Gregor Laimer, Edward W Johnston, Christiaan G Overduin, Iwan Paolucci, Muneeb Ahmed, Ronald S Arellano, Marie Beermann, Lukas P Beyer, David J Breen, Mark C Burgmans, Marco Calandri, Ming-Chih Chern, Laura Crocetti, Ronald M van Dam, Alban Denys, Bjørn Edwin, Dimitrios Filippiadis, Yuman Fong, Nicos Fotiadis, Jacob Freedman, Åsmund A Fretland, Mariano Gimenez, Rodrigo G Garcia, Rosario F Grasso, Thomas K Helmberger, Pim Hendriks, Roberto Iezzi, Sjoerd FM Jenniskens, Alexander Kupferthaler, Anja Lachenmayer, Fred T Lee Jr, Jeong M Lee, Susan van der Lei, Christiaan van der Leij, Ping Liang, Charles C-W Lin, Lukas Luerken, Manuel Maglione, Andreas Mahnken, Justin P McWilliams, Marcos Menezes, Govindarajan Narayanan, Franco Orsi, Philippe L Pereira, Uei Pua, Robbert S Puijk, Hyunchul Rhim, William S Rilling, Simeon J S Ruiter, Anthony G Ryan, Peter Schullian, Paul B Shyn, Ajith K Siriwardena, Maarten L J Smits, Constantinos T Sofocleous, Luigi Solbiati, Vlasios Sotirchos, Stefan Stättner, Marco van Strijen, Trygve Syversveen, Pascale Tinguely, Lambros Tselikas, Jean-Nicolas Vauthey, Thomas J Vogl, Tze M Wah, Sarah B White, Philipp Wiggermann, Bradford J Wood, Jan van der Meulen, S Nahum Goldberg, Martijn R Meijerink, Bruno C Odisio, Reto Bale
Thermal ablation offers a safer, less invasive, and more cost-effective curative-intent treatment for selected patients with primary and metastatic liver tumours than surgery; when done with appropriate technique, ablation can deliver similar oncological outcomes. However, effectiveness in routine practice varies because structured training, planning, and procedural governance remain scarce. These international multidisciplinary, multi-society guidelines—formally endorsed by the European Society of Surgical Oncology, the Cardiovascular and Interventional Radiological Society of Europe, and the Society of Interventional Oncology—define key domains contributing to procedural difficulty and practice variation in liver tumour thermal ablation. A Delphi consensus initiative held in Innsbruck, Austria, engaged 72 experts across three iterative rounds of scoring across 135 statements grouped into five domains: credentialing, indications, approach, procedural factors, and safety measures. Consensus was achieved for 94 (70%) of 135 statements. The least invasive route—typically percutaneous—should be prioritised, and margin adequacy was reaffirmed as the principal technical goal. Procedural difficulty was considered context-dependent, shaped by tumour factors, institutional infrastructure, and operator experience. Organ displacement techniques were endorsed to maintain safety and expand treatable indications. Complex ablations should be done by experienced operators (more than 100 previous cases), with programmes underpinned by structured training, multidisciplinary team participation, and routine audit. Future efforts should develop and validate practical tools such as difficulty scoring systems, standardised procedural reporting templates, and comprehensive training curricula to improve consistency, standardisation, and clinical outcomes globally.