In an excellent review of locoregional treatments for hepatocellular carcinoma (HCC), Lencioni1 states that there are no unequivocal data backing up radiofrequency ablation (RFA) as a replacement for hepatic resection as a first-line treatment for patients with early-stage HCC because optimal randomized controlled trials are lacking and a subset of HCCs that have a subcapsular location or are adjacent to the gallbladder or a large vessel are not candidates for RFA. Another advantage of hepatic resection over RFA that is not mentioned in the article is the pathological information obtained at resection, from which we learn about the presence or absence of established risk factors for recurrence, such as microscopic vascular invasion and satellite metastases.2 A proportion of clinically early HCCs have pathologically progressed. Patients with such tumors would benefit from adjuvant therapy after surgical resection or RFA because late recurrence, which can be defined as tumor relapse detected 24 months or more after the initial tumor ablation,3 is likely due to multicentric occurrence rather than local treatment failure. A randomized controlled trial was stopped prematurely because of significant advantages with respect to both overall survival and disease-free survival in patients who received an intra-arterial injection of radioactive 131I-labeled lipiodol after surgical resection.4 As briefly mentioned in the article, the ongoing Sorafenib as Adjuvant Treatment in the Prevention of Recurrence of Hepatocellular Carcinoma trial5 plans to randomize 1100 patients to adjuvant sorafenib or a placebo after hepatic resection or percutaneous ablation. New techniques with increased sensitivity to tumor aggressiveness, such as multi-arterial phase magnetic resonance imaging,6 may replace surgical resection with RFA followed by adjuvant therapy. From the patient's point of view, RFA is more feasible than surgery if equivalent outcomes are expected because RFA is likely to have the advantages of being less invasive, costing less, and requiring a shorter hospital stay.
To the Editors:
Tetsuji Fujita M.D.*, * Department of Surgery, Jikei University School of Medicine, Tokyo, Japan.