Application of hepatic artery interventional therapies in the conversion treatment of unresectable hepatocellular carcinoma: A systematic review and meta-analysis.

[BACKGROUND] The conversion therapy aims to transform initially unresectable hepatocellular carcinoma (uHCC) into a resectable state through systemic or locoregional treatment (LRT). However, there is no clear optimal conversion therapy strategy at present.

[METHODS] A systematic search was performed across PubMed, Web of Science, Cochrane Library, Embase to identify relevant studies. The primary endpoint was the conversion to surgery rate (CSR), with objective response rate (ORR), overall survival (OS), and progression-free survival (PFS) analyzed as secondary endpoints.

[RESULTS] A total of 44 studies were included, comprising data from 5065 patients. The pooled CSR in each treatment group was as follows: 6 ​% in the conventional transcatheter arterial chemoembolization (cTACE) group, 9 ​% in the hepatic arterial infusion chemotherapy (HAIC) group, 20 ​% in the drug-eluting beads transarterial chemoembolization (DEB-TACE) group, 25 ​% in the transarterial radioembolization (TARE) group, 42 ​% in the combination of TACE and HAIC (TACE-HAIC) group. Among dual therapies, the pooled CSR was 13 ​% in the TACE combined with tyrosine kinase inhibitor (TKI) group, 15 ​% in the HAIC plus TKI group, 8 ​% in the TACE-HAIC plus TKI group. For triple therapies, the pooled CSR was 29 ​% in the TACE combined with TKI and immune checkpoint inhibitor (ICI) group, 29 ​% in the TACE-HAIC plus TKI and ICI group, 33 ​% in the HAIC plus TKI and ICI group, and 41 ​% in the DEB-TACE-HAIC plus TKI and ICI group.

[CONCLUSIONS] Triple therapies yield significantly higher CSR than dual therapies, both surpassing single transarterial approaches. The DEB-TACE-HAIC ​+ ​TKI ​+ ​ICI regimen demonstrated the highest CSR. HAIC-based strategies outperformed cTACE-based approaches.