|Year : 2020 | Volume
| Issue : 5 | Page : 1027-1037
Transarterial chemoembolization combined with microwave ablation versus microwave ablation only for Barcelona clinic liver cancer Stage B hepatocellular carcinoma: A propensity score matching study
Xin Li1, Baohua Chen2, Chao An1, Zhigang Cheng1, Zhiyu Han1, Fangyi Liu1, Jie Yu1, Ping Liang1
1 Department of Interventional Ultrasound, Chinese PLA General Hospital, Beijing, China
2 Department of Hepatobiliary Surgery, The 908th Hospital of Chinese People's Liberation Army Joint Logistic Support Force, Yingtan, China
|Date of Submission||30-May-2019|
|Date of Decision||12-Sep-2019|
|Date of Acceptance||09-Nov-2019|
|Date of Web Publication||29-Sep-2020|
Department of Interventional Ultrasound, Chinese PLA General Hospital, 28 Fuxing Road, Beijing 100853
Department of Interventional Ultrasound, Chinese PLA General Hospital, 28 Fuxing Road, Beijing 100853
Source of Support: None, Conflict of Interest: None
Purpose: We aimed to compare the outcomes of microwave ablation (MWA) alone with those of transarterial chemoembolization combined with MWA (TACE-MWA) for Barcelona clinic liver cancer (BCLC) Stage B hepatocellular carcinoma (HCC) and to identify the prognostic factors associated with the two treatments.
Materials and Methods: This retrospective study was conducted in 150 BCLC Stage B HCC patients from April 2006 to November 2017. Of these, 88 patients were treated with MWA alone while 62 with TACE-MWA. Propensity score matching (PSM) was conducted to adjust for imbalances in clinical parameters. Procedure-related complications, local tumor progression (LTP), recurrence-free survival (RFS), and overall survival (OS) were analyzed.
Results: Before PSM, the maximal tumor diameters were 6.0 ± 1.0 cm and 6.7 ± 1.3 cm in the TACE-MWA and MWA groups, respectively, with a significant difference (P = 0.002); a significant difference was also detected in α-fetoprotein level (P = 0.013). After PSM, no difference was found in the two parameters (P = 0.067, 0.470). Before and after PSM, no difference was detected in the procedure-related complications (P = 0.803 vs. 1.000, P = 1.000 vs. 1.000), RFS (P = 0.786 vs. 0.689), and OS (P = 0.684 vs. 0.929). Tumor size and α-fetoprotein level were independent influencing factors for OS before and after PSM (P = 0.009, 0.023), while tumor size (D > 7) was an independent risk factor for poor OS (P = 0.011). Tumor number was an independent risk factor for RFS before and after PSM (P = 0.007 vs. P = 0.008). A significant difference was detected in LTP between the two groups with single tumor before and after PSM (P = 0.059 vs. P = 0.006).
Conclusions: The MWA alone group had RFS and OS comparable to that of the TACE-MWA group. TACE-MWA was effective in controlling LTP in patients with a single tumor.
