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The role of radiofrequency ablation of hepatocellular carcinoma in cirrhosis: from guidelines to real practice - a literature review

Fabio Fornari & Mauro Borzio

The epidemiologic features of hepatocellular carcinoma (HCC) in cirrhosis have been changing over the last decades as documented in field cohorts where the prevalence of elderly patients with severe comorbidities is progressively increasing. This may account, at least in clinical practice, for changing of treatment modalities for liver-confined HCC and for the worldwide increased popularity of percutaneous ablation which is undoubtedly more easily applied to weak patients. Radiofrequency ablation (RFA) is the standard reference technique for percutaneous ablation and it is currently included among the curative therapies of early HCC in cirrhosis by international guidelines. In particular, for single HCC<2 cm, RFA should be the first choice therapy, being effective as surgery but less invasive and less expensive. For larger HCCs (not exceeding 4 cm), RFA competes with resection in terms of survival benefit even though the latter provides better local disease control and longer disease-free survival. For non-resectable HCC greater than 4 cm, a treatment combining RFA and transarterial chemoembolization (TACE) can be performed to expand the ablated area. However, this approach needs to be standardized. Microwave (MWA) is a new ablative procedure potentially able to overcome some technical limits of RFA. The effectiveness of MWA is still under investigation even though preliminary results are encouraging. Emerging data from clinical practice outline the increasing role of ablative procedures for treatment of HCC in cirrhosis in the near future.