Long-term effectiveness of resection and radiofrequency ablation for single hepatocellular carcinoma 63 cm. Results of a multicenter Italian survey Maurizio Pompili 1,⇑ , Antonio Saviano 1 , Nicoletta de Matthaeis 1 , Alessandro Cucchetti 2 , Francesco Ardito 3 , Bruno Federico 4 , Franco Brunello 5 , Antonio D. Pinna 2 , Antonio Giorgio 6 , Stefano M. Giulini 7 , Ilario De Sio 8 , Guido Torzilli 9 , Fabio Fornari 10 , Lorenzo Capussotti 11 , Alfredo Guglielmi 12 , Fabio Piscaglia 13 , Luca Aldrighetti 14 , Eugenio Caturelli 15 , Fulvio Calise 16 , Gennaro Nuzzo 3 , Gian Ludovico Rapaccini 1 , Felice Giuliante 3 1 Department of Internal Medicine, Università Cattolica del Sacro Cuore, Rome, Italy; 2 Liver and Multiorgan Transplant Unit – Department of General Surgery, S. Orsola Malpighi Hospital, Bologna, Italy; 3 Department of Surgical Sciences, Università Cattolica del Sacro Cuore, Rome, Italy; 4 Department of Health and Sport Sciences, University of Cassino, Italy; 5 Department of Hepatology and Gastroenterology, San Giovanni Battista Hospital, Turin, Italy; 6 IX Infectious Disease and Interventional Ultrasound Unit, D Cotugno Hospital, Naples, Italy; 7 Department of Surgery, Spedali Civili University Hospital, Brescia University, Brescia, Italy; 8 Internal Medicine and Gastroenterology, University of Naples, Naples, Italy; 9 III Department of General Surgery, Istituto Clinico Humanitas, Milan University, Milan, Italy; 10 Gastroenterology, G. da Saliceto Hospital, Piacenza, Italy; 11 Department of Hepatopancreatobiliary and Digestive Surgery, Ospedale Mauriziano Umberto I, Turin, Italy; 12 Department of Surgery, Gian Battista Rossi University Hospital, Verona University, Verona, Italy; 13 Internal Medicine, S. Orsola Malpighi Hospital, Bologna, Italy; 14 Department of Surgery, Scientific Institute Vita-Salute, San Raffaele University, Milan, Italy; 15 Gastroenterology, Belcolle Hospital, Viterbo, Italy; 16 Unit of Hepatobiliary Surgery and Liver Transplantation, Antonio Cardarelli Hospital, Naples, Italy Background & Aims: The aim of this study was to compare liver resection and radiofrequency ablation in patients with single hepatocellular carcinoma 63 cm and compensated cirrhosis. Methods: The study involved 544 Child-Pugh A cirrhotic patients (246 in the resection group and 298 in the radiofrequency group) observed in 15 Italian centers. Overall survival and tumor recur- rence rates were analyzed using the Kaplan Meier method before and after propensity score matching. Cox regression models were used to identify factors associated with overall survival and tumor recurrence. Results: Two cases of perioperative mortality were observed in the resection group and the rate of major complications was 4.5% in the resection group and 2.0% in the radiofrequency group (p = 0.101). Four-year overall survival rates were 74.4% in the resection group and 66.2% in the radiofrequency group (p = 0.353). Four-year cumulative HCC recurrence rates were 56% in the resection group and 57.1% in the radiofrequency group (p = 0.765). Local tumor progression was detected in 20.5% of ablated patients and in one resected patient (p <0.001). After pro- pensity score matching, both survival and tumor recurrence were still not significantly different although a trend towards lower recurrence was observed in resected patients. Older age and higher alpha-fetoprotein levels were independent predictors of poor overall survival while older age and higher alanine-amino- transferase levels resulted to be independent factors associated with higher recurrence rate. Conclusions: In spite of a higher rate of local tumor progression, radiofrequency ablation can provide results comparable to liver resection in the treatment of single hepatocellular carcinoma 63 cm occurring in compensated cirrhosis. Ó 2013 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved. Introduction Liver resection (RES) is the first-line treatment for cirrhotic patients with early stage hepatocellular carcinoma (HCC) and well-preserved liver function. Radiofrequency ablation (RFA) is the standard of care for HCC patients within Milan criteria and compensated liver function not suitable for surgery. RFA is rec- ommended as the main ablative therapy providing local disease control and overall survival (OS) higher than that of percutaneous ethanol injection (PEI) in tumors >2 cm [1,2]. Whether ablation treatments are competitive alternatives to RES in compensated cirrhotic patients with HCC at very early (single HCC 62 cm) and early stage (single HCC 65 cm or no more than 3 nodules each 63 cm) according to Barcelona Clinic Liver Cancer (BCLC) staging system [3] is a matter of debate [4]. Journal of Hepatology 2013 vol. 59 j 89–97 Keywords: Hepatocellular carcinoma; Radiofrequency ablation; Liver resection; Long-term effectiveness; Overall survival; Tumor recurrence; Propensity score matching. Received 24 August 2012; received in revised form 5 March 2013; accepted 8 March 2013; available online 22 March 2013 ⇑ Corresponding author. Address: Department of Internal Medicine, Università Cattolica del Sacro Cuore, Largo F. Vito 1, 00168 Roma, Italy. Tel.: +39 06 30154335; fax: +39 06 35502775. E-mail address: mpompili@rm.unicatt.it (M. Pompili). Research Article