| Background and Purpose: Hepatic resection is the most effective modality in treating hepatocellular carcinoma(HCC), however the recurrence rate is extremely high. The treatment of recurrent HCC after hepatic resection is playing an important role in HCC history, but there is no a criterion for the selection of modalities for recurrent HCC. Repeated hepatic resection(RHR) is considered as the most valuable treatment, nevertheless the operation is more difficult than the initial, and the indications are relatively narrow. In recent years, percutaneous radiofrequency ablation(RFA) has been gradually used in treating recurrent HCC which had achieved favorable long-term results. In this study, we compared the safety and long-term survival rates of RHR with percutaneous RFA in treating recurrent HCC after hepatic resection to estimate the efficacy of these two treatmentsMaterrials and Methods: A total of 23178 cases of HCC patients received treatments from January 2010 to December 2011 in Shanghai Eastern Hepatobiliary Surgery Hospital. Of them, 416 cases were enrolled. Two hundred and sixty seven cases of initial recurrent HCC patients after hepatic resection received RHR, and 149 cases were treated with percutaneous RFA. Retrospectively collected clinical datas of enrolled patients including: pre-operational clinical characteristics; recurrent tumors; RHR or percutaneous RFA for recurrent tumors; second recurrence and follow-up. Propensity score matching(PSM) by 1:1 with pre-operational clinical characteristics was used to balance the baselines of two groups. After PSM, we compared the complications, local tumor progression(LTP), recurrence rate, recurrence free survival(RFS), and overall survival(OS) to estimate the long-term efficiency of these two treatments comprehensively, and prognostic factors were analyzed.Results: A total of 416 cases were enrolled, of which 267 received RHR(male 240, female 27); the mean age was 52.4 ± 10.9(23 ~ 79) years; the average number of recurrent tumor was 1.3 ± 0.6(1 ~ 5); the average maximum diameter was 3.3 ± 1.7(1.0 ~ 12.0)cm; the average interval period between primary HR and recurrence was 44.7 ± 40.7(1 ~ 247) months. One hundred and forty nine cases received percutaneous RFA(male 128, female 21), mean age was 53.7 ± 11.1(24 ~ 81) years. The average number of recurrent tumor was 1.3 ± 0.7(1 ~ 4); the average maximum diameter was 2.4 ± 1.0(1.0 ~ 7.2)cm; the average interval period between primary HR and recurrence was 30.3 ± 30.5(2.0 ~ 228.0) months.Before PSM, major complication was observed in 25 cases(25/267, 9.4%) in RHR group and 6 cases in RFA group(6/149, 4.0%), RFA was safer than RHR(χ2 = 3.949, P = 0.047). In RHR group, all recurrent tumors were reached R0 resection, complete resection rate was 100%(328/328); the technical success was achieved in 262 cases(262/267, 98.1%) because 5 cases died of postoperative liver failure within 2 weeks. In RFA group, 188 nodules in 141 patients achieved complete ablation after the first RFA; initial complete ablation rate was 95.4%(188/197). Local residual lesions were received complementary RFA and achieved complete ablation, technical success rate was 100%. There was no significant difference at technical success rate between these two groups(χ2 = 2.824, P = 0.093). At the censor of the follow-up, 22 cases developed LTP in RHR group(22/267, 8.2%) and 22 cases in RFA group(22/149, 14.8%). LTP rate in RFA group was significantly higher than that in RHR group(χ2 = 4.305, P = 0.038). The OS rates at 1-, 3-, 5- year were 92.9%, 69.3%, 58.6% in RHR group and 96%, 74.5%, 61.6% in RFA group, respectively; there was on significant difference between these two groups(χ2 = 0.792, P = 0.374). The RFS rates at 1-, 3-, 5- year were 