Time-lag performance of radiofrequency ablation after percutaneous ethanol injection for the treatment of hepatocellular carcinoma

We have previously reported that the combination therapy of percutaneous ethanol injection and radiofrequency ablation (PEI-RFA) was more effective than RFA alone to induce wider coagulated necrosis for the treatment of hepatocellular carcinoma (HCC). In the present study, the effect of time-lag performance of RFA after PEI was evaluated under the same ablation condition as PEI-RFA by analyzing the volume of coagulated necrosis, the energy requirement for ablation and the amount of ethanol injected into HCC. The comparative study between time-lag PEI-RFA and no time-lag PEI-RFA showed that the total energy requirement and the energy requirement per unit volume for whole and marginal coagulated necrosis were significantly smaller in the time-lag group than in the no time-lag PEI-RFA group. In time-lag PEI-RFA, the volume of coagulated necrosis induced positively correlated with the amount of ethanol injected into HCC as previously observed in PEI-RFA treatment. These results suggest that time-lag PEI-RFA can induce comparable coagulated necrosis with a smaller energy requirement than no time-lag PEI-RFA, and that time-lag PEI-RFA is likely to be less invasive than no time-lag PEI-RFA for inducing comparable coagulated necrosis. Thus, time-lag performance of RFA after PEI may make RFA treatment more effective and less invasive for the treatment of patients with HCC.     

Comparative study of the effects of percutaneous ethanol injection and radiofrequency ablation in cases treated with a straight or expandable electrode

Radiofrequency ablation (RFA) has become mainstream among non-surgical treatment modalities in clinical settings for the treatment of hepatocellular carcinoma. We have previously described the novel combination therapy of percutaneous ethanol injection and RFA (PEI-RFA) and reported that this combination therapy was more effective than RFA alone in terms of the induced volume of coagulated necrosis and the energy requirement for the treatment. RFA instruments are mainly divided into two types according to the electrode used, either the straight or expandable type electrode. Although PEI-RFA can be performed by either of the electrodes, there may be some important differences in PEI-RFA according to the type of electrode used. In the present study, the effect of using the straight or expandable electrode in PEI-RFA was evaluated by analyzing the ablation time, volume of coagulated necrosis, the energy requirement for ablation and the amount of injected ethanol into HCC. The comparative study showed that ablation time, total energy requirement and per unit volume of energy requirement for whole and marginal coagulated necrosis were significantly smaller in the group treated with the expandable electrode (E group) than those in the group treated with the straight electrode (S group). The volume of coagulated necrosis was similar between these groups. In group E, the amount of injected ethanol showed a positive correlation with the volume of coagulated necrosis and the size of the tumors. These results suggest that prior injection of ethanol works mainly by shortening the time and energy requirement for ablation in the time-lag PEI-RFA using the expandable electrode. Thus, prior injection of ethanol before RFA may make RFA treatment less invasive in the time-lag PEI-RFA using the expandable electrode as previously shown HCC cases treated with straight electrode.     

Thoracoscopic ethanol injection and radiofrequency ablation for the treatment of hepatocellular carcinoma located immediately under the diaphragm

We previously reported that the combination therapy of percutaneous ethanol injection and radiofrequency ablation (PEI-RFA) was more effective than RFA alone in inducing wider coagulated necrosis for the treatment of hepatocellular carcinoma (HCC). In the present study, we thoracoscopically applied the combination therapy to the treatment of HCC located immediately under the diaphragm. RFA electrode and ethanol injection needle were inserted into the tumor through the right side of the diaphragm in 6 patients with HCC close to the diaphragm. In all cases, the tumor was completely ablated with enough safety margin around the tumor. No local tumor recurrence has been observed in a relatively short-time follow-up period. The volume of coagulated necrosis and the energy requirement for coagulation in thoracoscopic ethanol injection and RFA (T-EI-RFA) were comparable to those of PEI-RFA. Although HCC located immediately under the diaphragm is difficult to treat with a percutaneous approach due to the poor visualization by ultrasonography, T-EI-RFA is considered to be an effective treatment modality.     

