We read with great interest the updated guidelines on hepatocellular carcinoma (HCC) by the American Association for the Study of Liver Diseases.1 The guidelines suggest that pre- or postresection adjuvant therapy is not recommended.1 As the guidelines recommend, it is suggested that preoperative transcatheter arterial chemoembolization (TACE), worsens overall survival (OS) rate and increases the risk of HCC recurrence for resectable HCC.2 As a result, they propose that preoperative TACE cannot be recommended as a routine procedure before hepatectomy for a resectable HCC, in accordance with our opinion.
However, for the postoperative period, guidelines ignore a significant amount of data about the use of TACE. Recently, accumulating evidence has demonstrated that patients with HCC can benefit from postoperative TACE. A prospective randomized trial in patients with stage IIIA HCC (clinical trial NCT00652587), recruited 115 patients with stage IIIA HCC to undergo hepatectomy with adjuvant TACE or to undergo hepatectomy alone.3 The 1-, 3-, and 5-year OS rates and median OS for hepatectomy with adjuvant TACE were 80.7%, 33.3%, 22.8%, and 23.0 months, respectively, and for hepatectomy alone were 56.5%, 19.4%, 17.5%, and 14.0 months, respectively (P = 0.048). The 1-, 3-, and 5-year disease-free survival (DFS) rates and median DFS for hepatectomy with adjuvant TACE were 29.7%, 9.3%, 9.3%, and 6.0 months, respectively, and for hepatectomy alone were 14.0%, 3.5%, 1.7%, and 4.0 months, respectively (P = 0.004). Thus, for patients with stage IIIA HCC, hepatectomy with adjuvant TACE efficaciously and safely improved survival outcomes when compared with hepatectomy alone. More importantly, a meta-analysis including six randomized controlled trials totaling 659 participants were included.4 For the 1-year tumor recurrence rate, hepatectomy plus TACE showed statistically significant less incidence of recurrence, with a pooled relative risk (RR) of 0.68 (95% confidence interval [CI] = 0.55-0.84, P = 0.0003). For 1- and 3-year mortality, the trials were favorable for TACE with a pooled RR of 0.48 (95% CI = 0.35-0.65, P < 0.00001) and with a pooled RR of 0.76 (95% CI = 0.64-0.90, P = 0.002). Therefore, when used as a postoperative treatment, TACE could decrease tumor recurrence and improve survival for the participants with HCC with risk factors.
Taken together, because TACE is the most effective adjuvant therapy for treatment of HCC, it should be complemented in the postoperative period for HCC. Thus, it seems plausible to infer that postoperative TACE should be recommended in the HCC treatment guidelines of the American Association for the Study of Liver Diseases.