Radiofrequency ablation vs surgical resection in elderly patients with hepatocellular carcinoma in Milan criteria

Table 1 Preoperative and clinical characteristics of patients with hepatocellular carcinoma in Milan criteria who underwent surgical resection and radiofrequency ablation

	Before PSM			After PSM
	RFA (n = 165)	Surgery (n = 429)	P value	RFA (n = 136)	Surgery (n = 136)	P value
Male, n (%)	116 (70)	319 (74)	0.35	98 (72)	104 (76)	0.48
Age (yr) median (range)	75 (70-89)	74.9 (70-90)	0.71	75 (70-88)	74.7 (70-86.1)	0.56
BMI (kg/cm²) median (range)	26.7 (19-51)	26.7 (19-52)	0.37	26.7 (19-51)	26 (21-41)	0.85
Co-morbidities > 2, n (%)	107 (64)	142 (33)	0.001	83 (61)	81 (60)	0.90
Cause of Cirrhosis n (%)			0.002			0.11
Hepatitis C virus	89 (54)	217 (50)		73 (54)	68 (50)
Hepatitis B virus	10 (6)	80 (19)		10 (7)	22 (16)
Alcohol	37 (22)	60 (14)		31(23)	23 (17)
Others	29 (18)	72 (17)		22 (16)	23 (17)
ASA score, n (%)			0.004			0.59
I-II	45 (27)	172 (40)		41 (30)	36 (26)
III-IV	120 (73)	257 (60)		95 (70)	100 (74)
Blood tests median (range)
Bilirubin (mg/dL)	1 (0.2-2.8)	0.9 (0.18-4.5)	0.41	1 (0.2-2.8)	0.8 (0.2-4.5)	0.02
Creatinine (mg/dL)	0.9 (0.5-2.5)	1 (0.2-2.5)	0.03	0.9 (0.5-2.3)	0.9 (0.4-2.5)	0.02
Platelet count × 109/L	131 (10-856)	178 (45-900)	0.00	131.5 (10-856)	155 (47-573)	0.57
INR	1.1 (0.9-2.4)	1.2 (0.6-2.5)	0.00	1.1 (0.9-2.4)	1.1 (0.8-2.5)	0.00
Child Pugh, n (%)			0.52			0.87
A	139 (84)	370 (86)		114 (84)	116 (85)
B	26 (16)	59 (14)		22 (16)	20 (15)
MELD median (range)	8 (6-18)	6 (6-17)	0.00	8 (6-18)	8 (6-17)	0.05
Tumors number, n (%)			0.07			0.71
Single nodule	142 (86)	392 (91)		117 (86)	120 (88)
Multi nodules	23 (14)	37 (9)		19 (14)	16 (12)
Tumor size (mm) n (%)	24 (10-50)	30 (7-50)	0.00	25 (10-50)	24.5 (7-50)	0.9
< 20	49 (30)	33 (8)	0.00	36 (26)	28 (21)	0.31
20-50	116 (70)	396 (92)		100 (74)	108 (79)
Bilobar tumor, n (%)	8 (5)	8 (2)	0.08	6 (4)	2 (1)	0.28
Tumor location, n (%)			0.28			0.17
1	2 (1)	8 (2)		1 (0.7)	1 (0.7)
2	14 (8)	41 (10)		13 (9)	14 (10)
3	12 (7)	42 (10)		10 (7)	20 (15)
4	20 (12)	53 (12)		15 (11)	13 (9)
5	28 (17)	63 (15)		21 (15)	27 (19)
6	27 (16)	87 (20)		23 (17)	29 (21)
7	18 (11)	60 (14)		16 (12)	11 (8)
8	44 (28)	75 (17)		37 (27)	21 (15)
Histologically proven, n (%)	42 (25)	115 (27)	0.75	36 (26)	42 (31)	0.50
Previous treatment, n (%)	53 (32)	53 (12)	0.00	42 (31)	21 (15)	0.004

Continuous variables were compared using an independent sample t-test and Mann-Whitney U test. Categorical variables were compared using the chi-square test and Kruskal-Wallis test respectively. PSM: Propensity score matching; BMI: Body mass index; ASA: American Society of Anesthesiologists; MELD: Model for End-Stage Liver Disease; RFA: Radiofrequency ablation; INR: International normalized ratio.

