Ablative techniques for hepatocellular carcinoma.

The optimal management of hepatocellular carcinoma (HCC) is resection, but this is feasible in only a minority of patients for a variety of reasons, including metastatic disease, major vascular invasion, end-stage liver disease, and poor hepatic reserve. Inoperable patients may be candidates for ablative procedures that may eradicate tumor while minimizing the loss of functioning hepatic tissue that is inevitable with surgical resection. Percutaneous ethanol injection (PEI), hepatic arterial chemoembolization, cryoablation, radiofrequency ablation (RFA), and microwave coagulation offer the potential of local tumor control and sometimes achieve long-term disease-free survival. This review will discuss the indications, anticipated benefits, and limitations of current ablative techniques and place these procedures in proper perspective as options for patients with HCC.     

肝动脉栓塞化疗后射频消融联合酒精消融对原发性肝癌的疗效评价

目的　探讨肝动脉栓塞化疗(TACE)后,CT导向下射频消融(RFA)联合无水乙醇消融(PEI)对原发性肝癌(HCC)的治疗效果。方法　经病理、AFP或典型影像学诊断证实的HCC 1 5 0例,每例肝内的病灶数目<3个,病灶大小3.1～7.9cm ,平均直径5 .5cm。全部患者按就诊单双日分为对照组和联合组。对照组74例,TACE后2周行单纯RFA ;联合组76例,TACE后2周行射频消融,间隔2 0～30d后再行PEI。结果　对照组的完全坏死率为75 .8%,联合组为89.5 %,两组间差异有统计学意义(P <0 .0 5 )。结论　HCC患者经TACE后,行CT导向下RFA联合PEI的疗效明显优于单纯RFA。     

Transarterial Chemoembolization Combined with Either Radiofrequency or Microwave Ablation in Management of Hepatocellular Carcinoma

Introduction: Local ablative therapy and trans arterial chemoembolization (TACE) are applied to ablate non resectable hepatocellular carcinoma (HCC). Combination of both techniques has proven to be more effective. We aimed to study combined ablation techniques and assess survival benefit comparing TACE with radiofrequency (RFA) versus TACE with microwave (MWA) techniques. Methods: We retrospectively studied 22 patients who were ablated using TACE-RFA and 45 with TACE-MWA. All were classified as Child A-B and lesions did not exceed 5 cm in diameter. TACE was followed within two weeks by either RFA or MWA. We recorded total and partial ablation rates and complication rates. Survival analysis was then performed. Results: TACE-MWA showed a higher tendency to provide complete response rates than TACE-RFA (P 0.06). This was particularly evident with lesions sized 3-5 cm (P 0.01). Rates of complications showed no significant difference between the groups. Overall median survival was 27 months. The overall actuarial probability of survival was 80.1% at 1 year, 55% at 2 years, and 36.3% at 3 years. The recurrence free survival at 1 year, 2years and 3 years for the TACE-RFA group was 70%, 42% and 14% respectively and for TACE-MWA group 81.2%, 65.1% and 65.1% without any significant difference (P 0.1). In relation to the size of focal lesions, no statistically significant difference in the survival rates was detected between the groups. Conclusion: TACE-MWA led to better response rates than TACE-RFA with tumors 3-5 cm, with no difference in survival rates.     

Transarterial Chemoembolization Monotherapy in Combination with Radiofrequency Ablation or Percutaneous Ethanol Injection for Hepatocellular Carcinoma

Purpose: To evaluate whether combined transarterial chemoembolization (TACE) with radiofrequency ablation (RFA) or percutaneous ethanol injection (PEI) for hepatocellular carcinoma (HCC) have superior efficacy to transarterial chemoembolization (TACE) alone a retrospective review was conducted. Methods: During January 2009 to March 2013, 108 patients with hepatocellular carcinoma underwent TACE or combined therapies (TACERFA or TACEPEI). The long-term survival rates were evaluated in those patients by various statistical analyses. Results: The cumulative survival rates in the combined TACERFA/PEI group were significantly superior to those in the TACE alone group. When the comparison among the groups was restricted to patients with two or three tumors fulfilling the Milan criteria, significantly greater prolongation of survival was observed in the combined TACE RFA/PEI group than in the RFA/PEI alone group. Conclusions: In terms of the effect on the survival period, combined TACE RFA/PEI therapy was more effective than TACE monotherapy, and also more effective than PEI or RFA monotherapy in cases with multiple tumors.     