Efficacy of combination therapies of percutaneous or laparoscopic ethanol-lipiodol injection and radiofrequency ablation

Percutaneous radiofrequency ablation (RFA) is able to destroy hepatocellular carcinoma (HCC) in a few sessions without major complications. We have previously shown that not only the combined use of percutaneous ethanol injection and RFA (PEI-RFA) but also injection of mixture of ethanol and lipiodol (PELIT) was useful for the treatment of HCC. In the present study, we further developed the combined use of PELIT and RFA through percutaneous or laparoscopic approach (PELI-RFA or LELI-RFA) and evaluated its usefulness. Nineteen nodules in 18 cases were treated with PELI-RFA or LELI-RFA. In the cases treated with LELI-RFA, no bleeding and no spilling milky fluid containing tumor cells were observed from the surface of ablated tumors. In the cases sufficiently treated with PELI-RFA or LELI-RFA, the mixture of ethanol and lipiodol was accumulated in the entire region of the tumor and low-density area was observed around the lipiodol deposit by computed tomography (CT). These delineations of coagulated area were helpful to evaluate the precise area of safety margin around the tumor treated with PELI-RFA or LELI-RFA. Furthermore, the total volume of coagulated necrosis significantly and positively correlated with the product of energy requirement for ablation and the volume of ethanol injected by PELI-RFA or LELI-RFA. Among the cases treated with PELI-RFA or LELI-RFA, local recurrence emerged only in one case in whom enough safety margin could not be achieved by PELI-RFA. Therefore, it is critical to evaluate whether enough safety margin could be obtained with RFA therapy, and PELI-RFA and LELI-RFA are helpful in visualizing the safety margin area.     

Percutaneous ethanol and lipiodol injection therapy for hepatocellular carcinoma

Radiofrequency ablation (RFA) therapy is of great significance in the treatment of hepatocellular carcinoma (HCC) or metastatic liver tumors. RFA is able to achieve widely coagulated necrosis in a few sessions without major complications. However, HCC cases exist that are resistant to RFA therapy for several reasons. In the present study, we performed injection of the mixture of ethanol and lipiodol (percutaneous ethanol-lipiodol injection therapy: PELIT) for HCCs that lacked clear visuality of the entire shape of the tumor by ultrasonography (US) or computed tomography (CT), or that were difficult to treat with RFA alone due to their locations in the liver or due to severe liver dysfunction of the patients. Local recurrence rates of HCC treated with PELIT were shown to be low in patients followed up for at least 4 months. In all patients treated with PELIT, lipiodol was accumulated in the entire region of the tumor after several trials of PELIT and the accumulation was kept for many months. The biopsy examination from the tumor treated with PELIT showed that HCC cells were totally destroyed by the PELIT. Although RFA therapy serves as a central role for the treatment of HCCs, PELIT, considered to be milder therapy, is likely to be important as a supportive treatment for HCCs and useful for the treatment of HCCs that are difficult to treat with RFA.     

射频消融联合瘤内注射无水乙醇治疗肝肿瘤的实验研究

背景与目的:射频消融(radiofrequencyablation,RFA)被认为是目前肝癌治疗中最为有效和最具前景的局部治疗手段之一,广泛应用于原发性和继发性肝癌的治疗中,而消融范围有限、复发率高是其主要缺点,因此国内外的研究主要集中于如何提高RFA的范围、降低复发率。本研究目的是探讨RFA与瘤内无水乙醇注射(percutaneousethanolinjection,PEI)联合应用能否提高单针消融的范围,及其产生的消融灶的大小、形态特征,并分析其联合方式。方法:应用离体猪肝和兔VX2肝肿瘤模型分别进行PEI、RFA、RFA-PEI、PEI-RFA,比较各组消融灶的大小、体积、形态特征,消融参数和副作用。结果:离体实验PEI-RFA组的消融范围明显大于PEI、RFA、RFA-PEI组(分别为2.05cm×2.35cmvs.0.63cm×1.45cm,1.58cm×1.94cm,1.63cm×2.02cm;P<0.05);PEI-RFA组消融体积较大[(6.33±2.86)cm3vs.(0.33±0.18)cm3,(3.21±1.18)cm3,(3.67±1.58)cm3,P<0.05];类圆率更接近于1.0(0.87vs.2.36,0.82,0.80),PEI组与其他三组相比差异有显著性(P<0.05)。活体实验PEI-RFA组的消融范围明显大于PEI、RFA、RFA-PEI组(1.92cm×2.22cmvs.1.00cm×1.56cm,1.17cm×1.55cm,1.23cm×1.64cm,P<0.05);PEI-RFA组消融体积较大[(5.26±2.22)cm3vs.(0.93±0.61)cm3,(1.60±0.87)cm3,(1.90±1.15)cm3,P<0.05];类圆率更接近于1.0(0.87vs.1.61,0.75,0.75,P<0.05)。结论:RFA前先行PEI(PEI-RFA)可以明显提高RFA的单针消融范围和体积,而且产生的消融灶形态与临床上所常见的小肝癌形态更加符合。     

