Systematic review of surgical resection vs radiofrequency ablation for hepatocellular carcinoma

Table 1 Proposed evidences and recommendations from international guidelines

Guidelines	Hepatic resection	Radiofrequency ablation
EASL	Resection is the first-line treatment option for patients with solitary tumors and very well-preserved liver function, defined as normal bilirubin with either hepatic venous pressure gradient ≤ 10 mmHg or platelet count ≥ 100000 (evidence 2A; recommendation 1B)	Local ablation with radiofrequency or percutaneous ethanol injection is considered the standard of care for patients with BCLC 0-A tumors not suitable for surgery (evidence 2A; recommendation 1B)
EORTC[9]	Additional indications for patients with multifocal tumors meeting Milan criteria ( ≤ 3 nodules ≤ 3 cm) or with mild portal hypertension not suitable for liver transplantation require prospective comparisons with loco-regional treatments. (evidence 3A; recommendation 2C)	In tumors < 2 cm, BCLC 0, Ethanol injection and radio-frequency ablation achieve complete responses in more than 90% of cases with good long-term outcome [evidence 1(i)A; recommendation 1C]
AASLD[10]	Patients who have a single lesion can be offered surgical resection if they are non-cirrhotic or have cirrhosis but still have well preserved liver function, normal bilirubin and hepatic vein pressure gradient < 10 mmHg (recommendation 2)	Local ablation is safe and effective therapy for patients who cannot undergo resection, or as a bridge to transplantation (recommendation 2); Alcohol injection and radiofrequency are equally effective for tumors < 2 cm. However, the necrotic effect of radiofrequency ablation is more predictable in all tumor sizes and its efficacy is clearly superior to that of alcohol injection in larger tumors (recommendation 1)
APASL[11]	Liver resection is a first-line curative treatment of solitary or multifocal HCC confined to the liver, anatomically resectable, and with satisfactory liver function reserve (evidence 2B, recommendation B)	Local ablation is an acceptable alternative to resection for small HCC (< 3 cm) in Child-Pugh A cirrhosis (evidence 2B, recommendation B); Local ablation is a first-line treatment of unresectable, small HCC with 3 or fewer nodules in Child-Pugh A or B cirrhosis (evidence 2B, recommendation B)

Strength of evidence according to study design: Level 1, Randomized controlled clinical trials or meta-analyses of randomized studies; Level 2, Non-randomized controlled clinical trials; Level 3, Case series. Strength of evidence according to end-points: A, Total mortality; B, Cause-specific mortality; C, Carefully assessed quality of life; D, Indirect surrogates. Grading of recommendation: 1, Strong recommendation warranted; 2, Weaker recommendation. Grading of recommendation: A, Further research is very unlikely to change out confidence in the estimate of effect; B, Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate; C, Further research is very likely to have an important impact on our confidence in the estimate of effect. BCLC: Barcelona Clinic Liver Cancer; HCC: Hepatocellular carcinoma; EASL: European Association for the Study of the Liver; EORTC: European Organisation For Research And Treatment Of Cancer; AASLD: American Association for the Study of Liver Diseases; APASL: Asian Pacific Association for the Study of the Liver.