Strategies to improve treatment outcomes of percutaneous radiofrequency ablation for hepatocellular carcinoma: a review

Percutaneous radiofrequency ablation (PRFA) is an important locoregional treatment for early hepatocellular carcinoma (HCC), particularly when surgery or transplantation is not feasible. However, incomplete ablation and local tumor progression remain major concerns for lesions that are poorly conspicuous on ultrasonography or computed tomography; larger than 3 cm; irregular in shape; adjacent to large vessels; or located near the diaphragm, heart, gallbladder, or gastrointestinal tract. A wide range of technical strategies has been proposed to address these challenges, including advanced image guidance and fusion navigation, combination therapy, stereotactic planning, adjunctive separation techniques, vascular flow modulation, improved in electrode design, real-time or intraprocedural ablation-margin monitoring, and software-assisted early post-ablation assessment. In this narrative review, we focus specifically on HCC and critically appraise the current evidence for these strategies. We distinguish approaches already used in expert clinical practice from those that remain selective, preclinical, or investigational. Overall, the most clinically mature advances are those that improve lesion visualization, needle placement, margin control, and procedural safety. However, translational strategies intended to augment thermal efficacy require validation in HCC-specific clinical studies.