肝动脉栓塞化疗后射频消融联合酒精消融对原发性肝癌的疗效评价

目的　探讨肝动脉栓塞化疗(TACE)后,CT导向下射频消融(RFA)联合无水乙醇消融(PEI)对原发性肝癌(HCC)的治疗效果。方法　经病理、AFP或典型影像学诊断证实的HCC 1 5 0例,每例肝内的病灶数目<3个,病灶大小3.1～7.9cm ,平均直径5 .5cm。全部患者按就诊单双日分为对照组和联合组。对照组74例,TACE后2周行单纯RFA ;联合组76例,TACE后2周行射频消融,间隔2 0～30d后再行PEI。结果　对照组的完全坏死率为75 .8%,联合组为89.5 %,两组间差异有统计学意义(P <0 .0 5 )。结论　HCC患者经TACE后,行CT导向下RFA联合PEI的疗效明显优于单纯RFA。     

Successful laparoscopic radiofrequency ablation of hepatocellular carcinoma adhered to the mesentery after transcatheter arterial embolization

A 54-year-old male with hepatocellular carcinoma (HCC) underwent transcatheter arterial embolization (TAE) at a nearby hospital. He was then referred to our hospital for the purpose of additional treatment of HCC. Because TAE was not a complete therapy and HCC was growing and protruding from the left lobe of the liver, laparoscopic radio-frequency ablation (RFA) was chosen for the treatment of HCC. After inserting a laparoscope into the abdominal cavity, it was observed that HCC unexpectedly adhered to the mesentery as a result of TAE performed previously. After cutting off the adhered mesentery and removing it from the tumor, the combination therapy of percutaneous ethanol injection and RFA (PEI-RFA), developed at our department, was performed on the tumor. The tumor was successfully abrogated by PEI-RFA and the sufficient safety margin was confirmed by computed tomography after the treatment.     

Seeding following percutaneous diagnostic and therapeutic approaches for hepatocellular carcinoma. What is the risk and the outcome?: Seeding risk for percutaneous approach of HCC

BACKGROUND: Tumour biopsy is usually considered mandatory for patient management by oncologists. Currently percutaneous ablation is used therapeutically for cirrhotic patients with small hepatocellular carcinoma (HCC), not suitable for resection or waiting for liver transplantation. However malignant seeding is a recognized complication of both diagnostic and therapeutic procedures in patients with HCC. Although percutaneous therapy whether with or without biopsy of a suspected HCC nodule may minimize the risk of seeding, this has not been confirmed. AIM: To evaluate the risk of seeding, defined as new neoplastic disease occurring outside the liver capsule, either in the subcutaneous tissue or peritoneal cavity following needle biopsy and/or local ablation therapy (LAT). METHODS: A literature search resulted in 179 events in 99 articles between January 1983 and February 2007: 66 seedings followed liver biopsy, 26 percutaneous ethanol injection (PEI), 1 microwave, 22 radiofrequency ablation (RFA), and 64 after combined biopsy and percutaneous treatment (5 microwave; 33 PEI; 26 RFA). RESULTS: In 41 papers specifying the total number of patients biopsied and/or treated, the median risk of seeding was 2.29% (range 0-11%) for biopsy group; 1.4% (1.15-1.85%) for PEI when used with biopsy and 0.61% (0-5.56%) for RFA without biopsy, 0.95% (0-12.5%) for RFA with biopsy and 0.72% (0-10%) for liver nodules (including non-HCC nodules) biopsied and ablated. CONCLUSION: Risk of seeding with HCC is substantial and appears greater with using diagnostic biopsy alone compared to therapeutic percutaneous procedures. This risk is particularly relevant for patients being considered for liver transplantation.     

Outcome of regional and local ablative therapies for hepatocellular carcinoma: a collective review.

