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To evaluate the efficacy of both surgical resection and stereotactic body radiotherapy for small hepatocellular carcinoma.Although the number of stereotactic body radiotherapies being performed for hepatocellular carcinoma has gradually increased, data comparing surgical resection and stereotactic body radiotherapy are limited.Between 2008 and 2015, a total of 281 patients with 1 to 3 small hepatocellular carcinoma tumors (≤3 cm in diameter), treated initially with curative intent (surgical resection, 254; stereotactic body radiotherapy, 27), were retrospectively analyzed. Overall survival and disease-free survival were compared in a propensity score matching analysis.Patients in the surgical resection group tended to be younger, had more tumors, and had better hepatic function than those in the stereotactic body radiotherapy group (P < .05). The percent recurrence of the same sub-segment in the stereotactic body radiotherapy group was significantly higher than that in the surgical resection group (P=.0034). Propensity score analysis revealed that 54 patients with surgical resection and 27 with stereotactic body radiotherapy had the same baseline characteristics. The 5-year overall survival and disease-free survival rates for the surgical resection and stereotactic body radiotherapy groups were 75.2% vs 47.8% (P=.0149) and 33.8% vs 16.4% (P=.0512), respectively. Multivariate analysis showed that surgical resection was a significant favorable factor for overall survival and disease-free survival of patients with one to three small hepatocellular carcinomas.Surgical resection provided better long-term overall survival and disease-free survival in patients with small hepatocellular carcinoma tumors. However, stereotactic body radiotherapy may be an effective alternative treatment for inoperable patients with early hepatocellular carcinoma.