Hepatocellular Carcinoma More Than 3？cm in Diameter: A Systematic Review of Transcatheter Arterial Chemoembolization Plus Percutaneous Ethanol Injection versus Transcatheter Arterial Chemoembolization Alone
Objective. To identify the efficiency and safety of transcatheter arterial chemoembolization (TACE) combined with percutaneous ethanol (PEI) for patients with hepatocellular carcinoma (HCC) more than 3？cm in diameter in comparison with those of transcatheter arterial chemoembolization monotherapy. Methods. All databases were searched up to February 22, 2013. The literature retrieval was conducted through Pubmed, Web of Science, and Cochrane Library. We also searched Chinese databases, including Chinese National Knowledge Infrastructure (CNKI), Chinese Biology Medicine (CBM), Wanfang database, and VIP Database for Chinese Technical Periodicals without language limitations. Results. Based on the criteria, we found 12？RCTs including 825 patients. Our results showed that TACE combined with PEI therapy compared with TACE monotherapy improved overall survival and tumor response. Conclusion. The combination of TACE and PEI compared with TACE monotherapy improved overall survival rates and tumor response of patients with large HCC. Besides, larger and more methodologically rigorous clinical trials are needed to confirm this outcome. 1. Introduction Transcatheter arterial chemoembolization (TACE) has been widely used in the treatment of hepatocellular carcinoma (HCC), so does percutaneous ethanol injection (PEI). However, the effectiveness of PEI is limited to small lesions less than 3？cm in diameter [1]. The possibility of profitably combination of intra arterial therapies with ethanol injection in large HCC was first suggested by Tanaka et al. [2]. However, previous studies assessing the effectiveness of TACE combined with PEI versus TACE alone reported conflicting results in large HCC [3–6]. Becker et al. [4] showed no significant difference in the overall survival among large HCC patients under combination therapy or monotherapy, whereas several studies demonstrated that the combination of TACE and PEI was more effective than TACE monotherapy for large tumors [3, 5, 6]. In 2011, a meta-analysis assessed the effectiveness of TACE and PEI; however, the tumor size in most studies included in this review was unclear [7]. So whether combination of TACE and PEI was more effective than TACE alone in large HCC is still unknown. To determine the effectiveness of the combination of TACE and PEI in HCC more than 3？cm in diameter, we performed this meta-analysis using the grading of recommendations, assessment, development, and evaluation (GRADE) system [8, 9]. 2. Methods 2.1. Search Strategy All databases were searched up to February 22, 2013. We searched PubMed, Web
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