Keywords: Hepatocellular carcinoma, microwave ablation, propensity score matching, transarterial chemoembolization
|How to cite this article:|
Li X, Chen B, An C, Cheng Z, Han Z, Liu F, Yu J, Liang P. Transarterial chemoembolization combined with microwave ablation versus microwave ablation only for Barcelona clinic liver cancer Stage B hepatocellular carcinoma: A propensity score matching study. J Can Res Ther 2020;16:1027-37
|How to cite this URL:|
Li X, Chen B, An C, Cheng Z, Han Z, Liu F, Yu J, Liang P. Transarterial chemoembolization combined with microwave ablation versus microwave ablation only for Barcelona clinic liver cancer Stage B hepatocellular carcinoma: A propensity score matching study. J Can Res Ther [serial online] 2020 [cited 2021 Sep 22];16:1027-37. Available from: https://www.cancerjournal.net/text.asp?2020/16/5/1027/296434
Xin Li and Baohua Chen contributed equally to this work
| > Introduction|| |
Hepatocellular carcinoma (HCC) is the sixth most common malignancy and the third leading cause of cancer-related mortality worldwide, and morbidity and mortality are still increasing.,, Surgery is the standard treatment for early-stage HCC, but most HCC patients with intermediate and advanced stages are not surgical candidates and managed with local ablative therapies (LATs) and transarterial chemoembolization (TACE). The Barcelona clinic liver cancer (BCLC) guidelines have been adopted by the American Association for the Study of Liver Disease and the European Association for the Study of the Liver as consensus recommendations for the treatments of HCC stratified by stage and performance status, which is the most widely used tool to predict prognosis and determine treatment modalities., Although TACE is the recommended treatment for patients with intermediate-stage and multifocal tumors, those with larger or infiltrative tumors and tumors bridging two or more liver Couinaud Bismuth segments could not be managed by monotherapies as they have lower rates of complete response. Due to the location and size of the tumor, stratification of treatment according to the BCLC guidelines is difficult to achieve based on the imaging results. Therefore, an effective alternative method should be used to address this problem.
TACE could slow tumor progression and improve survival and is considered as a palliative treatment for BCLC Stage B HCC. However, it can cause tumor ischemic necrosis by arterial embolization, induce tumor death by cytotoxicity of chemotherapeutic drugs, and cause a combination of these effects. Microwave ablation (MWA) as the main LAT with acceptable therapeutic efficiency for HCC has several advantages: it can produce larger ablation volume rapidly, is less affected by heat sink, and is less dependent on the electrical conductivities.,, MWA and TACE have their own limitations, which affect the adequate control of large HCC., The effect of TACE is influenced by blood supply, tumor size, and the ultra-selectivity of the catheter, and complete tumor necrosis is impossible to achieve by TACE alone. The remaining tumor cells may cause local recurrence and distant metastasis., For MWA, the incidence of incomplete ablation and local recurrence significantly increased with increasing tumor size, as high as 25% and 40.9% for larger HCC., The combined use of TACE and MWA might be appealing with synergistic effect. TACE has the following mechanisms: (1) It can block the hepatic arterial flow and decrease the heat-sink effect and increase the thermal efficiency and intratumor temperature of MWA; (2) The chemotherapeutic drugs and iodized oil that are used in TACE might increase the thermal sensitivity of tumor cells and the thermal conductivity of MWA.,, As reported recently, combination therapy can reduce HCC recurrence and improve survival compared with TACE or MWA alone.,, The combination therapy can be used as an alternative treatment and for the successful eradication of tumor and maximal preservation of liver function. However, only a few studies have provided a comparison between a combination of TACE and MWA and MWA alone as the treatment for BCLC Stage B HCC. Thus, this retrospective study aimed to compare the safety and efficacy of TACE combined with MWA (TACE-MWA) with MWA alone as treatment for BCLC Stage B HCC and to analyze the risk factors for oncological outcomes, including local tumor progression (LTP), recurrence-free survival (RFS), and overall survival (OS).
| > Materials and Methods|| |
Data collection and modality selection
This retrospective study protocol was approved by the Ethics Committee of the Chinese PLA General Hospital (Beijing, China) and conducted in accordance with the principles of the Declaration of Helsinki. A total of 555 consecutive treatment-naive HCC patients initially treated with TACE-MWA and MWA alone were enrolled from April 2006 to November 2017. Written informed consent was obtained from each enrolled patient before treatment. Patients (1) with Eastern Cooperative Oncology Group performance score of ≤2; (2) with Child–Pugh class A or B; (3) with 5 cm ≤ tumor maximum diameter <10 cm or/and tumor number ≥3; (4) with the absence of vascular invasion or extrahepatic metastases; (5) with normal serum total bilirubin level or serum total bilirubin level of <50 μmol/L; (6) with normal albumin level or albumin level of >25 g/L; (7) with platelet count >50 × 109/mm 3 and prothromb inactivity >50%; (8) whose final diagnosis was based on the biopsy findings performed before ablation; (9) with no history of other malignancies; and (10) who refused to undergo hepatectomy or liver transplantation were included in the study. By contrast, patients (1) with incomplete clinical data, (2) whose cause of death was not related to HCC progression, (3) who were lost to follow-up 3 months after ablation, and (4) with serious heart, lung, and renal function dysfunction and active severe infection were excluded. As presented in [Figure 1], 150 treatment-naive HCC patients with BCLC Stage B were screened and divided into two groups: MWA only group (n = 88) and TACE-MWA group (n = 62).
