Assessment of long-term prognosis at detection of early hepatocellular carcinoma remains unsolved
Authors: Fabio Piscaglia, Veronica Salvatore, Simona Leoni, Alessandro Cucchetti
Journal: Journal of Hepatology (2014)

Prediction of aggressiveness in early-stage hepatocellular carcinoma for selection of surgical resectionJournal of HepatologyVol. 60Issue 6PreviewIn early-stage hepatocellular carcinoma (eHCC), radiofrequency ablation (RFA) has comparable outcomes to surgical resection (SR); however, micrometastases may be present, resulting in tumor recurrence after local ablation. Therefore, we investigated predictors of aggressiveness in eHCC to select patients at high risk of recurrence after RFA who would benefit from SR. Full-Text PDF Reply to: “Assessment of long term prognosis at detection of early hepatocellular carcinoma remains unsolved”Journal of HepatologyVol. 61Issue 6PreviewOn behalf of the authors, we appreciate the interest of Piscaglia et al. in our recent publication “Prediction of aggressiveness in early-stage hepatocellular carcinoma for selection of surgical resection” [1]. Because of the higher risk of hepatocellular carcinoma (HCC) recurrence after radiofrequency ablation (RFA), as has been also recently demonstrated by the group of Piscaglia [2], we investigated the predictors of aggressiveness in early-stage HCC (eHCC) to select patients at high risk of recurrence after RFA who would have a greater benefit from surgical resection (SR). Full-Text PDF Open Access The study by Suh and coworkers [[1]Suh S.W. Lee K.W. Lee J.M. You T. Choi Y. Kim H. et al.Prediction of aggressiveness in early-stage hepatocellular carcinoma for selection of surgical resection.J Hepatol. 2014; 60: 1219-1224Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar] addresses a hot topic, namely the possibility to predict prognosis (recurrence and survival) in patients submitted to curative treatments for early hepatocellular carcinoma (HCC). The authors conclude that patients submitted to radiofrequency ablation are at higher risk of local intrahepatic recurrence in comparison to surgery and that survival is compromised in case of increased production of α-fetoprotein (AFP) by prothrombin, induced by vitamin K absence-II (PIVKA-II), compared to all other groups (not increased AFP by PIVKA-II product or surgical resection). We agree with the conclusion of the higher risk of recurrence, as we recently demonstrated [[2]Cucchetti A. Piscaglia F. Cescon M. Colecchia A. Ercolani G. Bolondi L. et al.Cost-effectiveness of hepatic resection versus percutaneous radiofrequency ablation for early hepatocellular carcinoma.J Hepatol. 2013; 59: 300-307Abstract Full Text Full Text PDF PubMed Scopus (267) Google Scholar], but in our view the second conclusion is not sufficiently supported by evidence. Moreover, some incorrect reporting of data prevent a full understanding of the study. Regarding the latter point, results about AFP and PIVKA-II were reported as mean values. This is unacceptable, as such data are not expected to follow a Gaussian distribution, thus, mean values are poorly or totally non-informative or may even be misleading under these circumstances. Median values have to be reported. Moreover, readers cannot understand how many patients had normal values of these two parameters. Secondly, the authors themselves point out that patients submitted to ablation had a slightly more compromised liver function than surgical patients. It is evident that cirrhotic patients with poorer liver function have a worse overall survival, regardless of the tumours status. We have recently shown in this Journal that resection may apparently provide better survival in early HCC, but only when entire patient series are analysed [[2]Cucchetti A. Piscaglia F. Cescon M. Colecchia A. Ercolani G. Bolondi L. et al.Cost-effectiveness of hepatic resection versus percutaneous radiofrequency ablation for early hepatocellular carcinoma.J Hepatol. 2013; 59: 300-307Abstract Full Text Full Text PDF PubMed Scopus (267) Google Scholar]. Such difference disappeared in very early HCC when patients were balanced in terms of background liver function and tumour features [[2]Cucchetti A. Piscaglia F. Cescon M. Colecchia A. Ercolani G. Bolondi L. et al.Cost-effectiveness of hepatic resection versus percutaneous radiofrequency ablation for early hepatocellular carcinoma.J Hepatol. 2013; 59: 300-307Abstract Full Text Full Text PDF PubMed Scopus (267) Google Scholar]. Suh and colleagues [[1]Suh S.W. Lee K.W. Lee J.M. You T. Choi Y. Kim H. et al.Prediction of aggressiveness in early-stage hepatocellular carcinoma for selection of surgical resection.J Hepatol. 2014; 60: 1219-1224Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar] did not show whether the four subgroups were superimposable in terms of highly relevant factors, such as liver function variables, tumour size and number, thus making the issue of survival questionable. This would be recommendable, especially in the two groups of patients, submitted to ablation, for which the information, derived from histology on which prognosis was designed, was not available. Thus, a re-analysis of the Korean data appears to be well-deserved before the conclusions, proposed by the authors, can be adopted. Fabio Piscaglia received advisory board and speakers fees from Bayer.