Systematic review of randomized trials for hepatocellular carcinoma treated with percutaneous ablation therapies

Abstract

According to the American Association for the Study of Liver Diseases guidelines, percutaneous ethanol injection (PEI) is a safe and highly effective treatment for small hepatocellular carcinomas (HCC) and should be the standard against which any new therapy is compared. The primary purpose of this study was to identify survival benefit of any percutaneous ablation therapy as compared with PEI in the treatment of patients with unresectable HCC. The secondary endpoints were initial tumor response, local tumor progression, and complications. Randomized controlled trials that compared pecutaneous ablative therapies with PEI were included. MEDLINE, the Cochrane Library, CANCERLIT, and manual search from 1978 to July 2008 were used. To control the potential heterogeneity, the random effects model of DerSimonian and Laird was used for a meta-analysis. Egger's test was performed to test a potential publication bias. We identified seven randomized controlled trials (RCTs), but only four RCTs including 652 patients that compared radiofrequency ablation (RFA) with PEI met the inclusion criteria to perform a meta-analysis assessing 3-year survival.

Well-differentiated hepatocellular carcinoma smaller than 15 mm in diameter totally eradicated with percutaneous ethanol injection instead of radiofrequency ablation

“…In a study of 232 patients (118 treated with RFA and 114 treated with PEI), the 4-year survival rate was 74% (95% confidence interval [CI] 65-84) for RFA and 57% (95% CI 45-71) for PEI, with a 46% smaller risk of death (adjusted relative risk, 0.54 [95% CI 0.33-0.89], P = 0.02), a 43% smaller risk of overall recurrence (adjusted relative risk, 0.57 [95% CI 0.41-0.80], P = 0.0009), and an 88% smaller risk of local tumor progression (relative risk, 0.12 [95% CI 0.03-0.55], P = 0.006) with RFA than with PEI [6]. Similarly, longer survival has also been suggested by the analysis of a subgroup trial in Taiwan [7], and Cho et al [8] have reported that RFA demonstrates significantly improved 3-year survival status by the meta-analysis of four randomized controlled trails. Moreover, RFA requires shorter hospitalization than PEI, which improves the quality of life.…”

Hepatocellular carcinoma treatment strategies – a case-based review

“…There es supporting R dard of care f be clearly seen n the surround latest improve erstandable tha HCC > 3 cm, t m [45,46] . In suc ve survival [44 ns that clinicia effusion and p eligible patient bility of incom in relation to mplete necrosis sular or within [43] [52,53] ) -accounting for 10%-15% of tumors [1] .…”

Drug therapy: Sorafenib

“…13,14 There is a trend to superior results with RFA over PEI. 15,16 The specific modality used is often based on institutional preference but there are also anatomical considerations. For example, exophytic lesions, subcapsular lesions, or lesions near intrahepatic vessels lend themselves less accessible to RFA, and TACE may be preferred.…”

“…In addition, the failure rate for PEI and RFA is higher with increase in the size of the lesions (>3 cm). 15,16 Multifocal disease often lends itself to TACE, but in some institutions RFA is still performed. In addition, poor liver function is a contraindication to locally ablative treatment as well.…”