To assess the effectiveness and the safety of radio-frequency thermal ablation (RFTA) in patients with hepatocellular carcinoma (HCC) ≤5 cm in compensated cirrhosis. A cohort of 202 consecutive patients (165 Child-Pugh class A and 37 class B) was prospectively assessed. A single lesion was observed in 160/202 (79.2%), two lesions in 29/202 (14.3%), and three lesions in 13/202 (6.4%) of patients. Sixty-seven patients died. Survival rates were 80% at 12 months, 67% at 24 months and 57% at 30 months (Child-Pugh A 59% and Child-Pugh B 48%). By Cox regression analysis, survival was independently predicted by serum albumin levels ≥35 g/L, platelet count ≥100.000/mmc, tumor size ≤3 cm, complete response at 1 month and Barcelona Clinic Liver Cancer (BCLC) staging classification. Overall recurrence rates were 22, 38, and 44% at 12, 24, and 30 months, respectively. One procedure-related death occurred. The proportion of major complications after treatment was 3.9%. A complete response after RFTA significantly increases survival. The longest survival is obtained in the presence of HCC ≤3 cm and of higher baseline albumin levels and platelet counts. BCLC staging classification is able to discriminate patients with good or poor prognosis.