Hepatocellular carcinomas measuring less than 5 cm in diameter became completely necrotic after arterial chemoembolization with Lipiodol, doxorubicin, and gelfoam more often than larger lesions. In 60 patients, we surgically debulked large unresectable tumors, with the aim of subsequently embolizing residual small tumors transarterially. Forty-seven patients were actually embolized. The rate of major non-fatal complications was similar to that seen after radical resections, but the hospital mortality rate was 30%, as compared with 4%. Stage I disease, including non-embolized patients and hospital mortality, had an estimated 5-year survival rate of 27%. This result approached that obtained after curative resections, and was better than that seen after embolization only. Stage II disease had no five-year survivors and its survival curve was intermediate, lying between those of curatively resected and embolization patients. No stage I patients with tumor growth in the portal trunk or lobar branches survived for 2 years. The results warrant further study of this treatment strategy.
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