Liver resection versus radiofrequency ablation or transarterial chemoembolization for early multinodular BCLC-A hepatocellular carcinoma: a systematic review and meta-analysis

Hepatocellular carcinoma (HCC) is the most common form of liver cancer, with high mortality rates worldwide. The optimal treatment strategy for patients with multinodular early-stage HCC (BCLC-A) is still controversial, particularly regarding liver resection (LR), radiofrequency ablation (RFA), and transarterial chemoembolization (TACE). This meta-analysis aims to evaluate the overall survival (OS) and disease-free survival (DFS) in patients with multinodular BCLC-A HCC treated with LR compared to RFA and TACE. A systematic literature review and meta-analysis were performed by searching PubMed, Embase, and the Cochrane Library for studies comparing LR with RFA and TACE. Pooled analyses of overall survival (OS) and disease-free survival (DFS) were performed using Hazard Ratios (HR) with 95% confidence intervals (CI). Fifteen studies, including two randomized controlled trials and 13 cohort studies, with a total of 2,869 patients, were included. LR was significantly associated with improved OS (HR 1.38; 95% CI 1.03-1.84; p = 0.01) and DFS (HR 2.16; 95% CI 1.26-3.70; p = 0.001) compared with RFA. Similarly, LR demonstrated superior OS (HR 2.11; 95% CI 1.37-3.25; p < 0.0001) and DFS (HR 2.77; 95% CI 1.04-7.36; p = 0.04) when compared with TACE. The more pronounced benefit observed for DFS likely reflects improved local tumor control achieved with surgical resection. In selected patients with multinodular BCLC-A HCC and preserved liver function (predominantly Child-Pugh A or B), LR is associated with significant improvements in OS and DFS compared with RFA and TACE when liver transplantation is not feasible. These findings support reconsideration of current treatment algorithms to prioritize LR in appropriately selected candidates.