Background : The efficacy of preoperative transarterial chemoembolization (TACE) for resectable hepatocellular carcinoma (HCC) remains unclear. This study aims to evaluate the impact of preoperative TACE on long-term outcomes after surgical resection for single HCC.

Methods : This retrospective cohort study included 4997 patients undergoing hepatectomy for resectable single HCC between December 2008 and March 2019 in Asan Medical Center in Seoul. Survival outcomes were compared before and after propensity score matching (PSM) according to different tumor size between patients who underwent preoperative TACE and patients who did not. Univariable and multivariable Cox regression analyses were performed to identify independent risk factors associated with overall-survival (OS) and recurrent-free survival (RFS).

Results : Of 4997 patients, 425 (8.5%) underwent preoperative TACE. Preoperative TACE group showed significantly better RFS (P<0.001) than upfront surgery group, but did not significantly improve OS except for HCC with size of 3-5cm (P=0.046). A total of 1489 patients were included after 1:3 PSM. In the matched cohort, preoperative TACE significantly improved OS (P=0.025) and RFS (P=0.015) only in HCC with size of 3-5cm. The multivariate regression analysis showed preoperative TACE (P = 0.003, Hazard ratio 0.52, 95 % Confidence interval 0.34-0.80) was significantly associated with improved RFS.

Conclusions : Preoperative TACE can be recommended as routine treatment for resectable single HCC, especially when the tumor size is between 3 cm and 5 cm, given its clear benefits of both RFS and OS. Further studies with large sample size and randomized controlled trials are necessary to clarify the effectiveness of preoperative TACE.