Selection of first-line systemic therapies for advanced hepatocellular carcinoma:A network meta-analysis of randomized controlled trials

BACKGROUND The majority of clinical trials of first-line systemic treatments for hepatocellular carcinoma(HCC)used placebo or sorafenib as comparators,and there are limited data providing a cross comparison of treatments in this setting,especially for newly-approved immune checkpoint inhibitor and vascular endothelial growth factor inhibitor combination treatments.AIM To systematically review and compare response rates,survival outcomes,and safety of first-line systemic therapies for advanced hepatocellular carcinoma.METHODS We searched PubMed,Science Direct,the Cochrane Database,Excerpta Medica Database,and abstracts from the American Society of Clinical Oncology 2020 annual congress.Eligible studies were randomized controlled trials of systemic therapy enrolling adults with advanced/unresectable HCC.Risk of bias was assessed with the Cochrane risk of bias tool for randomized controlled trials.A network meta-analysis was used to synthesize data and perform direct and indirect comparisons between treatments.P value,a frequentist analog to the surface under the cumulative ranking curve,was used to rank treatments.RESULTS In total,1398 articles were screened and 27 included.Treatments compared were atezolizumab plus bevacizumab,brivanib,donafenib,dovitinib,FOLFOX4,lenvatinib,linifanib,nintedanib,nivolumab,sorafenib,sunitinib,vandetanib,11 sorafenib combination therapies,and three other combination therapies.For overall response rate,lenvatinib ranked 1/19,followed by atezolizumab plus bevacizumab and nivolumab.For progression-free survival(PFS),atezolizumab+bevacizumab was ranked 1/15,followed by lenvatinib.With the exception of atezolizumab+bevacizumab[hazard ratios(HR)PFS=0.90;95%confidence interval(CI):0.64-1.25],the estimated HRs for PFS for all included treatments vs lenvatinib were>1;however,the associated 95%CI passed through unity for bevacizumab plus erlotinib,linifanib,and FOLFOX4.For overall survival,atezolizumab plus bevacizumab was ranked 1/25,followed by vandetanib 100 mg/d and donafinib,with lenvatinib ranked 6/25.Atezolizumab+bevacizumab was associated with a lower risk of death vs lenvatinib(HRos=0.63;95%CI:0.44-0.89),while the HR for overall survival for most other treatments vs lenvatinib had associated 95%CIs that passed through unity.Vandetanib 300 mg/d and 100 mg/d were ranked 1/13 and 2/13,respectively,for the lowest incidence of treatment terminations due to adverse events,followed by sorafenib(5/13),lenvatinib(10/13),and atezolizumab+bevacizumab(13/13).CONCLUSION There is not one single first-line treatment for advanced HCC associated with superior outcomes across all outcome measurements.Therefore,first-line systemic treatment should be selected based on individualized treatment goals.

Efficacy of a therapeutic strategy for eradication of Helicobacter pylori infection

AIM: To determine the efficacy of our therapeutic strategy for Helicobacter pylori (H. pylori) eradication and to identify predictive factors for successful eradication. METHODS: From April 2006 to June 2010, we retrospectively assessed 2428 consecutive patients (1025 men, 1403 women; mean age 55 years, age range 18-92 years) with gastric histology positive for H. pylori infection referred to our unit for 13-C urea breath test(UBT), after first-line therapy with proton pump inhibitor (PPI) b.i.d. + amoxicillin 1 g b.i.d. + clarithromycin 500 mg b.i.d. for 7 d. Patients who were still positive to UBT were recommended a second-line therapy (PPI b.i.d. + amoxicillin 1 g b.i.d. + tinidazole 500 mg b.i.d. for 14 d). Third choice treatment was empirical with PPI b.i.d. + amoxicillin 1 g b.i.d. + levofloxacin 250 mg b.i.d. for 14 d. RESULTS: Out of 614 patients, still H. pylori-positive after first-line therapy, only 326 and 19 patients respectively rechecked their H. pylori status by UBT after the suggested second and third-line regimens. "Per protocol" eradication rates for first, second and thirdline therapy were 74.7% (95% CI: 72.7%-76.4%), 85.3% (95% CI: 81.1%-89.1%) and 89.5% (95% CI: 74.9%-103%) respectively. The overall percentage of patients with H. pylori eradicated after two treatments was 97.8% (95% CI: 97.1%-98.4%), vs 99.9% (95% CI: 99.8%-100%) after three treatments. The study found that eradication therapy was most effective in patients with ulcer disease (P < 0.05, P = 0.028), especially in those with duodenal ulcer. Smoking habits did not significantly affect the eradication rate. CONCLUSION: First-line therapy with amoxicillin and clarithromycin produces an H. pylori eradication rate comparable or superior to other studies and secondline treatment can still be triple therapy with amoxicillin and tinidazole.