|Figure 1: Flowchart of patients screened and classified into microwave ablation group and transarterial chemoembolization-microwave ablation group|
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Clinical records were reviewed to verify patient and tumor characteristics, treatment details, and clinical outcomes. The collected clinical data were as follows: (1) patients' features (sex, age, comorbidities [hypertension, diabetes, heart disease, renal disease, pneumonectasis, and esophageal gastric varices], pathological differentiation degree, etiology, cirrhosis, Child–Pugh grade, and Eastern Cooperative Oncology Group status); (2) tumor features (size, number, and location); (3) preoperative data (alpha-fetoprotein and albumin-bilirubin grade); (4) ablation parameters (insertion points and primary complete ablation rate); and (5) postoperative data (complications, LTP, RFS, and OS).
Transarterial chemoembolization combined with microwave ablation procedure
All BCLC Stage B HCC patients were discussed at a multidisciplinary meeting, and TACE was performed 3–7 days before MWA. After routine skin sterilization, local anesthesia with 1% lidocaine was administered. Modified Seldinger catheter was used for femoral puncture, and a Simon I 4F catheter was employed for celiac artery and superior mesenteric artery angiography. When necessary, selective hepatic artery angiography was performed. According to the size, location, and arterial supply of the tumor, the catheter tip was advanced toward the tumor feeding arteries for selective embolization. All TACE procedures, which involved the administration of chemotherapeutic drugs through the feeding artery, were selectively performed using a microcatheter. After inserting the microcatheter into the target branch, chemotherapeutic drugs and iodized oil (Lipiodol, Guerbet) were injected followed by injection of gelatin sponge particles. Cisplatinum (30–60 mg) and fluorouracil (500–1000 mg) were used. Liquid drugs were administered directly, and powdered drugs were mixed with lipiodol for injection. Cisplatin was suspended in 5–20 ml of iodized oil. Injection of embolic materials was performed in cases of tumor shunting until complete occlusion of the shunt. Lipiodol and gelatin sponge permit the drug to concentrate in the tumor and are retained for weeks. One day after TACE, a computed tomography (CT) examination was performed [Figure 2].
|Figure 2: A 58-year-old, male patient with hepatocellular carcinoma tumor (7.8cm × 6.4cm) located in the S6 who received transarterial chemoembolization (TACE)-MWA treatment. The tumor was shown on a magnetic resonance (MR) image as a T2WI with high signal intensity (a) and verified on a digital subtraction angiography image, and then a TACE was performed (b) a computed tomography (CT) exam was performed 1 day after TACE with iodized oil deposition (c); then MWA was performed with five insertions under CT guidance (d) ablation was considered complete if there is absence of enhancement on MRI image 1 month after ablation (e) and the ablation zone gradually shrunk 6 months after ablation (f) (yellow arrow).|
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Microwave ablation procedure
Two cooled-shaft microwave systems (KY-2000, Kangyou Medical, Nanjing, China) with frequencies of 2450 MHz and 915 MHz were used with two generators, both capable of producing 1–100 W of power. The needle antenna has a diameter of 1.9 mm and one 18-cm shaft that can be easily visualized under image. A narrow radiating segment of 3 mm is embedded on the shaft, 11 or 22 mm away from the tip. The microwave machine is also equipped with a thermal monitoring system that continuously measures temperature in real time during ablation. The thermal monitoring needle has a diameter of 0.8 mm.
