Study: RFA treatment of choice for hepatocellular carcinoma

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Radiofrequency ablation (RFA) of hepatocellular carcinoma (HCC) in patients with cirrhosis yielded nearly 100 percent complete responsiveness, and resulted in a five-year recurrence rate of 82 percent, according to a study published online Oct. 21 in Hepatology.

HCC is the third leading cause of death from cancer worldwide, though with most patients presenting with underlying cirrhosis, treatment becomes more complicated and cancer is often not the direct cause of death, the authors reported. "Radiofrequency ablation (RFA) has proven effective for treating HCC nodules, but its repeatability in managing recurrences and the impact of this approach on survival has not been evaluated," wrote Sandro Rossi, MD, from the IRCCS Policlinico San Matteo Foundation, in Pavia, Italy, and colleagues.

According to Rossi, "limited data are available on the characteristics of the first recurrence, how it was managed, and whether or not the treatment was successful. Even less is said about subsequent recurrences although they, too, strongly affect survival. If survival is to be used as a meaningful marker of the long-term efficacy of a treatment for HCC, information must be provided on all the events observed during follow-up and management."

The authors analyzed the outcomes of 706 consecutive HCC patients with cirrhosis who were treated with RFA. Fifty-four patients with subcapsular nodules underwent laproscopic RFA, while the remaining 652 patients underwent percutaneous RFA, for a total of 805 nodules treated with one or two RFA sessions. Median followup was 29 months.

Complete responses were achieved in 796 nodules and in 696 patients. However, 465 of these patients developed a first recurrence, with three- and five-year cumulative incidences of first recurrence measured at 70.8 percent and 81.7 percent, respectively. Meanwhile, three-fourths of patients who experienced recurrences had multiple episodes of local and/or limited nonlocal recurrence, with one-third of these patients developing advanced nonlocal recurrence.

"Although RFA provided excellent local tumor control, one out of three patients developed some type of nonlocal recurrence each year, leading to a cumulative proportion of recurrence of almost 80 percent at 5 years," Rossi and colleagues wrote. "These findings demonstrate that, regardless of how the first nodules are treated, recurrence and progression are the rule for HCC."

Rossi and colleagues found their findings to bolster, rather than demur, the role of RFA. This is because the complete response rates observed with RFA were better than those reported after percutaneous injection therapies and roughly equivalent to the rates for surgical resection for nodules greater than 20 but less than 30 mm. Rossi and co-authors also pointed out that RFA "clean-up" sessions can eliminate these differences while boasting an overall major-complication rate of 1 percent and being a mortality-free procedure.

Overall, 315 patients died, with 188 of these deaths related to the HCC. Cumulative three- and five-year survival rates were measured at 67.0 percent and 40.1 percent, respectively. "The observed cumulative survival curves are entirely comparable with those reported in other series of HCCs treated with percutaneous ablative therapies or surgical resection," reported Rossi.

"Safe, effective, and minimally invasive treatments, thus, seem to be the most reasonable approach for HCC patients," given the disease's high recurrence rate regardless of treatment. This led the authors to conclude that "RFA should be the treatment of choice for patients with one or two small HCCs, whereas surgical resection can be reserved for patients with preserved liver function whose tumors cannot be treated with RFA or in which RFA did not produce CR [complete response]."