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LETTER TO Ablation for Hepatocellular Carcinoma: Where Do We Stand? Reply: e thank Drs Li and Wen for their comments on the article we recently published in Annals of Surgery.1 They pointed out several issues that could be incorporated into our article, and we would like to specifically address these points. The diagnosis of hepatocellular carcinoma (HCC) for patients receiving radio frequency ablation (RFA) was confirmed by biopsy sample obtained during RFA procedure or according to the HCC consensus guidelines put forward by the European Association for the Study of the Liver and American Association for the Study of Liver Diseases. Therefore, we did not have tissue samples for all of the RFA patients, and the impact of pathological features on patients’ survival could not be performed. Aside from tumoral factors, cirrhosis is another important risk factor for HCC recurrence. Indeed, a variable proportion of patients with HCC do not actually have cirrhosis. However, the Child-Turcotte-Pugh (CTP) classification system initially designed for predicting prognosis in patients with cirrhosis is still widely implemented in HCC staging systems. In this study, 181 patients were CTP class A5, whereas 56 patients were CTP class A6. Recently, the albumin-bilirubin (ALBI) grade was proposed to assess the degree of liver dysfunction for patients with HCC.2 According to the ALBI grade, 133 patients in the study were ALBI grade 1, whereas 104




patients were classified as ALBI grade 2. There are no significant differences between distribution of CTP class A5/A6 or ALBI grade 1/2 in patients receiving SR or RFA, both in all patient analysis, and in patients selected in the propensity model. Local recurrence was defined as local tumor progression at or adjacent to the ablation site after single RFA session in this study. It should be noted that the definitions of local recurrence varied between studies. In a recently published real-world study, patients who had contrast enhancement after initial ablation were considered as those with incomplete ablation rather than local recurrence.3 These different definitions regarding incomplete treatment and local recurrence, and diverse treatment strategies for patients with incomplete treatment, should be taken into consideration when comparing RFA results from different study groups. The ablative technique employed in the current study was percutaneous RFA. Open surgical or laparoscopic ablation seems to be promising therapeutic for patients with HCC. Open surgical ablation may achieve similar survival rates while offering better cost benefits and risk profiles than surgical resection.4 Laparoscopic tumor ablation was also reported as being safe and feasible with excellent therapeutic efficacy.5 Indeed, both surgical procedures and ablative techniques have witnessed enormous advancements. Microwave ablation, cryoablation, and laser ablation are emerging tools for local control of HCC.6 Meanwhile, clinical trials providing pairwise comparison between conventional surgical resection and various types of ablation are still lacking. Hopefully, these improvements can eventually translate into better long-term survival for patients with HCC.

Po-Hong Liu, MD Department of Medicine Taipei Veterans General Hospital, Taipei Faculty of Medicine National Yang-Ming University School of Medicine Taipei, Taiwan Teh-Ia Huo, MD Department of Medicine Taipei Veterans General Hospital, Taipei Institute of Pharmacology National Yang-Ming University School of Medicine Taipei, Taiwan [email protected]

REFERENCES 1. Liu PH, Hsu CY, Hsia CY, et al. Surgical resection versus radiofrequency ablation for single hepatocellular carcinoma 2 cm in a propensity score model. Ann Surg. 2015 March 13. [Epub ahead of print]. 2. Johnson PJ, Berhane S, Kagebayashi C, et al. Assessment of liver function in patients with hepatocellular carcinoma: a new evidence-based approach-the ALBI grade. J Clin Oncol. 2015;33:550–558. 3. Chinnaratha MA, Sathananthan D, Pateria P, et al. High local recurrence of early-stage hepatocellular carcinoma after percutaneous thermal ablation in routine clinical practice. Eur J Gastroenterol Hepatol. 2015;27:349–354. 4. Lei J, Wang W, Yan L. Surgical resection versus open-approach radiofrequency ablation for small hepatocellular carcinomas within Milan criteria after successful transcatheter arterial chemoembolization. J Gastrointest Surg. 2013;17:1752–1759. 5. de la Serna S, Vilana R, Sanchez-Cabus S, et al. Results of laparoscopic radiofrequency ablation for HCC. Could the location of the tumour influence a complete response to treatment? A single European centre experience. HPB (Oxford). 2015;17:387–393. 6. Wang C, Wang H, Yang W, et al. Multicenter randomized controlled trial of percutaneous cryoablation versus radiofrequency ablation in hepatocellular carcinoma. Hepatology. 2015;61:1579–1590.

Disclosure: The authors declare no conflicts of interest. Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0003-4932/14/26105-0821 DOI: 10.1097/SLA.0000000000001380

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Ablation for Hepatocellular Carcinoma: Where Do We Stand?

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