Systematic review of surgical resection vs radiofrequency ablation for hepatocellular carcinoma

Figure 1 Clinical cases in which performing hepatic resection or radiofrequency ablation had to be decided. A: Small hepatocellular carcinoma (HCC), 22 mm in diameter, located centrally in the right liver lobe in a patient with MELD 10 and clinical signs of portal hypertension. Surgery would have required a right hepatectomy, thus, radiofrequency ablation was preferred even if a reduced rate of complete necrosis could be expected due to the possible heat sink effect of the nearby large vessels; B: The tumor is located sub-capsular, close to the bowel loops and in strict contact with the gallbladder, implying various technical contraindications to percutaneous ablation. Open surgery was the strategy adopted; C: The tumor (long arrow), shown in the arterial phase of contrast enhancement at computed tomography scan, is located sub-capsular at the liver dome; D: Ultrasonography confirms the tumor (long arrow) to lie very deep and without a safe needle track; in fact, these images are taken in deep inspiration, the lesion being hardly visible during normal breathing. The location was considered to contraindicate percutaneous ablation and surgery was performed.

Figure 2 Clinical cases in which performing hepatic resection or radiofrequency ablation had to be decided. A: Ultrasonography through a right inter-costal scan shows a very early hepatocellular carcinoma (HCC) in segment 5 that can be reached with a safe needle track for thermal ablation. Given the small size and easy access, radiofrequency ablation was carried out; B: Post treatment assessment with contrast enhanced ultrasound shows a necrotic devascularized area (34 mm × 35 mm) that includes the tumor with a safety margin > 5 mm; C: Superficial HCC of 35 mm in hepatitis B virus related cirrhosis with preserved liver function. This lesion could be treated by either ablation or resection, but resection is preferable given the superficial location in segment 5 and the size > 3 cm; D: Tumor lesion partially treated by a previous trans-catheter arterial chemoembolization performed in another hospital, in a sub-capsular location close to the stomach. The theoretical path for radiofrequency ablation would lead the needle to puncture the tumor directly and thermal ablation would imply a risk of heat damage to the stomach wall. Laparoscopic resection was the strategy adopted. The long arrow indicates the HCC after treatment.