You will be presented with a collection of medical randomized controlled trial (RCT) reports addressing a shared clinical question -- for instance, the efficacy of a medical intervention on a disease or condition. Given the titles and abstracts of these reports, your task is to generate the conclusion of the systematic review article synthesizing the key findings. Your conclusion should be a few sentences long. In your response, include only the conclusion and no other text. The RCT reports are below.



Title 1:
Efficacy and safety of preoperative chemoembolization for resectable hepatocellular carcinoma with portal vein invasion: a prospective comparative study
Abstract 1:
Objectives To evaluate the outcomes of preoperative transarterial chemoembolization ( TACE ) for resectable hepatocellular carcinoma ( HCC ) with portal vein invasion . Methods From February 2006 to July 2011 , 320 patients initially diagnosed with resectable HCC and portal vein invasion were prospect ively non-r and omized into two arms . In the immediate resection arm ( Arm 1 , n = 205 ) patients received immediate surgical resection .  115 patients were included in the preoperative TACE  arm ( Arm 2 ) , and eventually 85 patients underwent TACE followed by surgical resection . Results The 1- , 3- and 5-year overall survival rates were 48.3 % , 18.7 % and 13.9 % for Arm 1 and 61.2 % , 31.7 % and 25.3 % for Arm 2 ( P = 0.001 ) , respectively . In the subgroup analysis of types I and II portal vein tumour thrombus ( PVTT ) , the preoperative TACE arm demonstrated significantly better survival rates than the immediate resection arm ( PI = 0.001 , PII = 0.036 ) . However , no significant difference was found for patients with type III PVTT ( PIII = 0.684 ) . No significant difference was found between the two arms in terms of complications and mortality . Conclusions Preoperative TACE seems to confer a survival benefit for resectable HCC with PVTT , especially for types I and II PVTT , and preoperative TACE should therefore be recommended as a routine procedure . Key Points• Preoperative TACE improves the clinical outcomes for patients with PVTT• Preoperative TACE could significantly improve the rate of en bloc thrombectomy• Preoperative TACE does not increase the related adverse


Title 2:
Surgical Outcomes in Hepatocellular Carcinoma Patients with Portal Vein Tumor Thrombosis
Abstract 2:
Background Different approaches to surgical treatment of portal vein tumor thrombosis ( PVTT ) have been advocated . This study investigated the outcomes of different surgical approaches in hepatocellular carcinoma ( HCC ) patients with PVTT . Methods We review ed prospect ively collected data for all patients who underwent hepatectomy for HCC at our hospital between December 1989 and December 2010 . Patients were excluded from analysis if they had extrahepatic disease , PVTT reaching the level of the superior mesenteric vein , or hepatectomy with a positive resection margin . The remaining patients were divided into three groups for comparison : group 1 , with ipsilateral PVTT resected in a hepatectomy ; group 2 , with PVTT extending to or beyond the portal vein bifurcation , treated by en bloc resection followed by portal vein reconstruction ; group 3 , with PVTT extending to or beyond the portal vein bifurcation , treated by thrombectomy . Results A total of 88 patients , with a median age of 54 years , were included in the analysis . Group 2 patients were younger , with a median age of 43.5 years versus 57 in group 1 and 49 in group 3 ( p = 0.017 ) . Group 1 patients had higher preoperative serum alpha-fetoprotein levels , with a median of 8,493 ng/mL versus 63.25 in group 2 and 355 in group 3 ( p = 0.004 ) , and shorter operation time , with a median of 467.5 min versus 663.5 in group 2 and 753 in group 3 ( p = 0.018 ) . No patient had thrombus in the main portal vein . Two ( 2.8 % ) hospital deaths occurred in group 1 and one ( 10 % ) in group 2 , but none in group 3 ( p = 0.440 ) . The rates of complication in groups 1 , 2 , and 3 were 31.9 , 50.0 , and 71.4 % , respectively ( p = 0.079 ) . The median overall survival duration s were 10.91 , 9.4 , and 8.58 months , respectively ( p = 0.962 ) , and the median disease-free survival duration s were 4.21 , 3.78 , and 1.51 months , respectively ( p = 0.363 ) . The groups also had similar patterns of disease recurrence ( intrahepatic : 33.8 vs. 28.6 vs. 40.0 % ; extrahepatic : 16.9 vs. 14.3 vs. 0 % ; both : 28.2 vs. 42.9 vs. 40.0 % ; no recurrence : 21.1 vs. 14.3 vs. 20.0 % ; p = 0.836 ) . Conclusions The three approaches have similar outcomes in terms of survival , complication , and recurrence . Effective adjuvant treatments need to be developed to counteract the high incidence of recurrence


