Surgery versus Radiofrequency Ablation for Small Hepatocellular Carcinoma: A Randomized Controlled Trial (SURF Trial)

Abstract

Introduction: It remains unclear which of surgery or radiofrequency ablation (RFA) is the more effective treatment for small hepatocellular carcinoma (HCC). We aimed to compare survival between patients undergoing surgery (surgery group) and patients undergoing RFA (RFA group). Methods: We conducted a randomized controlled trial involving 49 institutions in Japan. Patients with Child-Pugh scores ≤ 7, largest HCC diameter ≤ 3 cm, and ≤ 3 HCC nodules were considered eligible. The co-primary endpoints were recurrence-free survival (RFS) and overall survival (OS). The current study reports the final result of RFS, and the follow-up of OS is still ongoing. Results: During 2009–2015, 308 patients were registered. After excluding ineligible patients, the surgery and RFA groups included 150 and 151 patients, respectively. Baseline factors did not differ significantly between the groups. In both groups, 90% of patients had solitary HCC. The median largest HCC diameter was 1.8 cm (interquartile range, 1.5–2.2 cm) in the surgery group and 1.8 cm (interquartile range, 1.5–2.3 cm) in the RFA group. The median procedure duration (274 versus 40 minutes, P<0.01) and the median duration of hospital stay (17 days versus 10 days, P<0.01) were longer in the surgery group than in the RFA group. RFS did not differ significantly between the groups as the median RFS was 3.5 (95% confidence interval [CI], 2.6–5.1) years in the surgery group and 3.0 (95% CI, 2.4–5.6) years in the RFA group (hazard ratio, 0.92; 95% CI, 0.67–1.25; P=0.58). Discussion/Conclusion: Our study did not show which of surgery or RFA is the better treatment option for small HCC.

Advances in the surgical treatment of liver cancer

“…A Japanese multicenter RCT conducted in 2021 noted no significant difference in RFS between the LR and radiofrequency ablation groups in HCCs with a diameter < 3 cm and in those with three or fewer tumors (39). In this RCT, 69 of 150 patients (46%) underwent anatomical resection, but the prognostic impact of the technique was not studied.…”

“…If surgery cannot be delayed, other local treatments should be considered. For HCCs with a diameter < 3 cm and < 3 tumors, ablation can produce results comparable to surgery (39). For larger tumors, TACE may be considered as a bridging treatment until resection.…”

New concepts in the treatment of hepatocellular carcinoma

“…14,15 For small cancers (multiples tumors <2 cm), resection and thermal ablation showed similar results in terms of survival, while resection was associated with a lower rate of local progression, at the cost of greater morbidity. 9,16,17 For very early HCC and in the presence of two or three nodules ⩽3 cm, Cuchetti et al showed that RFA is more cost-effective than resection; for single larger early stage HCCs, surgical resection remains the best strategy compared to monopolar RFA because of better survival rates at an acceptable increase in cost. 16 Response rates to ablation are excellent, with 5year overall survival (OS) of up to 68%.…”

Microwave ablation in skilled hands. A treatment opportunity gaining room in the field of single HCC 3–5 cm

“…[ 15 ] The researchers decided indeed to carry out a propensity score adjustment to restrict the analysis to a subgroup of comparable subjects, finally including less than half of the total surgical population. Probably, only a restricted population of patients is really identically suitable for both resection and ablation, and indeed a recently published randomized trial comparing surgery to ablation [ 14 ] had to be prematurely terminated because of insufficient recruitment of patients eligible for randomization. Ablation will likely remain offered as the reference technique to more‐fragile patients, in keeping with the multidisciplinary choices.…”

“…Such a prospective, randomized study is likely to remain a dream rather than becoming reality, and, in fact, a recent randomized study addressed to patients with HCC <3 cm in size was prematurely concluded because of insufficient recruitment. [ 14 ] Given that, for the above reasons, a randomized study will not come early, or not at all, we must make a decision on the current evidence. We must then consider that MWA ablation provides comparable survival, but shorter RFS.…”