Radiofrequency ablation versus resection for hepatocellular carcinoma in patients with Child–Pugh A liver cirrhosis: a meta-analysis
Introduction
Hepatocellular carcinoma (HCC) is the fifth most common cancer in the world with an annual incidence of 5.9 per 100,000.16 Primary liver cancer is the third largest contributor to cancer mortality with an annual mortality of 6 per 100,000.17 Current American Association for the Study of Liver Disease (AASLD) guidelines recommend surgical resection (RES) as a treatment for patients with very early or early-stage HCC with a single tumour and normal portal pressure/bilirubin. Radiofrequency ablation (RFA) is indicated for patients with early-stage HCC with fewer than three nodules that are ≤3 cm and associated disease such as cirrhosis or portal hypertension that preclude resection.18
There is currently much interest in comparing outcomes between the two treatment modalities; however, published studies have arrived at conflicting results. Chen et al. performed the first prospective randomised controlled trial (RCT) that compared RES and RFA for treatment of solitary HCC. Statistically there was no difference in overall survival (OS) and disease-free survival (DFS) between the two treatment groups and complications were significantly more common in patients treated with RES.1 A second randomised controlled trial performed by Feng et al. found similar results.19 Conversely, Huang et al. in a randomised trial found that RES had significantly higher OS and DFS.6
A number of retrospective studies have also been performed with non-uniform conclusions. A collection of studies found no statistically significant difference in OS and DFS between RFA and RES9, 10, 11, 13, 15, 20 while others reported significantly improved OS and DFS with RES.3, 7, 14
As RFA is reserved for patients with a higher disease burden and comorbidities it is difficult to perform comparison studies in the absence of selection bias. We attempted to better balance patient groups in this meta-analysis by limiting inclusion to patients with Child-Pugh A liver cirrhosis and by performing subgroup analyses based on patient characteristics.
The purpose of this meta-analysis is to compare the efficacy of RES and RFA in patients with HCC and Child–Pugh Class A liver cirrhosis using OS and DFS as primary endpoints.
Section snippets
Materials and methods
This meta-analysis was performed under Institutional Review Board approval.
Literature search
Fig. 1 delineates the study selection process. Initially, 597 studies were retrieved. Evaluation of titles and abstracts excluded 563 studies based on non-adherence to the inclusion criteria. Thirty-four full-text articles were assessed for eligibility and 19 were excluded due to inclusion of patients with Child–Pugh class B or C liver cirrhosis and lack of a separate analysis specific to Child–Pugh class A patients. The included studies consisted of two randomised controlled trials1, 6 and 13
Discussion
This meta-analysis, limited to patients with Child–Pugh class A liver cirrhosis, demonstrates superiority of RES in 3-year and 5-year OS and DFS; however, subgroup analysis reveals important findings. In studies where all tumours are considered resectable and patients are not grouped into the different treatment groups by baseline characteristics, RES is not shown to have significantly improved 1- and 3-year OS and DFS when compared to RFA.1, 6, 10, 14 Of note, only one of these studies
Acknowledgements
The work was partially supported by the SIR Foundation Summer Medical Student Research Program.
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2019, Radiotherapy and OncologyCitation Excerpt :Advantages of RFA include the potential to perform ablation with a single procedure and the greater accumulated level of evidence for the method than exists for SBRT. In particular, RFA for tumors <3 cm in size showed survival outcomes comparable to surgical resection [35,36]. SBRT has the advantage of being a non-invasive modality, along with the ability to treat tumors regardless of their location, including those adjacent to major vessels, bile ducts, or the diaphragm [37–39].
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2020, Journal of Clinical and Experimental HepatologyCitation Excerpt :In a cirrhotic patient, with resectable solitary HCC of size ≤2 cm (BCLC-0), the clinical outcome of RFA is comparable to LR.127 A meta-analysis by Jia et al. that included 15 studies found that the OS and DFS were equivalent for patients receiving RFA versus resection in patients with small solitary tumors (<3 cm) and good liver status based on Child-Pugh score.128 Cochrane network meta-analysis129 also found no evidence of a difference in all-cause mortality at maximal follow-up between surgery and RFA in people eligible for surgery.