Maestri M, Cicerone O. Small tumors, big decisions: Rethinking resection and ablation in early hepatocellular carcinoma. World J Gastroenterol 2026; 32(29): 116653 [DOI: 10.3748/wjg.116653]
Corresponding Author of This Article
Marcello Maestri, MD, PhD, Professor, General Surgery Unit I - Liver Service, Fondazione IRCCS Policlinico San Matteo, P.le Golgi 19, Pavia 27100, Italy. m.maestri@smatteo.pv.it
Research Domain of This Article
Oncology
Article-Type of This Article
editorial
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA
Share the Article
Maestri M, Cicerone O. Small tumors, big decisions: Rethinking resection and ablation in early hepatocellular carcinoma. World J Gastroenterol 2026; 32(29): 116653 [DOI: 10.3748/wjg.116653]
World J Gastroenterol. Aug 7, 2026; 32(29): 116653 Published online Aug 7, 2026. doi: 10.3748/wjg.116653
Small tumors, big decisions: Rethinking resection and ablation in early hepatocellular carcinoma
Marcello Maestri, Ottavia Cicerone
Marcello Maestri, Ottavia Cicerone, General Surgery Unit I - Liver Service, Fondazione IRCCS Policlinico San Matteo, Pavia 27100, Italy
Ottavia Cicerone, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia 27100, Italy
Author contributions: Maestri M contributed to project administration; Maestri M and Cicerone O contributed to the concept and design of the study, writing of the original draft, and review and editing of the manuscript. Both of authors approved the final version to publish.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Corresponding author: Marcello Maestri, MD, PhD, Professor, General Surgery Unit I - Liver Service, Fondazione IRCCS Policlinico San Matteo, P.le Golgi 19, Pavia 27100, Italy. m.maestri@smatteo.pv.it
Received: November 17, 2025 Revised: December 30, 2025 Accepted: January 29, 2026 Published online: August 7, 2026 Processing time: 242 Days and 17.1 Hours
Abstract
The management of small hepatocellular carcinoma (HCC) remains a matter of active debate. The recent study by Lei et al provides valuable evidence comparing laparoscopic hepatectomy (LH) and radiofrequency ablation (RFA) in patients with tumors ≤ 5 cm. In this retrospective analysis of 254 cases, LH achieved superior three-year overall and disease-free survival compared with RFA (85% vs 66% and 64% vs 45%, respectively), despite longer operative times and higher postoperative morbidity. These findings reinforce the oncologic advantage of anatomical resection in removing microscopic disease beyond radiologically visible margins. The biological rationale is compelling: While RFA induces local necrosis within a constrained ablation zone, LH allows complete excision of the tumor and surrounding parenchyma, thereby addressing microvascular invasion and satellite nodules that frequently accompany early HCC. Nonetheless, RFA retains an essential role for patients with limited hepatic reserve or comorbidities precluding surgery, offering a safe and repeatable alternative with minimal physiological impact. The results of Lei et al also prompt reappraisal of the Barcelona Clinic Liver Cancer framework, which may inadequately reflect advances in laparoscopic and ablative technologies. Modern treatment selection should move beyond stage-based algorithms toward individualized decision-making integrating liver function, tumor biology, and patient frailty. In appropriately selected candidates, LH should remain the reference curative option, while RFA continues to provide meaningful benefit in high-risk or inoperable patients. Together, they represent complementary strategies within the evolving continuum of curative therapies for small HCC.
Core Tip: Early hepatocellular carcinoma is typically managed with resection or local ablation, yet growing evidence shows that resection provides superior long-term oncologic outcomes whenever feasible. Modern ablative technologies, no-touch radiofrequency ablation, microwave ablation, and fusion-imaging guidance, have improved local control but do not surpass the curative potential of anatomical resection. The limitations of the Barcelona Clinic Liver Cancer staging system highlight the need for individualized decision-making. The therapeutic hierarchy, ranking treatments by intrinsic curative power, offers a dynamic, patient-centered framework better aligned with contemporary practice. Selecting the highest feasible therapy for each patient ensures the best outcomes in early-stage hepatocellular carcinoma.
