Surgical resection is considered the ideal treatment for patients with early-stage HCC confined to the liver with no vascular invasion or distant metastases. However, only a minority of patients with HCC are suitable for the surgical choice due to various factors including the multiplicity of the lesions, poor residual liver functions, or tumor spread. Microwave ablation offers some advantages over surgery being suitable for patients with multiple lesions and those with a general condition that may interfere with fitness for surgery.
One important consideration regarding outcomes following HCC treatment is the response rate as regards ablation whether complete or partial. HCC response to therapy is typically evaluated using triphasic CT or dynamic MRI and assessment entail measurement of tumor size and the extent of necrosis as well as detection of new lesions, which is crucial in guiding subsequent treatment decisions and predicting patient outcomes [12]. The modified Response Evaluation Criteria in Solid Tumors (mRECIST) are currently adopted to evaluate the treatment response in HCC patients who are treated with loco-regional procedures [13]. Favorable response rates may be predicted in carefully selected patients undergoing surgical resection or locoregional ablation for HCC which was the case encountered in the current study where almost all patients responded to treatment according to mRECIST criteria whether complete or partial response. On the other hand, none of the studied patients had disease progression and only two patients showed a stationary disease. Response to treatment was independent of the treatment modality used which highly confirms that microwave ablation is not inferior to surgical resection in early-stage HCC in terms of cure.
Recurrence is the most frequent serious adverse event observed after treatment of HCC. It is due to micro-metastases in the liver or multi-centric carcinogenesis in the underlying cirrhotic liver [14]. The HCC recurrence rate after curative treatment is high, with cumulative 5-year recurrence rates > 60% [15]. Few studies showed that the total and early recurrence rates in patients who underwent MWA were significantly higher than those in patients who underwent liver resection [14, 16, 17]. On the other hand, a recent meta-analysis compared MWA with LR for the treatment of HCC and included nine observational studies from China or Japan. These results showed that there were no significant differences between MWA and LR for recurrence [18]. In the current study, the recurrence rate did not correlate with the treatment adopted whether resection or microwave ablation. The rate of recurrence, however, was significantly higher with increasing AFP levels irrespective of the treatment used while other parameters including liver status or site and size of the focal lesion had no value in predicting HCC recurrence.
The ultimate aim of any treatment for hepatocellular carcinoma (HCC) is to improve overall survival (OS) and advances to HCC treatment modalities in recent years had a clear impact on an improved survival rate. Each treatment option for HCC has its OS. However, multiple studies found no significant difference regarding overall survival between groups treated by liver resection or microwave ablation [19,20,21]. This agrees with the current study where no significant difference in OS was found between the group who was treated using microwave ablation and the other group who had surgical resection exhibiting a 1-year survival probability of 75.5% and 76.3% respectively.
Prognostic factors of HCC were categorized as factors related to the tumor itself, factors related to the liver functions, and general performance status. Univariate logistic regression analysis was performed to figure out predictors of survival in the studied population. Only post-treatment hepatic decompensation and failure to achieve response to treatment were shown to correlate with poor survival outcomes. Stationary disease and partial response to treatment independently predicted lower survival. Similarly, the odds ratio for survival in patients with post-procedure clinical decompensation was significantly low compared to those who did not have clinical decompensation. On the other hand, when multivariate logistic regression analysis was performed, post-procedure clinical decompensation was the only predictor of poor survival rate in treated patients. Similarly, a Chinese study comparing microwave ablation to surgical resection in HCC concluded that poor hepatic functions as stated by Child–Pugh and albumin/bilirubin (ALBI) scores are inversely proportional to overall survival [22]. In addition, a previous study stated that hepatic decompensation, as well as number and size of malignant lesions, are predictors of poor survival in patients with HCC treated by microwave ablation [23]. Other predictors of survival were identified by Jia-Yan et al., such as advanced BCLC stage, portal vein thrombosis, poor performance status, and tumor size [24].
In our study, we have some limitations. This includes the small sample size as well as the absence of the histological assessment for the tumor behavior in the studied population.
In conclusion, hepatic resection and microwave ablation showed similar satisfactory results in the treatment of early-stage HCC. Microwave ablation remains a promising alternative for patients not fit for surgical resection.
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