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Page 6 of 10 Naeem et al. Hepatoma Res 2018;4:18 I http://dx.doi.org/10.20517/2394-5079.2018.22

Table 2. Comparison of overall 3- and 5-year survival rates following resection and radiofrequency
ablation. Adapted from reference [60]
Resection Radiofrequency ablation
Number of patients 115 115
3-year survival rate 92.2% 69.6%
5-year survival rate 75.7% 54.8%

RFA VS. SURGICAL RESECTION
Underlying chronic liver disease presents a significant challenge in the treatment of hepatocellular carcinoma.
Hepatic failure often complicates surgical resection in cases where hepatic functional reserve is significantly
depleted. The decision to avoid surgery and opt for alternate loco-regional ablative procedures in such cases
thus seems rather prudent.

Where hepatic function is relatively preserved and lesions are amenable to resection, surgery is still regarded
as the mainstay of therapy, although a case can be made to opt for Radiofrequency ablation here in light of
the unavoidable risks of the procedure and the hospitalization. Even when performed by highly experienced
surgeons, operative mortality rates ranging from 1.6%-10% have been observed in various studies . Whereas
[59]
percutaneous radiofrequency ablation is much less invasive, is associated with a lower rate of complications
and mortality, and usually involves short hospital stays if needed at all. Unlike resection, it can also be used
in cases where HCC arises in the setting of cirrhosis secondary to oncogenic stimuli expected to persist
following treatment, such as metabolic conditions like hemochromatosis. Furthermore, RFA as well as PEI
may be used as bridging therapies for patients with HCC scheduled to undergo liver transplant.

Unfortunately, studies directed at comparing the efficacy of RFA relative to surgical resection have failed
to provide sufficient evidence to support its use in cases where patients may be candidates for both. In fact,
some studies have even reported better outcomes, in terms of 3- and 5-year survival rates following surgical
resection, as compared to RFA. The results of one such study performed on a cohort of 225 participants
fulfilling the Milan criteria have been presented in Table 2 and show significantly higher survival rates for
patients following resection .
[60]
With careful patient selection and good operative technique, surgical resection has been shown to
achieve 5-year and long-term survival rates of 78% and 40% respectively. Such optimal criteria for patient
selection include patients with solitary lesions less than 5 cm in diameter, absence of angio-invasion or
hepatic metastases, and adequate surgical margins of at least 1 cm. Current guidelines such as AASLD
also recommend hepatic resection over RFA for patients with resectable T1 or T2 HCC and Child-Pugh A
cirrhosis.

RFA VS. PEI
While PEI has shown to be almost as equally effective as RFA for small tumours, and costs much less since
it requires a minimal amount of equipment, its use has largely been restricted to situations where RFA
might not be available or for lesions located near the gall bladder, hepatic hilum or major vessels, precluding
thermal ablation . Factors responsible for this may include peri-procedural pain and the need for multiple
[25]
settings, both of which contribute to non-compliance, as well as higher local recurrence rates in comparison
with RFA as observed by various randomized trials and meta-analyses .
[61]
While both RFA and PEI have proven their feasibility and applicability in cases where surgical resection is
not a viable option, some studies do provide evidence of greater efficacy with the use of RFA, as evidenced
by greater 3-year survival rates as well as the lower rate of local recurrence following its use, as summarized
in Table 3 .
[62]