Proposal To compare the effectiveness of TACE + RFA with hepatectomy in patients with HCC within Milan criteria. Methods It is a retrospective matched case-control study from January 2006 to December 2010 in a tertiary cancer center. 74 patients with HCC within Milan criteria initially treated with TACE ? RFA were identified and compared with 148 matched controls selected from a pool of 782 patients who received hepatectomy. Patients were matched with respect to age, gender, tumor size and number, AFP and liver function test. Results The 1, 3, and 5 years overall survival (OS) was 94.6, 75.1 and 55.3%, respectively, in the combination group, and 91.2, 64.4, and 47.7%, respectively, in the hepatectomy group (P = 0.488). The 1, 3, and 5 years disease-free survival (DFS) in the combination group was 87.8, 48.3, and 33.5%, respectively, and 68.9, 49.2, and 40.9%, respectively, in the hepatectomy group (P = 0.619). In subgroups analyses according to the tumor size and number, no significant difference was identified in either OS or DFS for patients with single tumor smaller than 3.0 cm, 3.0-5.0 cm, and multiple tumors. Multivariate analysis showed that tumor size, ALT, and CLIP score were significant prognostic factors for OS, and ALT and Child-Pugh class were significant prognostic factors for DFS. Conclusion TACE + RFA is safe and as effective as hepatectomy for patients with HCC within Milan criteria.