肝细胞癌根治性肝切除术后预防性TACE疗效的meta分析

摘要

目的 评价肝细胞癌根治性肝切除术后行预防性肝动脉化疗栓塞术(transcatheter arterial chemoembolization,TACE)对提高生存获益的效果.方法 通过计算机检索Pubmed,Cochrane library,EMBASE,CNKI和万方数据库中的相关文献,检索时间为1975年1月1日至2017年7月20日.对符合纳入标准的研究采用R语言3.3.2版本及Review Manager 5.3 版本进行统计学分析.结果 共纳入34篇研究,其中随机对照研究8篇,观察性研究26篇,总计3 264名患者.meta分析显示,术后行预防性TACE组与不行预防性TACE组相比可以改善患者的总体生存与无瘤生存,两者的差异具有统计学意义(HR =0.65,95％ CI =0.59 ～0.70,I2=11％;HR =0.71,95％ CI =0.66 ～0.77,I2=3％).亚组分析显示,对于肿瘤直径＜5cm的小肝癌,术后预防性TACE只能改善无瘤生存.而对于肿瘤直径≥5cm的大肝癌以及存在微血管侵犯(MVI)的肝癌,术后预防性TACE可以改善总体生存和无瘤生存.结论 现有证据显示,肝细胞癌根治性切除术后行预防性TACE相比不行预防性TACE可以有效改善总体生存和无瘤生存,尤其是对大肝癌及存在MVI的患者.%Objective To evaluate the effect of transcatheter arterial chemoembolization (TACE) on survival benefit after curative hepatectomy of hepatocellular carcinoma.Methods Pubmed,Cochrane library,EMBASE,CNKI and Wanfang database were searched for randomized or nonrandomized studies comparing postoperative adjuvant TACE with curative resection alone,regardless of language.The search date was from January 1,1975 to July 20,2017.Data was screened and extracted by 2 independent investigators.The quality of randomized controlled studies was evaluated following the Cochrane Handbook for System Systematic Review of Intervention (Version 5.2,2011),and the quality of observational studies was assessed using the Newcastle-Ottawa Scale.Results 34 studies were matched the selection criteria,including 8 randomized controlled studies and 26 observational studies,for a total of 3 ?264 patients.Meta-analysis showed that the postoperative adjuvant TACE group could improve the overall survival and tumor-free survival compared with the non-TACE group,the difference was statistically significant (HR =0.65,95 ％ CI =0.59 ～ 0.70,I2 =11％;HR =0.71,95 ％ CI =0.66 ～ 0.77,I2 =3 ％).The results of observational studies were consistent with those of RCTs.Begg's funnel plots and the Egger's regression tests did not indicate any evidence of publication bias.Subgroup analysis showed that for small hepatocellular carcinoma with tumor diameter ＜ 5 cm,postoperative adjuvant TACE could only improve tumor-free survival (HR =0.56,95％ CI =0.43 ～ 0.72,I2 =0％) and could not improve overall survival(HR =0.53,95 ％ CI =0.27 ～ 1.04,I2 =52％).For large hepatocellular carcinoma with tumor diameter≥ 5 cm,postoperative adjuvant TACE could significantly improve the overall survival (HR =0.61,95％ CI =0.50 ～ 0.73,I2 =0％) and tumor-free survival (HR =0.71,95％ CI =0.59 ～ 0.85,I2 =4％).For the group with the presence of microvascular invasion (MVI),postoperative adjuvant TACE could also improve the overall survival (HR =0.52,95％ CI =0.36 ～ 0.73,I2 =43％).Conclusions The available evidence showed that postoperative adjuvant TACE compared with non-TACE could effectively improve the overall survival and tumor-free survival,especially for patients with large liver cancer and MVI.