BACKGROUND: Transcatheter arterial (chemo) embolization (TACE), cryoablation (CA) and percutaneous ethanol injection (PEI) were the first regional and local ablative techniques that came into use for irresectable HCC. Radiofrequency ablation (RFA) and interstitial laser coagulation (ILC) followed and have now evolved rapidly. It would not be ethical to compare resection with ablation in patients well enough to undergo major surgery. Therefore, hepatic resection and hepatic transplantation remain the only curative treatment options for HCC. METHODS: On the basis of a Medline literature search and the authors' experiences, the principles, current status and prospects of TACE and local ablative techniques in HCC are reviewed. RESULTS: Complete tumour necrosis can be achieved in 60-100% of patients treated with PEI (70-100%), cryoablation (60-85%), RFA (80-90%) or ILC (70-97%). After TACE significant tumour response is achieved in 17-61.9% but complete tumour response is rare (0-4.8%) as viable tumour cells remain after TACE. Five-year survival rates are available for TACE (1-8%), PEI (0-70%) and cryoablation (40%). Only PEI and RFA were compared in one RCT. RFA was associated with fewer treatment sessions and a higher complete necrosis rate. Furthermore, all techniques are associated with low morbidity and mortality, but cryoablation seems to be associated with a higher morbidity rate. CONCLUSION: TACE has shown to be a valuable therapy with survival benefits in strictly selected patients with unresectable HCC. RFA and PEI are now considered as the local ablative techniques of choice for the treatment of, preferably small, HCC. When tumours are located close to bile ducts or large vessels, PEI remains a valuable therapy. Completeness of ablation can be more easily monitored during cryoablation and another advantage of cryoablation is the possibility of edge freezing. The results of ILC are comparable to RFA with only few side effects and high tumour response rates.     

Radiofrequency ablation combined with percutaneous ethanol injection in the treatment of hepatocellular carcinoma and portal vein neoplastic thrombosis

In the last ten years new techniques, such as percutaneous ethanol injection (PEI) and radiofrequency ablation (RFA), have been developed for the treatment of hepatocellular carcinoma (HCC). Portal vein involvement is a complication of HCC and the role of surgical resection for HCC with tumor thrombi in the portal veins is controversial. Here we present the case of a 58-year-old man, with Child's class A cirrhosis and a focal lesion of HCC with thrombosis of the segmental portal branch extending into the right portal vein. We treated the nodule with RFA and the portal tumor thrombosis with ethanol injection. Twenty-two months after the combined treatment, an enhanced spiral CT scan showed complete necrosis of the nodule and color/power Doppler ultrasound demonstrated the complete patency of the right portal vein.     

Transarterial Chemoembolization Monotherapy in Combination with Radiofrequency Ablation or Percutaneous Ethanol Injection for Hepatocellular Carcinoma

Purpose: To evaluate whether combined transarterial chemoembolization (TACE) with radiofrequency ablation (RFA) or percutaneous ethanol injection (PEI) for hepatocellular carcinoma (HCC) have superior efficacy to transarterial chemoembolization (TACE) alone a retrospective review was conducted. Methods: During January 2009 to March 2013, 108 patients with hepatocellular carcinoma underwent TACE or combined therapies (TACERFA or TACEPEI). The long-term survival rates were evaluated in those patients by various statistical analyses. Results: The cumulative survival rates in the combined TACERFA/PEI group were significantly superior to those in the TACE alone group. When the comparison among the groups was restricted to patients with two or three tumors fulfilling the Milan criteria, significantly greater prolongation of survival was observed in the combined TACE RFA/PEI group than in the RFA/PEI alone group. Conclusions: In terms of the effect on the survival period, combined TACE RFA/PEI therapy was more effective than TACE monotherapy, and also more effective than PEI or RFA monotherapy in cases with multiple tumors.     

Radiofrequency ablation and percutaneous ethanol injection in patients with small hepatocellular carcinoma: a comparative study

BACKGROUND: Radiofrequency ablation (RFA) is a novel thermal ablation technique to achieve coagulative necrosis of hepatocellular carcinoma. A study was conducted to compare the antitumor effect and adverse effect of RFA with those of percutaneous ethanol injection (PEI) in patients with solitary small hepatocellular carcinoma. METHODS: The study population consisted of 119 consecutive patients with solitary hepatocellular carcinoma smaller than 3 cm in diameter. Among these, 23 patients were treated with RFA and the remaining 96 patients were treated with PEI. The antitumor effects of both treatments were assessed by contrast-enhanced computed tomography 1 month after treatment. RESULTS: Complete tumor necrosis was achieved in 23 patients (100%) of the RFA group and 90 patients (94%) of the PEI group (p = 0.48) and local recurrence rates at 1 year were 15% in the RFA group and 14% in the PEI group (p = 0.80). RFA required an average of 1.5 sessions to achieve complete necrosis, whereas PEI required an average of 4.0 sessions. As a consequence, the hospital stay in the RFA group (median 10 days) was significantly shorter than that in the PEI group (median 17 days). There were no serious adverse effects or complications except for one case of cholangitis in the PEI group, although deterioration of serum transaminase after RFA was significantly more severe than that after PEI. CONCLUSION: RFA achieved complete tumor necrosis for small hepatocellular carcinoma with fewer treatment sessions compared with PEI. There were no serious complications.     