Locally ablative therapies for primary and metastatic liver cancer

Locally ablative therapies have an increasing role in the effective multidisciplinary approach towards the treatment of both primary and metastatic liver tumors. In patients who are not considered surgical candidates and have low volume disease, these therapies have now become established into consensus practice guidelines. A large range of therapeutic options exist including percutaneous ethanol injection (PEI), radiofrequency ablation (RFA), microwave ablation (MWA), cryoablation, percutaneous laser ablation (PLA), irreversible electroporation (IRE), stereotactic body radiation therapy (SBRT) and high intensity focused ultrasound (HIFU); each having benefits and drawbacks. The greatest body of evidence supporting clinical utility in the liver currently exists for RFA, with PEI having fallen out of favor. MWA, IRE, SBRT and HIFU are relatively nascent technologies, and outcomes data supporting their use is promising. Future directions of ablative therapies include tandem approaches to improve efficacy in the treatment of liver tumors.     

Locoregional radiological treatment for hepatocellular carcinoma; Which, when and how?

Hepatocellular carcinoma (HCC) is one of the most frequent and deadliest cancers worldwide. Liver transplantation, surgical resection or local ablation offer the best survival advantages but most patients either present when the tumor is in an advanced stage or the degree of underlying liver disease precludes these options. Several therapies have been proposed for these patients with proven survival benefits. These therapies comprise the locoregional treatment for HCC, and include percutaneous ethanol injection (PEI), radiofrequency ablation (RFA), transarterial chemoembolization (TACE), transarterial radioembolization (TARE), and drug-eluting bead (DEB). PEI and RFA are considered curative treatments for early stage HCC; whereas TACE is a standard of care for intermediate stages. Additionally, evaluation of response to locoregional treatment in HCC is important, as objective response may become a surrogate marker for improved survival. Currently, there are several criteria for response assessment, including the World Health Organization (WHO), the Response Evaluation Criteria in Solid Tumors (RECIST), the European Association for the Study of the Liver Criteria (EASL), and the modified RECIST (mRECIST); however, there has been poor correlation between the clinical benefit provided by locoregional interventional therapies and conventional methods of response assessment.The aim of our study was to review and analyze the current evidence for radiological interventions in HCC, and to propose evidence based recommendations to improve the management of these patients.     

Population-based matching comparison between radiofrequency ablation and percutaneous ethanol or acetic acid injection for hepatocellular carcinoma

BackgroundLoco-regional therapies are evolving for hepatocellular carcinoma (HCC) treatment. Radiofrequency ablation (RFA) has changed the landscape in treating HCC; however, percutaneous ethanol or acetic acid injection (PEI/PAI) remains a widely used and easily performed technique by experienced clinicians. Nevertheless, the effectiveness of RFA compared to that of PEI/PAI remains unclear.MethodsRecords of 73,136 patients with newly diagnosed HCC between 2007 and 2013 were drawn from the Taiwan Cancer Registry. The primary outcome measures were the overall survival and local recurrence-free survival. Propensity score matching (PSM) was performed to compare the effectiveness of RFA and PEI. Median follow-up time was 61.6 months (36–120 months).ResultsAfter PSM, 4496 patients diagnosed with stage I-III HCC, who were initially treated with RFA (3372 patients) or PEI/PAI (1124 patients), were assessed. Compared to PEI/PAI, patients treated with RFA had better 5- and 9-year overall survival, cancer-specific survival, disease-free survival, and local recurrence-free survival. Median overall survival and recurrence-free survival of patients treated with RFA vs PEI/PAI were 61.5 vs 41.9 months and 72.1 vs 45.2 months, respectively. Multivariate Cox model analysis revealed that, except for patients with high cell grade or advanced stage, RFA resulted in better overall survival (HR: 0.74, 95% CI 0.68–0.81, P < 0.001) and local recurrence-free survival (HR: 0.69, 95% CI 0.63–0.75, P < 0.001) than PEI/PAI.ConclusionsRFA provides advantages over conventional PEI/PAI for HCC. Considering technological advances in instruments, loco-regional therapies for HCC can be employed in carefully selected patients.     

