Elsevier

Clinical Radiology

Volume 72, Issue 12, December 2017, Pages 1066-1075
Clinical Radiology

Radiofrequency ablation versus resection for hepatocellular carcinoma in patients with Child–Pugh A liver cirrhosis: a meta-analysis

https://doi.org/10.1016/j.crad.2017.07.024Get rights and content

Highlights

  • Many studies comparing radiofrequency ablation and surgical resection include bias as they are retrospective and treatment groups are separated based on disease characteristics, most frequently following AASLD guidelines with patients with more severe disease states treated with radiofrequency ablation.

  • In patients with Child Pugh A liver cirrhosis with solitary and small (<3cm) hepatocellular carcinoma lesions, radiofrequency ablation and surgical resection demonstrated comparable overall survival and disease-free survival rates.

Aim

To evaluate whether radiofrequency ablation (RFA) or surgical resection (RES) has superior overall survival (OS) and disease-free survival (DFS) in patients with hepatocellular carcinoma and Child–Pugh class A liver cirrhosis.

Materials and methods

Meta-analysis was used to compare 1-, 3-, and 5-year OS and DFS between RFA and RES. Those studies meeting inclusion criteria and published prior to 1 June 2015 were included. The odds ratio (OR) was used as the treatment effect measure. A priori defined sensitivity analyses of study subgroups was performed.

Results: Fifteen studies were included in this analysis. Subgroup analyses based on predetermined patient characteristics were performed to minimise bias. No difference in 1-year OS, 3-year OS, and 3-year DFS was found in analyses limited to studies where patients were equally eligible for both therapies. There was also not a significant difference in OS and DFS between RFA and RES when studies were limited to those with only solitary tumours or tumours <3 cm.

Conclusion

The data suggest the equivalence of RFA and RES in patients with solitary tumours <3 cm and good liver status based on Child–Pugh score.

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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