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Every clinical factor adverse to surgery included in the table was reported and confirmed by different studies.
For instance, the Liver Unit of Barcelona reported the usual 5-year overall survival rate around 50%. However, when the patients were divided according to two simple adverse prognostic factors, i.e. portal hypertension and abnormal bilirubin, a rate of 74% was obtained (the best so far reported) in patients with normal values and a rate of only 25% in the worst candidates.
So the fact that the survival of the worst candidates was comparable with two recently reported survival rates of untreated patients (20% and 16% respectively), even though with a more adverse profile, questions the indication for surgery in such patients. The high levels of transaminases resulted in an important rate of postoperative complications.
The surgical contraindications for the size less than 2 cm are related to the rate of successfull treatment with RFA reported in different studies. In case of single nodule between 2-3 cm, the selection has to be considered site dependent, or surgery could be used as salvage therapy after an unsuccessfull treatment with PAT.
As to the choice among the image-guided treatments, we consider them complementary, i.e. we use them as a multimodal tailored therapy. RFA, PEI and selective transarterial chemoembolization (sTACE), applied over time, are choosed patient by patient according to presentation of the disease. For instance, the same patient (or tumor) can be treated with different techniques.
RFA is currently considered the first choice treatment (figure 1). On this figure it is shown a HCC of the left lobe with the electrode located at the tumor periphery at the start of treatment, then the “boiling effect” covering all the tumor (oven effect) at the end of energy deposition, and then the CT control before and after RFA, demonstrating a complete necrosis.
Such a choice reflects the results of previous studies, demonstrating the advantages of RFA in terms of local efficacy and side effects. In these studies, RFA obtained a higher rate of necrosis than PEI in small tumors (table 4) and in infiltrating lesions of any size, and avoided the side effects (particularly transient increase in portal hypertension) occurring after single-session PEI when a large amount of ethanol was required.
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