Seeding following percutaneous diagnostic and therapeutic approaches for hepatocellular carcinoma. What is the risk and the outcome?: Seeding risk for percutaneous approach of HCC

BACKGROUND: Tumour biopsy is usually considered mandatory for patient management by oncologists. Currently percutaneous ablation is used therapeutically for cirrhotic patients with small hepatocellular carcinoma (HCC), not suitable for resection or waiting for liver transplantation. However malignant seeding is a recognized complication of both diagnostic and therapeutic procedures in patients with HCC. Although percutaneous therapy whether with or without biopsy of a suspected HCC nodule may minimize the risk of seeding, this has not been confirmed. AIM: To evaluate the risk of seeding, defined as new neoplastic disease occurring outside the liver capsule, either in the subcutaneous tissue or peritoneal cavity following needle biopsy and/or local ablation therapy (LAT). METHODS: A literature search resulted in 179 events in 99 articles between January 1983 and February 2007: 66 seedings followed liver biopsy, 26 percutaneous ethanol injection (PEI), 1 microwave, 22 radiofrequency ablation (RFA), and 64 after combined biopsy and percutaneous treatment (5 microwave; 33 PEI; 26 RFA). RESULTS: In 41 papers specifying the total number of patients biopsied and/or treated, the median risk of seeding was 2.29% (range 0-11%) for biopsy group; 1.4% (1.15-1.85%) for PEI when used with biopsy and 0.61% (0-5.56%) for RFA without biopsy, 0.95% (0-12.5%) for RFA with biopsy and 0.72% (0-10%) for liver nodules (including non-HCC nodules) biopsied and ablated. CONCLUSION: Risk of seeding with HCC is substantial and appears greater with using diagnostic biopsy alone compared to therapeutic percutaneous procedures. This risk is particularly relevant for patients being considered for liver transplantation.     

Hepatocellular carcinoma abutting large vessels: comparison of four percutaneous ablation systems

Purpose: To compare overall local tumour progression (OLTP), defined as the failure of primary ablation or local tumour progression, with single applicator monopolar radiofrequency ablation (RFA), microwave ablation (MWA), cluster-RFA and multi-bipolar radiofrequency (mbpRFA) in the treatment of hepatocellular carcinoma (HCC)?≤?5?cm abutting large vessels (≥3?mm).

Materials and methods: This multicenter, retrospective, per-nodule study was performed from 2007 to 2015. The study was approved by the ethics review board, and informed consent was waived. A total of 160/914 HCC nodules treated by thermal ablation and abutting large vessels (40 per treatment group) treated by monopolar RFA, MWA, cluster-RFA or mbpRFA were matched for tumour size, alpha-feto-protein level and vessel size. OLTP rates were compared by the log-rank test and the multivariate Cox model after matching.

Results: No differences were observed in tumour size, vessel size or alpha-feto-protein levels among the three groups (p?=?1). The cumulative 4-year OLTP rates following monopolar RFA, cluster-RFA, multi-bipolar RFA and MWA were 50.5%, 16.3%, 16.3% and 44.2%, respectively (p?=?0.036). On multivariate Cox regression, vessel size ≥10?mm, monopolar RFA and MWA were independent risk factors of OLTP compared to cluster-RFA or mbpRFA.

Conclusion: Multi-applicator RFA provides better local tumour control in HCC abutting large vessels than single-applicator techniques (monopolar RFA or MWA).     

The validity of radiofrequency ablation for hepatocellular carcinoma

Radiofrequency ablation therapy (RFA) has now become the mainstream percutaneous local treatment for hepatocellular carcinoma (HCC). RFA is superior to both percutaneous ethanol injection (PEI) and percutaneous microwave coagulation therapy (PMCT) because of the large coagulation area obtained by a single session of RF ablation. In addition, the local recurrence rate after RFA is lower than that after PEI. Recently, to improve tumor ablation efficacy, several devices have been reported. We also designed RFA with balloon occlusion of the hepatic artery (balloon-occluded RFA, BoRFA). The coagulation area obtained by BoRFA was significantly larger than that obtained by standard RFA. In Japan, the results for RFA remain insufficient because of the short follow-up periods after treatments. Within a few years, we expect to clarify the indications for RFA treatment for HCC and the choice between RFA and other local treatments.     

