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Invited Critique
December 1, 2007

Comparison of Percutaneous and Surgical Approaches for Radiofrequency Ablation of Small and Medium Hepatocellular Carcinoma—Invited Critique

Arch Surg. 2007;142(12):1143. doi:10.1001/archsurg.142.12.1143

Khan et al are to be commended for their results using RFA, either percutaneously or surgically, for the treatment of small (≤ 3 cm) and medium (3.1-5 cm) HCC. Their local ablation rate of 92% to 95% using either approach is a testimony to their experience with this modality. They demonstrate that RFA using either approach is equally effective for small lesions, in line with the experience of other groups.1,2 However, notwithstanding their improved results using a surgical approach, it remains to be seen whether RFA will be as effective for medium tumors. The treatment of HCC requires a multidisciplinary team, such as the Khan et al group, that can provide multimodal forms of therapy, including liver transplantation, an option that, although limited in availability, offers the best chance for a cure in patients with early-stage HCC. Despite the best efforts of Khan et al, their 3-year disease-free survival rates for both techniques, 22% to 33% and 0% to 19% for small and medium lesions, respectively, clearly demonstrate that RFA alone is not an effective primary treatment for HCC. The problem, of course, is not due to treatment failures but rather the development of new lesions elsewhere in the liver or metastasis, indicating that even in the setting of early HCC, RFA addresses neither the problem of new lesions developing in a background of chronic liver inflammation or cirrhosis nor the inherent biological potential of most lesions to spread hematogenously. The role of RFA in the treatment of early-stage HCC continues to be defined (there are ongoing prospective randomized studies assessing whether RFA is just as effective as hepatic resection for small tumors) and evolve, but its use must be guided by the sobering reality that HCC is almost never just a localized disease.

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