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Page 2 of 10 Zhao et al. Hepatoma Res 2019;5:17 I http://dx.doi.org/10.20517/2394-5079.2018.116

Results: A total of 1,210 patients from 13 eligible studies were included. The cooperation of TACE and SBRT notably
ameliorated the whole survival rates of half-year, one-year, two-year, the negative conversion rate of AFP, and the
total effective rate, compared with TACE or SBRT monotherapy [RR (the total effective rate), 1.412, 95%CI: 1.309-
1.523, P < 0.001], [RR (half-year survival rate), 1.196, 95%CI: 1.121-1.276, P < 0.001], [RR (one-year survival rate),
1.327, 95%CI: 1.236-1.424, P < 0.001], [RR (two-year survival rate), 1.479, 95%CI: 1.284-1.703, P < 0.001] and [RR
(negative conversion rate of AFP), 1.756, 95%CI: 1.502-2.059, P < 0.001]. Sensitivity analysis supported the above
results.

Conclusion: Combination therapy of SBRT and TACE provides survival benefits in intermediate-to advanced-stage
HCC patients compared to monotherapy of SBRT or TACE.

Keywords: Transcatheter arterial chemoembolization, hepatocellular carcinoma, stereotactic body radiation therapy,
meta-analysis

INTRODUCTION
Hepatocellular carcinoma (HCC) is the third leading cause of cancer-related death and the fifth most
common malignancy worldwide . The incidence and mortality rates of HCC shows an increasing trend
[1,2]
year by year . Although the application of new HCC biomarkers and advanced imaging methods may
[3]
improve the sensitivity and specificity of HCC in an early stage, a large proportion of HCC patients have
been already at the intermediate-to advanced-stage at the time of diagnosis.

TACE, radiofrequency ablation, microwave ablation are widely used in clinically, and each of them has been
proved to produce a great healing effect on patients in clinical practice . However, the limited indications
[4-6]
and contraindications restrict the clinical use of the monotherapy which may lead to a high recurrence
rate. In recent years, researchers have tried relevant clinical trials to seek the treatment effect of combined
treatment on patients with intermediate-and advanced-stage HCC [7-10] .

With the development of liver radiobiology and the significant progress of radiotherapy technology, SBRT
has been gradually applied to HCC in the intermediate and advanced stage . However, due to the relatively
[11]
small sample size of related clinical trials and the lack of multi-center and large-sample randomized
controlled studies, the efficacy of SBRT combined with TACE in the treatment of intermediate-and advanced-
stage HCC is difficult to draw definite conclusions. Therefore, the current meta-analysis was carried out to
evaluate the efficacy and safety of combination therapy and provide evidence for clinical decision making.

METHODS
Search strategy
Studies were acquired via searching English databases, covering PubMed, MEDLINE, and the web of science
(SCI). Chinese databases were also examined, including Chinese Knowledge resources integrated, Chinese
Scientific Journal Full-Text Database and China Biology Medicine. The closing date for documents search was
November, 2018,“transcatheter arterial chemoembolization” or TACE) or “transarterial chemoembolization”
and “hepatocellular carcinoma” or “liver carcinoma” or “liver cancer” or “HCC” and (“stereotactic body
radiation therapy” or “Gamma Knife”) were used as search terms. Additionally, the references of relevant
articles were also retrieved until no new potential material could be found.

Study selection
Including criteria for this meta-analysis were as follows: (1) randomized controlled trials and language
limited to Chinese or English; (2) the studies that included an observation group adopted SBRT combined