射频消融治疗原发性肝癌的生命质量对比评价

背景与目的以往对原发性肝癌(hepatocellularcarcinoma,HCC)各种治疗疗效的评价主要从治愈率、生存率和生存时间方面进行,近年来生命质量(qualityoflife,QOL)研究倍受关注,能较全面地反映肝癌患者体能恢复状况和切身感受而被广泛应用于癌症、慢性病的疗效评价。目前对于经皮射频消融(radiofrequencyablation,RFA)、经动脉插管栓塞化疗(transcatheterhepaticarterialchemo-embolization,TACE)治疗意义的评价大多关注局部肿瘤灭活率及患者生存率,而对治疗后患者生命质量的研究尚不多见。本研究从患者整体角度对比评估原发性肝癌经皮射频消融治疗后患者的生命质量。方法采用国内肝癌特异性生命质量量表(QOL-LCV2.0),对80例HCC经RFA治疗后QOL进行评定;并与同期40例经动脉插管栓塞化疗(TACE组)以及TACE RFA(联合组)40例分别进行比较。3组患者在年龄、性别、临床分期等方面分布均衡,无明显差异。结果RFA组的QOL总分中位数(168.6)高于TACE组(146.8),差异有显著性(P=0.025);RFA组和联合组在症状/副作用领域的得分中位数45.5、46.0,分别优于单纯TACE组38.1(P<0.01);RFA组躯体功能领域得分呈略高于TACE组的趋势。患者的年龄、收入、治疗后Child-Pugh分级、治疗后新生/复发率、并发症等方面与患者生命质量相关。TACE组和联合组于治疗后Child-Pugh分级提高的比例分别高于RFA组;TACE组新生/复发的比例明显高于RFA组。RFA组的1年、2年和3年生存率(92.8%、89.3%和76.5%)与联合治疗组(94.1%、87.4%、60.0%)比较无统计学差异,但高于TACE组(74.3%、48.2%、48.2%)。结论RFA治疗肝癌,多数患者可获得较好的疗效,严重的副作用少。TACE与RFA联合治疗与单纯TACE相比,可减少患者肝功能损伤,有利于提高原发性肝癌患者的生命质量。     

原发性肝癌综合介入治疗的疗效分析

目的探讨原发性肝癌综合介入治疗的疗效。方法回顾性分析1126例原发性肝癌患者手术前后行经导管肝动脉化疗栓塞术(TACE)、TACE后射频消融(RFA)治疗、TACE或经导管肝动脉化疗灌注治疗(TAI)后辅以中药和生物治疗的临床资料,分析患者肝功能、肿瘤标志物、癌灶影像资料和生存率等,比较各种综合介入治疗的价值。结果全组患者1、3、5年生存率分别为67.8%、28.7%和18.8%。其中术前TACE组1、3、5年生存率分别为74.7%、41.4%和36.9%,术后TACE组1、3、5年生存率分别为78.9%、40.4%和37.5%;TACE RFA组的近期有效率为93.4%,1、3年生存率分别为74.5%和36.8%;TACE组的近期有效率为83.2%,1、3、5年生存率分别为69.3%、21.7%和8.4%;TAI治疗的近期有效率为27.5%,1、3年生存率分别为11.6%和0。TACE RFA组和TACE组间肝功能Child降级、瘤内与瘤周血流信号消失和甲胎蛋白转阴率差异均无统计学意义,TACE RFA组、TACE组与TAI组肝功能Child降级差异无统计学意义。结论原发性肝癌手术切除前后TACE效果最佳,手术前与手术后行TACE疗效相近;TACE RFA疗效优于TACE;TAI疗效较差。     

Trans-arterial chemoembolization + radiofrequency ablation versus surgical resection in hepatocellular carcinoma – A meta-analysis

BackgroundHepatocellular Carcinoma (HCC) remains the third most common cause of cancer death worldwide, with countries in Asia being affected the most. The mainstay of curative therapy for early HCC is radiofrequency ablation (RFA) or surgery; either surgical resection (SR) or liver transplantation. Latest evidence however suggests that combination of TACE+ RFA may provide outcomes comparable to SR.AimTo compare oncologic outcomes and safety profile of TACE + RFA to SR alone in HCC.Materials and methodsA systematic review was conducted through Pubmed, EMBASE and Cochrane Library for literature published before April 2019. Outcomes measured were disease-free survival(DFS), overall survival(OS) and major complications. DFS was further divided into local tumour progression(LTP), intrahepatic distant recurrence(IDR) and distant metastasis(DM).ResultsEight retrospective studies and one randomized controlled trial, involving 1892 patients met eligibility criteria and were included. Unadjusted pooled analysis demonstrated no significant difference in 1-year, 3-year and 5-year OS and 1-year DFS between TACE+RFA and SR. SR had superior 3-year DFS (OR 0.78, 95% CI 0.62–0.98, p = 0.03) and 5-year DFS (OR 0.74, 95% CI 0.58–0.95, p = 0.02) compared to TACE+RFA. When analysing only the propensity matched data, the difference in 3-year DFS and 5-year DFS was not significant. TACE+RFA had a higher LTP rate (OR 2.48, 95% CI 1.05–5.86, p = 0.04) compared to SR but IDR and DM rates were not significant.Discussion and conclusionTACE+RFA offer comparable oncologic outcomes in patients with HCC as compared with SR and with added benefit of lower morbidity.     