The validity of radiofrequency ablation for hepatocellular carcinoma

Radiofrequency ablation therapy (RFA) has now become the mainstream percutaneous local treatment for hepatocellular carcinoma (HCC). RFA is superior to both percutaneous ethanol injection (PEI) and percutaneous microwave coagulation therapy (PMCT) because of the large coagulation area obtained by a single session of RF ablation. In addition, the local recurrence rate after RFA is lower than that after PEI. Recently, to improve tumor ablation efficacy, several devices have been reported. We also designed RFA with balloon occlusion of the hepatic artery (balloon-occluded RFA, BoRFA). The coagulation area obtained by BoRFA was significantly larger than that obtained by standard RFA. In Japan, the results for RFA remain insufficient because of the short follow-up periods after treatments. Within a few years, we expect to clarify the indications for RFA treatment for HCC and the choice between RFA and other local treatments.     

Less invasive medical therapy for hepatocellular carcinoma

Since hepatocellular carcinoma (HCC) usually occurs in chronic liver disease, especially viral cirrhosis, it often recurs even after surgical resection. Because of the high recurrence rate of HCC, less invasive therapies have become more common recently, including percutaneous ethanol injection (PEI), percutaneous microwave coagulation therapy(PMCT), and radiofrequency ablation(RFA). A PEI needle or a coagulation electrode is usually inserted into an HCC nodule under ultrasonographic-guidance, and chemical or heat ablation is carried out with local or general anesthesia. A patient with a few numbers of small HCCs of 3 cm or less in diameter is a good candidate for these therapy modalities. Although RFA is the easiest and most effective of these therapies the best therapy for each patient is selected according to the number, size, and location of target lesions.     

Population-based matching comparison between radiofrequency ablation and percutaneous ethanol or acetic acid injection for hepatocellular carcinoma

BackgroundLoco-regional therapies are evolving for hepatocellular carcinoma (HCC) treatment. Radiofrequency ablation (RFA) has changed the landscape in treating HCC; however, percutaneous ethanol or acetic acid injection (PEI/PAI) remains a widely used and easily performed technique by experienced clinicians. Nevertheless, the effectiveness of RFA compared to that of PEI/PAI remains unclear.MethodsRecords of 73,136 patients with newly diagnosed HCC between 2007 and 2013 were drawn from the Taiwan Cancer Registry. The primary outcome measures were the overall survival and local recurrence-free survival. Propensity score matching (PSM) was performed to compare the effectiveness of RFA and PEI. Median follow-up time was 61.6 months (36–120 months).ResultsAfter PSM, 4496 patients diagnosed with stage I-III HCC, who were initially treated with RFA (3372 patients) or PEI/PAI (1124 patients), were assessed. Compared to PEI/PAI, patients treated with RFA had better 5- and 9-year overall survival, cancer-specific survival, disease-free survival, and local recurrence-free survival. Median overall survival and recurrence-free survival of patients treated with RFA vs PEI/PAI were 61.5 vs 41.9 months and 72.1 vs 45.2 months, respectively. Multivariate Cox model analysis revealed that, except for patients with high cell grade or advanced stage, RFA resulted in better overall survival (HR: 0.74, 95% CI 0.68–0.81, P < 0.001) and local recurrence-free survival (HR: 0.69, 95% CI 0.63–0.75, P < 0.001) than PEI/PAI.ConclusionsRFA provides advantages over conventional PEI/PAI for HCC. Considering technological advances in instruments, loco-regional therapies for HCC can be employed in carefully selected patients.     

