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Editorial |
1 Department of Hepato-Bilio-Pancreatic Surgery, Hospital Beaujon, 100 Bd. du Général Leclerc, 92110 Clichy, France
2 Department of Radiology, Hospital Beaujon, University of Paris 7, 92110 Clichy, France
Correspondence: Address correspondence and reprint requests to: Jacques Belghiti, MD; E-mail: jacques.belghiti{at}bjn.aphp.fr.
The excellent long-term survival in cirrhotic patients with hepatocellular carcinoma (HCC) treated by radiofrequency (RF) ablation published by Raut et al.1 from the M. D. Anderson Cancer Center will trouble the surgical community and will be appreciated by radiologists. Until now, the uncertainty of complete tumor necrosis and the high rate of local tumor progression have limited the indication for RF to inoperable patients with small HCC.2 The current study leaves a strong impression because it included a large number of patients with a long follow-up and had a 5-year survival of >50%.
The current literature and our own experience make us think about the possible reasons for the excellent results of this study. The first possibility is meticulous patient selection. The authors excluded patients with biliary involvement and probably did not include those with vascular involvement. Both biliary and vascular involvement in HCC are indicative of infiltrative forms of HCC. This form, in contrast to the nodular form, is more aggressive. Second, most HCCs in this study were small, with a mean diameter of 3 cm, and previous reports have shown that RF ablation has the best results in small and nodular tumors.3 Third, the group could have achieved this outcome by using innovative and specialized techniques. The device used for the procedure was not new. It is interesting to note that the authors used both operative and percutaneous RF ablation. One could argue that intraoperative RF ablation can be more precise and meticulous and can achieve the best results. However, in this study, operative RF ablation was not shown to have better results compared with percutaneous RF ablation. Although intraoperative RF ablation is considered as an option in our institution, the rate of its performance is extremely infrequent (approximately 2%). Moreover, there is no mention regarding the use of pedicle clamping, which is speculated to increase the efficacy of RF ablation. It has been shown that the use of pedicle clamping, which reduces blood flow, is a certain advantage of open operative RF ablation because it is well known that high vascularity of the tumor and the presence of vascular structures in contact with the tumor impede the efficacy of RF ablation.
The last factor that could have influenced the results of this study is the quality of the investigators executing the procedure. According to the authors, the exquisite outcome of the study was achieved by meticulous performance of the procedure by the surgeon himself. Good surgeons are extremely meticulous in dissection and resection. Indeed, it is pleasurable to tame a difficult tumor, even if it requires hours of hard work.4 However, I am unsure that surgeons would show the same patience to perform a percutaneous procedure.
Surgeons who are dealing with malignant tumors are educated to follow the basic principles of oncological resection. The oncological resection of HCC includes excision of the tumor along with its portal territory. Anatomical resection ranging from sub-segmental to lobar resection characterizes oncological resection in HCC. With technical improvement and better perioperative management of patients with cirrhosis, it has been shown that anatomical resection gives good disease-free survival results.5 Anatomical resection is considered the gold standard of surgical resection with which the results of other treatment modalities should be compared. Although a 60% survival can be achieved after partial resection, the best long-term disease-free survival is achievable exclusively by liver transplantation (LT).
LT has the advantage of complete tumor removal as well as removal of the organ at risk to develop future malignancy. LT has been shown to have excellent long-term survival and low recurrence rates in patients with small HCCs that meet the Milan criteria6 (a single tumor of 
5 cm or no more than three nodules, none of which is >3 cm in maximum diameter). Reading this article on the excellent long-term results of RF ablation has evoked some questions. The first and most important is as follows: where should the patients with "transplantable" HCCs be referred? One would be seriously concerned about the treatment of transplantable patients in this study. In this report, many patients had good liver function with small HCCs. These patients would have been perfect candidates for LT. However, this option was not considered here, and many patients were denied the best treatment option. Patients with limited HCC associated with chronic liver disease need to be referred to a center where all treatment options (from local therapy to LT) are available.
However, organ shortage and, consequently, long waiting periods, which make transplantation impossible in many patients, have led to the evolution of bridging procedures during the waiting period or an initial definitive treatment followed by salvage LT if disease recurs. Bringing these concepts to wide practice would alleviate, at least partly, the eternal problem of organ shortage. Although there are controversies regarding the best modality of pre-transplantation treatment, it has been shown that prior anatomical resection does not increase post-transplantation morbidity in patients with small HCC.7 Thus, the next question is whether RF ablation can be used as an initial treatment before salvage transplantation or as a bridge treatment to LT.8 As the result of this study is being announced to the scientific world, one should seriously consider reinforcing the place of this modality in the management algorithm of patients with small HCCs who are transplantation candidates.
Received for publication March 25, 2005. Accepted for publication April 17, 2005.
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