Aims: Transarterial chemoembolization (TACE) is the gold-standard treatment in intermediate hepatocellular carcinoma (HCC), but long-term disease control remains low. Herein, we compared results of TACE followed by hypofractionated radiotherapy (TACE-hRT) to surgical resection (SR) in early single or paucinodular intra-hepatic HCC. Methods: Between June 2004 and November 2016, data on 160 consecutive patients with Barcelona Clinic Liver Cancer (BCLC) stage A Child-Pugh A HCC treated with SR or TACE-hRT in our expert center were retrospectively reviewed. Time-to-progression (TTP), progression-free survival (PFS) and overall survival (OS) were evaluated. Clinical outcomes were compared using stabilized weights inverse probability of treatment weighting propensity score. Results: Ninety-eight patients underwent SR and 62 were treated by TACE-hRT. Median total dose of RT was 54 Gy (IQR 54-54), 3 Gy fractions. Median OS follow-up was 93 months. TTP did not significantly differ with 1-year rates of 68.2% and 82.6% (p=0.17) between patients following SR and TACE-hRT, respectively. In contrast, PFS and OS were lower in TACE-hRT group (p=0.015 and p=0.006) with a median OS time being 37 vs 63 months for patients having surgery vs TACE-hRT, respectively. In multivariate analysis, a significant negative impact on PFS and OS was seen for age at diagnosis, on TTP for alcohol-related liver disease, and on OS for total number of HCC nodules. Symptomatic grade ≥3 adverse events were presented by 42 (42.9%) SR and 19 (30.6%) TACE-hRT patients (p=0.17). Conclusion: In patients presenting Child-Pugh A BCLC-A HCC who are merely fit for surgery, TACE-hRT can be an effective and safe treatment. However, surgical management remains the standard of care whenever possible.