Reply.

Abstract

Potential conflict of interest: Nothing to report. We thank Professor Lo for the interest in our study and the results. As indicated, studies have suggested that antiviral therapy in patients with hepatitis B virus (HBV)–related cirrhosis and/or hepatocellular carcinoma (HCC) and detectable HBV DNA may reduce hepatic decompensation and potentially prevent HCC recurrence. Actually, our study included 338 patients with HBV infection; 320 patients met the criteria based on the American Association for the Study of Liver Diseases/European Association for the Study of the Liver guidelines and received antiviral therapy with oral entecavir (0.5 mg, once a day). The other 18 patients with HBV infection were not on antiviral therapy due to undetectable serum HBV DNA. Because all of the patients meeting the indication for antiviral therapy received oral entecavir and there were no significant differences between the two groups, HBV treatment should not impact our final results as originally reported. We agree that patients with HCC who fail treatment with either cryoablation or radiofrequency ablation (RFA) could be offered an alternative complementary treatment, although Barcelona Clinic Liver Cancer Group HCC management guidelines do not recommend RFA due to a marked decrease in efficacy when the tumor size exceeds 3 cm.1 Indeed, with improved devices and techniques, many studies have reported encouraging results, including complete ablation and survival rates of RFA in treating HCC lesions >3 cm.2 In our study, patients with incomplete ablation after two sessions of the same technique were considered treatment failures and were further treated by percutaneous ethanol injection, microwave, RFA, cryoablation, or surgery, as appropriate. Our study was performed between February 2008 and October 2013, and six patients in the RFA group did not undergo an additional course of RFA treatment as they declined the option of RFA or cryoablation for additional treatment. It should be noted that this study included 158 patients with 168 HCC lesions 3.1‐4 cm (84 patients in the cryoablation group and 74 in the RFA group, P = 0.2882). Hence, some of the patients with incomplete ablation (three patients in the cryoablation group and six patients in the RFA group) received percutaneous ethanol injection treatment alone, which should not significantly influence the local tumor progression rate only in the RFA group. Indeed, the main conclusion of this study was the demonstration that percutaneous cryoablation can be effective for HCC lesions up to 4 cm in diameter. Our study was not aimed at determining if cryoablation is superior to RFA in treating larger HCC lesions (i.e., 3.1‐4.0 cm in diameter).