Does Surgical Resection Provide Better Outcomes Than Radiofrequency Ablation in Patients With BCLC Very Early-stage Hepatocellular Carcinoma?

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To the Editor:
We read with great interest the report by Liu et al1 which was recently published in Annals of Surgery. In this study, the authors proposed surgical resection provided better long-term overall survival and recurrence-free survival compared with radiofrequency ablation (RFA) in patients with a hepatocellular carcinoma (HCC) up to 2 cm.1 However, we suggested some issues should be clarified.
In this study, the authors did not compare the tumor biological factors, such as tumor differentiation and microvascular invasion, between patients who underwent liver resection and RFA. A number of investigations have confirmed that poor differentiation and microvascular invasion were related to poor outcomes for patients with HCC after liver resection or RFA.2–4 Moreover, cirrhosis is proposed as a risk factor for late HCC recurrence by many investigations.2 We suggested how many patients had cirrhosis in each group should be clarified in this study. We believe these limitations may be because some RFAs cannot obtain a tissue sample due to various causes.
In this study, high incidence of local recurrence in patients who received RFA was observed. Recently, Chinnaratha et al3 also reported high local recurrence of early-stage HCC was observed in patients who underwent percutaneous ablation. The local recurrence rate of patients with very early stage HCC was 15.9% in Chinnaratha et al's study, which was similar to the current study.1,3 RFA can be carried out percutaneously, laparoscopically, or as an open surgery. However, some investigators suggested open surgical ablation was superior to percutaneous ablation for patients with liver cancer.5–7 Kuvshinoff et al5 even confirmed percutaneous ablation was an independent risk factor for local recurrence. Open surgical ablation provides better ultrasonic scan and optimal RFA device placement warranting best local tumor control.6 Moreover, an adequate ablative margin is also very important to avoid postoperative recurrence. Masuda et al8 suggested local ablation therapy for HCCs adjacent less than 5 mm to the main or sectional portal vein may promote intrahepatic dissemination. During the thermal ablation, the intratumoral pressure will increase which could promote tumor cells flow into the adjacent portal vein, and as a result, dissemination may occur throughout the liver.8 Seki et al9 also reported that some patients suffered from rapid tumor progression after RFA. Mulier et al7 suggested RFA should achieve at least 1 cm ablative margin. Mulier at al's study7 also confirmed laparoscopic RFA contributed in a better local control. Percutaneous RFA should mainly be reserved for patients who cannot tolerate a laparoscopy or laparotomy.

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