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Page 6 of 17                                                   Chan et al. Hepatoma Res 2018;4:5  I  http://dx.doi.org/10.20517/2394-5079.2017.49


               Table 6. Recent studies on the efficacy of transarterial chemoembolization in the management of high-burden hepatocellular
               carcinoma
                Year        Place     Authors    Vascular   Number   1-year   3-year   5-year   Median   Recruitment
                                                invasion  of    survival   survival   survival   survival   year
                                                        patients   (%)   (%)     (%)    (months)
                                                         (n)
                2009  Japan       Ban et al. [42]  Vp3 and Vp4  45  69.6  37.4   22.4     20     1992-2008
                2010  China       Shi et al. [53]  Vp1 and Vp2  139  52.1  25.1  -        -      2001-2003
                2010  China       Shi et al. [53]  Vp3   169     38.2    17.7    -        -      2001-2003
                2010  China       Shi et al. [53]  Vp4   78      24.7    3.6     -        -      2001-2003
                2012  Taiwan      Chang et al. [28]  -   160     57.6    33.8    29.1     -      1991-2006
                2012  China       Peng et al. [43]  All types  201  42   14.1    11.1     20     2002-2007
                2012  China       Chen et al. [50]  All types  88  31.1  15.2    -        9      2006-2008
                2012  Japan       Matono et al. [52]  Vp3 and Vp4  29  62.1  24.1  17.2   16.6   1985-2005
                2013  USA         Roayaie et al. [46]  All types  165  -  -      14       13.1   1992-2010
                2013  China       Tang et al. [54]  All types  186  40.1  13.6   -        10     2006-2008
                2013  France, Italy, Japan,  Torzilli et al. [55]  All types  297  76  49  38  -  1990-2009
                     Argentina, USA
                2014  Taiwan      Liu et al. [48]  Vp1 to Vp3  247  85   68      61       64     2002-2012
                2014  Hong Kong   Chok et al. [57]  Vp3  71      45.8    22.7    11.2     10.9   1989-2010
                2015  Japan       Kojima et al. [44]  Vp3 and Vp4  25  68  32    12       21.5   2001-2010
                2016  Japan       Kokudo et al. [45]  All types  1877  74.8  49.1  39.1   34     2000-2007
                2016  Korea       Lee et al. [47]  Vp1 to Vp3  40  -     -       -        19.9   2000-2011
                2016  China       Zheng et al. [49]  All types  96  86.5  60.4   33.3     -      2000-2008
                2016  China       Li et al. [51]  Vp4    50      35.6    0       0        -      2010-2013
                2016  China       Zhang et al. [58]  Vp1 to Vp3  113  68.9  34.3  30.8    18.2   2005-2012
                2016  Japan       Kudo et al. [56]  Vp3 and Vp4  852  59.8  34.3  25      -      1996-2007
                2016  Japan       Kudo et al. [56]  Vp2  714     69.1    42.2    29.2     -      1996-2007
                2016  Japan       Kudo et al. [56]  Vp1  1908    84.9    62.4    48.2     -      1996-2007


               Table 7. Comparison of median overall survival of high-burden HCC treated with surgery and TACE
                               Solitary large HCC (surgery)  Solitary large HCC (TACE)  Overall (surgery)  Overall (TACE)
                1-year survival (%)    87.2                   87.9                74.3           68.4
                3-year survival (%)    63.2                   72.8                51.2           42.1
                5-year survival (%)     56.1                  49.6               39.2            31.1

               HCC: hepatocellular carcinoma; TACE: transarterial chemoembolization

               A small number of studies have explored the possibility of TACE as a palliative treatment in high-burden
               HCC with portal vein invasion [43,48,49,74-78]  [Table 8]. The median 1-year overall survival rate was 50.5%.
               Even fewer studies have reported the median 3-year overall survival rate, likely due to the poor prognosis
               associated with portal vein invasion. No study thus far has compared difference in survival rate between
               segmental branches involvements (Vp1 and Vp2) and 1st branch or main trunk involvement (Vp3 and Vp4).

               It is worth noting that many studies included in this review used conventional TACE (cTACE). However,
               drug-eluting bead TACE (DEB-TACE), since its introduction in 2006, was believed to be superior to cTACE.
                                                                                   [79]
               It has been demonstrated to have a lower toxicity profile compared to cTACE . However, studies so far
               failed to prove its ability to consistently prolong survival [79-84] . Moreover, as a relatively new agent, only a
               paucity of studies has looked at its effect on high-burden HCC, particularly those with portal vein invasion.
               More studies are needed for this particular population of patients.


               Transarterial radioembolization
               Although TACE has been shown to be an effective therapy for high-burden unresectable HCC, it is
               associated with substantial systemic toxicities. In a Cochrane review in 2011, post-embolization syndrome,
               with clinical manifestations of transient fever, abdominal pain and elevated transaminases, was reported
                                                             [85]
               to occur in up to 80% of the patients receiving TACE . Other serious adverse events, albeit uncommon,
                                                                               [79]
               include acute renal failure, ascites, encephalopathy and transient liver failure .
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