Comparison of the efficacy of laparoscopic hepatectomy and radiofrequency ablation for small hepatocellular carcinoma: A retrospective study

Abstract

BACKGROUND

Optimal treatment strategies for small hepatocellular carcinoma (HCC) remain under investigation. Laparoscopic hepatectomy (LH) and radiofrequency ablation (RFA) are key curative modalities.

AIM

To compare the long-term survival and perioperative outcomes of LH and RFA for small HCC.

METHODS

In this retrospective study, 254 patients with small HCC who were admitted to the First Affiliated Hospital of Chongqing Medical University between December 2022 and March 2025 were analyzed. Patients were divided into LH (n = 109) and RFA (n = 145) groups based on their treatment modality. Primary endpoints were 36-month overall survival (OS) and disease-free survival (DFS). Secondary endpoints included recurrence rate, perioperative outcomes, and complications. Assessments were conducted at baseline, immediately post-treatment, and at regular follow-up intervals up to 36 months.

RESULTS

Baseline demographic and clinical characteristics, except mean tumor size (LH: 3.05 ± 1.12 cm vs RFA: 2.48 ± 0.93 cm, P < 0.001) and platelet count (higher in LH, P = 0.008), were comparable between groups. LH was associated with longer operative time, greater blood loss, prolonged recovery, higher costs, and increased complication rates (62.39% vs 15.87% for RFA, P < 0.001). However, at 36 months, OS (85.32% vs 66.21%, P < 0.001) and DFS (64.22% vs 44.83%, P = 0.002) were significantly higher in the LH group. Multivariate Cox regression identified surgical approach (LH), lower tumor size, and lower platelet count as independent predictors for improved DFS; only LH independently improved OS (hazard ratio = 0.55; 95% confidence interval: 0.38-0.79; P < 0.001).

CONCLUSION

LH, though associated with increased perioperative morbidity, provides superior long-term survival outcomes compared with RFA in patients with small HCC. Surgical approach should be considered when selecting optimal therapy for this patient population.

Key Words: Hepatocellular carcinoma; Laparoscopic hepatectomy; Radiofrequency ablation; Survival outcomes; Disease-free survival; Postoperative complications

Core Tip: This study demonstrates that for patients with small hepatocellular carcinoma, laparoscopic hepatectomy (LH) offers significantly better long-term survival compared to radiofrequency ablation, despite a higher risk of short-term complications. LH was associated with higher 3-year overall and disease-free survival rates. The findings suggest that LH should be the preferred curative option for suitable patients with adequate liver function, while radiofrequency ablation remains a valuable less invasive alternative for higher-risk cases.

INTRODUCTION

Hepatocellular carcinoma (HCC) ranks as the sixth most common malignancy, is the third leading cause of cancer-related mortality globally, and accounts for over 800000 deaths each year[1]. Despite advances in diagnostic and therapeutic approaches, the prognosis for HCC remains poor, primarily due to late diagnosis, underlying cirrhosis, and high propensity for intrahepatic and extrahepatic recurrence[2]. Early detection programs have increased the proportion of patients diagnosed at a stage amenable to potentially curative local therapies[3]. Among these, patients presenting with small HCC, commonly defined as tumor(s) measuring < 3 cm in diameter or multiple (≤ 3) nodules, each ≤ 3 cm, represent a subset wherein curative-intent interventions may yield optimal outcomes[4].

With liver transplantation restricted by donor scarcity and eligibility constraints, two principal modalities are widely utilized for patients with small HCC and preserved liver function: Surgical resection and local ablation[5]. In particular, minimally invasive surgical techniques such as laparoscopic hepatectomy (LH) have garnered increasing favor over open resection and offers the benefits of reduced operative trauma, improved perioperative recovery, and equivalent oncological efficacy in carefully selected patients[6]. Simultaneously, image-guided loco-regional therapies, chief among them radiofrequency ablation (RFA), have been broadly adopted as standard care for small and early HCC due to their reduced invasiveness, repeatability, and favorable safety profile[6].

