Is scheduled second chemoembolization necessary for early stage hepatocellular carcinoma showing complete response after first chemoembolization?

The reported complete response rate after single session of chemoembolization for small hepatocellular carcinomas ranged from 75% to 80% on mRECIST evaluation of imaging studies. However, considerable proportion of tumor nodules with complete initial response after chemoembolization show local tumor progression during long-term follow-up. The cumulative 5-year local tumor progression rate of chemoembolization for early stage hepatocellular carcinomas was reported to be as high as 73%. There is a general belief that better local tumor control can lead to longer survival. Therefore, many physicians are enthusiastic to achieve complete local tumor control for early stage hepatocellular carcinomas by applying combination strategy or potent regimen. However, we have to remember that most of patients who receive chemoembolization have underlying liver cirrhosis and portal hypertension. In patients with portal hypertension, local tumor control and preservation of normal liver parenchyma is equally important (should be well balanced) because remote site recurrence is very common and multiple treatments are usually required during the course of the disease. Unfortunately, better local tumor control means greater hepatic parenchymal loss in general. Local tumor control rate is highest in hepatic resection followed by thermal ablation and chemoembolization. On the contrary, normal liver parenchymal damage or major adverse events are smallest in chemoembolization followed by thermal ablation and resection. As a result, retrospective comparison with propensity score matching revealed that there was no significant difference in long-term survival between hepatic resection and thermal ablation and chemoembolization in small hepatocellular carcinomas. In addition, recent large retrospective series for local thermal ablation also revealed that local tumor progression was not a significant prognostic factor for survival. Because of common local tumor progression after chemoembolization, scheduled 2 chemoembolization would be a reasonable option. Recently, the results of one randomized trial evaluating the role of additional angiography and chemoembolization in See Article on Page 42 Is scheduled second chemoembolization necessary for early stage hepatocellular carcinoma showing complete response after first chemoembolization?