An automatic biopsy gun with an 18-G cutting needle was used to carry out an ultrasound (US)-guided biopsy immediately before ablation. Consequently, the antennas were percutaneously inserted into the tumor and placed at a designated location under CT or US guidance. For tumors ≤2.0 cm, one antenna was inserted; for 2.0–3.0-cm tumors, two antennae were used simultaneously with two insertions; and for 3.0–5.0-cm tumors, four insertions were needed. A power output of 50–60 W was routinely used during MWA. After all insertions, intravenous anesthesia was administered during standard hemodynamic monitoring. Completed ablation was considered as the heat-generated hyperechoic water vapor completely encompassing the entire tumor in US image or no enhancement in CT image. As many of the tumors were located at challenging locations, induction of artificial pleural effusion and ascites was also performed., A case is shown in [Figure 3].
|Figure 3: A 65-year-old, male patient with hepatocellular carcinoma tumor (6.7cm × 5.8cm) located in the S6 who received MWA alone. The tumor was detected on a contrast-enhanced ultrasound image (a) and verified on a magnetic resonance (MR) image as hyperenhancement in the arterial phase (b); MWA was performed with four insertions with under ultrasound-guidance (c); the ablation was considered complete when there is absence of enhancement in the arterial phase on the MR image 1 month after ablation (d), and the ablation zone gradually shrunk 3 months after ablation (e) (yellow arrow)|
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The assistive technologies included in this study were hydrodissection, thermal monitoring, three-dimensional (3D) visualization planning, and multimodal image fusion guidance. If the lesions abutting gastrointestinal tract or diaphragm were found before MWA, hydrodissection is performed. A thermal monitoring needle was inserted into the tumor margin for real-time temperature monitoring during ablation. 3D visualization planning was defined as the interactive manual simulation of the tumor size, location, and the relationship between tumor and the surrounding organs in the 3D model. Multimodal image fusion guidance was defined as the puncture guidance by fused image from the registration of preoperatively acquired images (CT or magnetic resonance imaging) with intraoperative images (US) based on the specified anatomical landmark.
Follow-up and outcomes
Three days after the last course of a defined ablation protocol, contrast-enhanced imaging was performed to evaluate the treatment efficacy. Presence of an irregular peripheral enhancement in a scattered, nodular, or eccentric pattern indicates incomplete ablation, and another ablation was performed. Otherwise, complete ablation was achieved; then, routine contrast-enhanced imaging and serum tumor marker test were performed at 1 month, 3 months, and then every 6 months after treatment. For patients with suspected metastasis, chest CT, bone scan, or positron emission tomography-CT was performed. The end points of this study were death or termination. LTP was calculated from the date after treatment to the progression of the lesions. OS was calculated from the date of first session of MWA treatment to the date of death or last follow-up. RFS was calculated from the date of first session of MWA treatment to the date of tumor recurrence or the last follow-up. Complications were classified according to the Society of Interventional Radiology Classification System for Complications by Outcome. If recurrence and metastasis were detected, proper treatments were administered.
All patients who met the eligibility criteria at baseline were included, and their data were analyzed. The quantitative data were expressed as mean ± standard deviation (SD), and qualitative data were expressed as frequency. Differences in clinical parameters and imaging response outcomes between groups were calculated using logistic regression with propensity score matching (PSM), which was conducted using the nearest-neighbor algorithm (1:1). Before PSM, categorical data were compared using the Chi-square test or Fisher's exact test. After PSM, the Cochran–Mantel–Haenszel test was used to evaluate the differences in the categorical covariates. Conditional logistic regression was used after matching to account for the formation of pairs in the matched cohort. LTP, RFS, and OS rates were assessed by the Kaplan–Meier method using the log-rank test. A Cox proportional hazards model was used to identify the significant effects of risk factors on RFS and OS. Univariate and multivariate analyses of independent prognostic factors were evaluated by means of the forward stepwise Cox regression model. Statistical analyses were performed using SPSS 21.0 (SPSS, Chicago, IL, USA) and R software version (http://www.r-project.org/) 3.0.2. A P < 0.05 was considered statistically significant.