Despite the widespread use of LH and RFA, the optimal approach for the treatment of small HCC remains a subject of ongoing debate[7]. Several randomized controlled trials, retrospective cohort studies, and meta-analyses have compared the oncological outcomes and perioperative parameters of these modalities, yet the results have not been wholly consistent[8]. Many studies suggest that surgical resection may offer superior long-term oncologic control and lower local recurrence rates, particularly in patients with solitary tumors, favorable anatomy, and preserved hepatic reserve[8]. By contrast, RFA is lauded for its lower complication rates, shorter hospital stays, and comparable early survival outcomes, especially in patients with high risk for surgery, impaired liver function, or tumors in anatomically challenging locations[9]. Nevertheless, incomplete ablation and the inability of RFA to address microscopic vascular invasion or satellite nodules could result in higher recurrence rates than LH, even for small tumors[10].

Decision-making in clinical practice is further complicated by the significant heterogeneity among published studies concerning patient selection criteria, tumor morphology, procedural expertise, and perioperative care protocols[10]. Thus, a clear consensus on the relative benefits and optimal indications for LH vs RFA in small HCC is lacking, and robust, institution-specific investigations remain necessary to tailor treatment recommendations to real-world populations.

Given this context, the present retrospective cohort study was designed to compare the efficacy and safety of LH and RFA systematically in a well-characterized population of patients with small HCC. The aims of this study are to assess long-term outcomes, including disease-free survival (DFS) and overall survival (OS), as well as perioperative morbidity, hospital stay, and local recurrence. By elucidating factors that favor one modality over the other, this investigation seeks to inform individualized clinical decision-making, optimize the therapeutic algorithm for small HCC, and ultimately improve patient survival and quality of life.

MATERIALS AND METHODS

Case collection and grouping

This study retrospectively analyzed the clinical data of 254 patients with small HCC who were admitted to the First Affiliated Hospital of Chongqing Medical University from December 2022 to March 2025. Patients were divided into two groups based on their treatment modality: 145 cases underwent RFA (RFA group) and 109 cases underwent LH (LH group). The protocol of this retrospective study was reviewed and approved by the Institutional Review Board of the First Affiliated Hospital of Chongqing Medical University. Given the retrospective design of the study and the use of anonymized data, informed consent was not required.

Patients who met the following criteria were included: (1) First diagnosed with HCC and completed all treatments in our hospital; (2) Had a maximum tumor diameter of less than 3 cm and no more than three intrahepatic tumors, or a single intrahepatic lesion with a diameter of less than 5 cm; (3) Child-Pugh class A or B; (4) Barcelona Clinic Liver Cancer (BCLC) level 0 or A; (5) No intrahepatic and distant metastases; (6) No invasion of the portal vein, the hepatic vein trunk, or secondary branches; and (7) Indocyanine green retention rates of less than 30% at 15 minutes.

Patients who met the following criteria were excluded: (1) Postoperative permanent pathology results indicating benign focal nodular hyperplasia, inflammatory nodules, metastatic liver cancer, or other types of primary liver cancer; (2) Initial treatment outcomes that were suboptimal with unclear tumor boundaries, proximity to blood vessels, or poor differentiation, and subsequent receipt of additional antitumor therapies such as trans arterial chemoembolization, percutaneous ethanol injection, or chemotherapy immediately after surgery or RFA; (3) Discharged themselves from the hospital and those who met the inclusion criteria but did not complete their treatment due to socioeconomic reasons; (4) Had refractory ascites; (5) Had intrahepatic metastatic tumors; (6) Had concomitant jaundice; and (7) Had a history of upper abdominal surgery.

Surgical methods

RFA group: Patients underwent comprehensive preoperative evaluation, including assessment of liver function (Child-Pugh score), cardiopulmonary fitness, and coagulation profile. Patients fasted for 8 hours prior to the procedure. Ablation was performed percutaneously under conscious sedation and local anesthesia. The patient’s position (supine, lateral decubitus) was optimized based on the tumor location under ultrasound guidance. Either Talon or Cool-tip radiofrequency needles and their associated cooling systems were used. The contrast agent for ultrasound was SonoVue. Preoperative routine ultrasound contrast was performed to confirm the size, location, blood supply, surrounding organs, and major blood vessels of the lesion. The puncture point and needle insertion path were selected, and under ultrasound guidance, the radiofrequency needle was inserted into the tumor. Depending on the size of the tumor and its surroundings, a power of 60-80 W was typically used for 10-20 minutes, while changes in tumor echogenicity were observed. For tumors adjacent to critical organs or major blood vessels, anhydrous alcohol was injected near these structures before performing the ablation. The overall treatment aimed to cover the tumor completely and extend at least 0.5 cm beyond the tumor margin to ensure complete eradication of the lesion. Immediately after ablation, liver ultrasound contrast was performed to observe the extent of tumor ablation and the boundaries with surrounding critical areas. If any residual or suspected residual tumor was observed, additional ablation was administered. Upon withdrawal of the needle post ablation, the needle tract was simultaneously ablated to prevent bleeding or tumor seeding along the needle tract.

