Percutaneous treatments of hepatocellular carcinoma: Improving efficacy, applicability and extending ablation criteria

The main curative treatments of early hepatocellular carcinoma (HCC) are liver resection, liver transplantation and percutaneous ablation. Monopolar radiofrequency ablation (RFA) was the most widely used percutaneous treatment but has limitations in terms of applicability and efficacy. These limitations could be responsible for downgrading the treatment of early HCC not amenable to usual monopolar RFA, transplantation or resection and to a shift to palliative treatment. However, improvement in ablation techniques during the last 10 years including the development of microwave ablation, multibipolar RFA, irreversible electroporation but also new technical tricks for ablation allowed to optimize the efficacy and promote the wide application of percutaneous treatments in patients with early HCC. It helped also to explore the ability of percutaneous ablation to treat HCC outside current guidelines in order to ablate more lesions of larger sizes. In this review, we aim to describe how the improvement of ablation methods helps to maximize the number of patients treated for early HCC and to discuss if we could extend the usual ablation criteria in order to allocate more patients in a curative setting.