Title 3:
Efficacy of different treatment strategies for hepatocellular carcinoma with portal vein tumor thrombosis.
Abstract 3:
AIM To evaluate the efficacy of different treatment strategies for hepatocellular carcinoma ( HCC ) with portal vein tumor thrombosis ( PVTT ) and investigate factors influencing prognosis . METHODS One hundred and seventy-nine HCC patients with macroscopic PVTT were enrolled in this study . They were divided into four groups and underwent different treatments : conservative treatment group ( n = 18 ) , chemotherapy group ( n = 53 ) , surgical resection group ( n = 24 ) and surgical resection with postoperative chemotherapy group ( n = 84 ) . Survival rates of the patients were analyzed by the Kaplan-Meier method . A log-rank analysis was performed to identify group differences . Cox 's proportional hazards model was used to analyze variables associated with survival . RESULTS The mean survival periods of the patients in four groups were 3.6 , 7.3 , 10.1 , and 15.1 mo respectively . There were significant differences in the survival rates among the groups . The survival rates at 0.5- , 1- , 2- , and 3-year in surgical resection with postoperative chemotherapy group were 55.8 % , 39.3 % , 30.4 % , and 15.6 % respectively , which were significantly higher than those of other groups ( P<0.001 ) . Multivariate analysis revealed that the strategy of treatment ( P<0.001 ) and the number of chemotherapy cycles ( P = 0.012 ) were independent survival predictors for patients with HCC and PVTT . CONCLUSION Surgical resection of HCC and PVTT combined with postoperative chemotherapy or chemoembolization is the most effective therapeutic strategy for the patients who can tolerate operation . Multiple chemotherapeutic courses should be given postoperatively to the patients with good hepatic function reserve


Title 4:
Multimodality treatment in hepatocellular carcinoma patients with tumor thrombi in portal vein.
Abstract 4:
AIM To compare the therapeutic effect and significance s of multimodality treatment for hepatocellular carcinoma ( HCC ) with tumor thrombi in portal vein ( PVTT ) . METHODS HCC patients ( n=147 ) with tumor thrombi in the main portal vein or the first branch of portal vein were divided into four groups by the several therapeutic methods . There were conservative treatment group in 18 out of patients ( group A ) ; and hepatic artery ligation(HAL ) and /or hepatic artery infusion ( HAI ) group in 18 patients ( group B ) , in whom postoperative chemoembolization was done periodically ; group of  removal of HCC with PVTT  in 79 ( group C ) and group of transcatheter hepatic arterial chemoembolization ( TACE ) or HAI and /or portal vein infusion ( PVI ) after operation in 32 ( group D ) . RESULTS The median survival period was 12 months in our series and the 1-,3- , and 5-year survival rates were 44.3 % , 24.5 % and 15.2 % , respectively . The median survival times were 2 , 5 , 12 and 16 months in group A , B , C and D , respectively . The 1- , 3- and 5-year survival rates were 5.6 % , 0 % and 0 % in group A ; 22.2 % , 5.6 % and 0 % in group B ; 53.9 % , 26.9 % and 16.6 % in group C ; 79.3 % , 38.9 % and 26.8 % in group D , respectively . Significant difference appeared in the survival rates among the groups ( P < 0.05 ) . CONCLUSION Hepatic resection with removal of tumor thrombi and HCC should increase the curative effects and be encouraged for the prolongation of life span and quality of life for HCC patients with PVTT , whereas the best therapeutic method for HCC with PVTT is with regional hepatic chemotherapy or chemoembolization after hepatic resection with removal of tumor thrombi