LH group: Patients were administered general anesthesia. Pneumoperitoneum was established to a pressure of 12-14 mmHg via an observation port below the umbilicus, and a laparoscope was inserted. Patients were positioned in a 30° reverse Trendelenburg position. Additional 3-4 trocars and related surgical instruments were then placed in the upper abdomen. Depending on the specific situation, a hepatic pedicle occlusion band might be placed (Pringle maneuver, applied intermittently: 15-minute occlusion, 5-minute release). After marking the planned resection line, an ultrasonic scalpel was used to cut into the liver parenchyma gradually. If a regular hepatectomy was feasible, it was performed according to standard procedures. For cases where regular resection was difficult, the liver parenchyma more than 2 cm away from the tumor edge was carefully dissected. In special locations such as the caudate lobe or close to major blood vessels, where achieving a 2 cm margin was challenging, the resection margin was determined based on tumor size and location. The portal triad was then dissected and ligated using absorbable clips or Hem-o-lok clips before being divided. Bipolar coagulation or electrocautery was used to control bleeding at the resection surface. Dry gauze was used to inspect the liver resection surface carefully, and if necessary, Johnson and Johnson absorbable hemostatic fibers were applied. After confirming no significant active bleeding or bile leakage, an abdominal drain was placed, and the surgery was completed.

Study design

The main objectives of the study were to evaluate the 36-month DFS rate and OS rate. Secondary goals included assessing the total recurrence rate. DFS was calculated from the date of the procedure until the first detection of a recurrent tumor, whereas OS was measured from the date of the procedure to the time of death. Additional factors included duration of operation, volume of blood loss, necessity for blood transfusions, recovery after surgery, length of hospital stay, associated costs, and incidence of postoperative complications.

Follow-up

Following any procedure, the patient’s liver function was reassessed prior to discharge. A multidetector abdominal contrast computed tomography (CT) scan was conducted four weeks post-treatment and recommended every six months for the next three years. For patients at risk of radiation damage, abdominal B-ultrasound was a suitable alternative for CT scans. Dynamic contrast magnetic resonance imaging was used when intrahepatic recurrence could not be confirmed. If symptoms suggested possible extrahepatic metastasis (such as coughing, blood-tinged sputum, or bone pain), chest CT and bone emission CT scans were conducted. During follow-up visits, routine blood tests, liver function assessments, and serum α-fetoprotein (AFP) levels were checked. Post-three-year follow-ups were scheduled every 6-12 months based on patient preference. Contact with patients was maintained through phone calls every 3-6 months to ensure they received regular medical reviews and assistance with scheduling clinic appointments. This ongoing communication helped track their liver health and manage their condition effectively. Complete surgical excision was confirmed by pathology reports showing clear resection margins. Effective RFA was indicated by the absence of peripheral enhancement in the first post-treatment contrast-enhanced CT scan. Patients diagnosed with recurrence were readmitted for subsequent treatment.

Statistical analysis

For the statistical analysis, SPSS software version 29.0 (IBM Corp., NY, United States) was used. Continuous variables were reported as mean ± SD and analyzed through independent samples t-tests. Categorical variables were expressed as n (%), and comparisons were made using χ² tests. DFS and OS curves were generated using the Kaplan-Meier method. Univariate and multivariate Cox proportional hazards regression models were utilized to identify factors associated with DFS and OS. Variables that showed significance (P < 0.05) in univariate analysis were entered into the multivariate model to determine their independent effects on survival outcomes. Hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated. A two-sided P value < 0.05 was considered statistically significant.

RESULTS

Patient characteristics

The demographic and baseline clinical characteristics of the LH group (n = 109) and the RFA group (n = 145) are summarized in Table 1. No statistically significant differences regarding age, sex distribution, body mass index (BMI), prevalence of type II diabetes, family history of cancer, alcohol consumption, cigarette smoking, Child-Pugh classification, BCLC stage, hepatitis B surface antigen positivity, hepatitis C antibody positivity, liver cirrhosis, portal hypertension, or tumor number were observed between the LH and RFA groups (all P > 0.05). The mean age of patients was 60.62 ± 12.37 years in the LH group and 62.45 ± 11.32 years in the RFA group. The majority of patients in both groups were male (84.40% in LH and 86.21% in RFA) and had Child-Pugh class A liver function (95.41% in LH and 93.10% in RFA). The incidence of cirrhosis was comparable between groups (66.97% vs 68.97%). However, the mean tumor size was significantly larger in the LH group than in the RFA group (3.05 ± 1.12 cm vs 2.48 ± 0.93 cm, respectively; t = 4.319, P < 0.001). Other clinicopathologic features did not differ significantly between the two groups.

