Hepatocellular carcinoma: new options for image-guided ablation.

Image-guided percutaneous ablation is currently accepted as the best therapeutic choice for patients with early-stage hepatocellular carcinoma (HCC) when transplantation and resection are precluded. Several methods for chemical or thermal tumor destruction have been developed and tested clinically during the past two decades. The seminal technique used for local treatment of HCC has been percutaneous ethanol injection (PEI). Several studies have provided indirect evidence that PEI improves the natural history of nonsurgical patients with early-stage HCC. Its major limitation is the high rate of local recurrence. Radiofrequency (RF) ablation has been the most widely assessed alternative to PEI. Five randomized controlled trials have shown that RF ablation achieves more effective and reproducible tumor destruction than PEI, leading to a better local control of the disease. As a result, RF ablation has been established as the primary ablative modality. The value of newer thermal and non-thermal methods for local tumor treatment, such as microwave ablation, irreversible electroporation (IRE), and light activated drug therapy, should be investigated in the setting of randomized controlled trials.