injection in patients with early hepatocellular carcinoma. The latter result is limited by the inhomogeneous patient group, the paucity of patients examined, and the methodological weaknesses of the trials leading to high risks of systematic errors (bias) in the trials.

Abstract (click to read)

Background:

Hepatocellular carcinoma (HCC) is the fifth most common global cancer. When HCC is detected early, interventions such as percutaneous ethanol injection (PEI), percutaneous acetic acid injection (PAI), and radiofrequency thermal ablation (RFTA) have curative potential and represent low invasive alternatives to surgery. The role of PEI or PAI has not been addressed in a systematic review.

Objectives:

To evaluate the beneficial and harmful effects of PEI or PAI in adults with early HCC.

Search strategy:

A systematic search was performed in The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and ISI Web of Science in May 2009. Meeting abstracts of six oncological and hepatological societies (ASCO, ESMO, ECCO, AASLD, EASL, APASL) and references of articles were handsearched. Researchers in the field were contacted.

Selection criteria:

Randomised trials comparing PEI and PAI with other percutaneous interventions or surgery and trials comparing PEI or PAI with no intervention or sham intervention for the treatment of early HCC were considered regardless of blinding, publication status, or language. Studies comparing RFTA or combination treatments were excluded.

Data collection and analysis:

Two authors independently selected trials for inclusion, extracted, and analysed data. The hazard ratios for median overall survival and recurrence-free survival were calculated using the Cox regression model with Parmar's method. Type and number of adverse events were reported descriptively.

Main results:

Three randomised trials with a total of 261 patients were eligible for inclusion. The risk of bias was high in all trials. Two of the trials compared PEI with PAI. Overall survival (HR 1.47; 95% confidence interval (CI) 0.68 to 3.19) and recurrence-free survival (HR 1.42; 95% CI 0.68 to 2.94) were not significantly different. Data on the duration of hospital stay were inconclusive. Data on quality of life were not available. There were only mild adverse events in both treatment modalities.

The other trial compared PEI with surgery. There was no significant difference in overall survival (HR 1.57; 95% CI 0.53 to 4.61) and recurrence-free survival (HR 1.35; 95% CI 0.69 to 2.63). No serious adverse events were reported in the PEI group. Three postoperative deaths occurred in the surgery group.

Authors' conclusions:

PEI and PAI do not differ significantly regarding benefits and harms in patients with early HCC, but only a limited number of patients have been examined and the risk of bias was high in all trials. There is also insufficient evidence to determine whether PEI or segmental liver resection is more effective. While some data from the single trial suggested that PEI was safer, the high risk of bias and the lack of any confirmatory evidence make an assessment impossible.

This record should be cited as:

Schoppmeyer K, Weis S, Mössner J, Fleig WE. Percutanous ethanol injection or percutaneous acetic acid injection for early hepatocellular carcinoma. Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD006745. DOI: 10.1002/14651858.CD006745.pub2

Assessed as up to date:

May 9, 2009

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Primary Review Group:

Hepato-Biliary Group

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Percutanous interventions for early hepatocellular carcinoma

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