Table 1 Comparison of demographic characteristics between the two groups, n (%).

Variable	LH group (n = 109)	RFA group (n = 145)	t/χ2	P value
Age (years)	60.62 ± 12.37	62.45 ± 11.32	1.229	0.220
Male gender	92 (84.40)	125 (86.21)	0.163	0.687
BMI (kg/m2)	23.19 ± 3.06	22.68 ± 3.74	1.189	0.236
Type-II diabetes	17 (15.60)	25 (17.24)	0.122	0.727
Lineal descent cancer history	27 (24.77)	38 (26.21)	0.067	0.795
Alcohol use	44 (40.37)	56 (38.62)	0.079	0.778
Cigarette smoking	43 (39.45)	54 (37.24)	0.129	0.720
Child-Pugh classification ratio [A/(A + B) × 100%]	104 (95.41)	135 (93.10)	0.597	0.440
BCLC level [0/(0 + A) × 100%)]	24 (22.02)	36 (24.83)	0.272	0.602
HBsAg (+)	89 (81.65)	114 (78.62)	0.356	0.551
Hepatitis C antibody (+)	5 (4.59)	5 (3.45)	0.019	0.892
Liver cirrhosis	73 (66.97)	100 (68.97)	0.114	0.736
Portal hypertension	5 (4.59)	13 (8.97)	1.812	0.178
Tumor number			0.422	0.516
One	101 (92.66)	131 (90.34)
Two	8 (7.34)	14 (9.66)
Mean tumor size (cm)	3.05 ± 1.12	2.48 ± 0.93	4.319	< 0.001

BMI: Body mass index; BCLC: Barcelona Clinic Liver Cancer; HBsAg: Hepatitis B surface antigen; LH: Laparoscopic hepatectomy; RFA: Radiofrequency ablation.

The preoperative laboratory test results of patients who underwent LH and those treated with RFA were compared in detail (Figure 1). The tests included alanine aminotransferase, aspartate aminotransferase (AST), AFP, albumin levels, platelet count, prothrombin time delay, and total bilirubin. Error bars represent SD, and P values indicate statistical significance. No significant differences were observed for alanine aminotransferase, AST, total bilirubin, albumin, prothrombin time delay, or AFP levels between the two groups (all P > 0.05). However, the LH group exhibited a significantly higher platelet count than the RFA group (P = 0.008). These findings suggest that baseline liver function and tumor markers, except platelet counts, were comparable between the two cohorts.

Figure 1 Comparison of preoperative laboratory test results between the two groups. ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; AFP: Α-fetoprotein; LH: Laparoscopic hepatectomy; RFA: Radiofrequency ablation.

Surgical information

The intraoperative and postoperative outcomes of the LH and RFA groups were analyzed (Table 2). Compared with the RFA group, the LH group had significantly longer operating time (120.52 ± 33.19 minutes vs 43.68 ± 8.48 minutes), greater intraoperative blood loss (240.05 ± 95.19 mL vs 14.95 ± 4.67 mL), and higher need for blood transfusion (23.85% vs 3.45%), and all P < 0.001. Postoperative recovery was also less favorable in the LH group, with significantly higher pain scores on postoperative day 1 (3.14 ± 0.93 vs 0.95 ± 0.32), delayed ambulation (2.32 ± 0.94 days vs 0.76 ± 0.27 days), and postponed first oral intake (2.42 ± 0.60 days vs 1.12 ± 0.14 days), and all P < 0.001. Additionally, the LH group exhibited higher AST levels on postoperative day 2 (155.03 ± 57.40 IU/L vs 78.35 ± 37.74 IU/L, P < 0.001), longer postoperative hospital stays (10.42 ± 4.51 days vs 6.30 ± 2.90 days, P < 0.001), and higher hospitalization costs (30563.72 ± 3447.61 Chinese Yuan vs 22872.80 ± 2059.51 Chinese Yuan, P < 0.001). All differences between the two groups were statistically significant.

