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Wednesday, November 7, 2018

Comparison of Radiofrequency Ablation and Hepatic Resection for the Treatment of Hepatocellular Carcinoma 2 cm or Less 


Summary


A retrospective analysis to compare the survival outcomes after Radiofrequency ablation (RFA) verses Surgical resection(SR) for Hepatocellular cancer(HCC) measuring ≤ 2cm was undertaken. The National Cancer Database was the source. 833 patients with tumors measuring between 5 and 20 mm who underwent either RFA or SR between 2004 and 2014 were included. 620(74.4%) received RFA and 213 (25.6%) received SR. Mean age 60, median tumor size 15mm, 70.1% males, 61% Caucasians, 42.3 with no comorbidities. Demographic and tumor characteristics between the 2 cohorts were compared using the student’s t test for continuous variables and Chi Square test for categorical variables. Log regression was used to determine variables governing choice of treatment, Kaplan Meier analysis and log rank test were used to compared overall survival (OS). A 2 sided P value of < 0.05 was considered significant.

Median follow up was 33.6 months-32.9 for RFA and 35.4 months for SR. The only factor which showed statistical significance regarding how patients were selected for RFA vs SR was a MELD score of >9. Median OS for the entire cohort was 62.7 months (95% CI 50.6-74.8).1,3 and 5-year survival RF group was 90%,64%,47% and the SR group 89%,75%,62%. SR was not associated with longer OS with HR 0.758(CI 0.538-1.068, P .113). OS was longer with multivariate regression analysis for female gender, African American or Asian ethnicity and median income ≥ $48,000 and shorter for higher MELD scores.



Figure 2. Kaplan-Meier curves of patients who received RF ablation and SR (a) before and (b) after propensity score matching. Dotted lines represent 95% confidence intervals.

Commentary


The authors have tried to address the question whether RFA and SR are comparable for small HCCs. Several studies in the past have given conflicting conclusions. The unique feature of this study is source of the data. The national database has a larger number of patients with diverse backgrounds in terms of ethnicity, etiologies and liver functions. The size criteria are stricter and there is an attempt to compare apples to apples with inclusion of just RFA and no other ablative modalities unlike previous studies. The authors used MELD score to represent liver functions and included all comers not just BCLC A patients. They did not find any difference in OS. The authors also compared the influence of gender, ethnicity, income and liver functions on OS for the entire cohort. They found better prognosis for female gender, African American or Asian ethnicity, higher socioeconomic strata and poorer prognosis for higher MELD scores. The study limitations include its retrospective nature. No information on Child Score, specific etiology, local recurrence rate, complications, recurrence free survival, effect of location of the tumor was available. Also the group studied will not meet the LIRADs criteria of LR5 for HCC due to the size criteria making the diagnosis of HCC questionable. MELD was a determining factor in choosing the treatment option and could be interpreted as the RFA cohort had poorer liver functions. Yet the survival was comparable. The effect of treating sicker patients and having comparable outcome favors RFA to SR. Overall survival is not a great end point in isolation for these small tumors and early HCC as the natural history of these tumors may not be affected by the treatment.

Click here for abstract

Huang Y, Shen Q, Bai HX, et al. Comparison of Radiofrequency Ablation and Hepatic Resection for the Treatment of Hepatocellular Carcinoma 2 cm or Less. J Vasc Interv Radiol 2018; 29:1218-25 e2.

Post Author:
Anil K Pillai, MD
Associate Professor and Section Chief,
University of Texas Health Science Center
@AnkupiMD

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