Surgical Resection Versus Local Ablation for HCC on Cirrhosis: Results From a Propensity Case-Matched Study
Andrea Ruzzenente*, Tommaso Campagnaro, Alessandro Valdegamberi, Simone Conci, Fabio Bagante, Gianni Turcato, Calogero Iacono, Alfredo Guglielmi
Department of Surgery, University of Verona Medical School, Verona, Italy
Background: Surgery for hepatocellular carcinoma (HCC) had great improvements in last decades with low morbidity and mortality and with good long-term results. Percutaneous local ablative therapies (LAT) such as radiofrequency ablation (RFA) and ethanol injection (PEI) for HCC gained consent for its efficacy and safety. Patients submitted to resection (LR) or LAT have large differences on their characteristics. Propensity case matched studies proved to reduce selection bias of retrospective analyses and allow comparison between different therapies.Aims:The aim of this study was to evaluate survival comparing LR and LAT in two groups of cirrhotic patients with HCC matched with propensity score analysis.Methods: Four-hundred and seventy-eight cirrhotic patients with HCC treated with LR or LAT with curative intent between January 1995 and December 2009 were included in the study. One hundred and eighty-one patients underwent LR and 297 patients were treated with LAT. Tumor stage and severity liver impairment was evaluated in all patients. To balance the covariates in the two groups, a one-to-one propensity case-matched analysis was used. A multivariate model based on age, sex, etiology of cirrhotic, Child-Pugh class, number of nodules, maximum diameter of nodules and serum alpha-fetoprotein level, was used to obtain one-to-one match, using the nearest neighbor matching model for LR and LAT. After propensity matched analysis 176 patients were compared, 88 patients in each group.Results: Median survival was 65,1 months (95% CI 48,5-81,7) after LR and 37,3 months (95% CI 29,3-45,3) after LAT (p=0,008). For patients in Child-Pugh class A with single HCC with diameter <5 cm, median survival was 65 months (95% CI 58,4-71,6) for LR group and 63,7 months (95% CI 31,8-95,7) for LAT group (p=0,73). For patients in Child-Pugh class A with single HCC with diameter ≥5 cm, median survival was 79,9 months (95% CI 40,1-119,8) for LR group and 21,5 months (95% CI 10,8-32,1) for LAT group (p=0,023). For patients in Child-Pugh class A with 2-3 nodules and <3 cm of maximum diameter, mean survival was 69,3 months (95% CI 48,7-89,9) for LR group and 45,7 months (95% CI 22,8-68,7) for LAT group (p=0,168). For patients in Child-Pugh class A with 2-3 nodules and maximum diameter >3 cm, median survival was 82,9 months (95% CI 52-113,7) for LR group and 18,9 months (95% CI 6,3-31,4) for LAT group (p=0,001). Conclusion:Our propensity case-matched study confirmed that survival is similar after LR and LAT for single HCC smaller than 5 cm and for oligofocal HCC (up to 3 nodules) smaller than 3 cm; instead, for HCC larger than 5 cm or oligofocal HCC (up o 3 nodules) larger than 3 cm surgical resection improves significantly long term survival
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