The results of combined trans-arterial chemoembolization (TAE) and percutaneous ethanol injection (PEI) followed by liver transplantation for hepatocellular carcinoma (HCC) are described. Fourteen patients (G2) with tumour stages I-III received a mean of 2 times TAE and 4 times PEI prior to transplantation. Six patients (G1) received no pre-transplant therapy. Tumor size reduced from 37 +/- 16 to 28 +/- 16 mm and alpha-FP from 339 +/- 1057 to 224 +/- 711 ng/mL (p = n.s.). On histopathologic examination (G2 vs. G1) a 100% necrosis of the tumour nodules was seen in 80 vs. 0% (p = 0.001); 60-90% in 3 vs. 1 and 10-50% in 3 vs. 2. Eighty six percent of nodules in G2 and 36% in G1 had a tumour capsule (p = 0.02). After a median follow-up of 26 months (3-60), 2 patients in G1 developed a recurrence of HCC as compared to 0 in G2 (p = 0.0005). The actuarial patient disease-free survival after 48 months was 82% in G2 and 65% in G1. It is concluded that combined treatment with TAE and PEI is inducing necrosis in HCC associated with improved patient disease-free survival following liver transplantation.