Nowadays, careful screening protocols permit the diagnosis of HCC in an earlier and earlier phase of the disease, with the resulting possibility of efficient therapeutic management in more and more cases . The size of the lesion at diagnosis is an extremely important factor, since those of less than 3 cm treated with RFA present a local relapse rate of less than 10% , which means that the use of this procedure is becoming more and more frequent, especially in those patients where surgical management is not indicated.
Nowadays, liver surgery is considered to be the best approach to early-stage HCCs in patients with cirrhosis who are not candidates for liver transplant , and presents the lowest local relapse rate. Nevertheless, in such cases, depending on the site of the neoplasia, and where small tumours are concerned, RFA should be considered as a valid alternative to surgical resection , which should be reserved for use in cases of disease relapse in other segments, since this is part of the natural history of HCC and may occur after various periods of time in over 70% of cases.
One of the most complicated problems involved in the difficult management of HCCs is the presence of a multifocal neoplasia, which may not permit the use of one procedure only, but may require a multimodal approach, all at the same or at different periods, so that it may not be possible to consider the therapeutic value of each single procedure individually.
In this context also, resective treatment is still extremely important, possible associated with efficient loco-regional procedures, both at one and the same time (RFA) [2, 3] and with different timing (TACE).
With regard to surgical management, it should be borne in mind that the last few years have seen the development of more and more sophisticated techniques and the use of more and more efficient instruments, making it possible to perform several procedures presenting a lower mortality rate and fewer and fewer complications, and, moreover, without the need to use clampage of the hepatic peduncle; this means that such procedures can be used in patients with low grade portal hypertension, with an extremely limited blood loss and a much shorter operating time . A further apparent advantage deriving from the use of RFA is the possibility of "sterilising" the resected surface, thus producing an area of coagulative necrosis of about one cm and reducing the risk of local relapse. In most cases, RFA can be performed subcutaneously and may be effectively associated with surgical procedures, especially in smaller lesions (< 3 cm) whose site would otherwise involve the large-scale removal of hepatic parenchyma in patients where the disease will inevitably bring about liver failure .
Therapeutic management consisting of hepatic resection combined with simultaneous RFA, initially proposed for the treatment of patients with colorectal liver metastases , is, in our opinion, particularly indicated for patients with larger peripheral tumours, where a limited resection is possible, together with one or two tumoral nodules of less than 3 cm.
In conclusion, we maintain that this strategy directed at the management of multifocal HCC, may prove more useful for the reduction of surgical risk and post-operative progression of the liver cirrhosis than large-scale hepatectomy, since it presents no peri-operative mortality and a complication rate of less than 10% .