Title 5:
Natural history of untreated nonsurgical hepatocellular carcinoma: Rationale for the design and evaluation of therapeutic trials
Abstract 5:
This study analyzed the natural history and prognostic factors of patients with nonsurgical hepatocellular carcinoma ( HCC ) . Twenty variables from 102 cirrhotic patients with HCC who were not treated within prospect i ve r and omized controlled trials ( RCT ) were investigated through uni‐ and multivariate analyses . None of them was suitable for radical therapies ( surgical resection , liver transplantation , or ethanol injection ) or presented end‐stage disease as reflected by an Okuda stage 3 or a Performance Status ≥3 . Sixty‐five patients were Child‐Pugh A , 34 were B , and 3 were C. Most of them exhibited a preserved Performance Status Test ( PST ) ( 0 = 56 ; 1 = 38 ; 2 = 8) . Tumor was solitary in 26 ( ≤5 cm in 16 ) and multinodular/massive in 76 . After a median follow‐up of 17 months , 79 patients died , the 1‐ , 2‐ , and 3‐year survival being 54 % , 40 % , and 28 % . The multivariate study identified PST ( P = .01 ) , constitutional syndrome ( P = .04 ) , vascular invasion ( P = .001 ) , and extrahepatic spread ( P = .04 ) as independent predictors for mortality . The 1‐ , 2‐ , and 3‐year survival for the 48 patients without adverse factors ( Stage 0 ) was 80 % , 65 % , and 50 % , respectively , and 29 % , 16 % , and 8 % in the 54 patients with at least one adverse parameter ( Stage I ) . Therefore , Stage 0 would correspond to an intermediate stage , while Stage I would represent an advanced status , before reaching an end‐stage phase . In conclusion , the outcome of nonsurgical HCC is not homogeneously grim and may be predicted by assessing the presence of symptoms and of an invasive tumoral pattern . Therapeutic trials should be design ed and evaluated considering these characteristics


Title 6:
Efficacy and safety of sorafenib in patients with advanced hepatocellular carcinoma: subanalyses of a phase III trial.
Abstract 6:
BACKGROUND & AIMS The Sorafenib Hepatocellular Carcinoma ( HCC ) Assessment R and omized Protocol ( SHARP ) trial demonstrated that sorafenib improves overall survival and is safe for patients with advanced HCC . In this trial , 602 patients with well-preserved liver function ( > 95 % Child-Pugh A ) were r and omized to receive either sorafenib 400 mg or matching placebo orally b.i.d . on a continuous basis . Because HCC is a heterogeneous disease , baseline patient characteristics may affect individual responses to treatment . In a comprehensive series of exploratory subgroup analyses , data from the SHARP trial were analyzed to discern if baseline patient characteristics influenced the efficacy and safety of sorafenib . METHODS Five subgroup domains were assessed : disease etiology , tumor burden , performance status , tumor stage , and prior therapy . Overall survival ( OS ) , time to progression ( TTP ) , disease control rate ( DCR ) , and safety were assessed for subgroups within each domain . RESULTS Subgroup analyses showed that sorafenib consistently improved median OS compared with placebo , as reflected by hazard ratios ( HRs ) of 0.50 - 0.85 , similar to the complete cohort ( HR=0.69 ) . Sorafenib also consistently improved median TTP ( HR , 0.40 - 0.64 ) , except in HBV-positive patients ( HR , 1.03 ) , and DCR . Results are limited by small patient numbers in some subsets . The most common grade 3/4 adverse events included diarrhea , h and -foot skin reaction , and fatigue ; the incidence of which did not differ appreciably among subgroups . CONCLUSIONS These exploratory subgroup analyses showed that sorafenib consistently improved median OS and DCR compared with placebo in patients with advanced HCC , irrespective of disease etiology , baseline tumor burden , performance status , tumor stage , and prior therapy
Conclusions HR may lead to longer OS for some selected HCC patients with PVTT than TACE , especially for type I or II PVTT , with less difference being observed for type III or IV PVTT