Management of intermediate-stage hepatocellular carcinoma (BCLC-B) typically relies on transarterial chemoembolization (TACE), while systemic therapy is used for cases unsuitable for TACE. However, curative outcomes remain limited, prompting investigation into the role of surgical resection (SR), with or without adjunctive radiofrequency ablation (RFA). A retrospective review included 70 BCLC-B HCC patients treated with surgery as the first-line intervention between 2000 and 2022 (median age 67.5 years; 44 patients beyond up-to-7 criteria). Forty-five patients underwent SR alone, and 25 received SR combined with RFA. Outcomes assessed included recurrence-free survival (RFS) and overall survival (OS). Baseline liver function was slightly better in the SR-only group (median ALBI −2.74 vs. −2.52; p = 0.02). No statistically significant differences were observed between the groups for median RFS (17.7 vs. 13.1 months) or OS (66.6 vs. 72.0 months). Patients beyond up-to-7 criteria showed comparable outcomes. Five-year survival exceeded 50% in both groups (54% vs. 64%). Surgical resection, with or without complementary RFA, achieves meaningful long-term survival in selected BCLC-B HCC patients. These results support the consideration of SR as a viable curative option, even in patients with extensive tumor burden.