Cryosurgery and radiofrequency ablation for unresectable colorectal liver metastases

AimsTo report immediate local treatment efficacy and long-term results of cryosurgical ablation (CSA) and radiofrequency ablation (RFA) in patients with colorectal liver metastases not eligible for resection.MethodsFifty-eight patients with unresectable colorectal liver metastases were included. Under ultrasound guidance, CSA or RFA were performed with or without concomitant resection. CT scanning and FDG-PET were used to determine local efficacy of the ablative procedure.ResultsMedian follow-up was 26 and 25 months for CSA and RFA, respectively. One and 2-year survival rates were 76 and 61% for CSA and 93 and 75% for RFA, respectively. In a lesion based analysis, the local recurrence rate was 9% after CSA and 6% after RFA. Complication rates were 30 and 11% after CSA and RFA, respectively, (p=0.052). In a subgroup analysis on 43 patients with 104 ablated lesions, CT scan immediate after treatment was not able to predict local treatment failure, whereas FDG-PET scan within 3 weeks after local ablative treatment predicted six of the seven local recurrences.ConclusionsIn patients with unresectable colorectal liver metastases, CSA and RFA can be used either alone or as an effective adjunct to resection in achieving complete tumour clearance of the liver. More widespread use of these techniques seems promising but requires further investigation in randomized trials comparing local ablative treatment with chemotherapy.     

Ablation of kidney tumors

While surgical excision remains the gold standard for curative treatment of small renal cell carcinomas, ablative therapy has a place as a minimally invasive, kidney function-preserving therapy in carefully selected patients who are poor candidates for surgery. Although laparoscopic cryoablation and percutaneous radiofrequency ablation (RFA) are commonly performed, percutaneous cryoablation and laparoscopic RFA are reportedly being performed with increasing frequency. The renal function and complication profiles following ablative therapy are favorable, while oncologic outcomes lag behind those of surgery, thus reinforcing the need for careful patient selection.     

肝细胞癌的局部联合疗法

肝细胞癌(HCC)是最常见的恶性肿瘤之一,由于快速浸润性生长及合并肝硬化因此其预后不良。局部介入疗法的出现,是治疗不能切除HCC的重大突破,局部治疗HCC有许多疗法,包括经肝动脉的化疗栓塞(TACE)疗法,经皮酒精注射(PEI)疗法、射频消融(RFA)疗法、微波凝固疗法(MCT)、激光疗法(LITT)、免疫疗法、基因疗法、血管生成抑制疗法、中医疗法等。肝动脉的化疗栓塞(TACE)是最常用的疗法,每一种疗法都有其优势和不足,而TACE和其他的局部疗法联合能够克服一些不足,提高患者的生存率。     

Less invasive medical therapy for hepatocellular carcinoma

Since hepatocellular carcinoma (HCC) usually occurs in chronic liver disease, especially viral cirrhosis, it often recurs even after surgical resection. Because of the high recurrence rate of HCC, less invasive therapies have become more common recently, including percutaneous ethanol injection (PEI), percutaneous microwave coagulation therapy(PMCT), and radiofrequency ablation(RFA). A PEI needle or a coagulation electrode is usually inserted into an HCC nodule under ultrasonographic-guidance, and chemical or heat ablation is carried out with local or general anesthesia. A patient with a few numbers of small HCCs of 3 cm or less in diameter is a good candidate for these therapy modalities. Although RFA is the easiest and most effective of these therapies the best therapy for each patient is selected according to the number, size, and location of target lesions.     

