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Di Costanzo et al. Hepatoma Res 2018;4:53 I http://dx.doi.org/10.20517/2394-5079.2018.56 Page 3 of 7

Another possibility may be the combined treatment with sorafenib and RFA or triple combination also with
TACE, with the aim of increasing the necrosis and reducing the rate of recurrence [42-44] . Regarding complica-
tions of RFA ablation, in a large survey 6 deaths (0.3%) were observed. Five of these patients had large HCC
complicating cirrhosis, in 3 patients the cancer nodules were located in risky areas and two had Child-Pugh
[45]
B cirrhosis . Therefore, caution should be observed in such cases. Major and minor complications occurred
in 2% and 5%, respectively. Similar rates have been observed in more recent studies [46,47] . A pre-RFA value of
[48]
bilirubin > 2.5 mg/dL may predict liver decompensation after treatment .
MICROWAVE ABLATION
Due to the advancement of microwave technology and the development of cooled electrodes, percutaneous
microwave ablation (MWA) is actually considered a safe and effective alternative to RFA for thermal ablation
of HCC [49,50] . As compared to RFA, MWA has theoretical advantages including the shorter procedural
time, very rapid increase in tissue temperature, and it is less affected by tissue impedance and the heat-sink
[51]
effect . Both in ex vivo and in vivo porcine liver model, MWA produced larger coagulation zones than
[52]
bipolar RFA .
[54]
Two metanalyses comparing the two techniques have been published [53,54] . Chinnaratha et al. analyzing
three studies including 450 patients with HCC nodules > 5.0 cm or more than 3 nodules found a benefit for
MWA as compared to RFA with a pooled OR of 1.88 [55-57] . Furthermore, MWA treatment was associated
with a lower rate of local tumor progression in large HCC as compared to RFA. The evaluation of studies
including larger HCC and the metanalysis of Facciorusso et al confirmed that MWA was significantly more
effective than RFA in inducing the complete necrosis of tumours [58,59] . Also other authors confirmed MWA is
[62]
safe and effective in the treatment of large HCC [60,61] and subcapsular lesion .

A recent randomised controlled trial did not show superiority of MWA over RFA in terms of efficacy, major
complications and local tumour progression at 2 years of follow-up in patients with hepatocellular carcinoma
[63]
[64]
[65]
lesions of 4 cm or smaller , confirming a previous study published in 2002 . Chong et al. suggested
to apply ALBI score for the selection of patients in order to identify the cases with worse liver function in
whom to prefer MWA to surgery.
More than overlapping insertions, the placement of multiple antennas may obtain larger ablation areas,
[66]
mainly when simultaneous activation is used . This is an advantage as compared to RFA that do not allow
the simultaneous activation of multiple electrodes. Another approach is the insertion of electrode under
laparoscopic guidance. This technique resulted effective in small nodules, but it might be useful for the
[67]
treatment of large nodules with an exophytic growth . A study in 14 centers on 736 patients treated with
MWA using the AMICA system found 22 (2.9%) major complications, 54 (7.3%) minor complication, and no
[47]
deaths .

LASER ABLATION
Laser ablation (LA) is the less popular technique for performing thermal ablation and there is only one case-
control study designed to evaluate the efficacy of this treatment in large HCC. This study compared LA with
[68]
the multifiber technique and TACE for the treatment of solitary large HCC with a diameter of 4.0-7.5 cm .
LA approach resulted more effective than TACE in inducing complete tumour necrosis. Overall, 26 (63.4%)
patients from the LA group and 8 (19.5%) from the TACE group showed a complete response to treatment
(P < 0.001). In univariate analyses, baseline predictors of complete response were Child-Pugh class A and
treatment modality with LA. Furthermore, the rate of local cancer progression was observed in 19.5% of LA
successfully treated patients and in 75% of TACE treated (P < 0.001). In nodules with a median diameter of
5.2 cm (3.1-9.6 cm), combined treatment with LA performed before TACE obtained the complete ablation
[69]
in 90% of 45 tumours in 30 patients . In our Unit, a study evaluating the use of sorafenib as neoadjuvant