We investigated the long-term outcome of combined transcatheter arterial chemoembolization (TACE) and percutaneous ethanol injection (PEI) for the treatment of hepatocellular carcinoma (HCC). A series of 86 patients with biopsy-proved HCC were treated at our Institution January, 1991, to June, 1996. All patients had a single primary tumor bigger than 3 cm, occurring solitary or associated with no more than 2 daughter nodules. Forty-eight patients were in Child class A and 38 patients were in Child class B. The diameter of the lesions ranged 3 to 8 cm (mean: 5.3 cm). The treatment schedule included a single TACE performed via a segmental approach by injecting an emulsion of 20-70 mg adriblastin or farmorubicin and 5-20 ml Lipiodol followed by gelatin sponge particles. Four weeks later, CT and MR follow-up studies were performed and PEI was subsequently started. PEI included 4-16 treatment sessions (mean: 6.8 sessions) performed under US guidance. The total amount of alcohol administered ranged 16 to 215 ml (mean: 69 ml). All patients were followed after therapy with clinical examinations. laboratory tests, and US, CT, and MR studies performed at regular time intervals. The follow-up period ranged 4 to 65 months (mean: 27.8 months; median: 26 months). No major treatment-related complication occurred. The therapeutic response, as assessed with imaging studies performed after the end of treatment, was complete tumor necrosis in 71 of 86 patients (82%) and partial tumor necrosis in the remaining 15. Overall survival rates by the Kaplan-Meier method were 92% at 1 year, 83% at 2 years, 69% at 3 years, 58% at 4 years, and 47% at 5 years. The survival of Child A patients (75% at 3 years and 59% at 5 years) was significantly longer (p < .01) than that of Child B patients (61% at 3 years and 35% at 5 years). During the follow-up, a recurrence of the treated tumors was observed in 5 patients, and new HCCs appeared in 46 patients. The 1-, 2-, 3-, 4-, and 5-year recurrence rates by the Kaplan-Meier method were 14%, 35%, 56%, 69%, and 82%, respectively. The long-term results of combined treatment with TACE and PEI confirm the effectiveness of this therapeutic approach in patients with large uninodular HCC.