According to the American Association for the Study of Liver Disease treatment guidelines for hepatocellular carcinoma (HCC), the role of surgery has been expanded beyond the Barcelona Clinic Liver Cancer (BCLC) algorithm. We compared primary hepatectomy (PH) with transarterial chemoembolization (TACE) in patients with intermediate to advanced (BCLC stage-B/C) stage HCC to determine the current evidence. Through database search, we included 18 high-quality studies (1 randomized controlled trial [RCT], 5 propensity-score matching non-randomized comparative trials [NRCT], and 12 NRCTs) that compared survival outcomes of 5,986 patients after PH and TACE. We found significant survival benefits for PH over TACE in BCLC stage-B/C patients (Hazard ratio [HR]: 0.59; 95% confidence interval [CI]: 0.51-0.67; P＜0.00001; I2 = 84%). According to the BCLC, both stage-B and stage-C patients showed significantly better overall survival for PH compared to TACE (HR: 0.53; 95% CI: 0.43-0.65; P＜0.00001; I2 = 77%; HR: 0.67; 95% CI: 0.59-0.77; P＜0.00001; I2 = 79%, respectively). Five-year survival rates for PH were significantly higher than those for TACE in BCLC stage-B/C, stage-B, and BCLC stage-C patients (OR: 2.71, 2.77, and 3.03, respectively; all P＜0.00001). Survival benefits persisted across subgroup, sensitivity, and meta-regression analyses; inter-study heterogeneity remained constant.
Conclusion: This meta-analysis suggests that surgical resection provides survival benefits in patients with intermediate to advanced stage HCC. The evidence found herein may assist in the choice of treatment modality based on diverse definitions of operability. This article is protected by copyright. All rights reserved.