A commentary on ‘Survival benefit of liver resection following complete response to transarterial chemoembolization for intermediate-stage hepatocellular carcinoma: a retrospective, multicenter, cohort study’

Dear Editor,

We have read the multicenter retrospective study conducted by Hu et al.¹ with great interest. The study focused on the impact of surgical resection for complete remission after transcatheter arterial chemoembolization (TACE) in advanced hepatocellular carcinoma (HCC). The study included 281 HCC patients who achieved complete remission after TACE. Out of these, 170 patients underwent surgical resection (TLR group), while 111 patients were under continuous observation (TACE group). The results of 98 pairs of patients, matched by propensity score, indicated that the surgical resection group had better overall survival (OS) and disease-free survival (DFS) outcomes compared to the TACE group. However, it was observed that surgical resection did not provide any benefits for intermediate liver cancer above grade 7 criteria. Although this study offers valuable clinical insights for selecting treatment strategies after complete remission of TACE therapy in mid-stage liver cancer, there are still several aspects that warrant further discussion.

Firstly, the authors do not provide detailed information about the specific strategies for including TACE adjuvant therapy, such as whether it was combined with TKI or immunotherapy. The recent TACTICS study demonstrated that combining TACE with sorafenib led to a significant prolongation of OS and improvement in progression-free survival (PFS) for patients with mid-term liver cancer². Similarly, Marinelli et al.³ found that combining TACE with PD-1 inhibition delayed disease progression and resulted in tumor shrinkage in some patients with HCC. Therefore, it is important to either exclude patients who received TKI or immunotherapy from the study or provide baseline characteristics or propensity scores to account for this treatment combination. Additionally, although the authors mentioned the proportion of patients with hepatitis in both groups, they did not provide information regarding antiviral treatment for these patients. Antiviral therapy during the perioperative period is crucial for delaying disease progression and reducing postoperative recurrence of HBV-related HCC⁴. Thus, it is unclear whether differences in antiviral therapy between the two groups had an impact on long-term outcomes.

Secondly, the grouping of the number of TACE in the two groups is inaccurate. The grouping of multiple TACE is too broad and does not provide enough specificity. Multiple TACE procedures often indicate poor tumor biological characteristics. To improve the study, it would be beneficial to refine the grouping and investigate the correlation between the number of TACE procedures and the long-term effects after tumor resection. Additionally, the specific methods of hepatectomy in the TLR group are not clearly described. It is important to mention whether anatomical or non-anatomical resections were performed and the proportion of laparotomy and minimally invasive surgeries. These details are crucial in evaluating the safety and effectiveness of surgical resection after complete remission. Furthermore, if the author can provide more information about the preoperative and intraoperative data of the TLR group, such as operation time and intraoperative blood loss, it would enhance the rigor of the study’s results.

Finally, in order to improve clarity and flow without changing the meaning or adding more content, it may be more reasonable to modify the definition of outcome indicators. One suggestion is to include the time interval from complete remission of TACE to death in the definition of OS. This modification can help avoid the deviation caused by the duration of treatment in the two groups of TACE. Additionally, it is more appropriate to describe the TACE group and the TLR group separately in the definition of DFS. It is also important to note that the author did not provide information on the treatment strategies for postoperative recurrence or progression between the two groups. This lack of information may affect the results of OS between the two groups, as the difference in treatment strategies for postoperative recurrence cannot be properly assessed. To truly reflect the long-term benefits brought by surgical resection, it is suggested to consider using DFS as the primary outcome indicator and OS as the secondary outcome indicator. This adjustment may lead to a more reasonable conclusion.

We are grateful to the author for sharing their valuable clinical experience regarding the treatment strategy after complete remission following TACE for mid-term liver cancer. The conclusions drawn from this study provide significant evidence to support surgical treatment for complete remission after TACE in mid-term liver cancer patients. However, it is important to conduct multicenter randomized control trial studies in the future to further validate the long-term effects of surgical resection and explore additional treatment strategies that can prolong the survival of mid-term liver cancer patients.

Ethical approval

Not applicable.

Sources of funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author contribution

F.G. and X.Z.: study design and writing; Q.X. and J.Y.: critical review; H.W.: study supervision.

Conflicts of interest disclosure

No conflicting relationship exists for any of the authors.

Research registration unique identifying number (UIN)

1. Name of the registry: not applicable.

2. Unique identifying number or registration ID: not applicable.

3. Hyperlink to your specific registration (must be publicly accessible and will be checked): not applicable.

Guarantor

Prof Hong Wu, E-mail: wuhong@scu.edu.cn, Liver Transplantation Center, No. 37, Guoxue Lane, Wuhou District, Chengdu, Sichuan Province, People’s Republic of China.

Data availability statement

All data generated or analyzed during this study are included in this article. The data are available from the corresponding author upon reasonable request.