OBJECTIVE: To investigate the impact of preoperative transarterial lipiodol chemoembolization (TACE) in the management of patients undergoing liver resection or liver transplantation for hepatocellular carcinoma. PATIENTS AND METHODS: TACE was performed before surgery in 49 of 76 patients undergoing resection and in 54 of 111 patients undergoing liver transplantation. Results were retrospectively analyzed with regard to the response to treatment, the type of procedure performed, the incidence of complications, the incidence and pattern of recurrence, and survival. ). Multivariate analysis of the factors associated with response to TACE showed that downstaging occurred more frequently for tumors G 5 cm. CONCLU-SIONS: Downstaging or total necrosis of the tumor induced by TACE occurred in 62% of the cases and was associated with improved disease-free survival both after liver resection and transplantation. In liver resection, TACE was also useful to improve the resectability of primarily unresectable tumors. In liver tranplantation, downstaging in patients with tumors G 3 cm was associated with survival similar to that in patients with less extensive disease. COMMENTSHepatocellular carcinoma (HCC) can only be cured by surgical resection or liver transplantation. Resection has generally been considered first line therapy, with transplantation being reserved for patients with tumors that are unresectable because of location or severity of underlying liver disease. Both surgical approaches have inherent limitations because most patients with HCC have locally advanced or metastatic disease at the time of diagnosis. An additional limitation of liver transplantation is the scarcity of donor organs and long waiting times between diagnosis and treatment. Liver resection (LR) and liver transplantation (LT) can offer patients with HCC a 1-year survival of 66% to 70%; this is better than no treatment, but recurrence is frequent and 5-year survival is poor (35% after LR and 31% after LT). 1 In an attempt to increase survival in patients with unresectable HCC, systemic chemotherapy, radiation therapy, and hepatic arterial infusion of chemotherapy have been investigated. As a whole, these modalities have shown no survival advantage and are associated with substantial morbidity. One promising nonsurgical therapy for HCC is percutaneous ethanol injection (PEI); however, the efficacy of PEI is limited to tumors smaller than 3 cm in diameter that can be identified radiographically and accessed percutaneously. 2 Transarterial chemoembolization (TACE) involves the administration of a chemotherapeutic agent (usually doxorubicin, mitomycin C, or cisplatin) into the hepatic artery followed by hepatic artery embolization (usually with gelatin sponge). In some cases an oily contrast medium, lipiodol, is also administered. Lipodiol is selectively retained by neoplastic tissue for an extended period of time and may enhance visualization of small satellite lesions. As liver tumors preferentially receive their blood supply from the he...