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In the name of Alla

In the name of Alla. Transarterial chemoembolization in combination with percutaneous ablation therapy in unresectable hepatocellular carcinoma: a meta-analysis. Prepared by: Dr. Samah Ali Mansoor Mater Under supervision by: Ass. Prof. Dr. Abdul Hakeem Atamimi May/2010.

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In the name of Alla

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  1. In the name of Alla

  2. Transarterialchemoembolization in combination with percutaneous ablation therapy in unresectablehepatocellular carcinoma: a meta-analysis Prepared by: Dr. Samah Ali Mansoor Mater Under supervision by: Ass. Prof. Dr. Abdul Hakeem Atamimi May/2010

  3. The contributers: Wei Wang, Jian Shi and Wei-fen xie Department of Gasteroenterology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China

  4. INTRODUCTION

  5. Hepatocellular carcinoma (HCC) • The 6th common cancer in the world • Small proportion with early stage may benefit from radical options • Surgical resection isn’t the 1st treatment of choice in the presence of large lesion or poor liver function

  6. Transcatheter arterial chemoembolization (TACE) and percutaneous ablation (PA) are prescribed to prevent and relive suffering and improve qulity of life • Percutaneous ethanol injection (PEI) and radiofrequency ablation (RFA) are highly effective in the treatment of small lesion

  7. Transcatheter arterial chemoembolization (TACE) improve the survival in large and multiple lesions • Some viable tumor cells remain after transcatheter arterial chemoembolization (TACE)

  8. Recent evidence suggest that the combination of transcatheter arterial chemoembolization (TACE) with percutaneous ethanol injection (PEI) or radiofrequency ablation (RFA) may have a synergistic effect in treating large lesions that don’t response adequately to either procedure alone • For 5 cm lesions, 90-100% of complete response rate at 1 year was reported by applying radiofrequency ablation (RFA) after transcatheter arterial chemoembolization (TACE)

  9. Kirioshi et al.reported better results in tumor response and overall survival with combination of transcatheter arterial chemoembolization (TACE) and percutaneous ablation (PA) as compared with either procedure alone • However, several studies found no significant difference in the overall survival between combination and monotherapy

  10. Aim of the presented study Identify the survival benefits of this combination therapy for patients with unresectable hepatocellular carcinoma (HCC) with those of either procedure alone.

  11. PATIENTS AND METHODS

  12. Study objectives • The primary outcome The survival rate • The secondary outcome The initial complete response rate, and The tumour recurrence rate

  13. Search strategy Trials assesed the survival benefit or tumour recurrence for patients with unresectable hepatocellular carcinoma (HCC) were searched : - On PubMed, Embase and Web of Science ( all from 1990 to July 2009 ) - On Cochrane library database ( 2009, issue 2 ) - Manually, in general reviews on hepatocellular carcinoma (HCC) and references from published clinical trials

  14. Including criterea • A prospective randomized-controlled clinical trials • Above 18 years old patients • Patients were scheduled to undergo transcatheter arterial chemoembolization (TACE) with percutaneous ethanol injection (PEI) or radiofrequency ablation (RFA)

  15. Non-randomized studies • Recurrence of the tumour after • hepatectomy, liver metastases • Non of the three intervention • procedures was applied • No clinical data were collected for • primary and secondary outcomes Exclusion criterea

  16. Qualitative analysis Jadad composite scale used to score the included trials (from 0 to 5 points ) as assesses descriptions of : Randomization ( 0-2 point ) Blinding ( 0-2 point ) dropouts or withdrawals ( 0-1 point ) _______________________________________ ** High-quality reports at least with 3 points. ** Low-quality reports with 2 points or less.

  17. All calculations for the current meta-analysis were performed using REVIEW MANAGER (version 5.0 for Windows; the Cochrane Collaboration, Oxford, UK). This article follows the QUARUM and the Cochrane Collection guidelines (http:// www.cochrane.de) for reporting meta-analysis.

  18. Statistical methods The meta-analysis was carried according to the Cochrane Reviewer’s Handbook recommended by Cochrane Collaboration. Pooled odd ratio (OR) was calculated using DerSimonian and Laird method (random- affected model). The quantitative heterogeneity between trials was evaluated by the DLQ statistic. A funnel plot was used to test potential publication bias.

  19. RESULTS

  20. Identification of eligible randomized-controlled trials from different medicine databases.

  21. - Clinical data from 595 patients from those 10 trials were pooled to comparing for the current meta-analysis. - One trial was with no difference in most baseline characteristics. - Two trials involved 3 study arms. - No overlapping cases were among the 10 trials.

  22. Baseline characteristics of randomized trials included in the meta-analysis

  23. Qualitative analysis of randomized trials - 9 trials including 512 patients reported the 1-year survival rate. - 7 trials reported the 2-years and 3-years survival rate separately. - 1 trial assessed the qualiy of life and used in calculating the secondary outcome.

  24. Treatment arms among the 10 selected randomized controlled studies

  25. Methodological characteristics of randomized trials included in the meta-analysis

  26. Child-Pugh score Parameter 1 Point 2 Points 3 Points _________________________________________________ Serum bilirubin <2 2–3 >3 (mg/dL) Albumin (g/dL) >3.5 2.8–3.5 <2.8 Prothrombin time 1–3 4–6 >6 ( ↑ S) Ascites None Slight Significant Encephalopathy None 1–2 3–4 _________________________________________________ Grades: • A, 5 to 6 points • B, 7 to 9 points • C, 10 to 15 points

  27. Sensitivity analysis of survival

  28. Prognosis of patients reported in the randomized controlled trials included in the meta-analysis

  29. DISCUSSION

  30. The presented study demonstrated that the combination of transcatheter arterial chemoembolization (TACE) with percutaneous ablation (PA) was superior to transcatheter arterial chemoembolization (TACE) or percutaneous ablation (PA) alone for the significant benefit of survival and decrease of tumour recurrence for hepatocellular carcinoma patients.

  31. Noenough adverse events data can be pooled for systematic analysis among the selected randomized controlled trials (RCTs), so no safety profile and risk analysis with the different interventions was established in this meta-analysis presentation.

  32. The conclusion The combinationof transcatheter arterial chemoembolization (TACE) with percutaneous ablation (PA): • Improve the overall survival status, especially with percutaneous ethanol injection (PEI), more significantly than a single monotherapy. • Decrease the tumour recurrence rate compared with that of monotherapy.

  33. THANKS

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