A promising new treatment strategy for advanced hepatocellular carcinoma--"multi-ablation therapy" consisting of radio-frequency ablation (RFA), microwave coagulation therapy (MCT) and ethanol injection therapy (EIT)]

We introduce a new treatment strategy (multi-ablation therapy) for advanced hepatocellular carcinoma (HCC). The therapy consists of radio-frequency ablation (RFA), microwave coagulation therapy (MCT) and ethanol injection therapy (EIT). We assessed the efficacy of the therapy in 20 patients with advanced HCCs, including 10 patients with stage III and 10 patients with stage IV. The average tumor diameter was 3.6 cm (max: 6.6 cm) and the average tumor number was 3.6 (max: 11). RFA, MCT and EIT were performed in 20, 14 and 9 cases, respectively. A percutaneous, endoscopic and open approach was applied in 2, 11 and 7 cases, respectively. The average number of times treated on initial admission was 1.1. The response rate, calculated by the tumor necrosis effect, was 100%. The cumulative two-year recurrent rate in the treated sites was 33% and the 2-year cumulative survival rate was 90%. Complications were encountered in two patients (liver failure and pyothorax). Multi-ablation therapy provides an excellent prognosis for advanced HCC patients whose condition could not be controlled with conventional therapeutic modalities.     

Percutaneous ethanol injection under interventional radiographic computed tomography-fluoroscopic guidance for the treatment of small hepatocellular carcinomas

Background Some small hepatocellular carcinoma (HCC) lesions show as tumor stains by dynamic CT, but cannot be detected by ultrasonography. Percutaneous ethanol injection (PEI) is effective for treating small HCC lesions, but lack of adequate visualization of some lesions can limit its use. In this study, interventional radiographic, CT-fluoroscopically-guided PEI was performed as a new method for treating small HCC lesions that were diffucult to detect by ultrasonography. Methods Interventional radiographic, CT-fluoroscopically-guided PEI was performed on 11 patients (12 lesions) with HCC lesions measuring 2 cm or less in diameter. A thin needle was introduced into each tumor under CT-fluoroscopic guidance, with injection of contrast medium into the dominant hepatic artery. While lesions were observed using CT-fluoroscopy with the arteriogram, absolute ethanol was injected into the tumors. The ethanol injection rate and volume were monitored by observation of loss of tumor staining during real-time CT angiography. Results Needle introduction was successful in all 12 lesions, and disappearance of tumor staining was immediately observed on CT images after ethanol injection. Complications noted after treatment were local abdominal pain in all 11 patients, a slight fever in 9 patients, pneumothorax, right pleural effusion, and ascites, each in 1 patient. No other serious complications were observed. Conclusions Interventional radiographic, CT-fluoroscopically-guided PEI is effective in the treatment of small HCC lesions, which are difficult to show by ultrasonography and treat by conventional PEI.     

Radiofrequency ablation for hepatocellular carcinoma

Abstract

Hepatocellular carcinoma (HCC) is one of the most common causes of cancer-related mortality worldwide. Unfortunately, only 20% of HCC patients are amenable to curative therapy (liver transplantation or surgical resection). Locoregional therapies such as radiofrequency ablation (RFA), percutaneous ethanol injection, microwave coagulation therapy, and transcatheter arterial chemoembolisation play a key role in the management of HCC. The choice of the treatment modality depends on the size of the tumour, tumour location, anatomic considerations and the number of tumours present and liver function. RFA therapy for HCC can be performed safely using a percutaneous, laparoscopic, or an open approach, even in patients with poor functional reserve. Since the introduction of RFA, several randomised controlled trials and non-randomised studies comparing RFA and other therapies for HCC have been conducted. In addition, in the last decade there have been technical advances in RFA therapy for HCC, resulting in significant improvement in the prognosis of HCC patients treated with this modality. In this review, we primarily focus on percutaneous RFA therapy for HCC and refer to current knowledge and future perspectives for this therapy. We also discuss new emerging ablation techniques.     

Locally ablative therapies for primary and metastatic liver cancer

Locally ablative therapies have an increasing role in the effective multidisciplinary approach towards the treatment of both primary and metastatic liver tumors. In patients who are not considered surgical candidates and have low volume disease, these therapies have now become established into consensus practice guidelines. A large range of therapeutic options exist including percutaneous ethanol injection (PEI), radiofrequency ablation (RFA), microwave ablation (MWA), cryoablation, percutaneous laser ablation (PLA), irreversible electroporation (IRE), stereotactic body radiation therapy (SBRT) and high intensity focused ultrasound (HIFU); each having benefits and drawbacks. The greatest body of evidence supporting clinical utility in the liver currently exists for RFA, with PEI having fallen out of favor. MWA, IRE, SBRT and HIFU are relatively nascent technologies, and outcomes data supporting their use is promising. Future directions of ablative therapies include tandem approaches to improve efficacy in the treatment of liver tumors.