Surgical Resection Versus Transarterial Chemoembolization for Intermediate Stage Hepatocellular Carcinoma (BCLC‐B): An Unsolved Question

Potential conflict of interest: Nothing to report. TO THE EDITOR: We have read the article of Hyun et al. with great interest.1 We commend the authors for this study that tackles a crucial point in the treatment of hepatocellular carcinoma (HCC). There is a critical need to refine and eventually to expand the selection criteria of HCC patients who may benefit from curative therapies such as surgical resection (SR). There is accumulating evidence on improved survival after SR as opposed to transarterial chemoembolization (TACE) in patients with intermediate stage HCC (Barcelona Clinic Liver Cancer Stage B; BCLC‐B), although American (American Association for the Study of Liver Diseases) and European (European Association for the Study of the Liver; EASL) consensus guidelines recommend TACE in this setting.2 To investigate the advantage of SR in HCC patients with intermediate‐ (BCLC‐B) and advanced‐stage (BCLC‐C) HCC, the authors performed a systematic review and meta‐analysis of studies comparing SR and TACE; their results showed increased 5‐year survival rates in patients undergoing SR, in both stages. The main debate is on whether a subset of HCC patients with BCLC‐B should undergo SR rather than TACE. We would like to address two shortcomings of this meta‐analysis: (1) one study (by Luo et al.) included patients with sequential treatments (SR and TACE)4; it is therefore difficult to collect accurate survival data from this article, and, more important, (2) 4 of 9 analyzed studies included patients with single large HCC. As stipulated by the recent EASL guidelines for HCC, the current intermediate HCC definition includes a wide range of patients, in particular large solitary HCC beyond 5 cm with an expansive growth. This large definition triggers controversies and refinement is needed. If technically feasible, those patients may benefit from surgical resection and should be classified as BCLC‐A.3 As a consequence, the meta‐analysis of Hyun et al. included a substantial number of patients who were rather at BCLC‐A stage. For these reasons, the question of SR versus TACE for HCC patients at intermediate stage remains unsolved and other meta‐analyzes or randomized controlled trials, strictly including BCLC‐B HCC, are needed.