Sequential or simultaneous transarterial chemoembolization and radiofrequency ablation for hepatocellular carcinoma within the Milan criteria: A retrospective real-world study

Aims Few studies have investigated differences in sequential transarterial chemoembolization (TACE), radiofrequency ablation (RFA), and simultaneous RFA-TACE for the treatment of hepatocellular carcinoma (HCC) using the Milan criteria. This study explored the differences in safety and prognosis between sequential TACE-RFA and simultaneous RFA-TACE. Methods This retrospective real-world study included 109 patients with HCC within the Milan criteria who underwent sequential TACE-RFA (n = 75) or simultaneous RFA-TACE (n = 34) at the Eastern Hepatobiliary Surgery Hospital between January 2017 and 2021. Postoperative complications, length of hospital stay, and long-term prognosis were compared. The median follow-up duration of these patients was 39.1 months. Overall survival (OS) and time to tumor recurrence (TTR) curves were plotted using the Kaplan-Meier method and were compared using the logarithmic rank test. Independent risk factors for OS and tumor recurrence (TR) were analyzed using the Cox risk regression model. Results Multivariate analysis showed that tumor diameter >3 cm (hazard ratio [HR]: 2.201, 95% confidence interval [CI]: 1.106-4.378, p = 0.025; HR: 2.236, 95% CI: 1.271-3.934, p = 0.005, respectively) and alpha-fetoprotein (AFP) > 400 mu g/L (HR: 2.362, 95% CI: 1.195-4.668, p = 0.013; HR: 1.798, 95% CI: 1.048-3.086, p = 0.033, respectively) were independent risk factors for OS and TTR, whereas the presence of multiple tumors (HR: 2.352, 95% CI: 1.127-4.907, p = 0.023) was an independent risk factor for TTR. Simultaneous RFA-TACE did not have an effect on OS or TTR. After propensity score-matched, comparable results were obtained and RFA-TACE still had no effect on OS or TTR. No significant differences were observed in grade III/IV complications (2/75 [2.7%] vs. 1/34 [2.9%], p = 1.000) between the two groups. However, the RFA-TACE group had fewer complications than the TACE-RFA group (24/34 [70.6%] vs. 66/75 [88.0%], p = 0.026). The RFA-TACE group had a shorter hospital stay and less total cost during hospitalization compared with the TACE-RFA group (6.0 vs. 10.0 days, p < 0.001; 30,000 vs. 35,000 CNY, p < 0.001). Conclusions For HCC within the Milan criteria, there was no significant difference in OS and TTR between RFA-TACE and TACE-RFA. However, RFA-TACE could reduce all-grade complications and shorten the length of hospital stay compared with TACE-RFA. Therefore, simultaneous RFA-TACE may be considered for patients with HCC and good liver function falling within the Milan criteria.