Radiofrequency Ablation versus Hepatic Resection for Small Hepatocellular Carcinoma: Systematic Review of Randomized Controlled Trials with Meta-Analysis and Trial Sequential Analysis

Abstract

Purpose To compare the benefits and harms of radiofrequency ablation (RFA) and hepatic resection (HR) and to test the consistency of currently available evidence. Materials and Methods PubMed, Embase, and the Cochrane Library were systematically searched for randomized controlled trials (RCTs) that compared the effects of HR and RFA for Barcelona Clinic Liver Cancer very early or early stage hepatocellular carcinoma (HCC). The primary outcome was overall survival, and secondary outcomes were recurrence rate, complication rate, and hospitalization duration. A random- or fixed-effects model according to the level of heterogeneity was applied. The meta-analysis was performed by using software, and trial sequential analysis (TSA) was performed. Results Five trials examining 742 patients were included in this study (sizes of trials: 161, 230, 168, 120, and 63 patients). The meta-analysis showed that RFA and HR had similar overall survival at 1 year (relative risk [RR], 1.39; 95% confidence interval [CI]: 0.36, 5.33; P = .63) and 3 years (RR, 1.40; 95% CI: 0.75, 2.62; P = .29), whereas RFA resulted in decreased overall survival compared with HR at 5 years (RR: 1.91; 95% CI: 1.32, 2.79; P = .001). The TSA showed that more trials were needed to control random errors. The incidence of overall recurrence was markedly higher and the hospitalization duration was significantly shorter in the RFA group than in the HR group, which was confirmed by TSA. Complications may have been less frequent in the RFA group, but TSA showed that additional trials were necessary to confirm this conclusion. Conclusion The indication for RFA as a primary treatment for patients who are eligible for HR with early stage HCC is unclear, and additional well-designed RCTs are needed. RSNA, 2017 Online supplemental material is available for this article.

The impact of age and ageing on hepatocarcinoma surgery: Short‐ and long‐term outcomes in a multicentre propensity‐matched cohort

“…Nonetheless, limited parenchyma resections do not significantly affect the oncologic prognosis or recurrence risk in the treatment of HCC . We should also acknowledge the increasing evidence on less invasive approaches (as thermal ablation) offering similar outcomes to resection for select patient populations with less incidence of complications and provide an alternative treatment strategy for patient management . These types of approaches need to be considered as part of a broader, multimodality strategy in the treatment and management of HCC patients especially in high risk patient as elderly ones.…”

“…Strong patient motivation for surgery and a lack of standardized risk assessment may expose patients to excessive risk of major post‐operative morbidity and mortality or poor long‐term prognosis. Conversely, failure to offer surgery with curative intent to patients who are judged unfit based on generic and imprecise risk variables is unacceptable …”

Open Liver Resection, Laparoscopic Liver Resection, and Percutaneous Thermal Ablation for Patients with Solitary Small Hepatocellular Carcinoma (≤30 mm): Review of the Literature and Proposal for a Therapeutic Strategy

“…However, these data are not conclusive because of some methodology limitations. In fact, large retrospective series [101-104], propensity score analyses [105-112], one randomized trial [80], and 2 recent meta-analyses [94, 113] demonstrated superiority of surgery over RFA in terms of local disease control, even for 2–3 cm HCC. One multicentre Italian study collected 544 patients with single HCC ≤3 cm and compensated cirrhosis [104].…”

“…Short-term outcomes were improved by LLR and MWA, but disease-free survival was decreased in the local ablation group. In the meta-analysis conducted by Xu et al [113], RFA and resection had similar overall survival at 1 and 3 years, whereas RFA resulted in decreased overall survival compared with resection at 5 years. More trials are needed to control random errors and to reach conclusive evidences, but until date, resection is preferable to ablation for HCC of 2–3 cm.…”

“…Percutaneous ablation, mainly RFA, has proved to be as effective as surgical resection for the treatment of very early HCC (< 2 cm), when they are neither subcapsular nor perivascular (Glissonean pedicles) [5, 103, 112, 115]. In HCC of 2–3 cm in size, the results of percutaneous ablation are still under evaluation, and until date, surgery is preferable [80, 94, 101-113]. LLR has reached an excellent safety and reproducibility profile for superficial limited resections of all the liver segments and for left-sided AR [11].…”