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The recurrence of hepatocellular carcinoma (HCC) after percutaneous ablation is poorly evaluated.Thirty-six cases of recurrence after percutaneous ablation (PA) (Group 1) are compared to those after surgery, treated with re-resection (26 patients, Group 2) and PA (31 patients, Group 3).Recurrence was usually local after PA and distant after resection. Compared to Groups 2 and 3, local recurrences after PA were larger (4.2 vs. 2.3 cm) and more often invasive (43% vs. 10%). No different clinical/pathological aspects were noted in distant recurrences among the groups. After treatment the survival rate (1, 2, 3 and 5 years) was no different between the groups; in an intention-to-treat analysis of survival for local recurrences, survival was significantly lower in Group 1 (78%, 78%, 67% and 28%) than in Groups 2 and 3 (100%, 88%, 75% and 45%) (P<0.05).PA and surgery can be sequentially employed for HCC. The type of primary treatment does not influence the features of distant liver recurrence, while local recurrence after PA often requires more extensive liver resection.