Liver cancer is highly prevalent and harmful in China. Although surgical treatment (including liver transplantation and hepatectomy) can often achieve better results, only about 20% of patients are able or willing to undergo surgical treatment due to the heavy degree of cirrhosis, the central location of the tumor, and many concomitant diseases, as well as factors such as many complications and high costs of surgical treatment. To further improve the efficacy of non-surgical treatments, to allow more patients to obtain satisfactory treatment results through minimally invasive treatments, and to maintain liver function reserve and quality of life to the greatest extent, and to reduce medical costs, is undoubtedly one of the most important clinical development directions for liver cancer in the future. In the past decade, local treatment modalities represented by radiofrequency ablation (RFA) have developed considerably and achieved satisfactory efficacy, gradually becoming the mainstream treatment modality for liver cancer, especially early-stage liver cancer, and to a certain extent changing the mode of liver cancer treatment. However, compared with the survival efficacy and social benefits of RFA treatment, its recognition and acceptance by both doctors and patients in China still need to be further improved. In this paper, we would like to summarize the work of RFA for hepatocellular carcinoma in China in the past ten years, analyze the current situation and make a prospect for the future, aiming to further improve the scientific application of this work in China. In 1992, McGahan et al. performed a trial of percutaneous puncture of porcine liver with a monopolar radiofrequency needle under ultrasound guidance, and after 5 weeks, RFA was performed by ultrasound and autopsy. Rossi et al. were the first to report the successful use of RFA in the treatment of clinical hepatocellular carcinoma. Since then, RFA has gradually become one of the common local treatments for hepatocellular carcinoma. The domestic application of RFA in the treatment of hepatocellular carcinoma began in the late 1990s, and the ten-year development process can be roughly divided into three stages. The first stage was from 1999 to 2003, which was the exploration stage of “crossing the river by feeling the stones”. At the beginning of the work, physicians lacked sufficient understanding of the safety and efficacy of this technology, and tended to be cautious in selecting the indications, usually choosing late stage liver cancer that had lost the chance of surgery. Problems are identified in the process of exploration, and the understanding is enhanced in the process of problem solving. Through this stage of exploration, physicians have gained a more comprehensive understanding of important issues such as technical essentials, indications, and prevention and management of complications, laying the foundation for further and more extensive development. At this stage, the “one-world” treatment pattern of hepatocellular carcinoma surgery did not change significantly. The second stage was from 2003 to 2007, which showed the characteristics of “freedom of all kinds of frosts”. With the accumulation of experience in RFA for hepatocellular carcinoma in China, the safety and efficacy of RFA were further improved, and even for some cases of hepatocellular carcinoma that were previously considered unsuitable for percutaneous RFA, such as hepatoportal hepatocellular carcinoma, percutaneous RFA could be safely and effectively performed by one-lung ventilation. At the same time, physicians’ self-confidence began to build, the selection of indications tended to be rational and optimal, and physicians began to carefully compare RFA with other treatment modalities. The landmark changes in this stage are twofold: (1) The status of RFA in the comprehensive treatment of hepatocellular carcinoma has been significantly enhanced, and its potential as a mainstream treatment has been brought into play to a certain extent, and the pattern of “domination” by surgical treatment has been changed. ② The status of RFA in the family of local treatment has increased significantly. The results of several overseas randomized clinical trials have confirmed that RFA is the preferred local treatment for liver cancer over microwave ablation, subhelium cryoablation and anhydrous alcohol injection, taking into account safety and efficacy factors. This is also reflected in the changes in the relevant sections of the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines for Liver Cancer, V.1.2004 to V.1.2006, where the ranking of ablative procedures in V.1.2004 and V.1.2005 is anhydrous alcohol injection, cryotherapy and RFA. V.1.2004 and V.1.2005, the ranking of the ablative procedures was RFA, anhydrous alcohol injection and cryotherapy, whereas in V.1.2006 the ranking of the ablative procedures has changed to RFA, anhydrous alcohol injection and cryotherapy. The third phase, from 2007 to 2010, can be characterized as the development of RFA as “the desire to compete with the sky”. This phase is characterized by the increasing potential of RFA as a curative measure. For resectable hepatocellular carcinoma, RFA and surgical treatment are now in parallel. For unresectable hepatocellular carcinoma, especially those with tumors located in the peripheral region of the liver, physicians focus more on individualized RFA treatment plans. RFA is also useful for recurrent hepatocellular carcinoma. In addition, some large hepatocellular carcinomas that were previously considered contraindicated by RFA have achieved satisfactory long-term treatment results with RFA. The NCCN Clinical Practice Guidelines for Liver Cancer V.1.2010 shows that both surgical resection and ablative therapy can be chosen for tumors that are potentially resectable. 2. Analysis of current status The ten-year development process of treatment is the process of mutual reference, joint application and conceptual integration with traditional liver cancer treatment, and the process of continuous improvement of safety and efficacy. During this period, physicians have done a lot of innovative work in three segments and more than ten nodes: preoperative, intraoperative and postoperative, and have obtained systematic results and systemic advancement. The main milestones include: more rational and scientific selection of surgical indications; adoption of more precise guidance means such as CT guidance and adjunctive measures of tracheal intubation to control breathing, which further improved the efficiency and accuracy of RFA needle puncture and needle deployment; meanwhile, general anesthesia measures eliminated pain during patient treatment and greatly improved patient compliance and tolerance; and cooperation with laparoscopic techniques, open surgery, transarterial interventional embolization, anhydrous alcohol injection, and drug placement; optimization of postoperative follow-up pathways, especially in the determination of efficacy, the concept of pathological complete ablation was proposed; in further enhancing the efficacy, the application