BACKGROUND/AIMS The treatment of choice for HCC remains controversial. We evaluated the therapeutic impact of surgical resection, PEI, and RFA for HCC on outcomes. METHODS A database derived from a Japanese nationwide survey of 17,149 patients with HCC treated by resection, PEI, or RFA between 2000 and 2003 was used to identify 7185 patients with no more than 3 tumors (< or = 3 cm) and a liver function of Child-Pugh class A or B. The patients classified into either a resection (n=2857), RFA (n=3022), or PEI group (n=1306) and their long-term outcomes were compared. RESULTS The median follow-up period was 10.4 months. The 2-year time-to-recurrence rate was 35.5%, 55.4%, and 73.3% in the resection, RFA, and PEI groups, respectively, while the number of recurrences was 2410, 2368, and 862. Although the number of deaths was 55 (1.9%), 49 (1.6%), and 39 (3.0%), the overall survival rates were not different. In a multivariate analysis, surgical resection was a significant negative factor for recurrence as compared with RFA (relative risk, 0.62 [95% confidence interval, 0.54-0.71], P<0.0001) and PEI (0.45 [0.38-0.52], P<0.0001). CONCLUSIONS This preliminary report suggested that surgical resection may provide less time-to-recurrence rate than either RFA or PEI in patients with HCC.