Table 2 Comparison of intraoperative and postoperative data between the two groups.

Variable	LH group (n = 109)	RFA group (n = 145)	t/χ2	P value
Operating time (minutes)	120.52 ± 33.19	43.68 ± 8.48	23.598	< 0.001
Blood loss (mL)	240.05 ± 95.19	14.95 ± 4.67	24.665	< 0.001
Pain score on postoperative day 1 (points)	3.14 ± 0.93	0.95 ± 0.32	23.372	< 0.001
Time to ambulation after surgery (days)	2.32 ± 0.94	0.76 ± 0.27	16.808	< 0.001
Time to first oral intake after surgery (days)	2.42 ± 0.60	1.12 ± 0.14	22.103	< 0.001
AST on postoperative day 2 (IU/L)	155.03 ± 57.40	78.35 ± 37.74	12.117	< 0.001
Need for blood transfusion	26 (23.85)	5 (3.45)	24.179	< 0.001
Hospital stay (days)	10.42 ± 4.51	6.30 ± 2.90	8.327	< 0.001
Hospital costs (Chinese Yuan)	30563.72 ± 3447.61	22872.80 ± 2059.51	20.681	< 0.001

AST: Aspartate aminotransferase; LH: Laparoscopic hepatectomy; RFA: Radiofrequency ablation.

Complications

The bar chart illustrates the incidence rates of postoperative complications following LH and RFA (Figure 2). The overall complication rate was significantly higher in the LH group (62.39%) than in the RFA group (15.87%, χ² = 58.579, P < 0.001). Specific complications such as biliary fistula (13.76% vs 2.76%, P < 0.001), pleural effusion and postoperative bleeding (both at 8.26% vs 2.07%, P = 0.021), intra-abdominal infection (13.76% vs 4.14%, P = 0.006), and liver dysfunction (18.35% vs 4.83%, P < 0.001) were all significantly more common in the LH group. These data highlight the increased risk profile associated with the surgical approach vs the minimally invasive technique.

Figure 2 Comparison of postoperative complications between the two groups. LH: Laparoscopic hepatectomy; RFA: Radiofrequency ablation.

Survival outcome analysis

The survival outcomes for LH and RFA treatments for small HCC were compared (Table 2 and Figure 3). The OS and DFS rates at 36 months revealed that the LH group demonstrated significantly better OS (85.32% vs 66.21%, χ² = 11.939, P < 0.001) and DFS (64.22% vs 44.83%, χ² = 9.398, P = 0.002) than the RFA group. These findings indicate superior long-term survival outcomes for patients undergoing LH compared with RFA.

Figure 3 Comparison of survival outcomes between the two groups. LH: Laparoscopic hepatectomy; RFA: Radiofrequency ablation.

Cox regression analysis of the impact on DFS

Cox regression analysis identified mean tumor size, platelet count, and surgical approach as significant factors influencing DFS (Table 3). In univariate analysis, mean tumor size (≥ 2.84 cm vs < 2.84 cm: HR = 0.50; 95%CI: 0.31-0.81; P = 0.005), platelet count (≤ 125.42 vs > 125.42 × 10⁹/L: HR = 0.67; 95%CI: 0.47-0.95; P = 0.022), and surgical approach (LH vs RFA: HR = 0.55; 95%CI: 0.38-0.79; P = 0.001) were significant factors influencing DFS. In multivariate analysis, a mean tumor size ≥ 2.84 cm was associated with a significantly lower risk of recurrence compared with < 2.84 cm (HR = 0.60; 95%CI: 0.37-0.97; P = 0.037). Patients with a platelet count ≤ 125.42 × 10⁹/L also demonstrated a reduced risk of recurrence compared with those with higher counts (HR = 0.70; 95%CI: 0.49-0.99; P = 0.045). Notably, the LH approach was independently associated with a lower risk of recurrence compared with RFA (HR = 0.50; 95%CI: 0.34-0.73; P < 0.001). No other factors (including age, gender, BMI, cirrhosis status, Child-Pugh grade, BCLC stage, and AFP level) showed a significant effect on DFS after adjustment for confounders.

Table 3 Cox regression analysis of the impact variables on disease-free survival.

