The efficacy of transarterial chemoembolization combined with microwave ablation for unresectable hepatocellular carcinoma: a systematic review and meta-analysis

Figures & data

Figure 1. PRISMA flow diagram of eligible studies for this meta-analysis.

Table 1. Characteristics of the clinical trials included in the meta-analysis.

Study	Period	Design	Treatment	Patients	Age	Sex (M/F)	Child-pugh (A/B/C)	Tumor response (CR/PR/SD/PD)	Follow up (Months)	Quality
Liu 2011 [23]	2004–2006	Retrospective	TACE + MWA	18	51.9 ± 13.6	15/3	9/8/1	14/2/2 (CR + PR/SD/PD)	8 (2–28)	H
			TACE	16	52.1 ± 14.5	14/2	8/7/1	7/5/4 (CR + PR/SD/PD)
Xu 2013 [24]	2004–2011	Retrospective	TACE + MWA	56	54.5 ± 13.0	48/8	NR	NR	41 (6–96)	M
			TACE	80	53.1 ± 14.8	73/7	NR	NR
Sheta 2016 [25]	NR	RCT	TACE + MWA	10	NR	NR	8/2/0	8(CR + PR)	NR	H
			TACE	20	NR	NR	14/6/0	10(CR + PR)
Li 2016 [26]	2005–2015	Retrospective	TACE + MWA	42	NR	NR	NR	19/11/7/5	3.5–24	M
			TACE	42	NR	NR	NR	10/8/9/15
Chen 2017 [27]	2014–2015	Retrospective PSM	TACE + MWA	48	59.7 ± 10.5	28/20	39/9/0	44/1/1/2	16.8	H
			TACE	96	58.8 ± 9.6	54/42	84/12/0	30/23/7/33
Zhang 2018 [28]	2007–2016	Retrospective PSM	TACE + MWA	50	NR	43/7	46/4/0	37/13 (CR + PR + SD/PD)	16.2 (1–98.7)	H
			TACE	100	NR	91/9	94/6/0	56/44 (CR + PR + SD/PD)
Smolock 2018 [29]	2007–2016	Retrospective	TACE + MWA	23	61 (44–85)	NR	14/9/0	15/7/1/0	9.4 (1.3–15.5)	H
			TACE	24	64 (43–76)	NR	14/7/3	9/9/5/1
Zheng 2018 [30]	2011–2015	Retrospective	TACE + MWA	92	NR	79/13	NR	54/12/9/17	21.2 (4–45)	H
			TACE	166	NR	143/23	NR	21/49/22/74
Wei 2018 [31]	2010–2015	Retrospective	TACE + MWA	12	55.0 ± 11.0	11/1	5/7/0	NR	NR	H
			TACE	69	51.0 ± 11.0	59/10	15/47/7	NR
Study		Etiology	Tumor size	Tumor number	PVTT	Extrahepatic metastasis	BCLC stage
	Treatment	(HBV/HCV)	(cm)	(S/M)	(Yes/No)	(Yes/No)	(A/B/C/D)
Liu 2011 [23]	TACE + MWA	17/1	6.7 ± 1.5	2.1 ± 1.4	5/13	0/18	NR
	TACE	14/2	6.8 ± 1.5		4/12	0/16	NR
Xu 2013 [24]	TACE + MWA	56/0	NR	NR	NR	0/56	NR
	TACE	80/0	NR	NR	NR	0/80	NR
Sheta 2016 [25]	TACE + MWA	NR	5.2 ± 0.3	NR	0/10	0/10	NR
	TACE	NR	4.8 ± 0.6	NR	0/20	0/20	NR
Li 2016 [26]	TACE + MWA	NR	6.7	1.6	NR	0/42	0/42/0/0
	TACE	NR	7.1	1.7	NR	0/42	0/42/0/0
Chen 2017 [27]	TACE + MWA	31/17	2.7 ± 1.1	37/11	0/48	0/48	NR
	TACE	53/43	2.9 ± 1.3	77/19	0/96	0/96	NR
Zhang 2018 [28]	TACE + MWA	NR	NR	NR	NR	NR	0/50/0/0
	TACE	NR	NR	NR	NR	NR	0/100/0/0
Smolock 2018 [29]	TACE + MWA	NR	4.2(3.0–5.0)	20/3	0/23	NR	10/9/4/0
	TACE	NR	3.75(3.0–5.0)	8/16	1/23	NR	0/11/11/2
Zheng 2018 [30]	TACE + MWA	87/5	8.2 ± 2.5	20/72	NR	NR	NR
	TACE	155/11	9.1 ± 2.8	33/133	NR	NR	NR
Wei 2018 [31]	TACE + MWA	12/0	12.9 ± 2.5	2.3 ± 0.9	NR	NR	NR
	TACE	69/0

Note: TACE: transarterial chemoembolization; MWA: microwave ablation; CR: complete response; PR: partial response; SD: stable disease; PD: progressive disease; RCT: randomized controlled trial; NR: not report; H: high; M: medium. PVTT: portal vein tumor thrombus; BCLC: Barcelona Clinic Liver Cancer; HBV: hepatitis B virus; HCV: hepatitis B virus; TACE: transarterial chemoembolization; MWA: microwave ablation; NR: not report.

