Transarterial radioembolization for hepatocellular carcinoma with major vascular invasion: a nationwide propensity-score matched analysis with target trial emulation.

Abstract

PURPOSE\nExamine National Cancer Database (NCDB) data to comparatively evaluate overall survival (OS) between transarterial radioembolization (TARE) and systemic therapy in hepatocellular carcinoma (HCC) with major vascular invasion (HCC-MVI).\n\n\nMATERIALS AND METHODS\n1514 HCC-MVI patients receiving first-line TARE or systemic therapy were identified from the NCDB. OS was compared by propensity-score matched Cox regression and landmark analysis. Efficacy was also compared within a target trial framework.\n\n\nRESULTS\nTARE usage doubled between 2010 and 2015. Pre-treatment intervals were longer for TARE than for systemic therapy (mean (median) 66.5 (60) days versus 46.8 (35) days, respectively, p < 0.0001). Propensity-score matched and landmark-time adjusted analysis associated TARE with HR 0.74 (95% CI 0.60 to 0.91, p = 0.005) and median OS 7.1 months (95% CI 5.0 to 10.5) versus 4.9 months (95% CI 3.9 to 6.5) for systemically-treated patients. Target trial emulation involving 236 patients with unilobular HCC-MVI, low comorbidities, creatinine < 2.0 mg/dL, bilirubin < 2.0 mg/dL, and INR < 1.7, associated TARE with HR 0.57 (95%CI 0.39 to 0.83, p = 0.004) and median OS 12.9 months (95% CI 7.6 to 19.2) versus 6.5 months (95% CI 3.6 to 11.1) for the systemic therapy arm.\n\n\nCONCLUSION\nPropensity-score matched analyses involving pragmatic and target trial HCC-MVI cohorts associated TARE with significant survival benefits over systemic therapy. While not a substitute for prospective trials, these findings suggest rising use of TARE for HCC-MVI is accompanied by improved OS. Further trials of TARE in HCC-MVI are needed.