| > Results|| |
Baseline of patient, tumor, and ablation characteristics before and after propensity score matching
The clinical and pathological characteristics of 150 BCLC Stage B HCC patients with 288 tumors are summarized in [Table 1]. There were 24 female and 126 male patients with a mean age of 62.2 ± 11.3 years (range: 34–83). The mean ± SD of maximal tumor diameter was 6.3 ± 1.2 cm (5.1–10.0). Among the 15 clinical parameters, two showed a significant difference. The maximal tumor diameter in the TACE-MWA group (6.7 ± 1.3 cm) was significantly larger than that in the MWA only group (6.0 ± 1.0 cm) before PSM (P = 0.002). After further analysis, according to maximal tumor diameter (larger than 7 cm or <7 cm), the number of patients (19, 30.1%) in the TACE-MWA group with tumor larger than 7 cm was significantly higher than that in the MWA only group (11, 12.5%) (P = 0.006) before PSM. A significant difference was detected in preoperative α-fetoprotein levels of the TACE-MWA group (36 cases, 58.1%), which was higher than that in the MWA only group (33 cases, 37.5%) (P = 0.013). No difference was observed in the rest of the clinical parameters.
|Table 1: Baseline patient characteristics before and after propensity score matching|
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To further eliminate the differences among the clinical parameters, PSM was performed. There was no difference in the maximal tumor diameter (P = 0.067, 0.093) and preoperative α-fetoprotein level (P = 0.470) after PSM between the TACE-MWA group and MWA only group. Although no difference was detected in the primary complete ablation rate, the rate in MWA only group was slightly higher than that in the TACE-MWA group before and after PSM (P = 0.525, 0.812).
Comparison of long-term oncological outcomes between the transarterial chemoembolization combined with microwave ablation group and microwave ablation only group before and after propensity score matching
The median follow-up period was 37.8 months (range: 3–136). The 1- and 3-year RFS rates in the MWA only group were 56.6% and 35.5%, respectively, which were higher than that in the TACE-MWA group (51.4% and 32.3%). The 5-year RFS in the MWA only group was 22.3%, which was lower than that in the TACE-MWA group (27.6%), and no difference was detected before PSM (P = 0.786) by Kaplan–Meier method using the log-rank test [Figure 4]a. After PSM, the 1-, 3-, and 5-year RFS rates in the MWA only group were 51.6%, 34.5%, and 22.6%, which were similar to that in the TACE-MWA group (51.4%, 32.3%, and 27.6%) (P = 0.689) [Figure 4]b.
|Figure 4: Before (a) and after (b) propensity score matching, the 1-, 3-, and 5-year recurrence-free survival rates in the microwave ablation only group were compared with those in the transarterial chemoembolization combined with microwave ablation group (P = 0.786, P = 0.689)|
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The 1-year OS in the MWA only group was 82.3%, which was higher than that in the TACE-MWA group (78.2%). The 3- and 5-year OS rates were 48.6% and 21.8%, respectively, which were lower than that in the TACE-MWA group (49.2% and 28.8%), and no difference was detected before PSM (P = 0.684) [Figure 5]a. After PSM, the 1-, 3-, and 5-year OS rates in the MWA only group were 83.7%, 47.6%, and 21.2%, respectively, which were similar to that in the TACE-MWA group before PSM (78.2%, 49.2%, and 28.8%) (P = 0.929) [Figure 5]b.
