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While complete ablation rates are similar when performing the percutaneous approach versus the surgical approach for medium-sized HCC (3.1-5 cm), 1- and 3-year survival rates are significantly higher in patients managed via the surgical approach [62]. 26. RFA is superior to ethanol injection in the treatment of small HCCs in terms of treatment response, recurrence, and OS [5]. (Level 1) 27. Percutaneous ethanol injection still has a role in small HCC 28. Microwave ablation is a safe and effective Bortezomib modality for treatment of HCC. It is an alternative option to RFA. (Level 4) 29. Microwave ablation may be more effective than RFA for tumors adjacent to big vessels owing to less heat-sink effect; more clinical studies are needed to confirm this benefit. (Level 4) In some Asian centers, microwave ablation is utilized as an alternative to RFA, with several studies reporting similar survival outcomes [64,65,66,67]. The heat-sink effect is defined as tissue cooling by adjacent visible vessels Selumetinib that causes deflection of the ablation zone away from the vessel [68]; this protective effect of blood flow in the liver may help explain the high rate of local recurrence seen in some clinical series of RFA Dabigatran [69]. In animal models, pathological examination of lesions that had been subjected to microwave ablation showed significantly less blood vessel-mediated cooling than lesions post-RFA [69,70], suggesting that microwave ablation may lead to fewer tumor recurrences in the long term. However, prospective studies comparing microwave ablation to RFA are needed to show its clinical benefit for tumors close to major vessels. 30. High-intensity focused ultrasound (HIFU) ablation is safe and effective in the treatment of small HCCs. It can achieve survival outcomes comparable to those of RFA and thus serves as a good alternative treatment for patients with cirrhosis. (Level 4) 31. HIFU ablation is generally well tolerated in HCC patients with Child-Pugh A/B cirrhosis. It may have some advantage in selected patients, such as those with ascites or with tumors close to major bile ducts. (Level 4) 32. HIFU may be used as an alternative bridging therapy for HCC patients awaiting liver transplantation. (Level 4) HIFU is now in use at one Hong Kong center [71], where similar survival outcomes compared with RFA for patients with HCC