Appropriate treatment modality for solitary small hepatocellular carcinoma: Radiofrequency ablation vs. resection vs. transplantation?

Abstract

There has been controversy regarding the first-line treatment modality for the patients who have small solitary hepatocellular carcinoma (HCC); radiofrequency ablation (RFA) or percutaneous ethanol injection (PEI), surgical hepatic resection (HR) and liver transplantation (LT). For selection of treatment modality of HCC, it should be considered of hepatic reservoir function as well as the tumor stage. If the liver function is good enough, HR may be the first choice regardless of the tumor size. However, recent studies comparing RFA with resection showed comparable outcome and similar survival rates. RFA, HR and LT provide good outcome for patients who have small HCCs. RFA would be desired in patients who have below 3.0 cm in size and low alpha-fetoprotein (<200 ng/mL). However, in small HCC with high tumor marker, HR should be considered. Better patient selection for the 'resection first' approach and early detection of recurrence can achieve better outcomes of the salvage LT strategy. Another benefit of resection first strategy is that it make possible to do enlist of LT for patients before recurrence at high risk of HCC recurrence after resection on the basis of pathologic aggressiveness, microvascular invasion and/or satellites nodule. They should be applied appropriately according to the tumor size, location, tumor markers and underlying liver parenchymal disease.

Keywords: Hepatectomy; Hepatocellular carcinoma; Liver transplantation; Radiofrequency ablation.

Figure 1.

Feasibility of treatment modality according to the tumor size. Radiofrequency ablation, hepatic resection and liver transplantation (LT) can be applicable for single hepatocellular carcinoma less than 5 cm. (A) Tumor less than 2 cm. (B) Tumor between 2 and 3 cm. (C) Tumor between 3 and 5 cm. Overall survival (OS) and disease free survival (DFS) for less than 2 cm with radiofrequency ablation and resection is same, same OS but better DFS in 2–3 cm tumor and both OS and DFS are better with hepatic resection for 3–5 cm tumor. LT can be applicable to tumor <5 cm according to the status of liver function and tumor aggressiveness.