Microwave Ablation Versus Radiofrequency Ablation for Hepatocellular Carcinoma: A Systematic Review and Meta-Analysis

Microwave ablation (MWA) and radiofrequency ablation (RFA) are established curative-intent treatments for early-stage hepatocellular carcinoma (HCC), but their relative benefits remain uncertain. We systematically synthesized comparative evidence on the effectiveness and safety of MWA versus RFA in adults with HCC. PubMed/Medical Literature Analysis and Retrieval System Online (MEDLINE), Web of Science, Scopus, SciELO, and Latin American and Caribbean Health Sciences Literature (LILACS) were searched through March 2026. Study eligibility, extraction of treatment-specific data, and methodological quality assessment were independently evaluated by two reviewers. Quantitative synthesis used random-effects models, with risk ratios (RRs) for dichotomous endpoints and hazard ratios (HRs) for time-to-event endpoints. Confidence in the evidence for each outcome was judged according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. Thirty-eight studies, including seven randomized controlled trials, contributed 8,347 participants. Initial complete ablation was similar with MWA and RFA (28 studies; 6,036 participants; RR 1.01, 95% confidence interval (CI) 1.00-1.02; I²=0%). MWA was associated with less local tumor progression (27 studies; 5,166 participants; RR 0.67, 95% CI 0.54-0.83; I²=54%), with a consistent association in randomized trials (RR 0.55, 95% CI 0.40-0.76; I²=0%). No conclusive between-technique differences were found for intrahepatic distant recurrence, overall survival, recurrence-free survival, major or minor complications, or periprocedural mortality. No statistically conclusive difference in initial complete ablation was demonstrated between MWA and RFA. MWA may provide better local control, although current evidence does not show a corresponding survival benefit. Treatment choice should incorporate tumor location, the expected ablation margin, procedural safety, operator experience, technology availability, and cost.