Variable	Univariate		Multivariate
	HR (95%CI)	P value	HR (95%CI)	P value
Mean tumor size (≥ 2.84 vs < 2.84)	0.500 (0.310-0.810)	0.005	0.600 (0.370-0.970)	0.037
Platelet count (≤ 125.42 vs > 125.42)	0.667 (0.470-0.947)	0.022	0.700 (0.490-0.990)	0.045
Surgical approach (LH vs RFA)	0.550 (0.380-0.790)	0.001	0.500 (0.340-0.730)	< 0.001

HR: Hazard ratio; CI: Confidence interval; LH: Laparoscopic hepatectomy; RFA: Radiofrequency ablation.

Cox regression analysis of the impact on OS

In univariate Cox regression analysis, mean tumor size (≥ 2.84 cm vs < 2.84 cm: HR = 0.55; 95%CI: 0.35-0.86; P = 0.008), platelet count (≤ 125.42 vs > 125.42 × 10⁹/L: HR = 0.70; 95%CI: 0.50-0.98; P = 0.038), and surgical approach (LH vs RFA: HR = 0.60; 95%CI: 0.42-0.86; P = 0.004) were significant factors influencing OS (Table 4). Multivariate Cox regression analysis demonstrated that the surgical approach was independently associated with OS, and LH conferred a significantly lower risk of death than RFA (HR = 0.55; 95%CI: 0.38-0.79; P < 0.001). Although mean tumor size ≥ 2.84 cm and platelet count ≤ 125.42 × 10⁹/L were associated with improved OS in univariate analysis, these associations did not reach statistical significance in the multivariate model (P = 0.085 and P = 0.120, respectively). No other factors (including age, gender, BMI, cirrhosis status, Child-Pugh grade, BCLC stage, and AFP level) showed a significant effect on OS after adjustment for confounders.

Table 4 Cox regression analysis of the impact variables on overall survival.

Variable	Univariate		Multivariate
	HR (95%CI)	P value	HR (95%CI)	P value
Mean tumor size (≥ 2.84 vs < 2.84)	0.550 (0.350-0.860)	0.008	0.650 (0.400-1.060)	0.085
Platelet count (≤ 125.42 vs > 125.42)	0.700 (0.500-0.980)	0.038	0.750 (0.520-1.080)	0.120
Surgical approach (LH vs RFA)	0.600 (0.420-0.860)	0.004	0.550 (0.380-0.790)	< 0.001

HR: Hazard ratio; CI: Confidence interval; LH: Laparoscopic hepatectomy; RFA: Radiofrequency ablation.

DISCUSSION

The present retrospective study provides further insight into the comparative efficacy and safety of LH and RFA for small HCC. Rather than simply summarizing the observed outcomes, this work discusses the mechanisms, clinical rationale, and broader oncological context that likely underlie these findings. One of the most striking observations in the field, consistently substantiated by the current study and mounting external evidence, is the superior long-term DFS and OS associated with LH compared with RFA for patients with small HCC[11]. This effect is most plausibly rooted in fundamental differences in the way each modality eliminates malignant tissue and addresses potential locoregional recurrence. LH, as a surgical approach, enables the complete excision of the tumor and a margin of surrounding liver tissue and removes any adjacent microscopic disease or satellite nodules that may harbor occult cancer cells[12]. This comprehensive resection stands in contrast to RFA, which relies on the localized application of thermal energy to induce coagulative necrosis within the tumor mass[13]. However, the ablation margin achievable by RFA is often limited by heat sink effects from adjacent blood vessels, safety concerns related to proximity to vital structures, and technical difficulty in achieving uniform destruction throughout irregularly shaped or poorly demarcated lesions[14]. Even under optimal conditions, RFA may not reliably eliminate microscopic disease in the peritumoral area and may be predisposed to higher local recurrence rates over time[15].

Differences in the biology and microenvironment of HCC further magnify the inherent limitations of RFA[16]. HCC is well known for its high propensity for microvascular invasion and the development of satellite nodules adjacent to the main lesion[16]. LH can remove these foci by virtue of resecting a margin of nontumorous tissue alongside the index tumor; RFA is fundamentally incapable of targeting disease beyond the ablation zone, particularly if microscopic extensions breach the periphery of the intended treatment field[16]. Thus, while ablation may be sufficient for small, well-demarcated tumors that lack microinvasion, the inability to address multifocal or infiltrative disease may lead to earlier recurrence in a non-negligible proportion of patients[17].

