Recent progress in diagnostics has facilitated early identification of HCC. Despite this advancement, some patients continue to be diagnosed at a late stage. Ruptured HCC often represents a more advanced tumor stage, as reflected by the tumor size, tumor number, vascular invasion, and tumor marker values. Furthermore, a comparison between ruptured HCC and non-ruptured HCC revealed that spontaneous tumor rupture was more frequent among patients with a poor liver functional reserve, as reflected by Child–Pugh grade and liver damage classification [
2]. Diagnosing ruptured HCC can be difficult, although the development of imaging studies have improved the rate of preoperative diagnosis. An abdominal-pelvic CT scan is currently the most important radiological investigation to perform as the patient becomes hemodynamically stable [
1]. The second step is the control of bleeding: whatever technique is chosen, the main goal is to obtain effective hemostasis and stabilize cardiorespiratory reserve. The tumor treatment is secondary: there is actually no evidence to recommend an invasive approach, such as emergency liver resections. Many scholars tend to choose emergency liver resection because it may effectively restore complete hemostasis and at the same time resect the primary lesions. However, even if the bleeding is stopped temporarily, death due to liver function failure and/or other comorbidity of the patient are important reasons to consider for patient outcomes [
15]. Most patients lack the functional reserve to tolerate surgery and the disease is often surgically unresectable at the time of rupture. Hepatic reserve should be evaluated once hemostasis is achieved, and only when selected patients are in a stable phase should tumor treatment, such as elective hepatectomy or TAE, be performed [
16]. TAE in stable patients with ruptured HCC and active bleeding is currently the treatment of choice, even if the optimal standards and therapeutic values of treatment have not reached a unified consensus. Its advantage lies in its simplicity, minimal invasiveness, fast hemostasis, and rapid postoperative recovery. TAE followed by elective hepatectomy is also considered an effective strategy for patients with ruptured HCC [
4]. In selected patients, prolonged survival is also possible using TAE as initial therapy with or without a delayed resection and systemic therapy [
17]. However, TAE is not always feasible without major procedural complication. A recent study evaluated the outcome of emergent embolization of ruptured HCC; patients with a Child–Pugh score of B/C, those with a MELD of 10 or more, and patients with portal vein thrombosis prior to embolization had a higher risk of death [
18]. If embolization is unavailable and patients are hemodynamically unstable, then emergency surgery may be necessary. The goals are rapid and effective control of bleeding. The preferred technique of hemostasis is packing, after temporary clamping of the hepatic pedicle. The techniques of suture, intratumoral injection of alcohol [
19], and ligation of the proper hepatic artery [
5] should no longer be performed because of reports of low efficacy and high morbidity. Patients with a poor liver function reserve cannot tolerate surgical resection or aggressive angiographic intervention. Therefore, Child–Pugh and MELD, which reflect reserved hepatic function, could be important pretreatment factors. In some cases, conservative treatments are selected, but recent studies showed that this may not be the best approach. A study from Taiwan [
20] concluded that a conservative approach was associated with a significantly worse survival rate compared with hepatectomy alone or in combination with TAE. Jin
et al. [
21] suggested that the post-treatment outcomes of surgery or TAE are better than those of supportive care in these patients, and that surgical hemostasis might provide better survival benefit than TAE. In this setting, tumor RFA is a possible therapeutic policy that has exhibited significant progress in the last decade. In recent years, the efficacy of this method for achieving hepatic hemostasis has become greatly appreciated in the treatment of liver trauma and in cases of ruptured liver tumors [
1]. RFA is a minimally invasive treatment and can be performed laparoscopically or during open surgery in patients who are in poor general condition or who have liver dysfunction. RFA uses pulsed radiofrequency current to quickly heat and ablate large volumes of tissue. At temperatures above 60 °C, cellular proteins rapidly denature and coagulate. The ability of radiofrequency to coagulate tissues, arresting the microcirculating blood, is in fact responsible for its hemostatic effect [
22]. Manikam
et al. reported two cases of ruptured HCC in which RFA successfully achieved hemostasis [
23]. Sun
et al. performed RFA as both salvage therapy and curative treatment for spontaneous rupture of HCC [
24]. Cheung
et al. reported that the use of RFA for hemostasis during laparotomy greatly reduced the hospital mortality rate when compared with conventional hepatic artery ligation [
14].