Table 2. Interventions of included studies.

Study	Treatment	Drugs and dosage/Frequency and power	Courses
Liu 2011 [23]	TACE	Cisplatin (80–120 mg)/adriamycin (40–60 mg)+lipiodol(10–20 ml)	1.6 (1–3) courses in TACE, 1.3 (1–2) courses in combined group
	MWA	US guided, 2450 MHZ, 100 W	Performed after TACE, the intervals was 2–4 weeks, 1.9 courses in combined group
Xu 2013 [24]	TACE	Fluorouracil deoxynucleoside(500–100 mg)+pirarubicin(20–40 mg)+hydroxycamptothecin (5–15 mg)/mitomycin(2–8)mg + lipiodol(15–30 ml)	2.9 (1–6) courses in TACE, 2.9 (1–6) courses in combined group
	MWA	CT guided, 60–70 W, 10–20 minutes	Performed after TACE, the intervals was 1–3 weeks, 1.9 (1–5) courses in combined group
Sheta 2016 [25]	TACE	Doxorubicin hydrochloride(50–100 mg), mixed a ratio 2–3:1 lipiodol	NR
	MWA	CT guided, 2450 MHZ, 100 W	Performed before TACE, single courses in combined group
Li 2016 [26]	TACE	Fluorouracil (500–100 mg)+cisplatin (40–60 mg)+epirubicin-gemcitabine (10–20 mg)+lipiodol (10–30 mL)	NR
	MWA	CT guided, 40–60 W, 6–15 minutes	Performed after TACE, the intervals was 1–4 weeks
Chen 2017 [27]	TACE	Epirubicin (20–40 mg)+lipiodol (1–10 mL)	1.9 ± 1.7 courses in TACE
	MWA	CT guided, 2450 ± 50 MHZ, 150 W	Performed after TACE, the intervals was 2 weeks
Zhang 2018 [28]	TACE	Lobaplatin(50 mg)+pirarubicin(30 mg)+lipiodol (5–10 mL)	NR
	MWA	CT guided, 2450 MHZ, 50–100 W, 10–20 minutes	NR
Smolock 2018 [29]	TACE	Doxorubicin (30 mg)+mitomycin C(20 mg) +cisplatin(100 mg), mixed a ratio 1:1 lipiodol	NR
	MWA	CT guided, 65 W, 5–10 minutes	Performed after TACE, the intervals was 2 weeks
Zheng 2018 [30]	TACE	Lobaplatin (50 mg)+epirubicin (30 mg) + lipiodol (5–15 ml)	NR
	MWA	CT guided, 60–80 W	Performed after TACE, the intervals was 1–2 weeks
Wei 2018 [31]	TACE	Doxorubicin(40 mg)+ embosphere microspheres(300–500 µm)+lipiodol (25 ml)	2.4 (1–14) courses in TACE, 2.5 (1–7) courses in combined group
	MWA	CT guided, 2450 MHZ, 60–80 W, 8–20 minutes	Performed after TACE, the intervals was 1–3 weeks, 1.8(1–5) courses in combined group

Table 3. Subgroup analysis stratified by tumor size. (A) tumor size ≤5 cm. (B) tumor size >5 cm.

Subgroup	Studies included	Overall Survival
		Participants	Effect model	OR (95%CI)	p
Tumor size ≤5 cm
1 year [27,28]	2	213	Fixed	1.83 (0.61–5.47)	.28
2 years [27,28]	2	213	Fixed	1.69 (0.75–3.81)	.30
Tumor size >5 cm
1 year [23,24,30,31]	4	509	Fixed	3.82 (2.38–6.13)	<.001
2 years [23,24,30]	3	428	Fixed	3.83 (2.37–6.19)	<.001
3 years [24,30]	2	394	Fixed	4.12 (2.51–6.77)	<.001

Figure 2. Forest plot of overall survival rates between TACE + MWA and TACE alone. (A) 1-year survival rate. (B) 2-year survival rate. (C) 3-year survival rate.

Figure 3. Forest plot of the tumor response between TACE + MWA and TACE alone. (A) Objective remission rate. (B) Local control rate.

Figure 4. Forest plot of the severe adverse events between TACE + MWA and TACE alone.

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