|Figure 5: Before (a) and after (b) propensity score matching, the 1-, 3-, and 5-year overall survival rates in the microwave ablation only group were compared with those in the transarterial chemoembolization combined with microwave ablation group (P = 0.684, P = 0.929)|
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Complications related to microwave ablation only and transarterial chemoembolization combined with microwave ablation groups before and after propensity score matching
The complications related to MWA only and TACE-MWA procedures are listed in [Table 2]. The major complications detected in the MWA only group were pleural effusion requiring drainage (n = 5), massive hemorrhage of gastrointestinal tract (n = 1), subcapsular hemorrhage (n = 2), liver abscess (n = 1), and tumor needle seeding (n = 1), while the minor complications were new ascites (n = 3), pleural effusion (n = 3), hemoglobinuria (n = 1), liver dysfunction (n = 1), and others (n = 2). The corresponding results in TACE-MWA procedures were 4, 0, 2, 1, 0, 4, 2, 1, 2, and 3 cases, respectively. There was no difference in major and minor complications between the two groups before and after PSM (P = 0.803, 1.000 and P = 1.000, 1.000). The results suggested that the two procedures with similar safety were suitable for BCLC Stage B HCC patients. Moreover, all complications were treated, and the patients recovered within 1 week.
|Table 2: Complications related to microwave ablation or transarterial chemoembolization|
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Univariate and multivariate analyses of independent prognostic factors for overall survival and recurrence-free survival
Univariate and multivariate logistic regression analyses were performed to identify the factors influencing the long-term outcomes of BCLC Stage B HCC patients who underwent MWA alone or TACE-MWA. The univariate analyses showed significant differences in terms of OS, depending on tumor size (P = 0.009) and preoperative α-fetoprotein levels (P = 0.032) [Table 3]. The multivariate analyses showed that the tumor size (D > 7 cm) was an independent risk factor for poor OS (P = 0.011, hazard ratio [HR]: 1.932, 95% confidence interval [CI]: 1.165–3.206) [Table 3].
The univariate analysis showed significant differences in terms of RFS, depending on the tumor number only (P = 0.007). Further, the multivariate analysis showed that tumor number >1 was an independent risk factor for RFS (P = 0.008, HR: 1.804, 95% CI: 1.170–2.782) [Table 4].
Local tumor progression control in Barcelona clinic liver cancer Stage B hepatocellular carcinoma patients with a single tumor
LTP was an important factor influencing the long-term outcomes in HCC patients who underwent treatments., The results of univariate and multivariate analyses of independent risk factors for OS and RFS, tumor size, and number were important independent risk factors. Hence, 51 BCLC Stage B HCC patients with single tumor were selected, and the LTP was analyzed.
The 1-, 3-, 6-, and 12-month LTP rates in the MWA only group were 8.6%, 9.8%, 28.8%, and 35.7%, respectively, which were higher than that in the TACE-MWA group (0%, 5.2%, 17.5%, and 21.7%), and no difference was detected before PSM (P = 0.059) by Kaplan–Meier method using the log-rank test [Figure 6]a. After PSM, 1-, 3-, 6-, and 12-month LTP rates in the MWA only group were 8.6%, 14.7%, 33.0%, and 44.2%, respectively, which were obviously higher than that in the TACE-MWA groups (0%, 5.2%, 17.5%, and 21.7%), and a significant difference was detected (P = 0.006) [Figure 6]b.