of repeated RFA strategies was emphasized; RFA was used as the main treatment tool to save spontaneous rupture bleeding from giant hepatocellular carcinoma; special The function of special equipment such as RFA needle and generator has also been significantly improved; etc. The above efforts have significantly improved the safety and efficacy of RFA in the treatment of hepatocellular carcinoma, and the potential of RFA as a curative tool is becoming more and more prominent, gradually becoming another curative treatment modality after liver transplantation and hepatectomy. The results of numerous studies have shown that RFA-based minimally invasive treatment options can achieve similar long-term outcomes as hepatectomy or even liver transplantation for early-stage liver cancer; have good efficacy for advanced liver cancer; can be used as a transitional treatment for liver cancer patients waiting for liver transplantation; can be used as a remedial measure for recurrent liver cancer; in addition, it also has good controlled efficacy for metastatic liver cancer with few lesions . Several articles published in recent months have more fully demonstrated the curative potential and multifaceted value of RFA in the treatment of hepatocellular carcinoma. The Japanese scholar Kagawa et al. studied 117 patients with early-stage hepatocellular carcinoma admitted between 2000 and 2005, of which 62 were included in the local treatment group, where the main treatment modality of patients was RFA + interventional embolization, and the other 55 were included in the hepatic resection group, where the main treatment modality of patients was hepatectomy. The median follow-up months for both groups were 50 and 49 months, respectively. The results showed that the age, liver function and cancer foci were basically the same in both groups; the survival rates at 1, 3 and 5 years were 100%, 94.8% and 64.6% in the local treatment group, respectively, while the survival rates at 1, 3 and 5 years were 92.5%, 82.7% and 76.9% in the hepatectomy group, respectively, with no statistical difference in the results compared with the two groups. The results suggest that the efficacy of RFA + interventional embolization is the same as that of hepatectomy. Kim et al. in Korea retrospectively studied the data of 121 patients with hepatocellular carcinoma who survived for more than 5 years. Among them, 61 cases underwent RFA while 60 cases underwent hepatectomy. Comparing the data of the two groups showed that there was no statistically significant difference in survival between the two groups, although the time of recurrence was earlier in the RFA-treated group than in the hepatectomy group and there were more recurrences than in the hepatectomy group. It is suggested that the long-term efficacy of RFA treatment is not significantly different from that of hepatectomy. Cheung et al. from Queen Mary Hospital in Hong Kong retrospectively studied the data of 19 patients with multifocal hepatocellular carcinoma treated with hepatectomy + RFA and compared them with 54 patients with multifocal hepatocellular carcinoma treated with hepatectomy only. The results showed that the age, liver function and cancer lesions were basically the same in both groups; in the combined treatment group, the number of patients with cancer lesions involving both liver lobes was significantly higher than that in the hepatectomy group (73.6% vs. 5.5%, P = 0.04), and the number of patients who underwent hemihepatectomy was significantly lower than that in the hepatectomy group ((32% vs. 65%, P = 0.012)). The number of patients who underwent hemihepatectomy was significantly lower than that of the hepatectomy group ((32% vs. 65%, P = 0.012). The results suggest that RFA combined with hepatectomy can significantly reduce surgical trauma, broaden the indications for hepatectomy for multifocal hepatocellular carcinoma, and achieve the same long-term outcome as extensive, high-risk hepatectomy. Schumacher et al. from the University of British Columbia, Canada, retrospectively analyzed the clinical data of 247 patients with hepatocellular carcinoma who were not suitable for liver transplantation admitted from 1996 to 2006. The treatment methods included six types of hepatectomy, RFA, anhydrous alcohol injection, transarterial interventional embolization, chemotherapy, and medical observation. The results showed that the mean survival time of the whole group was 77 months; grouped by the means of initial treatment, it was seen that the mean survival time of the hepatectomy group (93 months), RFA group (66.2 months) and anhydrous alcohol injection group (81 months) was significantly higher than that of the transarterial interventional embolization group (47 months), chemotherapy group (25 months) and observation treatment group (31 months). Grouped by remedial treatments for local tumor growth after initial treatment, it was seen that the mean survival time was 54 months in the liver resection group, 102 months in the RFA group, 65 months in the anhydrous alcohol injection group, 89 months in the transarterial interventional embolization group, and 47 months in the chemotherapy group. The results suggest that RFA treatment can provide similar efficacy to hepatectomy, both as an initial treatment and as a remedy for local tumor growth after initial treatment. 3. Looking into the future Looking into the future, it is foreseeable that the status and role of RFA in the comprehensive treatment of liver cancer will become more and more important. There are three main reasons for this: firstly, RFA has won the hearts of doctors and patients. Compared with other treatment methods, RFA has the advantages of less trauma, higher quality of life, less complications and easier cost control. At present, the national medical strategy has gradually tended to shift the medical focus forward, with more emphasis on early diagnosis and individualized treatment of liver cancer, so as to maximize the medical cost and resources saving. Thirdly, basic research on RFA has flourished, which has played a strong role in boosting the clinical application of RFA. A large number of basic and clinical experimental research results have confirmed that a single RFA can enhance the anti-tumor immune response but the duration of such response is short and it is difficult to achieve the expected anti-tumor immunotherapy effect. Based on the clinical data of satisfactory efficacy of repeated RFA in liver cancer treatment accumulated in the past decade and its suggestion of the existence of immune mechanism, combined with the modern theory of tumor-specific immune response, and inspired by the research results related to tumor vaccine, based on the research that single RFA can stimulate a transient tumor-specific immune response, repeated RFA within a certain period of time may become one of the effective ways to amplify or enhance the anti-tumor immunotherapy effect. The results of this study suggest that repeated RFA over a certain period of time may be one of the effective ways to amplify or enhance the effect of anti-tumor immunotherapy.