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

therapy in patients with large HCC who receive LA is ongoing. A multicenter Italian study evaluated the rate
and type of complications after LA with the multifiber technique. Among 520 patients and 1004 sessions, 4
deaths (0.8%), 15 major complications (1.5%), and 62 minor complications (6.2%) were observed. All deceased
[70]
patients had intermediate or large tumours and 2 of these were in Child-Pugh C class .
CONCLUSION
Thermal ablation is a very popular technique for the treatment of unresectable HCC in patients with
cirrhosis. In small HCC sized < 3.0 cm, RFA may achieve good results that in some cases are comparable
to that of surgical resection. Compared to surgery, local ablation features, mini-invasive approaches, with
less impact on liver function less morbidity and hospital stay and less costs. The applicability of thermal
ablation in nodules > 3 cm which constitutes the objective of this review, is still a matter of debate. During
the last 25 years, technical advances have increased the efficacy of such technique, expanding the range
of its application. However, the level of evidence is poor due to the scarcity of appropriated designed
randomized studies. A main problem in inducing the complete necrosis of large HCC nodules is the lack of
very experienced operators. In fact it is evident that a single needle insertion is insufficient in inducing the
complete necrosis of large tumors. The increase in the potency emitted by a single source may be insufficient
to ablate the periphery of large nodules and may be risky causing unwanted complications. In this setting,
overlapping electrode placements and multiple needle insertions are the better way to increase the treatment
effectiveness. The correct placement of electrodes inside the nodules is crucial for obtaining the therapeutic
success. The simultaneous activation of inserted needles seems more effective than alternate activation in
inducing larger and confluent coagulation areas. Therefore, theoretically MWA and LA might be favored as
compared to RFA in the treatment of large tumors. A strategy frequently used in clinical practice is the use
of combined treatments, mainly percutaneous ablation and TACE. The sequential use of such treatments
seems to achieve a better local tumor control, but randomized studies are awaited to define its applicability.

DECLARATIONS
Authors’ contributions
Concept and design of study, drafting the article, final approval of the version to be published: Di Costanzo
GG
Acquisition of data or analysis and interpretation of data; drafting the article, final approval of the version to
be published: Tortora R
Acquisition of data or analysis and interpretation of data; revising it critically for important intellectual
content; final approval of the version to be published: Opramolla A
Concept and design of study; revising it critically for important intellectual content; final approval of the
version to be published: Guarracino M

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
All authors declare that there are no conflicts of interest.

Ethical approval and consent to participate
Not applicable.
Consent for publication