73.7%, 51.9%, 37.5% in RHR group and 71.1%, 44.3%, 33.6% in RFA group, respectively; there was no significant difference between these two groups(χ2 = 1.788, P = 0.181). In subgroup analysis, for patients with early recurrence(ER) after initial HR, the OS rates at 1-, 3-, 5- year were 80.0%, 35.0%, 27.5% in RHR group and 91.5%, 66.0%, 50.9% in RFA group, respectively; OS rate in RFA group was significant higher than that in RHR group(χ2 = 5.292, P = 0.021). The RFS rates at 1-, 3-, 5- year were 47.4%, 34.2%, 18.4% in RHR group and 66.0%, 44.7%, 34.0% in RFA group, respectively; there was no significant difference between these two groups(χ2 = 1.799, P = 0.180). For patients with late recurrence(LR) after initial hepatic resection, the OS rates at 1-, 3-, 5- year were 95.2%, 75.3%, 64.2% in RHR group and 98.0%, 78.4%, 66.4% in RFA group, respectively; there was no significant difference between these two groups(χ2 = 0.545, P = 0.460). The RFS rates at 1-, 3-, 5- year were 78.1%, 54.9%, 41.0% in the RHR group and 73.5%, 44.1%, 33.5% in the RFA group, respectively(χ2 = 3.246, P = 0.072).A total of 125 patients from each group were paired by the PSM. The major complication rate was 10.4%(13/125) in RHR group and 3.2%(4/125) in RFA group, RFA is safer than RHR(χ2 = 5.112, P = 0.024). In RHR group, all recurrent tumors were reached R0 resection, complete resection rate was 100%(157/157); the technical success was achieved in 122 cases(122/125, 97.6%) because 3 cases died of postoperative liver failure within 2 weeks. In RFA group, 160 nodules in 121 patients achieved complete ablation after initial RFA; the initial complete ablation rate was 96.3%(160/166). Four patients with local residual underwent complementary RFA and achieved complete ablation after then; the technical success rate was 100%. These was no significant difference technical success rate between these two groups(χ2 = 3.306, P = 0.081). The LTP rate in RHR group was 6.4%(8/125) and 14.4%(18/125) in the RFA group, LTP rate in RFA group was higher than in RHR group. The OS rates at 1-, 3-, 5- year rates were 96%, 73.6%, 64.6% in RHR group and 96%, 73.6%, 61.5% in RFA group; there was no significant difference between these two groups(χ2 = 0.056, P = 0.813). The RFS rates at 1-, 3-, 5- years rates were 78.9%, 57.7%, 42.4% in RHR group and 72%, 44%, 32.8% in RFA group. The RFS rate in the RHR group significantly higher than that in the RFA group(χ2 = 4.529, P = 0.033). In subgroup analysis, for patients with ER, the OS rates at 1-, 3-, 5- year were 85.7%, 42.9%, 35.7% in RHR group, and 92.9%, 66.7%, 52.2% in RFA group; OS rate in RHR group was higher than that in RFA group(χ2 = 1.046, P = 0.043). The RFS rates at 1-, 3-, 5- year were 55.6%, 40.7%, 25.9% in RHR group and 66.7%, 45.2%, 35.70% in RFA group; there was no significant difference between these two groups(χ2 = 0.404, P = 0.525). For patients with LR, the OS rates at 1-, 3-, 5- year were 99.0%, 82.5%, 73.1% in RHR group and 97.6%, 77.1%, 66.1% in RFA group(χ2 = 0.498,P = 0.460). The RFS rates at 1-, 3-, 5- year were 85.4%, 62.5%, 47.3% in RHR group and 74.7%, 43.4%, 31.3% in RFA group. The RFS rate in the RHR group was significantly higher than that in RFA group(χ2 = 7.675, P = 0.006).Conclusions: Both RHR and RFA are effective treatments for recurrent HCC after hepatic resection. Compared with RHR, RFA is safer, OS period after treatment is comparable, but the LTP rate is higher and the RFS period is shorter. The OS period of ER HCC patients after RFA was higher than that of after RHR, and the RFS period was comparable, RFA may be considered as the first choice when feasible. For large recurrent HCC, RHR is still the first option. |
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