Factors such as tumor size further tip the balance in favor of surgery because the efficacy of RFA diminishes substantially as the lesion approaches a diameter of 3 cm or greater. Larger tumors pose a higher risk of incomplete ablation due to thermal gradients and variability in tissue conduction properties in addition to possible microvascular invasion that extends beyond imaging resolution. By contrast, LH, when feasible, is not constrained in margin width by heat sink effects, so it is oncologically advantageous for tumors exceeding the ideal size for ablation.

Platelet count, an independent prognostic factor emerging from this and other studies, may be seen as a proxy for tumor biology and underlying hepatic substrate[18,19]. Elevated platelet counts, particularly in the context of preserved liver function, have been associated with an increased risk of early HCC recurrence, plausibly due to their role in facilitating tumor cell survival within the circulation[20]. Platelets can cloak circulating tumor cells and shield them from immune surveillance and aiding metastatic seeding[21]. This effect may be particularly relevant following incomplete local treatments such as RFA, where residual or shed tumor cells may more readily enter the systemic circulation[21]. Notably, the integration of circulating tumor cell quantification with platelet measurements further enhances recurrence risk stratification and reinforces the importance of considering hematological parameters in surveillance strategies[22]. Conversely, low platelet counts are often associated with advanced fibrosis and cirrhosis, featuring portal hypertension–a scenario that not only increases perioperative risk but may also limit eligibility for extensive resection[23]. In these cases, although LH may theoretically offer better oncological control, patient selection becomes critical; RFA may be the only safe option for individuals with decompensated hepatic reserve[24].

Addressing the higher perioperative complication rates observed with LH compared with RFA is also important[25]. This disparity is fundamentally attributed to the invasiveness of surgery, which, despite advances in laparoscopic techniques, still entails significant dissection, control of hepatic inflow and outflow, and manipulation of the fragile cirrhotic liver bed[26]. The risks of bleeding, biliary fistula, infection, liver dysfunction, and other complications are inherently higher with hepatectomy due to its physiological effect and the complexity of reconstructive steps required post-resection[27]. By contrast, percutaneous RFA is minimally invasive, generally performed under local or brief general anesthesia, with much lower associated blood loss and avoidance of extensive parenchymal trauma[28]. These advantages make RFA particularly appealing for patients at greater risk from surgery, including the elderly and those with poor hepatic function[29]. However, the reduced morbidity of RFA comes at a cost: Increased susceptibility to incomplete tumor eradication and recurrence. The shorter hospital stays and faster recoveries must be balanced against this risk, especially in patients likely to benefit from durable tumor clearance, based on tumor characteristics and hepatic function status.

Synthesizing these mechanistic considerations, the current study’s findings reinforce the growing consensus in the literature that LH should be considered the first-line curative modality for small HCC in patients with adequate hepatic reserve. RFA, while offering clear benefits of minimal invasiveness and rapid convalescence, may optimally serve as an alternative for those with significant comorbidities, high surgical risk, or poor liver function. The interplay between tumor size, biology, and patient background is paramount in individualized treatment selection.

Despite the strengths of our study, several limitations should be acknowledged: As a retrospective study, potential for selection bias and confounding factors that were not controlled for is inherent. Future prospective randomized trials would provide more robust evidence. The decision to undergo either LH or RFA was made based on clinical judgment and patient-specific factors, which could introduce bias. Although the sample size was substantial, it may still be insufficient to detect subtle differences in outcomes between the two modalities, especially for subgroups with specific tumor characteristics or comorbidities. LH and RFA techniques have evolved over time, and variations in operator experience and institutional protocols could influence outcomes. This study primarily focused on DFS and OS but did not comprehensively evaluate quality of life, which is an important aspect of treatment decision-making.

Ongoing advances in ablative technologies (such as microwave ablation) and surgical techniques (including robotic and anatomic resections) may further refine the risk-benefit ratio of each approach. Improving preprocedural risk stratification by integrating radiomic, hematological, and molecular markers will likely play an increasing role in guiding personalized therapy. Moreover, recurrence after either treatment underscores the need for vigilant post-treatment surveillance and potentially, adjuvant or salvage strategies that address the residual risk of intrahepatic or extrahepatic spread.

CONCLUSION

The latent mechanisms driving superior long-term outcomes for LH relative to RFA in small HCC fundamentally derive from the greater completeness of tumor and peritumoral tissue removal, along with the technical and oncological limitations of localized thermal ablation. Individualization of management, balancing oncological efficacy, procedural risk, and patient-specific factors, remains the cornerstone of optimal care in this challenging, evolving field.