Table 2 Clinical and perioperative characteristics of patients with hepatocellular carcinoma in Milan criteria who underwent surgical resection and radiofrequency ablation

	Before PSM			After PSM
	RFA (n = 165)	Surgery (n = 429)	P value	RFA (n = 136)	Surgery (n = 136)	P value
Operative time (min) median (range)	25 (5-250)	205 (55-600)	0.002	25 (5-250)	190 (55-600)	0.001
Blood transfusion, n (%)	13 (8)	66 (15)	0.01	11(8)	23 (17)	0.04
Dindo-Clavien Classification, n (%)			0.001			0.002
I-II	163 (99)	378 (91)		134 (98)	121 (89)
III-IV	2 (1)	38 (9)		2 (1)	15 (11)
Postoperative complication, n (%)			0.001			0.002
Yes	31 (19)	188 (44)		28 (21)	75 (55)
No	134 (81)	241 (56)		108 (79)	61 (45)
Type of complication, n (%)
Liver failure	1 (1)	35 (8)	0.002	1 (0.7)	14 (10)	0.001
Ascites	3 (2)	60 (14)	0.003	3 (2)	17 (12)	0.002
Biliary leakage	0 (0)	9 (2)	0.064	0 (0)	3 (2)	0.25
Hemorrhage	4 (2)	19 (4)	0.340	3 (2)	11 (8)	0.51
Systemic Infection	4 (2)	30 (7)	0.03	4 (3)	14 (10)	0.03
Intra-abdominal abscess	0 (0)	23 (5)	0.00	0 (0)	8 (6)	0.007
Wound infection	2 (1)	12 (3)	0.37	2 (1)	7 (5)	0.17
Portal thrombosis	1 (1)	3 (1)	1.007	1 (0.7)	2 (1)	1
Pulmonary	7 (4)	33 (8)	0.15	6 (4)	15 (11)	0.07
Cardiac	1 (1)	18 (4)	0.03	1 (0.7)	8 (6)	0.03
Renal	1 (1)	18 (4)	0.03	1 (0.7)	6 (4)	0.12
Reoperation, n (%)	0 (0)	7 (2)	0.19	0 (0)	2 (1)	0.5
Postoperative treatment, n (%)	3 (2)	19 (4)	0.15	3 (2)	10 (7)	0.08
Length of hospital stay median (range)	2 (1-23)	6 (1-203)	0.00	2 (1-23)	7 (1-203)	0.00
Mortality 90 d, n (%)	3 (2)	13 (3)	0.001	3 (2)	4 (3)	1

Continuous variables were compared using an independent sample t-test and Mann-Whitney U test. Categorical variables were compared using the chi-square test and Kruskal-Wallis test respectively. PSM: Propensity score matching; RFA: Radiofrequency ablation.

Table 3 Univariate and multivariate models for survival

	Univariate analysis	Multivariate analysis
	P value	RR (95%CI)	P value
RFA	0.001	1.46 (1.1-1.79)	0.001
Age ≤ 75 yr	0.63
Male	0.001
Co-morbidity ≥ 2	0.001
BMI < 24	0.001
ASA score III-IV	0.07
TBil (mg/dL > 2)	0.001
Crea (mg/dL > 1)	0.57
PLT (U/μL > 150 × 10³)	0.001
INR (> 1.3)	0.001	1.60 (1.03-2.49)	0.03
Tumor size < 3 cm	0.001
Multiple nodule	0.001	1.19 (1.08-4.17)	0.03
Child Pugh A	0.001
MELD > 10	0.007	1.89 (1.21-2.92)	0.005

The relative prognostic significance of the variables in predicting overall survival and overall recurrence was established using univariate and multivariate Cox proportional hazards regression models. Radiofrequency ablation, international normalized ratio > 1.3 mg/dL, and Model for End-Stage Liver Disease score >10 were independent risk factors for overall survival. RFA: Radiofrequency ablation; INR: International normalized ratio; MELD: Model for End-Stage Liver Disease; RR: Relative risk; CI: Confidence interval; BMI: Body mass index; ASA: American Society of Anesthesiologists; PLT: Platelets; TBil: Total bilirubin; Crea: Creatinine.

Table 4 Univariate and multivariate models for recurrence

	Univariate analysis	Multivariate analysis
	P value	RR (95%CI)	P value
RFA	0.001	1.37 (1.17-1.60)	0.0001
Age ≤ 75 yr	0.28
Male	0.91
Co-morbidity ≥ 2	0.01
BMI < 24	0.61
ASA score III-IV	0.61
Bilirubin (mg/dL > 2)	0.37
Creatinine (mg/dL > 1)	0.62
PLT (U/μL > 150 × 10³)	0.001
INR (> 1.3)	0.02
Tumor size < 3 cm	0.001
Multiple nodule	0.07
Child Pugh A	0.26
MELD > 10	0.01	1.51 (1.04-2.17)	0.03

The relative prognostic significance of the variables in predicting overall survival and overall recurrence was established using univariate and multivariate Cox proportional hazards regression models. Radiofrequency ablation and Model for End-Stage Liver Disease score > 10 were considered poor prognostic factors. RFA: Radiofrequency ablation; INR: International normalized ratio; MELD: Model for End-Stage Liver Disease; RR: Relative risk; CI: Confidence interval; BMI: Body mass index; ASA: American Society of Anesthesiologists; PLT: Platelets.