Surgical Resection Versus Radiofrequency Ablation Very Early-stage HCC (≤2 cm Single HCC)

A Propensity Score Analysis

Hee Ho Chu; Jin Hyoung Kim; Pyo Nyun Kim; So Yeon Kim; Young-Suk Lim; Seong Ho Park; Heung-Kyu Ko; Sung-Gyu Lee


Liver International. 2019;39(12):2397-2407. 

In This Article

Abstract and Introduction


Background & aim: Hepatocellular carcinoma (HCC) is increasingly being detected at a very early-stage due to the wide implementation of the surveillance of at-risk patient populations combined with improved imaging technologies. Whether patients with HCC at a very early stage can be offered local ablation as a first-line treatment option still remains controversial. We retrospectively compared the effectiveness of surgical resection (SR) and radiofrequency ablation (RFA) for Barcelona Clinic Liver Cancer (BCLC) very early-stage HCC in patients with long-term follow-up.

Methods: Propensity score analysis using inverse probability weighting (IPW) from a large-volume liver centre. We included adult patients who between 2000 and 2013 received a diagnosis of very early-stage HCC (BCLC stage 0; a single tumour ≤2 cm, Child-Pugh A class, eastern cooperative oncology group [ECOG] 0) and who were treated with SR or RFA as the first-line treatment.

Results: We identified 1208 patients, 631 in the SR group and 577 in the RFA group. The median follow-up time was 86.2 months. After propensity score analysis using IPW, the 15-year overall survival rates were 60.4% and 51.6% in the SR and RFA group respectively. RFA group showed poorer overall survival than SR group (adjusted hazard ratio, 1.29; P = .0378). The 15-year recurrence-free survival rates were 37% and 23.6% in the SR and RFA group respectively (P < .001).

Conclusion: For patients with very early-stage HCC, the SR group was associated with better overall and recurrence-free patient survival compared to the RFA group. Therefore, SR should be considered as the first-line treatment for these patients.


Barcelona Clinic Liver Cancer (BCLC) very early-stage HCC (BCLC stage 0) refers to a population of patients with Child-Pugh class A liver function with a single tumour ≤2 cm and the absence of cancer-related symptoms, macrovascular invasion or extrahepatic metastasis.[1] Because of the advent of surveillance of at-risk populations along with new multi-detector CT or MRI technologies, HCC is increasingly being detected at a very early stage (single tumour of 2 cm or less).[2–5] According to the current American Association for the Study of Liver Diseases (AASLD) and European Association for the Study of Liver (EASL) management guidelines, the recommended treatment options for very early-stage HCC include surgical resection (SR), radiofrequency ablation (RFA), and liver transplantation, based on the presence or absence of portal hypertension and associated diseases.[1,6,7] As the lack of liver donors is a major limitation for liver transplantation,[8] SR and RFA are frequently used for very early-stage HCC.[9,10]

Whether SR or RFA should be the first-line treatment for very early-stage HCC patients remains a matter of debate, without a universally accepted protocol.[11–13] The majority of studies report that, in terms of overall patient survival, RFA is as effective for small HCCs as SR.[14–17] Moreover a number of studies suggest that, even when SR is feasible, RFA may be the treatment of choice for patients with a single HCC of 2 cm or smaller.[18–22] However, using propensity score analysis, a very recent study found that SR provided better overall patient survival and recurrence-free survival than RFA in the treatment of a single HCC ≤2 cm.[7] The conflicting information seems to have arisen due to insufficient sample sizes and lack of long-term follow-up; the evaluation of patient survival outcomes in those with a single HCC ≤2 cm may require a prohibitively large sample size and long-term follow-up period because of the relatively long survival time of these patients (BCLC stage 0) compared with those with other stages, that is, BCLC A, B, C and D. Therefore, the purpose of this retrospective study was to compare the effectiveness of SR and RFA for very early-stage HCC (BCLC stage 0) in a large patient cohort (n = 1208) with long-term follow-up. Propensity score analysis was also used to minimize the effects of potential confounding factors associated with patient enrolment.