Surgery versus external beam radiotherapy for hepatocellular carcinoma involving the inferior vena cava or right atrium: A systematic review and meta-analysis

Abstract

Purpose: As the treatment efficacy of systemic therapy for patients with advanced stage HCC is insufficient, locoregional therapies are performed in the clinical practice. We investigated the efficacy and safety of two most potent therapies, surgery and external beam radiotherapy (EBRT), in patients with HCC involving the IVC and/or right atrium (RA) through comparative meta-analysis. Method: A systematic search of Pubmed, MEDLINE, EMBASE, and the Cochrane library was performed for entries up to July 2020. The primary endpoints were 1 and 2 year overall survival (OS) rates, while secondary endpoints were response rate, local control rate, and grade >=3 toxicities. Results: Eighteen studies with 22 cohorts were included, encompassing 755 patients. The pooled median OS and 1 and 2 year OS rates were 14.2 months, 55.6%, and 27.4%, respectively. The pooled median OS in the surgery and EBRT arms were 15.3 and 11.7 months, respectively. The pooled 1 year OS rate of the surgery arm was significantly higher than that of the EBRT arm (62.4%, 95% CI: 53.8–70.3 vs. 48.8%, 95% CI: 40.9–56.8; p=0.023). However, the 2 year OS rates were comparable (26.9%, 95% CI: 20.7–34.2 vs. 27.5%, 95% CI: 19.7–37.1; p=0.913). The pooled response and local control rates in the EBRT arm were 74.3% and 87.2%, respectively. In the surgical arm, the perioperative mortality and grade >=3 complication rates were 0–7.6% and 3.9–67%, respectively. Grade >=3 complications and radiation induced liver disease were rarely observed in the EBRT arm. Conclusions: Both surgery and EBRT are effective treatment options for patients with HCC involving IVC/RA invasion. Outcomes and safety should be further evaluated in well-controlled clinical trials.