Hepatic resection versus radiofrequency ablation for hepatocellular carcinoma in cirrhotic individuals not candidates for liver transplantation: A Markov model decision analysis

• Published in: The American journal of surgery 2009-09, Vol.198 (3), p.396-406
• Main Authors: Molinari, Michele, M.D, Helton, Scott, M.D
• Format: Article
• Language: English
• Subjects: Ablation; Age; Age Factors; Biological and medical sciences; Cancer therapies; Carcinoma, Hepatocellular - mortality; Carcinoma, Hepatocellular - surgery; Catheter Ablation; Clinical trials; Computer Simulation; Decision analysis; Disease; Disease Progression; General aspects; Health risks; Hepatectomy; hepatic resection; Hepatitis; Hepatocellular carcinoma; Humans; Length of Stay; Life expectancy; Liver; Liver cancer; Liver Cirrhosis - complications; Liver Cirrhosis - mortality; Liver Neoplasms - mortality; Liver Neoplasms - surgery; Liver transplantation; Liver transplants; Liver, biliary tract, pancreas, portal circulation, spleen; Markov Chains; Markov model; Markov processes; Medical prognosis; Medical sciences; Metastasis; Neoplasm Seeding; Other treatments; Patients; Probability; Quality of life; Quality-Adjusted Life Years; Radio frequency; Radiofrequency ablation; Randomized Controlled Trials as Topic; Risk Factors; Sensitivity analysis; Sensitivity and Specificity; Standard deviation; Surgery; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Surgery of the digestive system; Survival; Survival Analysis; Transplantation; Treatment Outcome; Treatment. General aspects; Tumors
• ISSN: 0002-9610; 1879-1883
• DOI: 10.1016/j.amjsurg.2009.01.016

Abstract Background Several observational studies have suggested that radiofrequency ablation (RFA) may have survival benefits similar to hepatic resection (HR) in cirrhotic patients affected by hepatocellular carcinoma (HCC) are not candidates for liver transplantation. A small randomized controlled trial confirmed these findings, although underpowered to detect a significant difference at 5-year interval. Methods A Markov model was created to simulate a randomized trial comparing the quality of life–adjusted survival for individuals undergoing HR versus RFA for HCCs less than 5 cm in diameter. Results HR was the best therapeutic option with 5.33 (standard deviation ±.42) versus 3.91 (standard deviation ±.38) quality-adjusted life years except for in individuals older than 75 years of age ( P = .02, log rank test). One-way sensitivity analysis showed that RFA was the preferred strategy if the perioperative mortality of HR was more than 30%, if the percentage of patients with negative margins was less than 60%, and if RFA could be performed at least 60% of the time for recurrent disease after a previous ablation. The quality of life associated with both procedures did not influence the results of this model. Conclusions HR provided better quality of life–adjusted survival as ablation therapy was associated with increased risk of local recurrent disease requiring multiple sessions. For older individuals, RFA appears to be the best therapeutic option. If the probability of ablation for recurrent disease is equal in the 2 arms, survival benefits of RFA is similar to HR.