Combined transarterial chemoembolization and radiofrequency ablation for hepatocellular carcinoma

Transarterial chemoembolization (TACE) and radiofrequency ablation (RFA) are both efficacious in treating well-selected patients who have hepatocellular carcinoma (HCC). The sequential combination of these two modalities has a sound theoretical basis and raises the probability of complete local response in tumors that are beyond the size at which the likelihood of failure with RFA alone begins to rise. Cheng et al. have found that when limited to patients with well-compensated liver disease, combined TACE and RFA does not seem to dramatically increase the risk of complications beyond the risk levels associated with the individual procedures. The survival benefit demonstrated in this recent article is, however, an artifact of a rigid study design that did not allow rational selection of treatment on the basis of individual patient and tumor characteristics. This study bolsters the evidence that the combination of TACE with RFA enhances local response, strengthening the status of nonsurgical treatment compared with resection for the treatment of early HCC.     

Combined radiofrequency ablation and ethanol injection versus repeat hepatectomy for elderly patients with recurrent hepatocellular carcinoma after initial hepatic surgery

Purpose: To retrospectively compare the efficacy and safety of combined radiofrequency ablation and percutaneous ethanol injection (RFA–PEI) with repeat hepatectomy for elderly patients with initial recurrent hepatocellular carcinoma (HCC) after hepatic surgery.

Methods: From January 2009 to June 2015, 105 elderly patients (≥70?years) who underwent RFA–PEI (n?=?57) or repeated hepatectomy (n?=?48) for recurrent HCC?≤?5.0?cm were included in the study. The overall survival (OS) and recurrence-free survival (RFS) were analysed with the Kaplan–Meier method and compared by the log-rank test. Non-tumour-related death, complications and hospital stays were assessed. Univariate and multivariate analyses were performed to identify the prognostic significance of the variables in predicting the OS and RFS.

Results: OS rates were 78.2%, 40.8% and 36.7% at 1, 3 and 5?years after RFA–PEI and 76.3%, 52.5% and 42.6% after repeat hepatectomy, respectively (p?=?0.413). Correspondingly, the 1-, 3- and 5-year RFS rates after RFA–PEI and repeat hepatectomy were 69.5%, 37.8%, 33.1% and 73.1%, 49.7%, 40.7%, respectively (p?=?0.465). Non-tumour-related deaths in the RFA–PEI group (2/57) were significantly fewer than those in the repeat hepatectomy group (10/48) (p?=?0.016). RFA–PEI was superior to repeat hepatectomy regarding the major complication rates and length of in-hospital stay (both p?p?=?0.037) and RFS (HR?=?1.866, 95% CI?=?1.064–3.274, p?=?0.030).

Conclusion: RFA–PEI provides comparable OS and RFS to repeat hepatectomy for elderly patients with small recurrent HCC after hepatectomy but with fewer non-tumour-related deaths, major complications and shorter hospital stays.     

Treatment outcomes for hepatocellular carcinoma using chemoembolization in combination with other therapies

BACKGROUND: Although transarterial chemoembolization (TACE) improves survival in patients with hepatocellular carcinoma (HCC), it is not known if TACE combined with other treatments is beneficial. Aim: To evaluate the evidence for improved outcomes in HCC with a multimodal treatment approach involving TACE. METHOD: PubMed search for all cohort and randomized trials (n=84) evaluating TACE combined with other therapies; meta-analysis performed where appropriate. RESULTS: A meta-analysis involving 4 RCTs showed a significant decrease in mortality favouring combination treatment (TACE plus percutaneous ablation) compared to monotherapy in patients with either small (<3cm) or large HCC nodules (>3cm) (OR, 0.534; 95% CI, 0.288-0.990; p=0.046). TACE combined with local radiotherapy improved survival in patients with tumour thrombosis of the portal vein in 7 non-randomized studies. Two RCTs and 13 non-randomized studies showed that TACE prior to hepatic resection does not improve survival nor tumour recurrence. Conversely, 2 RCTs and 5 comparative studies showed that transarterial injection of chemotherapeutic drugs mixed with lipiodol (TOCE) following hepatectomy confers survival benefit and less tumour recurrence. TACE before liver transplantation is safe and reduces drop-out rate from the waiting list, but there is no current evidence of improvement in subsequent survival or recurrence rate. CONCLUSIONS: A combined approach involving TACE and percutaneous ablation improves survival. Adjuvant TOCE improves outcome after hepatectomy. TACE is useful to control tumours burden while on the waiting list for OLT. Multimodal treatment seems to be the best way to optimize TACE outcomes in HCC.