A s the incidence of hepatocellular carcinoma (HCC) rises in western countries, including the United States, its natural history is also changing, as a result of more-widespread surveillance, improved imaging technology, and novel treatments. 1,2 Currently, small HCC lesions are being diagnosed with greater frequency, but the management of these patients remains challenging. Several options are available, from liver transplantation (LT) to radiofrequency ablation (RFA) or surgical resection, with overlapping short-term results.There is reasonable agreement that patients presenting with an HCC 2 cm and a history of decompensated cirrhosis, or a Model for End-Stage Liver Disease (MELD) score higher than 15, should be listed for transplant and the tumor should be ablated before liver function decreases further. Ablation remains the treatment of choice, if transplant cannot be offered.On the other hand, the treatment of patients with a single lesion 2 cm in diameter, compensated cirrhosis, and very good functional status (very early HCCs or stage 0, according to the Barcelona Clinic Liver Cancer [BCLC] classification) may create a therapeutic dilemma.According to the BCLC algorithm, which has been endorsed by the American and European liver study associations (the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver, respectively), 3 resection of the lesion is recommended for patients without portal hypertension (PH) and with healthy bilirubin. Furthermore, several retrospective reports showed that shortterm results of surgical resection and RFA for BCLC stage 0 HCC are similar, 4,5 suggesting that BCLC stage 0 patients may be equally considered for hepatic resection or RFA.Therapy with RFA, a procedure that is most effective when applied to singe-nodule HCC less than 3 cm in diameter, has increasingly gained acceptance as a first-line modality for very early HCC. Livraghi et al. 6 reported on the outcomes of patients with a single HCC lesion 2 cm and well-compensated disease and noted a 68.5% survival rate at 5 years, with a high HCC recurrence rate at 5 years (80%).The largest retrospective experience on the outcomes of surgical resection in very early HCC was reported on by Ikai et al. (2,320 patients), who showed a 3-and 5-year survival of 84% and 66%, respectively. 7 Lee el al. 8 reported a 3-year survival of 82.5% for tumors 2 cm and 67.7% for tumors between 2 and 3 cm. Overall survival for very early HCC was markedly affected, if microvascular invasion was found on histology (54.8% at 3 years).This issue of HEPATOLOGY publishes the result of a combined effort from two large referral centers, based in New York and Milan, 9 reporting on the outcomes and prognostic factors of surgical resection in patients with HCC <2 cm in diameter. In this large western series, survival at 5 years was 70% and was influenced by the presence of satellites and by platelet count, with the best results obtained in patients with more than 150,000 platelets (83% survival at 5 ye...