Early diagnosis of hepatocellular carcinoma (HCC) is important in terms of treatment modalities and success. Surgical options must be considered first, and if the surgical option is precluded, image guided tumor ablation is recommeded in properly selected patients.

The Barcelona Clinic Liver Cancer (BCLC) classification system commonly used for clinical management of patients with HCC. This classification system is also important base for image guided tumor ablation (figure1).

According to BCLC system, percutaneous tumor ablation is recommeded for early stage HCC with no extrahepatic spread and without vascular invasion.

HCC nodules less than 2 cm, not subcapsular or perivascular are the ideal nodules for image guided RF ablation. In patients with early HCC, the rate of complete response is about 97% with a 68% of 5 year survival rate.

Early stage HCC: Includes patients with preserved liver function (Child pugh A or B), with solitary HCC or up to three nodules less than 3 cm in size.

An important factor affecting the success of RF ablation is to ablate all viable tumor cells and to create tumor free margin. The best results are achieved if the tumor size is less than 3 cm. if the tumor size is between 3-5 cm, the success rate of RF ablation is decreased. Therefore, combination treatment methods are recently emerged to get beter results if the HCC nodule is larger than 3 cm and smaller than 5 cm.

The RF ablation offers beter survival than ethanol injection if the nodule larger than 2 cm.

Microwave (MW) ablation is another alternative to RF ablation. MW ablation cause higher intratumoral temperatures, larger tumor ablation volumes, faster ablation times. However, no statistically significant differences were observed comparing with RF ablation.

A new nonchemical and nonthermal image guided ablation technique is irreversible electroporation (IRE). IRE cause irreversible distruption of cell membrane integrity by changing the transmembrane potential. One advantage of this technique complete ablation of the margin of the vessels. It can be applied to the nodules that is centrally located.