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HOME > J Liver Cancer > Volume 24(1); 2024 > Article
Letter regarding “Treatment options for solitary hepatocellular carcinoma ≤5 cm: surgery vs. ablation: a multicenter retrospective study”
Jongman Kimorcid
Journal of Liver Cancer 2023;24(1):3-4.
Published online: December 12, 2023

Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

Corresponding author: Jongman Kim, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea E-mail:
• Received: November 21, 2023   • Accepted: December 4, 2023

© 2024 The Korean Liver Cancer Association.

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Dear Editor,
I read with interest the research performed by Kariyama et al.1 on the therapeutic efficacy of ablation and surgery in solitary hepatocellular carcinoma (HCC) measuring ≤5 cm. The study's division of patients into different size categories and the comparison of treatment effects within these groups offer valuable insights. Notably, the lack of significant differences in recurrence-free survival (RFS) and overall survival (OS) between the two treatment modalities for HCC ≤3 cm and the preference for surgical liver resection in the 3-5 cm range provide valuable insights for clinicians managing patients with HCC. The median RFS of 3.6 years following surgical resection compared to 2.0 years for the ablation group after surgical resection suggests a potential advantage of surgery in terms of delayed recurrence. Notably, however, there was no significant difference in OS between the two treatment modalities. Their findings were based on a cohort database of 2,067 individuals. It is crucial to acknowledge the limitations of observational studies, such as the potential confounding factors and biases that may affect treatment outcomes.
Several Asian guidelines recommend local ablation for very earlyor early-stage HCCs ≤3 cm,2 and Chinese guidelines extending this recommendation to solitary HCC ≤5 cm,3 reflect the regional variations and evolving perspectives on the optimal treatment strategies for different stages of HCC. Previous randomized controlled trials (RCTs) that did not find surgery to be superior to radiofrequency ablation (RFA) in terms of OS aligned with existing literature.4-6 However, the observation that RFS was significantly longer or tended to be longer in patients undergoing surgery than in those undergoing RFA is an interesting point.5,7 This discrepancy between RFS and OS outcomes suggests that while surgery may delay recurrence, it may not necessarily translate into a significant improvement in OS. The study by Shin et al.,8 which included a substantial number of RCTs and matched non-randomized trials, suggested that liver resection may be superior to RFA in terms of oncological outcomes. However, it is important to consider the specific patient populations, study designs, and methodologies of the included trials when interpreting these results.
This study could have implications for clinical decision-making and may contribute to the ongoing discussion regarding the optimal treatment approach for solitary HCC ≤5 cm. When determining the most appropriate treatment strategy for individual cases, it is imperative to consider factors such as patient comorbidities, overall health status, and tumor characteristics including tumor size, number, and location. The heterogeneity of HCC, even within defined criteria, such as the Milan criteria, underscores the need for tailored treatment strategies. A well-designed RCT focusing on solitary HCC of various sizes could help address some existing gaps in the literature and contribute to a more nuanced understanding of the optimal treatment approach for this specific patient population. In addition, clinical research that considers not only clinical outcomes, but also patient-reported outcomes and quality-of-life measures could further enhance our understanding of the holistic impact of different treatment modalities.

Conflict of Interest

The author has no conflicts of interest to disclose.

Ethics Statement

Not applicable.

Funding Statement


Data Availability

Not applicable.

Author Contribution

Conceptualization, investigation, project administration, visualization, writing - original draft, writing - review & editing: JMK

  • 1. Kariyama K, Nouso K, Hiraoka A, Toyoda H, Tada T, Tsuji K, et al. Treatment options for solitary hepatocellular carcinoma ≤5 cm: surgery vs ablation: a multicenter retrospective study. J Liver Cancer 2023;Nov 6 doi: 10.17998/jlc.2023.09.11. [Epub ahead of print].
  • 2. Cho Y, Kim BH, Park JW. Overview of Asian clinical practice guidelines for the management of hepatocellular carcinoma: an Asian perspective comparison. Clin Mol Hepatol 2023;29:252−262.ArticlePubMedPMCPDF
  • 3. Zhou J, Sun H, Wang Z, Cong W, Wang J, Zeng M, et al. Guidelines for the diagnosis and treatment of hepatocellular carcinoma (2019 edition). Liver Cancer 2020;9:682−720.PubMedPMC
  • 4. Chen MS, Li JQ, Zheng Y, Guo RP, Liang HH, Zhang YQ, et al. A prospective randomized trial comparing percutaneous local ablative therapy and partial hepatectomy for small hepatocellular carcinoma. Ann Surg 2006;243:321−328.ArticlePubMedPMC
  • 5. Huang J, Yan L, Cheng Z, Wu H, Du L, Wang J, et al. A randomized trial comparing radiofrequency ablation and surgical resection for HCC conforming to the Milan criteria. Ann Surg 2010;252:903−912.ArticlePubMed
  • 6. Feng K, Yan J, Li X, Xia F, Ma K, Wang S, et al. A randomized controlled trial of radiofrequency ablation and surgical resection in the treatment of small hepatocellular carcinoma. J Hepatol 2012;57:794−802.ArticlePubMed
  • 7. Liu H, Wang ZG, Fu SY, Li AJ, Pan ZY, Zhou WP, et al. Randomized clinical trial of chemoembolization plus radiofrequency ablation versus partial hepatectomy for hepatocellular carcinoma within the Milan criteria. Br J Surg 2016;103:348−356.ArticlePubMedPDF
  • 8. Shin SW, Ahn KS, Kim SW, Kim TS, Kim YH, Kang KJ. Liver resection versus local ablation therapies for hepatocellular carcinoma within the Milan criteria: a systematic review and meta-analysis. Ann Surg 2021;273:656−666.PubMed

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        Letter regarding “Treatment options for solitary hepatocellular carcinoma ≤5 cm: surgery vs. ablation: a multicenter retrospective study”
        J Liver Cancer. 2024;24(1):3-4.   Published online December 12, 2023
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