|Figure 6: Before (a) and after (b) propensity score matching, the 1-, 3-, 6-, and 12-month local tumor progression rates in the microwave ablation only group were compared with those in the transarterial chemoembolization combined with microwave ablation group (P = 0.054, P = 0.006)|
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| > Discussion|| |
In our present study, the safety and efficiency of MWA alone were compared with those of TACE-MWA in BCLC Stage B HCC patients. After the analysis, the results showed that MWA alone and TACE-MWA had similar survival outcomes. Specifically, the MWA only group had a tendency to have longer 1- and 3-year RFS than the TACE-MWA group, but no significant difference was observed. By contrast, the 5-year RFS rate in the MWA only group was lower than that in the TACE-MWA group before PSM with no significant difference. With regard to OS, the tendency toward longer 1-year OS was observed in the MWA only group compared with the TACE-MWA group without significant difference, while the 3- and 5-year OS rates in the MWA only group were lower than that in the TACE-MWA group before PSM with no difference. The results indicate that the MWA only group showed better short-term tumor control than the TACE-MWA group, while the TACE-MWA group showed long-term tumor control and survival. This is probably because MWA causes complete coagulation necrosis, while TACE induces hypoxia within the tumor; moreover, ischemic injury after embolization induces the upregulation of angiogenic factors, which may favor tumor proliferation., However, this tendency disappeared, and the RFS and OS rates between the two groups were almost the same after PSM. Therefore, there was no difference detected in the procedure-related major and minor complications, RFS, and OS between the two groups. All of these results indicated that the safety and clinical efficiency of TACE-MWA and MWA alone were similar, and both procedures could be considered as alternative treatments for BCLC Stage B HCC. Moreover, the RFS and OS rates were similar to those reported in previous studies using combination therapy., This is probably due to the adjustment of the differences in clinical variables between the two groups. PSM is a statistical method that attempts to reduce the bias due to confounding variables that could occur when estimating the treatment effect obtained from simply comparing the outcomes of patients who received the treatment from those who did not receive the treatments, which has been used in several nonrandomized clinical studies.,, In this study, patients in the TACE-MWA group tend to have larger tumor size and higher α-fetoprotein level. As reported in this study, the tumor size was related to the α-fetoprotein level in some HCC patients. After PSM, the difference in α-fetoprotein level was eliminated. The use of PSM helped reduce the bias between the two groups.
To determine the risk factors affecting the long-term survival, univariate and multivariate analyses were performed. The tumor size and number were vital influencing factors. Similar to other reports, our study results suggested that tumor size larger than 7 cm and tumor number >1 were associated with poor survival., Although the tumor size in the TACE-MWA group was larger than that in the MWA group, no significant difference was detected in the RFS and OS rates between the two groups. This can be explained by the fact that TACE performed before MWA could reduce the tumor size and further promote thermal efficiency, expand the ablated area, and facilitate complete ablation.,
Based on the above analysis, tumor size was vital for predicting the RFS and OS in BCLC Stage B HCC patients. LTP was also an important factor for predicting long-term outcomes. Hence, the BCLC Stage B HCC patients with single tumor were selected, and the LTP was analyzed. Furthermore, the 1-, 3-, 6-, and 12-month LTP in the MWA only group was obviously higher than that in the TACE-MWA group, but no significant difference was detected before PSM, while a significant difference was detected after PSM. The results further indicated that TACE played an important role in LTP control, especially in the single tumors larger than 7 cm. These findings were also attributed to the mechanisms of TACE.
Our study has several limitations that must be addressed. First, this was a retrospective study and the possibility of variation in operators' technical proficiency might affect the accuracy of ablation results. Second, MWA was performed under CT guidance as combination treatment, while the US guidance was applied in the MWA only group. The difference might also influence the results. Third, the sample size of this study is relatively small. Hence, a multicenter study with larger sample size should be performed to consolidate these results.
| > Conclusions|| |
This study demonstrated that MWA alone could provide RFS and OS comparable to that of TACE-MWA for BCLC Stage B HCC patients. Both modalities are capable of achieving favorable imaging response and oncological outcomes. Tumor size and number were also independent risk factors for long-term prognosis. For tumor size larger than 7 cm, TACE-MWA was more effective in controlling LTP in patients with a single tumor. These results suggest other therapeutic alternatives for BCLC Stage B HCC patients, aside from TACE.
Financial support and sponsorship
This work was supported by the National Key R and D Program of China (No. 2017YFC0112000), grants (81430039, 81627803, and 81801723) from the National Scientific Foundation Committee of China, by the National Natural Science Foundation of China (No. 81771955), and by the Clinical Research Support Foundation of the Chinese PLA General Hospital (No. 2017FC-CXYY-3005).
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2], [Table 3], [Table 4]