No Survival Difference Between Re-Resection, Percutaneous RFA in Recurrent HCC

By Marilynn Larkin

December 09, 2019

NEW YORK (Reuters Health) - In patients with early-stage recurrent hepatocellular carcinoma (HCC), long-term survival does not differ between repeat hepatectomy and percutaneous radiofrequency ablation (RFA), a randomized trial in China suggests.

Dr. Feng Shen of Second Military Medical University in Shanghai and Dr. Wan Yee Lau of the Chinese University of Hong Kong and colleagues enrolled 240 patients with recurrent HCC (median age, 53; 90% men). Participants had a solitary nodule with a diameter of up to 5 cm, or up to three nodules, each no more than 3 cm in diameter, and no macroscopic vascular invasion or distant metastasis.

Patients were randomized to resection or RFA from 2010-2013, with a median follow-up of 44.3 months; 217 completed the trial, published in JAMA Oncology.

After resection, the 1-, 3-, and 5-year overall survival rates were 92.5%, 65.8%, and 43.6%, respectively. RFA rates were similar: 87.5%, 52.5%, and 38.5%.

Corresponding recurrence-free survival rates were were 85%, 52.4% and 36.2% after surgery and 74.2%, 41.7%, and 30.2% after RFA.

RFA was associated with a higher incidence of local repeat recurrence (37.8% versus 21.7%) and early repeat recurrence compared with repeat hepatectomy (40.3% vs. 23.3%).

In subgroup analyses, RFA was associated with worse overall survival compared with repeat hepatectomy among patients with an HCC nodule diameter greater than 3 cm (hazard ratio, 1.72) or an alpha fetoprotein level greater than 200 ng/mL (HR, 1.85).

However, surgery had a higher complication rate (22.4% versus 7.3%).

Drs. Shen and Lau did not respond to requests for a comment. However, several liver cancer experts not involved in the study commented on it in emails to Reuters Health.

Dr. David Geller, Director of the UPMC Liver Cancer Center in Pennsylvania, commented, "The study is important because it's difficult to do these trials and it shows that percutaneous RFA is a reasonable treatment option for a small tumor. The advantage of this approach is avoiding a second open liver surgery."

"However," he said, "it's important to note that percutaneous RFA has a steep learning curve and is operator-dependent. In addition, not all tumors - based upon location - are amenable to percutaneous RFA."

"Also, over half the patients in the study did not have cirrhosis, whereas the majority of US patients with HCC have a background liver of cirrhosis," he added. "We usually refer these patients for a liver transplant as long as they are within MELD criteria."

Dr. Sasan Roayaie, a hepatobiliary and pancreatic surgeon at White Plains Hospital in New York, said, "If this study is valid, then ablation may be the preferred method because it would achieve the same results with a significantly less invasive and cheaper procedure. Ablation (also) has a shorter hospital stay and less complications than resection."

He also noted, like Dr. Geller, that not all tumors are amenable to ablation. "Tumors near critical structures like the bowel, diaphragm, and major bile ducts cannot be safely ablated. Also, the chances of completely destroying a tumor >3cm with ablation is only about 30%."

"If you look at the survival curves, there is a very clear trend favoring surgery both in overall survival and recurrence-free survival," he said. "It simply did not reach statistical significance, most likely because the study was underpowered. Also, if you look at the subgroup analysis, there was a significant benefit with surgery for patients with HCC >3cm and AFP >200."

"Finally," he added, "this was a single institution study and needs to be replicated by other centers before it would be incorporated into practice guidelines."

Dr. Sanjay Reddy, an assistant professor in the Department of Surgical Oncology at Fox Chase Cancer Center in Philadelphia, added, "Ultimately, which technique is chosen depends on the available resources. Repeat resection can be a challenging operation, but if... interventional radiology for ablation, or operative ablation, is not routinely done (at a given institution), one must choose what they have available to them."

SOURCE: JAMA Oncology, online November 27, 2019.